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Title: Mental Health

Mental Health Diagnosis Training
  • 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
  • Persistent concern about having additional
  • 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

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.

(No Transcript)
Specific Phobias
  • Marked and persistent fear of a specific object
    or situation with exposure causing an immediate
    anxiety response that is excessive or
  • 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 gt 6

Specific Phobias
  • Animal phobias most common childhood phobia.
  • Also frequently afraid of the dark and imaginary
  • 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
  • Persistent and excessive worry about losing, or
    about possible harm befalling, major attachment
  • Persistent and excessive worry that an untoward
    event will lead to separation from a major
    attachment figure (e.g., getting lost or being
  • Persistent reluctance or refusal to go to school
    or elsewhere because of fear of separation

Separation Anxiety Disorder
  1. Persistently and excessively fearful or reluctant
    to be alone or without major attachment figures
    at home or without significant adults in other
  2. Persistent reluctance or refusal to go to sleep
    without being near a major attachment figure or
    to sleep away from home
  3. Repeated nightmares involving the theme of
  4. 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?
  • Shelleys 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
  • 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)
  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.)
  2. Recurrent distressing dreams of the event. (Note
    In children, there may be frightening dreams
    without recognizable content.)
  3. 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.)
  4. 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)
  1. Efforts to avoid thoughts, feelings, or
    conversations associated with the trauma
  2. Efforts to avoid activities, places, or people
    that arouse recollections of the trauma
  3. Inability to recall an important aspect of the
  4. Markedly diminished interest or participation in
    significant activities
  5. Feeling of detachment or estrangement from others
  6. Restricted range of affect (e.g., unable to have
    loving feelings)
  7. Sense of a foreshortened future (e.g., does not
    expect to have a career, marriage, children, or a
    normal life span)

Increased Arousal (2)
  1. Difficulty falling or staying asleep
  2. Irritability or outbursts of anger
  3. Difficulty concentrating
  4. Hypervigilance
  5. 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

  • Epidemiology
  • 2.5 of children, up to 5 of adolescents
  • Prepubertal-11/MF adolescence-41/FM
  • 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 teachers 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

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
  • 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.

  • Modifications in DSM- IV for children
  • irritable mood (vs. depressive mood)
  • observed apathy and pervasive boredom (vs.
  • failure to make expected weight gains (rather
    than significant weight loss)
  • somatic complaints
  • social withdrawal
  • declining school performance

Adolescent Development
Adolescent Development
  • Periods of transient milder problems with low
    self-esteem, anxiety, depressive feelings are
    quite common.
  • Needs to be differentiated from clinical

  • Attempts- 31/FM, Completions- 41/MF
  • 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
  • Suicide accounts for 13.5 of all deaths in this

1 Murphy, SL, 1998 2 The Surgeon Generals 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 cant recall a time
    when she didnt 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 lt 5
  • 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. Josephs
    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

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
  • Inattention
  • Poor organization
  • Does not seem to listen when spoken to
  • Loses objects
  • Easily distracted
  • Forgetful in daily activities
  • Hyperactivity/Impulsivity
  • Fidget
  • Leaves seat often
  • Runs or climbs excessively
  • Always on the go
  • Talks excessively
  • Blurts out answers
  • Cant wait turn, interrupts others

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 providers 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 Jonathons 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. Jonathons
    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 -2-31
  • 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.
    Matthews negative behaviors began before
    puberty, when he started hanging out with
    negative peers. Matthews 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. Matthews 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)
  • Aggression toward people or animals
  • Deceitfulness or Theft
  • Serious violation of rules
  • Destruction of property

Conduct Disorder (CD)
  • Prevalence-1.5-3.4
  • Boys greatly outnumber girls (3-51)
  • Comorbid ADHD in 50, common to have LD
  • Course-remits by adulthood in 2/3. Others become
    Antisocial Personality Disorder

Conduct Disorder (CD)
You left your D__M car in the driveway again!
Disruptive Behavior Disorder NOS
  • Disorders characterized by conduct or
    oppositional defiant behaviors that do not meet
    criteria for ODD or CD
  • Still must have impairment in functioning

Substance Abuse
(No Transcript)
  • Experimentation with substances is common,
    particularly during adolescence.
  • Teenagers use alcohol and drugs for a variety of
  • curiosity
  • to reduce stress
  • to fit in with a peer group
  • it feels good
  • Difficult to determine which
  • youths will experiment and stop and
  • which will develop more serious problems
  • with substances.

Adolescent Brain Changes
  • Earlier drinking more likely to result in alcohol
    dependence independent of family hx (Grant 1998)
  • Exposure of alcohol may indeed cause alterations
    in brain chemistry. There are studies indicating
    heaving drinking during adolescence causes memory
    and neuropsychological changes (Brown, et al)
  • Animal studies show that early exposure to
    alcohol results in longer term problems such as
    cognitive and behavioral problems

Dependence vs. Abuse
  • Dependence A maladaptive pattern of substance
    use, leading to clinically significant impairment
    or distress, as manifested by three (or more) of
    the following, occurring at any time in the same
    12-month period
  • Tolerance, as defined by either of the following
  • A need for markedly increased amounts of the
    substance to achieve intoxication or desired
    effect or
  • Markedly diminished effect with continued use of
    the same amount of the substance
  • Withdrawal, as manifested by either of the
  • The characteristic withdrawal syndrome for the
    substance or
  • The same (or a closely related) substance is
    taken to relieve or avoid withdrawal symptoms
  • The substance is often taken in larger amounts or
    over a longer period than was intended.

Dependence vs. Abuse
  1. There is a persistent desire or unsuccessful
    efforts to cut down or control substance use.
  2. A great deal of time is spent n activities
    necessary to obtain the substance (e.g., visiting
    multiple doctors or driving long distances), use
    the substance (e.g., chain-smoking), or recover
    from its effects
  3. Important social, occupational, or recreational
    activities are given up or reduced because of
    substance use.
  4. The substance use is continued despite knowledge
    of having a persistent physical or psychological
    problem that is likely to have been caused or
    exacerbated by the substance (e.g., current
    cocaine use despite recognition of
    cocaine-induced depression, or continued drinking
    despite recognition that an ulcer was made worse
    by alcohol consumption).

Dependence vs. Abuse
  • Abuse A maladaptive pattern of substance use,
    leading to clinically significant impairment or
    distress, as manifested by one (or more) of the
    following, occurring at any time in the same
    12-month period
  • Recurrent substance use resulting in a failure to
    fulfill major role obligations at wok, school, or
    home (e.g., repeated absences or poor work
    performance related to substance use
    substance-related absences, suspensions, or
    expulsions from school neglect of children or
  • Recurrent substance use in situations in which it
    is physically hazardous (e.g. driving an
    automobile or operating a machine when impaired
    by substance use)
  • Recurrent substance-related legal problems (e.g.,
    arrests for substance-related disorderly conduct)
  • Continued substance use despite having persistent
    or recurrent social or interpersonal problems
    caused or exacerbated by the effects of the
    substance (e.g., arguments with spouse about
    consequence of intoxication, physical fights)
  • The symptoms have never been met the criteria for
    Substance Dependence for this class of substance.

Dependence vs. Abuse?
  • Martina was referred to the substance abuse
    counselor because her teacher thinks she has been
    high during class. Martina reported to the
    counselor that she has been drinking alcohol and
    smoking marijuana for the past couple of years,
    and that she is having to drink and smoke more to
    feel the same effects that she used to. She
    notices that when she does not drink, she has
    trouble sleeping at night. Martina reports trying
    to stop drinking and smoking in the past, but she
    never succeeded. She has recently been cutting
    classes to purchase alcohol and drugs.

Dependence vs. Abuse?
  • During his sports physical at the SBHC, Samuel
    reported that he has drank alcohol in the past
    several months. He indicated that he only drinks
    on the weekend, and that he usually drinks the
    same amount (a few beers) each weekend. His
    family and his girlfriend have complained to him
    that his drinking is causing problems in their
    relationships, and have asked him to stop. Over
    the past summer, Samuel was arrested for drinking
    while driving. He also said that he has been late
    to work a few mornings because he had stayed out
    late drinking.