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NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH

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NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH Graham Martin The University of Queensland g.martin_at_uq.edu.au Case Study Jason Recent History of Diagnostic Systems ... – PowerPoint PPT presentation

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Title: NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH


1
NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH
  • Graham Martin
  • The University of Queensland
  • g.martin_at_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
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 co-variation between signs
    and symptoms

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)

8
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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 clients 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
    clients 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
    clients 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 examiners overall judgment of the
    clients 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 persons
    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 (SgtR)
  • caregiver responsiveness to childs 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     dont 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
S
R
C
Aggressive behaviour
Toy of other child
Positive reinforcement gets the toy
S
R
C-
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 caretakers love (15-36 months) anxiety
    over loss of caretakers 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

51
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52
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

53
Psychological Tests
  • Psychological tests are standardized procedures
    designed to measure a persons 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

54
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55
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

56
Projective Tests - Rorschach
57
Intelligence Tests
  • Intelligence (IQ) tests can be used to
  • provide a standardized assessment of a persons
    current mental abilities
  • diagnose learning disabilities
  • determine whether a person is mentally retarded
  • identify intellectually gifted children

58
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59
Example of Nonverbal Intelligence Task
60
Examples of Verbal Intelligence Tasks
  • Knowledge
  • Definition of the word table
  • Name the seven continents
  • Analogies
  • DogCat as ????
  • E.g., DayNight

61
Examples of Educational Test Domains
  • Phonological Processing
  • Reading Comprehension
  • Arithmetic Abilities
  • Written Expression

62
Neuropsychological Assessment
  • Brain-behaviour relations assessed
  • Tests validated on neurologically-impaired
    individuals so that Task A is sensitive to
    Frontal Lobe functioning, for example

63
Test of Planning Frontal Lobe
64
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65
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

66
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?

67
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68
Behavioral Methods
  • Direct observation of behavior
  • Self-monitoring
  • Reactivity behavior changes during monitoring
  • Interviews
  • Self-report inventories
  • Other procedures
  • Thought listing

69
Causal Modeling of Psychopathology
Distinguishing levels of analysis
  • Biological
  • Psychological
  • Behavioural

From Morton Frith 1995
70
Causal Modeling Distinguishing levels of analysis
  • Biological
  • Psychological ???
  • Behavioural poor peer relations

71
Causal Modeling Distinguishing levels of analysis
  • Biological
  • Psychological language social cognition
    introvert
  • impairment? impairment?
    personality?
  • Behavioural poor peer relations

72
Causal Modeling Distinguishing levels of analysis
  • Biological
  • Psychological language social cognition
    introvert
  • impairment? impairment?
    personality?
  • Behavioural poor peer relations
  • ?poor verbal ?poor recognition ?good
    sibling
  • comprehension of thoughts/feelings
    relations

73
Causal Modeling E.g. of biologically-defined
disorder (A)
  • Biological Fragile-X
  • Psychological ? ? ?
  • Behavioural gaze avoidance low IQ spatial

74
Causal Modeling E.g. of cognitively-defined
disorder (X)
  • Biological ? Genes ?
  • Psychological theory of mind deficit
  • Behavioural social communication impaired
  • handicap difficulties imagination

75
Causal Modeling E.g. of behaviourally-defined
disorder (V)
  • Biological ? Genes ?
  • Psychological poor delay
  • inhibition? aversion?
  • Behavioural impulsive/inattentive

76
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
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