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NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH Graham Martin The University of Queensland

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Presentation on theme: "NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH Graham Martin The University of Queensland"— Presentation transcript:

1 NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH Graham Martin The University of Queensland

2 Case Study Jason

3 Recent History of Diagnostic Systems WHO added mental disorders to the International List of Causes of Death WHO expanded list to International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD) Diagnostic and Statistical Manual (DSM-I) American Psychiatric Association DM-II published – 185 categories similar to the WHO system – not widely accepted

4 Recent History of Diagnostic Systems cont 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 DSMIIIR - minor changes, 297 categories DSMIV categories, 17 major headings 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)

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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 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 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 Other Classes of Disorders

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 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

28 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 Other Disorders

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 1. 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)

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

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 S R Toy of other child Aggressive behaviour Operant Conditioning of Problematic Behaviour C+ Positive reinforcement “gets the toy” S R Thought about dentist Cancellation of appointment C- 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: 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

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

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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 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

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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 person’s current mental abilities – diagnose learning disabilities – determine whether a person is mentally retarded – identify intellectually gifted children

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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 – Dog:Cat as ??:?? E.g., Day:Night

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

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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?

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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. Phenylketonuriadiet Psychological e.g. dyslexiaorthography Behavioural e.g. literacy problemsschool absence


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