Mental Health Diagnosis Training
Anxiety • Panic Disorder • Agoraphobia • Obsessive Compulsive Disorder • Specific Phobias • Separation Anxiety Disorder • Posttraumatic Stress Disorder • Generalized Anxiety Disorder • Anxiety Disorder NOS
What Type of Anxiety? • Marcus has come for a follow-up appointment at the SBHC. He reported several anxiety symptoms during his comprehensive risk assessment, and screened positively for panic attacks during the Diagnostic Predictive Scales. Marcus indicates that the panic attacks are triggered by a fear of being called on in class. He experiences symptoms of panic (heart palpitations, nervousness, sweating, etc) on the way to school, while sitting in class, and even just thinking about being in class.
Panic Disorder –Diagnostic Criteria I. Recurrent, Unexpected Panic Attacks Criteria for Panic Attack: A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: • Palpitations, pounding heart, or accelerated heart rate • Sweating • Trembling or shaking • Sensations of shortness of breath or smothering • Feeling of choking • Chest pain or discomfort • Nausea or abdominal distress • Feeling dizzy, unsteady, lightheaded, or faint • Derealization(feelings of unreality) or depersonalization (being detached from oneself) • Fear of losing control or going crazy • Fear of dying • Paresthesias(numbness or tingling sensations) • Chills or hot flushes
Panic Disorder –Diagnostic Criteria II. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: • Persistent concern about having additional attacks • Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy") • A significant change in behavior related to the attacks
What Type of Anxiety? • Philip was referred to the SBHC by his mother, because she has become increasingly concerned by his fears of going outside. Upon interview, Philip reveals that after being attacked by a neighborhood dog a few years ago, he has developed a fear of dogs. His fear is getting worse, and he is beginning to limit his outdoor activities. He reports getting nervous even when seeing dogs on television, even though he knows they cannot hurt him.
Specific Phobias • Marked and persistent fear of a specific object or situation with exposure causing an immediate anxiety response that is excessive or unreasonable • In children, anxiety may be expressed as crying, tantrums, freezing, or clinging. • Adults recognize that their fear is excessive. Children may not. • Causes significant interference in life, or significant distress. • Under 18 years of age – symptoms must be > 6 months
Specific Phobias • Animal phobias most common childhood phobia. • Also frequently afraid of the dark and imaginary creatures • In older children, fears are more focused on health, social and school problems
What Type of Anxiety? • Sally is brought to the SBHC by her parents, who are worried about her poor attendance in school. Sally has had some difficulty leaving her parents for the past several years, but her concerns have grown increasingly more intense. She reports having fears that if she goes to school, her parents will abandon her or something very bad might happen to them. She sometimes has dreams that they have died, and she wakes up in a panic. Sally has come to the SBHC several times in the past few months complaining of headaches and stomachaches, requesting that she be sent home.
Separation Anxiety Disorder • Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following: • Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated • Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures • Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped) • Persistent reluctance or refusal to go to school or elsewhere because of fear of separation
Separation Anxiety Disorder • Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings • Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home • Repeated nightmares involving the theme of separation • Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
Separation Anxiety Disorder • Duration of at least 4 weeks • Causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning
What Type of Anxiety? • James walks into the SBHC for an appointment. He reports having great difficulty concentrating in his classes because of his increased worrying. He cannot pinpoint his worries; Rather, he reports being nervous about many things in his life, including his relationships with peers, his grades, and even his performance in basketball. His worries are beginning to impact his sleep, and he is finding himself becoming more irritable than usual.
Generalized Anxiety Disorder • Excessive anxiety + worry for at least 6 months, more days than not • Worry about performance at school, sports, etc. • DSM IV criteria less stringent for children (Need only one criteria instead of three of six): • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
What Type of Anxiety? • Shelley’s teacher brings her down to the SBHC because he is concerned that her grades have been declining, and he has noticed that she has not been completing her homework. Shelley reports that she is being plagued by distressing thoughts of doing bad things, including hurting herself and others. In order to get rid of the thoughts, Shelley often has to engage in intricate routines, including counting to 1000 and backwards, and touching her desk at home in specific patterns. Although these routines decrease her anxiety, they are causing her to skip homework assignments and even lose sleep.
Obsessive Compulsive Disorder • Presence of Obsessions (thoughts) and/or Compulsions (behaviors) • Although adults may have insight, kids may not • Interferes with life or causes distress • One third to one half of all adult patients report onset in childhood or adolescence
What Type of Anxiety? • Ginny comes to the SBHC for a sports physical. During her risk assessment, she reveals that her parents have a history of domestic violence, and that she witnessed her father attack her mother on several occasions. In the past few months, Ginny has been having nightmares about the abuse, and finds herself having flashbacks even during class. Ginny has been avoiding certain rooms in her house that remind her of the incidents. She also reports having difficult sleeping and concentrating in class.
Post-Traumatic Stress Disorder (PTSD) • The person has been exposed to a traumatic event in which both of the following were present: • The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others • The person's response involved intense fear, helplessness, or horror. (Note: In children, this may be expressed instead by disorganized or agitated behavior.)
Persistent Re-Experiencing of Event (1+) • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.) • Recurrent distressing dreams of the event. (Note: In children, there may be frightening dreams without recognizable content.) • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (Note: In young children, trauma-specific reenactment may occur.) • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Avoidance and Numbing (3+) • Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect (e.g., unable to have loving feelings) • Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
Increased Arousal (2+) • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response
Post-Traumatic Stress Disorder (PTSD) • At least one month duration. • Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • Note: Many students with PTSD meet criteria for another Axis I Disorder (e.g., major depression, Panic Disorder) – both should be diagnosed
Anxiety Disorder NOS • Disorders with anxiety symptoms BUT do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with Mixed Anxiety and Depressed Mood • Example: mixed anxiety-depressive disorder • Also used in situations in which clinician has concluded that an anxiety disorder is present, but is unable to determine whether it is primary, due to medical condition, or substance induced
Depressive Disorders • Major Depressive Disorder • Dysthymic Disorder
Depression Epidemiology • 2.5% of children, up to 5% of adolescents • Prepubertal-1:1/M:F; adolescence-4:1/F:M • Average length of untreated MDD-7.2 months • Recurrence rates-40% within 2 years Genetics • Most important risk factor for the development of depressive illness is having at least one affectively ill parent
What Type of Depression? • Tonya has come for an initial appointment to the SBHC. During the risk assessment, Tonya reports a number of depressive symptoms, including suicidal ideation. Tonya seems to display a lot of negative thinking and cognitive distortions. For example, she believes that “nobody” likes her and that s/he will “never” be successful in school. Her math teacher often compliments her work, but Tonya dismisses the teacher’s comments as him “just trying to be nice.” Tonya has good grades in all classes except for one, yet she only acknowledges her below average Chemistry grade. Tonya has felt extremely sad for about three weeks, which is a contrast from her usually happy disposition.
Major Depressive Disorder • Major Depressive Episode: • Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning. At least one symptom is either (1) depressed mood or (2) loss of interest or pleasure. • Depressed mood most of the day, nearly every day, as indicated by subjective report or based on the observations of others. In children and adolescents, this is often presented as irritability. • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day • Significant weight loss when not dieting or weight gain (change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day • Insomnia or hypersomnia nearly every day • Psychomotor agitation or retardation nearly every day (observable by others) • Fatigue or loss of energy nearly every day • Feelings of worthlessness or inappropriate guilt nearly every day • Diminished ability to think, concentrate, make a decision nearly every day • Recurrent thoughts of death, recurrent suicidal ideation with or without a specific plan, or an actual suicide attempt
Major Depressive Disorder • Symptoms cause clinically significant distress or impairment in social or academic functioning • Symptoms are not due to the direct physiological effects of a substance (drugs or medication) or a general medical condition • Although there is a different diagnostic category for individuals who suffer from Bereavement, many of the symptoms are the same and counseling techniques may overlap.
Depression Modifications in DSM- IV for children: • irritable mood (vs. depressive mood) • observed apathy and pervasive boredom (vs. anhedonia) • failure to make expected weight gains (rather than significant weight loss) • somatic complaints • social withdrawal • declining school performance
Adolescent Development • Periods of transient milder problems with low self-esteem, anxiety, depressive feelings are quite common. • Needs to be differentiated from clinical depression!
Suicide • Attempts- 3:1/F:M, Completions- 4:1/M:F • Most common means of completed suicide: FIREARMS • Most often associated with depressive disorder. • Risk factors: Age, sex, presence of psychiatric illness, family history, isolation from friends, substance abuse
Adolescents and Suicide • In 1998, 4,153 young people, ages 15-24, committed suicide in the United States an average of 11.3 per day.1 • Suicide is the third leading cause of death in this age group following unintentional injury and homicide2 • Suicide accounts for 13.5% of all deaths in this age-group1 1 Murphy, SL, 1998 2 The Surgeon General’s Call to Action to Prevent Suicide, 1999
Mortality in Children Ages 1-19 years Source: CDC Wonder Mortality Statistics; Center for Disease Control and Prevention, 2001
What Type of Depression? • Maria comes for a follow-up appointment to the SBHC. Her risk assessment showed that she has felt sad or blue for at least two weeks. Upon further inquiry, Maria reports that she generally feels sad, and finds little enjoyment in activities. She reports having felt this way for several years. In fact, she can’t recall a time when she didn’t feel mostly down. She denies suicidal ideation, and is doing pretty well in school. She is not very social, but does have a few friends.
Dysthymic Disorder • Major difference between a diagnosis of Major Depressive Disorder and Dysthymia is the intensity of the feelings of depression and the duration of symptoms. • Dysthymia is an overarching feeling of depression most of the day, more days than not, that does not meet criteria for a Major Depressive Episode. • Impairs functioning and lasts for at least one year in children and adolescents, two in adults.
Depressive Disorder NOS • Disorders with depressive symptoms BUT do not meet criteria for: Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder with Depressed Mood, or Adjustment Disorder with Mixed Anxiety and Depressed Mood • Examples: premenstrual dysphoric disorder, minor depressive disorder (at least 2 weeks, but < 5 symptoms) • Also used in situations in which clinician has concluded that a depressive disorder is present, but is unable to determine whether it is primary, due to medical condition, or substance induced
Disruptive Disorders In Children • Attention Deficit Hyperactivity Disorder • Oppositional Defiant Disorder • Conduct Disorder • Disruptive Behavior Disorder NOS
What Type of Disruptive Behavior Disorder? • Joseph was referred to the main office by his teacher for disrupting her class. Joseph’s teacher reported that she cannot manage him in class because he is constantly out of his seat and will not concentrate on work. He has a hard time completing tasks, and is very disorganized. He talks back to her occasionally when frustrated, but is not frequently defiant. His peers are getting tired of him constantly interrupting them, and he is losing friends quickly.
Attention Deficit Hyperactivity Disorder • Symptoms for at least six months to a degree that it is maladaptive and INCONSISTENT with developmental level • Some symptoms present prior to age 7 years • Two or more settings
Attention Deficit Hyperactivity Disorder Hyperactivity/Impulsivity • Fidget • Leaves seat often • Runs or climbs excessively • Always “on the go” • Talks excessively • Blurts out answers • Can’t wait turn, interrupts others Inattention • Poor organization • Does not seem to listen when spoken to • Loses objects • Easily distracted • Forgetful in daily activities
Attention Deficit Hyperactivity Disorder • Attention deficit disorder can occur WITH and WITHOUT hyperactivity • Hyperactivity is more common in boys than girls
Attention Deficit Hyperactivity Disorder • ADHD can be a lifetime disorder with 30-50% having symptoms as adults • Learning Disabilities are frequently seen in children with ADHD • Behavior in a provider’s office does NOT always reflect the situation at home or in school
What Type of Disruptive Behavior Disorder? • The principal of your school has called you to a meeting with Jonathon’s parents and his teachers, all of whom complain that Jonathon has been “acting out” for over a year, and refuses to listen to their direction. He is constantly arguing with all authority figures, and will not take responsibility for his actions. Jonathon’s teacher and mother say that he is “always angry,” and that he lashes out at everyone around him. He has been breaking more rules at home and in school. He has not been drinking alcohol or using drugs, not has he broken the law up until this point, but his parents are worried that his behaviors are going to grow steadily worse.
Oppositional Defiant Disorder A pattern of negativistic, hostile and defiant behavior lasting greater than 6 months of which you have 4 or more of the following: • Loses temper • Argues with adults • Actively defies or refuses to comply with rules • Often deliberately annoys people • Blames others for his/her mistakes • Often touchy or easily annoyed with others • Often angry and resentful • Often spiteful or vindictive
Oppositional Defiant Disorder(ODD) • Prevalence-3-10% • Male to female -2-3:1 • Outcome-in one study, 44% of 7-12 year old boys with ODD developed into CD • Evaluation-Look for comorbid ADHD, depression, anxiety &LD/MR
What Type of Disruptive Behavior Disorder? • Matthew was referred to the social worker at the SBHC because he has been “going down the wrong path for several years,” according to his mother. Matthew’s negative behaviors began before puberty, when he started hanging out with negative peers. Matthew’s mother has caught him hurting their family pet as well as other animals, and he was recently arrested for vandalizing school property. He has been getting into frequent fights at school without apparent instigation. Matthew’s mother also realized that he had stolen from her when she noticed $50 missing from her purse and found it in his pocket.
Conduct Disorder (CD) • Deceitfulness or Theft • Aggression toward people or animals • Serious violation of rules • Destruction of property
Conduct Disorder (CD) • Prevalence-1.5-3.4% • Boys greatly outnumber girls (3-5:1) • Comorbid ADHD in 50%, common to have LD • Course-remits by adulthood in 2/3. Others become Antisocial Personality Disorder