NERD ALERT!!! This is a posting of an old assignment I did in school & represents an attempt, on my part, to refamiliarize myself with various DSM-5 diagnoses.
Borderline Personality Disorder (BPD) is a “pervasive pattern of instability of interpersonal relationships, self-image, and affect [with] marked impulsivity” (American Psychiatric Association, 2013, p663). Over the years, I’ve noticed that RN’s at work frequently mention BPD as one of the most difficult diagnoses to and manage. What follows is an overview of (1) how a BPD might influence an individual’s parenting styles, and (2) how this affects their child’s development. Insights from an article titled “Children and Mothers with Borderline Personality Disorder”, have been included (Stepp, et al, 2012)
Affects of BPD Parenting
Fear of Abandonment
Criterion 1A of the DSM-5 manual describes fear of abandonment as a key characteristic of this disorder (American Psychiatric Association, 2013). This fear can produce extreme frantic reactions in the face of perceived rejection and separation. Underlying role confusion between parent and child is a potential byproduct. Stepp, et al, (2012), states that BPD parents can reinforce an alternating parent/friend role for their children.
Dramatic Interpersonal Shifts
BPD also involves dramatic and unpredictable shifts in how oneself and/or others are perceived. For example, the DSM-5 Manual suggests that BPD parents can vacillate between “needy supplicant…[or] righteous avenger (American Psychiatric Association, p664). Ultimately, this unpredictability is the consequence of how others are perceived in accordance with BPD-defined fears. Stepp, et al, (2012) state that: “oscillations between extreme forms of hostile control and passive aloofness in their interactions with their children may be unique to mothers with BPD (p76). The consequences of this for BPD offspring, include unstable attachments, higher levels of depressive symptoms, and an overall global impairment (Stepp, et al, 2012, p79)
Marsha Linehan’s work is helpful in understanding the consequences of BPD-related affective stability on parenting. According to DBT, chronic invalidation in childhood produces an environment of poor emotional socialization. Since BPD parents often come from this background, the result is an impaired ability to understand emotions and affective instability. Interpersonal vulnerability and insecure attachments are common consequences for BPD offspring (Stepp, et al, 2012). Additionally, chronic-stress is frequently observed BPD offspring as a due to unpredictable parental hostility (Stepp, et al, 2012).
BPD also involves self-destructive impulsive behaviors that involve activities such as gambling, substance abuse, suicidality, self-harm, or unsafe sex practices (American Psychiatric Association, 2013). An unstable home environment is a likely byproduct of this BPD-related symptom.
Treating a child with a behavior problem who has a parent with BPD is problematic at best, in light of the all this. In order to counsel and treat a client like this, it would be important to ensure that the parent is also receiving ongoing treatment. The effectiveness of any interventions for this child would depend on willing parental participation.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Stepp, S. D., Whalen, D. J., Pilkonis, P. A., Hipwell, A. E., & Levine, M. D. (2012; 2011). Children of mothers with borderline personality disorder: Identifying parenting behaviors as potential targets for intervention. Personality Disorders, 3(1), 76-91. doi:10.1037/a0023081
PART #1: The first portion of this post is essentially a reposting of an old paper I did on ADHD in school….
Attention Deficit Hyperactivity Disorder (ADHD) is defined as a “persistent pattern of inattention and hyperactivity-impulsivity that interferes with functioning or development” (American Psychiatric Association, 2013, p59). Hyperactivity involves a persistently excessive level of motor activity that interferes with an child’s social and academic activities (American Psychiatric Association, 2013; Orvashel, et al, 2001). Impulsivity involves poorly thought out actions that reflect an attention toward immediate rewards that manifest as socially inappropriate (American Psychiatric Association, 2013; Orvashel, et al, 2001). Finally, inattentiveness produces an inability to maintain attention and difficulty sustaining focus on an activity (American Psychiatric Association, 2013; Orvashel, et al, 2001). Inaba & Cohen, (2014) note that ADHD is thought to be the result of dopamine depletion. Therefore, medications, which increase the availability of dopamine, are useful. The next section provides a brief overview of various types of ADHD medication…
What are “Amphetamine Congers”
“Congers” & Dopamine
Our textbook provides a description of “Amphetamine Congers” for the treatment of ADHD (Inaba & Cohen, 2014, p. 3.29). This class of stimulant drugs, produce effects similar to methamphetamine, only not as strong. For example, Methylphenidate, also known as Ritalin, works by inhibiting the reuptake of dopamine and promoting its release by the transport system (Preston, et al, 2010). Since dopamine acts as a the reward molecule in the brain, this increases motivation and attention in ADHD sufferers. It is interesting to note that ADHD sufferers who are treated with Ritalin in childhood are “84% less likely to abuse drugs and alcohol when they get older” (Inaba & Cohen, 2014, p. 3.31).
“Congers” & Serotonin
Preston, et al, (2010) note that the effects of stimulants for ADHD only last “for a short period of time…[therefore] co-administration of antidepressants may be an option” (p. 257). SSRI’s like Wellbutrin, block the reuptake of Serotonin by the neurotransmitters and increase its activity in the brain. Our textbook notes this provides a useful “calming effect on those with ADHD” (Inaba & Cohen, 2014, p. 3.30).
Finally, our textbook provides several notable controversies surrounding ADHD and its treatment. Firstly, since no explicit diagnostic testing exists, controversy exist surrounding the accuracy of diagnosis in light of an epidemic rise of this issue in recent years (Inaba & Cohen, 2014). Secondly, controversy remains surrounding the pharmacological treatment of this disorder. In particular, stimulants have unknown long-term effects on children, and are associated with an increase risk of psychosis and mania (Inaba & Cohen, 2014).
For accurate diagnosis, it is firstly important that they reach a level of clinical significance and exist a normal developmental range (American Psychiatric Association, 2013; Orvashel, et al, 2001). In order to assess this diagnostic factor accurately, it will be important for the therapist to have a knowledge of childhood development is important. It is also worth noting that the DSM-5 manual requires these symptoms be present prior to the age of 12 (American Psychiatric Association, 2013, p61). Therefore, an understanding of childhood development up through the age of twelve is critical.
A second consideration involves a confirmation that these symptoms exist across several settings (American Psychiatric Association, 2013). In order to assess for this factor, it will be important to gather collaborative information from the child’s home and school environment. In addition to interviewing teachers and parents, it will also be useful to examine the child’s school records. What is the home environment like? How do they describe family interactions? Is there a family history of psychiatric illness? Regarding the child’s academic history, is there a learning disability or history of underachievement? How is the child interacting with peers? How have the child’s peer interactions influenced their overall self-esteem?
Finally, Orvashel, et al, (2001), state that this disorder rarely exists without a co-morbid diagnosis. For example while 1/3 of all ADHD cases coincide with anxiety or depression, another ½ of all ADHD cases coincide with ODD or CD (Orvashel, et al, 2001). It is also important to note that antisocial problems and substance abuse are frequent responses to prolonged levels of peer rejection. Additionally, individuals with ADHD often present with a learning disability, as a result of ADHD symptoms. It is at this point, at which diagnosis becomes quite complex. It will be important to carefully observe the client’s history of presenting symptoms to understand their underlying patterns.
The Over-diagnosis of ADHD
Attention Deficit Hyperactivity Disorder, (ADHD) is defined as a “persistent pattern of inattention and hyperactivity-impulsivity that interferes with functioning or development” (American Psychiatric Association, 2013, p59). The DSM-5 maintains the same symptomatic categories for ADHD (American Psychiatric Association, 2013). Nonetheless, the definition of these symptoms is expanded to include a list of examples on how they present in clientele (American Psychiatric Association, 2013). Other notable changes, include diagnostic criterion for adults with ADHD as well as an extensive list of differential diagnoses (American Psychiatric Association, 2013). This paper addresses public criticism regarding the over-diagnosis of ADHD. Research at the heart of this controversy is reviewed.
The Origin of Controversy
LeFever’s Epidemiological Findings
This paper reviews research by Gretchen LeFever, a psychologist in southeastern Virginia, who noted high rates of ADHD diagnosis and drug treatment in her community (Watson, et al, 2014). Utilizing a pool of 29,734 children, LeFever discovered that just fewer than 10% of children in southeastern Virginia were being medicated for ADHD (Watson, et al, 2014). Additionally, 19% of all children in grades one through five were diagnosed with ADHD and 84% from this group were taking medication for the disorder (Watson, et al, 2014). LeFever also noted that a majority of participants were the youngest in their class. (Watson, et al, 2014) This indicated to her, an underlying difficulty in distinguishing ADHD from normal development (Watson, et al, 2014). Finally, LeFever’s research provided evidence that drug treatment alone was largely ineffective for study participants, (Watson, et al, 2014, p44). Published in the American Journal of Public Health during the mid 90’s, this study drew massive media attention (Watson, et al, 2014).
LeFever’s SHINE Program
On the basis of LeFever’s research results, she felt the problem was twofold. Firstly, measures were needed to improve the identification of children with ADHD (Watson, et al, 2014). Secondly, LeFever believed it was important to expand the treatment approach to ADHD, beyond the utilization of drug treatment regimens (Watson, et al, 2014). In an effort to address these issues, she developed the School Health Initiative for Education (SHINE) program (Watson, et al, 2014). Receiving local, state, and federal support, the SHINE program addressed four key issues: “(1) systematic behavior management, (2) school-provider communication, (3) teacher training and education, and (4) parent training and support” (Watson, et al, 2014), p44). The SHINE program instituted community wide interventions including teacher training, parenting classes, as well as training for clinicians to accurately diagnose the disorder (Watson, et al, 2014). As a result of these efforts, a 32% decrease in ADHD diagnosis was seen in southeastern Virginia between 1998 and 2004 (Watson, et al, 2014). Participants also displayed improvements in academic performance.
Allegations of Scientific Misconduct
In 2004, LeFever received an anonymous allegation of scientific misconduct that questioned the legitimacy of her research (Watson, et al, 2014). These allegations claimed she reported inflated rates of ADHD prevalence in order to support an anti-medication agenda (Watson, et al, 2014). Although LeFever was eventually cleared of all charges, the effects of this allegation were long lasting. Immediate consequences included an immediate end to the SHINE program as well as any ongoing research efforts (Watson, et al, 2014). Long-term consequences included a career derailment, threatened firing, and public scrutiny (Watson, et al, 2014). In retrospect, Watson, et al, (2014) describe these attacks as “orchestrated” (p45) efforts on the part individuals with vested interests in the pharmaceutical industry. One individual, specifically mentioned in this claim is Russell Barkley, PhD., (her most vocal critic). While it is impossible to verify this, it is clear the heated debate resulting from these events is ongoing (Barkley, et al, 2004; Watson, et al, 2014).
A Heated Debate
In the years since LeFever’s work was shut down, the CDC has reported a continual rise in the diagnosis of ADHD (Watson, et al, 2014). As a result of this continual rise, today “14% of American children are being diagnosed before reaching adulthood” (Watson, et al, 2014, p43). Additionally, Watson, et al, (2014) provide alarming statistics on the rise of antipsychotics and antidepressants as a treatment regiment for ADHD. Finally, although LeFever, (now Mrs. Watson), appears to deny an anti-drug agenda, her criticism centers on this argument (Watson, et al, 2014). For example, this article concludes with a citation of evidence from the National Institutes of Health on the ineffectiveness of drug treatments (Watson, et al, 2014). With this evidence in mind, she strongly encourages scientists to “address the inflation of benefits of drug therapies and the minimization of risks” (Watson, et al, 2014, p52).
In a desire to hear the other side of the story, I uncovered an article by LeFever’s strongest critic (Barkley, et al, 2004). In this article, Barkley responds to LeFever’s allegations that his actions represented an agenda to promote drug treatments (Barkley, et al, 2004). Barkley states that in addition to misconstruing his motives, critics such as LeFever are guilty of misrepresenting evidence (Barkley, et al, 2004). Critical of the standards they utilize in their arguments regarding ADHD, Barkley, et al, (2004) state the following: “To them genuine disorders: (1) cannot exist without some “medical test” being available for their diagnosis; (2) cannot change in having their defining features revised or improved upon across their history; (3) cannot vary in prevalence across segments of society, countries, or geographic regions; (4) cannot have other disorders coexist with them (comorbidity); (5) must have a distinct and specific neurobiological lesion identifiable as their etiology; and (6) cannot have heritability or other contributing factors that may overlap with other disorders” (p66).
After completing this assignment, I am unsure what to feel about the issue. The arguments presented from both articles have strong points worthy of consideration. The biggest lesson is the importance of objectivity and the scientific method as discussed in the DSM-5. It is important for researchers and clinicians to set aside any agendas in search of the truth.
PART #2: The second portion of this post will consists of some pragmatic research I’m doing to formulate a realistic treatment for a child with ADHD….
Addressing symptoms of Inattention
A Behavioral Description of Inattention…
“Short attention span; difficulty sustaining attention on a consistent basis.
Susceptibility to distraction by extraneous stimuli and internal thoughts.
Gives impression that he/she is not listening well.
Repeated failure to follow through on instructions or complete school assignments or chores in a timely manner.
Poor organizational skills as demonstrated by forgetfulness, inattention to details, and losing things necessary (Jongsma, et al, 2014, p. 74)”
Treatment Plan Goal Ideas…
Where I work, we must first write the client’s goals in their own words. Then we must include a deadline for this goal. Finally, we need to include what specific evidence to look for as proof that this goal is met. My way of conceptualizing this process is to first simply ask the client what they wish to achieve in therapy. Then, with the diagnosis and IDI information in mind, I need to develop a DSM-5 based description of the client’s goal in the evidenced by section. What follows is a listing of ADHD-relevant treatment goals I’ve found., as time progresses, I will include examples of how client describes these goals in their own words…
“Client will be able to sustain attention and concentration for consistently longer periods of time by (Date) as demonstrated by an increase frequency of completion of school assignments, chores, and household responsibilities.
Addressing Symptoms of Hyperactivity & Impulsivity
A Behavioral Description of Hyperactivity & Impulsivity
“Hyperactivity as evidenced by a high energy level, restlessness, difficulty sitting still, or loud or excessive talking.
Impulsivity as evidenced by difficulty awaiting turn in group situations, blurting out answers to questions before the questions have been completed, and frequent intrusions into others’ personal business.
Tendency to engage in carelessness or potentially dangerous activities.
Difficulty accepting responsibility for actions, projecting blame for problems onto others, and failing to learn from experience.
Low self-esteem and poor social skills (Jongsma, et al, 2014, p. 74)”
Treatment Plan Goal Ideas…
Where I work, we must first write the client’s goals in their own words. Then we must include a deadline for this goal. Finally, we need to include what specific evidence to look for as proof that this goal is met. My way of conceptualizing this process is to first simply ask the client what they wish to achieve in therapy. Then, with the diagnosis and IDI information in mind, I need to develop a DSM-5 based description of the client’s goal in the evidenced by section. What follows is a listing of ADHD-relevant treatment goals I’ve found., as time progresses, I will include examples of how client describes these goals in their own words…
Hyperactivity & Impulsivity Goals…
Client will be able to develop positive social skills to help maintain lasting peer friendships by (Date) by increasing the frequency of socially appropriate behaviors with peers.
Client will be able to identify stressors or painful emotions that trigger increase in hyperactivity and impulsivity by (Date) by exploring and identifying stressful events or factors that contribute to and increase in impulsivity.
Client’s parents/teachers’ will set firm, consistent limits, and maintain appropriate parent-child boundaries by (Date) implementing parenting techniques and approaches in which parents utilize reward/punishment system, contingency contract, and/or token economy.
The Client will be able to demonstrate marked improvement in impulse control by (Date) by identifying and listing constructive ways to utilize energy.
The client will increase on task behaviors by March 1, 2010 as demonstrated by the completion of homework and chores daily.
The client will decrease the motor activity by March 1, 2010 as demonstrated by the client being able to remain in their seat for longer periods of time.
The client will reduce the severity of temper tantrums by March 1, 2010 as demonstrated by the client not using any physically aggressive acts.
The client’s parents will set firm and consistent limits for the client by March 1, 2010 as demonstrated by the family setting up a behavior reward chart and using it for 4 weeks consistently.
The client’s parents or teacher will use a reward system by March 1, 2010 as demonstrated by them completing the system and using it daily.
The client will improve their self esteem by March 1, 2010 as demonstrated by the client making 3 positive statements about themselves a day.
The client will maintain lasting peer relationships by March 1, 2010 as demonstrated by journaling and playing with the same kid 3 out of 5 school days a week.
The client will demonstrate improvement in impulse control by March 1, 2010 as demonstrated by decrease in negative attention seeking behaviors and the elimination of physically aggressive behaviors.
American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders, (5th ed, ). Washington DC: American Psychiatric Association.
Barkley, R.A. (2004). Critique or misrepresentation? A reply to timimi et al. Clinical Child and Family Psychology Review, 7(1), 65-69. Doi: 10.1023/B:CCFP.0000020193.4817.30
NERD ALERT!!! The purpose of this post is to review various conduct disorders in the DSM-5 manual…..
Paper #1: IED, ODD, & CD….
Similarities & Differences
Intermittent Explosive Disorder (IED), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) together fall under a new classification of diagnoses in the DSM5 titled “Disruptive Impulse-Control and Conduct Disorders” (American Psychiatric Association, 2013). Diagnoses that fall under this category present with symptoms of poor behavioral and emotional impulse control (American Psychiatric Association, 2013). Behaviors associated with these diagnoses “violate the rights of others…and bring the individual into significant conflict with societal norms or authority figures” (American Psychiatric Association, 2013, p461). ODD, CD, and IED vary in the degree and type of poor impulse control that predominates (American Psychiatric Association, 2013). A review of these diagnoses is next:
Oppositional Defiant Disorder (ODD)
ODD has three categories of symptoms including: (1) an angry mood, (2) vindictiveness, and (3) defiant behavior (American Psychiatric Association, 2013). The DSM5 has expounded upon its definition of ODD with guidelines on how to assess the frequency and pervasiveness of symptoms (American Psychiatric Association, 2013). ODD is intermediate in severity between CD and IED and is associated with difficulties in both behavioral and emotional self-control (American Psychiatric Association, 2013). Additionally, while CD focuses more on behavioral impulse control, IED focuses primarily on dysregulated emotional outbursts (American Psychiatric Association, 2013). One final point of differentiation between these diagnoses exists in the nature of aggressive behaviors. The aggression associated with ODD is generally less severe than CD (American Psychiatric Association, 2013). Additionally, ODD triggers are much more specific than IED and pertain to interactions with authority figures (American Psychiatric Association, 2013)
As stated earlier, Conduct Disorder focuses on poorly controlled behavioral impulses that violate societal norms and the rights of others (American Psychiatric Association, 2013). The DSM5 describes four types of behavioral impulses as symptomatic of Conduct Disorder, including: “(1) aggression to people and animals… (2) destruction of property…(3) deceitfulness and theft…(4) serious rules violation” (American Psychiatric Association 2013, p470). Specifiers that pertain to the assessment of limited pro-social emotions shed light on how this diagnosis differs from ODD and IED. CD is associated with a lack of guilt, empathy, and remorse as well as shallow emotions (American Psychiatric Association, 2013). A callous interpersonal style and tendency to “misperceive the intentions of others” (American Psychiatric Association, 2013, p472) also underlies the symptomatology of this disorder. Factors such as these appear to be a root cause of CD symptoms, while ODD and IED are caused by dysregulated emotions (American Psychiatric Association, 2013)
Intermittent Explosive Disorder
IED diagnosis is characterized by symptoms of poorly controlled emotional outbursts that are out of proportion with triggering events experienced as distressing (American Psychiatric Association, 3103). Unlike ODD, the aggressive outbursts associated with IED are the result of a broader array of triggers (American Psychiatric Association, 2013). Additionally, the premeditated form of aggression associated with conducted disorder isn’t present in IED (American Psychiatric Association 2013). Instead, poorly regulated emotions exist as the root cause of IED symptomatology (American Psychiatric Association, 2013).
An Example of Co-Morbidity
Morrison, (2014) states that comorbid diagnoses should be considered if a primary diagnoses fails to address certain elements of observed symptoms. Additionally, the presence of two mental disorders in the same diagnostic category “indicates underlying common pathology” (Morrison, 2014, p59). One example of comorbid diagnoses can include an observation of Oppositional Defiant Disorder alongside Conduct Disorder. Criterion C of the DSM-IV-TR states clients are not to be diagnosed with ODD if they also fit criterion for CD (American Psychiatric Association, 2000). In contrast, the DSM-5 has dropped this criterion C. This change is an acknowledgement of research that indicates that ODD can develop into CD, and in certain cases exist as comorbid diagnoses (American Psychiatric Association, 2013).
Paper #2: Comparing ODD & CD….
Conduct & Oppositional Defiant Disorder
According to Netherton, Holmes & Walker, noncompliant behaviors tend to be the most common reasons for children being referred to for help (Netherton, et al, 1999, 118). An awareness of diagnoses falling under the category of disruptive behavior is therefore vital. This paper takes a look at two such disorders and will begin with a comparative description of each.
Oppositional Defiant Disorder
“Annoying or aversive interpersonal behaviors, noncompliance with authority….defiance of social norms and physically aggressive behaviors” are just a few common complaints of children with disruptive behavior disorders. (Netherton, 1999, 118). Other common features can include social skill deficits, and impulsive and overactive behavior. So what is it that differentiates oppositional defiant disorder from conduct disorder?
Children with oppositional defiant disorder present a consistent pattern of hostility and noncompliance towards authority (Karnik, et al, 2006, 100). According to the DSM-IV-TR, a diagnosis of ODD, requires such behaviors be present for at least six months and occur with a resultant functional impairment (Karnik, et al, 2006; Netherton, et al, 1999). Essentially, it appears that underlying ODD symptomatology is a child who is easily angered and resentful towards behavioral controls (Karnik, et al, 2006).
A key point of differentiation for conduct disorder, are that presenting symptoms all manage to violate the basic rights of others, and defy societal norms (Karnik, et al, 2006; Netherton, et al, 1999). The DSM-IV-TR diagnostic criterion includes a presentation of such symptoms for at least six months of time (Netherton, et al, 1999). Additionally, for a CD diagnosis, it is expected that the child should experience significant impairments functionally (Netherton, et al, 1999). Common behavior patterns of children with conduct disorder include bullying, substance abuse, precocious sexual activity, physical aggression, and even property destruction (Karnik, et al, 2006, 102).
Society defines what is pathological or criminal. For example, society regards stealing, robbery, and violence as unacceptable. These social mores and rules are not naturally ingrained, but need to be learned. Individuals incorporate such values and social rules developmentally over time. Actions markedly outside such expectations may be perceived as psychopathological, depending on the circumstance. (Karnik et al, 2006, 99)
As the above quote alludes to, it appears this diagnostic category is based on a preconception of society’s norms of acceptable behavior (Karnik et al, 2006; Nock, et al, 2007). The reason underlying this is that norms can help define the measure of acceptable behavior, against which the child assessed from an adaptive standpoint. For example, OCD can be characterized as a milder form of defiant behavior, diagnosed in childhood with a higher likelihood of remitting (Greene et al, 1999; Karnik et al, 2006; Nock, et al, 2007). Conduct disorders, on the other hand, tends to be more stable over time, presenting in late adolescence, and can develop into ASPD (Karnik, et al, 2006, 100). Therefore, if OCD symptoms appear “closest to normal” (Nock, 2007, 703), then CD symptoms can be seen comparatively as more highly deviant (Karnik, et al, 2006).
On the basis of all this, it appears symptoms underlying these disorders are differentiated on basis of severity and degree of functional impairment. Indeed, several resources for this paper characterize disruptive behavior disorders as existing a developmental trajectory, with a spectrum of diagnoses (Karnik, et al, 2006; Nock, et al, 2007):
The Diagnostic and Statistical Manual of Psychiatric Disorders, 4th Edition, Text Revision, includes a spectrum of diagnoses relating to varying degrees of maladaptive aggression, antisocial behavior, and criminal behavior…These diagnoses represent what is often considered a developmental trajectory that begins in childhood with oppositional behavior, evolves into law-breaking with CD, and eventually becomes a characterologic pattern of behavior in adults, who are then diagnosed with APSD. (Karnik, 2006, 99)
Prognosis for ODD.
With all this in mind, what can be said about the comparative prognosis for adults with these disorders? In the case of ODD, while this disorder amenable to remittance over time, it is also associated with a higher likelihood of developing subsequent disorders (Nock, 2007, 713). Despite this fact, what bodes well for individual’s with this diagnosis is that it tends to be associated with reactive aggression. Unlike proactive variety, it doesn’t usually involve a premediated decision to act aggressively without remorse (Karnik, et al, 2006, 100). Instead, this form of aggression involves a reactionary control problem, with a heightened tendency toward anger.
Prognosis for CD.
In comparison to oppositional defiant disorder, conduct disorder poses a higher likelihood of developing into Antisocial Personality Disorder. Additionally, it can be characterized as involving a recurrent violation of others rights and societal norms. As a result, it is more strongly associated with a proactive aggression. Involving a greater degree of decisive action, aggressive acts underlying this disorder are more likely to be taken without remorse and greater degree of forethought (Karnik, et al, 2006, 100). Assessing the long-term prognosis of those with conduct disorder, involves differentiating between its forms and age of onset (Odgers, et al, 2007, 1241). Additionally, family history assessments provide other powerful indicators of a person’s prognosis long-term (Odgers, et al, 2007, 1241).
Complex Transactional Etiologies
The issue of treating ODD and CD involves first understanding the etiology of these disorders. In reality, this means taking things beyond a DSM-based psychological assessment. Consideration should also be made of “a broad range of possible explanations” (Merton, et al, 2004, p727) from an array of theoretical perspectives. In fact, if one thing is clear, it is that there are many potential etiological perspectives of these disorders. What follows is an overview of a few causal etiologies underlying ODD and CD.
Biological and genetic factors are one causal factor often cited in research underlying a diagnosis ODD and CD. For example, one resource cites the increased occurrence of neurotransmitter abnormalities and deficits in the autonomic nervous system in individuals with these disorders (Karnik, et al, 2006, 104). Still others cite issues such as deficient prenatal development due to poor nutrition and maternal drug use. (Morton, et al, 736) These factors are said to be linked to key deficiencies in verbal and executive functions resulting in an inability to effectively control behavior. (Morton, et al, 736).
A key factor associated with both conduct and oppositional defiant disorder, is compromised self-regulation and affect modulation. (Greene, et al, 1999, 133). In fact this compromised ability to self-regulate is cited in research as an underlying cause of the aggressive coping style that is definitive of these disorders. (Kranik, et al, 2006, 104). Other proposed psychological factors in research point at deficiencies in cognitive process, including perceptions of others, as well as selection and evaluation of alternative responses (Krol, et al, 2004, 739).
Coercive Parenting Practices
From a transactional perspective, the nature of the parent-child interaction is a key factor underlying ODD and CD. In particular, from this perspective it is the parenting styles in conjunction with a child’s characteristics that can result in the development of these disorders (Greene, et al 1999; Morton, et al 2004). What underlies these parent-child relationships is a coercive way of relating that is mutually incompatible. Inadequate disciplinary models and negative reinforcement systems utilized by parents, are met with a rise in oppositional behavior. (Greene, et al, 1999, 137).
A final etiological factor that warrants mention is the social environment of the child. In fact, the family environment is cited in several resources as being of primary influence in the development of these disorders, (Kranik, et al, 2006; Merton, et al, 2004). For example, research correlates criminal activity, and substance use, and a hostile unstable home environment as key factors associated often with these disorders (Kranik, et al, 2006, 103). Why is this?
To better understand of the reasons for this strong correlation between, a few underlying etiological explanations have been uncovered. One source cites difficulties in learning to process social information, pointing at a hyper-vigilance for cues of potential hostility (Merton, et al, 2004, 731). Still another points at problems with the intergenerational attachment relationships, as another key etiological factor (Odgers, et al, 2007).
If one thing is it is that the etiologies underlying these conditions are quite complex. Its for this reason, a thorough assessment, and understanding of all relevant factors is key. A multidimensional approach reflecting these assorted etiological factors should be considered.
Greene, R. W., & Doyle, A. E. (1999). Toward a transactional conceptualization of oppositional defiant disorder: Implications for assessment and treatment. Clinical Child and Family Psychology Review, 2(3), 129-48. doi:10.1023/A:1021850921476
Krol, N., Morton, J., & De Bruyn, E. (2004). Theories of conduct disorder: a causal modelling analysis. Journal Of Child Psychology And Psychiatry, And Allied Disciplines, 45(4), 727-742.
Netherton, S., Holmes, D., & Walker, C. (Eds.). (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, U.K.: Oxford University Press. ISBN 978-0-19-509961-4. (NHW)
Nock, M., Kazdin, A., Hiripi, E., & Kessler, R. (2007). Lifetime prevalence, correlates, and persistence of oppositional defiant disorder: results from the National Comorbidity Survey Replication. Journal Of Child Psychology And Psychiatry, And Allied Disciplines, 48(7), 703-713.
Odgers, C, Milne, B, Caspi, A, Crump, R, Poulton, R, & Moffit, T. (2007). “Predicting Prognosis for the Conduct-Problem Boy: Can Family History Help?”. Journal of the American Academy of Child and Adolescent Psychiatry(0890-8567), 46 (10).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians, 2nd ed. New York: The Guildford Press.
Depression is a sneaky thief, slipping into a life gradually and robbing it of meaning one loss at a time. The losses are imperceptible at first, but eventually weigh so heavily that the person’s life becomes empty. Once begun, the course of depression varies with the individual and with the form of illness. Untreated, it can last weeks, months or even years. (Ainsworth, 2000, p1)
Referred to as the “common cold of psychopathology”, (Blaney & Millon, 2009, p230), our textbook states depression is associated with a complexity of conceptual understandings. Commonly thought of from a laymen’s perspective as a concept that refers to feelings of sadness, it is also a serious potentially disabling diagnostic category within the DSM (Blaney & Millon, 2009). So with all this said, how might one define the concept?
Depressive disorders are characterized by persistent depressed mood or loss of interest (normally for at least two weeks) and at least four other symptoms such as change in eating patterns or appetite, sleep disturbance, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, difficulty in concentration, and suicidal thoughts, plans, or attempts. (Depression, 2005)
For the purposes of this paper, we focus on unipolar dimension with above-described symptomatology. In the next section, we will examine several proposed etiological perspectives from which to better understand this disorder.
Currently there are a variety of theoretical perspectives with which to better understand the underlying causality of depression. In fact, research as of late reflects an ever-increasing understanding of the complex multifactorial nature of the causal factors underlying depression. It appears that an individual’s temperament and biological vulnerabilities interact with interpersonal problems, life events, and environmental factors in a cyclical and complex manner. Apparently as many etiological perspectives allude to, we define our life events and are influenced by them as well. Of relevance for this paper, are the specific etiologies that relate to the three psychotherapy models we examine for depression. Therefore, it must be kept in mind, that while these etiological factors are listed below separately, they are interrelated in a complex manner, (Blaney & Millon, 2009).
Life Event Models.
As our textbook states: “One might suppose that one reason people get depressed is that bad things happen to them.” (Blaney & Millon 2009, p233). In fact research shows that while this is true, the reality is a bit more complex. Essentially, the effect of these life events is as a result of how the individual is affected by it long term. In other words, these life events are simply often a trigger for the onset of depressive episodes, but the recurrent maintenance of a depressive disorder diagnosis, is the result of individual vulnerabilities.
Another proposed etiology can be found in research that shows a individuals who suffer from depression, tend to suffer from a high degree of interpersonal problems (Reinke, et al, 2007). It appears from this perspective the etiological focus is upon the specific manner in which one’s social environment responds to displays of hopelessness, and withdrawal, and irritability (Reinke, et al, 2007). From this standpoint, someone suffering from depression takes in these reactions as a reinforcement of their negative belief systems. Therapy methods aimed at addressing this issue, are focused on improving the social skill deficits commonly seen in depressed individuals (Blaney & Millon, 2009, p239)
Cognitive models of depression focus on a person’s thinking as a primary source of vulnerability for suffers (Blaney & Millon, 2009, p239). A person’s cognitive world essentially defines the manner with which information is processed and underlying flavor of life events. According to Beck’s Cognitive Theory of Depression, individuals organize experience around self-schemas (Blaney & Millon, 2009, p239). With depressed individuals, these self-schemas just happen to be fraught with an array of cognitive distortions. Stressful life events exacerbate these schematic perceptions, and increase a person’s vulnerability to depression.
Therapies for Depression.
With this overview of etiological perspectives, it is now possible to move forward with a discussion of three therapies for depression. What follows is a discussion of cognitive behavioral therapy, interpersonal therapy, and rational emotive therapy. A cursory overview of these treatment methods as forms of psychotherapy for depression will be provided.
Cognitive Behavioral Therapy.
Cognitive therapy for depression addresses the schematic cognitive models with which individuals use to understand life experiences (Blaney & Millon, 2009; Corsini, 2011). The key issues of focus one’s thoughts, emotions, and beliefs that define their perspective. What makes is actually quite intriguing about this therapy method, is the wealth of research it is based on. Most notable among this research is the work of Aaron T. Beck, who helped define the cognitive state of depressed individuals (Corsini, et al, 2011). In addition to developing a useful groundwork to better understand the self-schemas associated with depression, he also created useful testing-tools such as the Beck Depression Inventory (Reinke, et al, 2007). Essentially, it appears a cognitive triad, consisting of unexamined beliefs of self, others and the future predominate depressed states. These unexamined beliefs appear to result in unexamined thought processes result in a negative view of life. In cognitive therapy, interventions are aimed at helping the individual re-examining this underlying cognitive foundation. Through thought monitoring, and self-examination clients can be empowered to better understand and address this self-schema.
As discussed earlier, etiologically, depressed individuals tend to suffer from a greater degree of interpersonal issues. It appears, that a person’s way of coping in response to stressful life events, tends to also influence the nature of their interactions with others.
Cognitively, the individual becomes excessively self-focused, self crtitical, pessimistic, and more aware of discrepancies between personal standards and actual accomplishments. Behaviorally, the person withdraws, has more social difficulties and becomes less motivated. These cognitive and behavioral consequences combine to spiral the individual into an ever-deepening state of depression. (Blaney & Millon, 2009; 237).
Interpersonal therapy, is a form of brief therapy that is based heavily on empirical research. In this respect, it is well suited in today’s mental health environment. It is focused on addressing underlying attachment histories that are often associated with the interpersonal difficulties of depressed individuals. Conceptually, it is based on a biopsychosocial causal model of depression. Essentially, according to this perspective, depression is the byproduct of biological factors, individual temperament, attachment history, which can all be placed within the context of their social relationships (Corsini, et al, 2011).
As a brief therapy, it is phasic and goal directed starting off with assessments and interventional design (Reinke, et al, 2007).. Involving client education, this allows a cline to better understanding of interpersonal patterns, and an adoption of the sick role. With this understanding in place, a collaborative and goal-directed approach can ensue, to improve a person’s interpersonal coping patterns (Reinke, et al, 2007).
Rational Emotive Therapy
Developed by Albert Ellis, rational emotive behavioral theory “holds that when a charged emotional consequence (C) follows a significant activating event (A), event A may seem to, but actually does not cause C. Instead emotional consequences are largely created by B – the individual’s belief system” (Corsini & Wedding, 2011, p196). Unique amongst other therapy methods, this therapy approach focuses on one’s individual belief system. Whereas many other methods are focused on addressing the activating events and/or emotional consequences, few appear to address the belief systems that interrelate these two factors.
MDD vs. BD
Major Depressive Disorder (MDD)
A diagnosis of MDD requires a depressed mood and loss of pleasure/interest for at least two weeks (American Psychiatric Association, 2013). Other symptoms include low self-esteem, feelings of guilt, sleep difficulties, fatigue, loss of energy, inability to concentrate, and weight loss (American Psychiatri Association, 2013). Preston, et al, (2013) list six major groups of antidepressants, including: (1) Tricyclic antidepressants, (2) Selective serotonin reuptake inhibitors (SSRI’s), (3) Serotonin and Norepinephrine Reuptake Inhibitors (SNRI’s), (4) Norepinephrine Reuptake Inhibitors (NRI’s), (5) Monamine Oxidase Inhibitors (MAOI’s), and (6) atypical antidepressants (p173).
Bipolar Disorders (BD)
The DSM-5 manual includes a chapter titled “Bipolar and Related Disorders” (American Psychiatric Association, 2013, p123). “Diagnoses included in this chapter are: bipolar 1 disorder, bipolar 2 disorder, cyclothymic disorder” (American Psychatric Association, 2013), and disorders related to substance use and medical conditions. These diagnoses have in common episodes of depression intermingled with either hypomania or mania. In contrast to depression, described above, mania involves racing thoughts, elevated mood, and distractability (American Psychiatric Association, 2013). Differentiating between MDD and BD is critical because each has unique treatment considerations. Before discussing this it will be important to briefly review the types of medications utilized with each disorder.
Tricyclics: Tricyclics work by increase the activity of serotonin and monamines by blocking the reuptake of these neurotransmitters, and allowing them to remain in effect for a longer time period. Since these drugs effect many neurotransmitter systems, they produces a long list of unwanted side effects, (anticholinergic, adrenergic, and antihistamic), and are lethal in small doses (Preston, et al, 2013, p175). For this reason they are not the first choice in the treatment of depression.
SSRI’s: Sertonin is an inhibitory neurotransmitter produced within the neuron that is unable to cross the blood-brain barrier (Lambert & Kinsley, 2011). The prefrontal cortex utilizes serotonin in an effort to regulate emotions in the limbic system. SSRI’s act as antidepressants by blocking the reuptake of serotonin. Since the action of SSRI’s are much more selective than Tricyclic antidepressants, they have fewer side effects. Side effects include GI “upset, sweating, anxiety, insomonia, headache, restlessness and sexual dysfunction” (Preston, et al, 2013, p175). Despite these benefits, it is important to note their action is delayed, and clients may need to wait 4-6 weeks before noticing an improvement.
SNRI’s: These dual action antidepressants block the reuptake of both serotonin and norepinephrine. Side effects include GI complaints, sexual dysfunction, drowsiness, nervousness, and insomnia.
MAOI’s: Monamine Oxidase Inhibitors work by inhibiting the action of monamine oxidase enzymes. These enzymes are responsible for breaking down catecholamine neurotransmitters and serotonin (Lambert & Kinsley, 2011). Side effects include “hypotension, dizziness, sedation, insomnia, weight gain, dry mouth and sexual dysfunction” (Howard, 2006, p10). Some MAOI’s are able to inhibit the action of these enzymes for up to 2-3 weeks after patient’s stop taking them (Howard, 2006). For this reason, they are considered quite powerful. These drugs are no longer a first choice in the treatment of depression since they are associated with a significant for drug interaction.
NRI & CRH Blockers – Two final medications mentioned in our course textbooks include NRI’s (Norepinephrine Reuptake Inhibitors) and CRH blockers (Corticotropin Releasing Hormone Blockers) (Lambert & Kinsley, 2011; Preston, et al, 2013). Since these medications are newer, less is known about them. NRI’s block the reuptake of norepinephrine, and enhance it effects in heightening vigilance and drive (Lambert & Kinsley, 2011, p276). This effect is helpful in addressing mood and cognition in depressed patients. CRH blockers, block the release of CRH within the HPA Axis, dampening the stress response (Broadbear, 2005). While little is know about the effectiveness of this drug, it is nonetheless briefly mentioned as yet another medication to help with depression.
Lithium: “Lithium is now firmly established as a safe and effective treatment for acute mania and for the prevention of manic-depressive episodes” (Preston, et al, 2013, p199). Surprisingly, while this medication remains as a “1st line agent” (Preston et al, 2013, p199) for BD, the mode of action for this drug is, as yet, unclear. It is, nonetheless, hypothesized that Lithium’s effectiveness is somehow related to its ionic state and ability to stabilize cell membranes (Preston, et al, 2013). It is very important to note that Lithium has a very narrow therapeutic window, putting clients at a higher risk for toxic overdose. Consequently, this medication is prescribed based on blood level, requiring ongoing monitoring from this standpoint. An extensive list of side effects is discussed in Preston, et al, (2013), indicating it influenes the renal, GI, endocrine, cardiovascular, hematological, and dermatological systems.
Anticonvusants & Antipsychotics: Anticonvulsants such as Depakote, Tegretol, and Lamictal, are also FDA approved for BD, despite the fact that their mode of action is not clearly defined (Preston, et al, 2013). Finally, Preston, et al, (2013) briefly mention Antipsychotics as yet another medication useful in the treatment of mania or mixed-mania. They also are associated with an added benefit of fewer extrapyramidal side effects.
Regarding BD, effective treatment starts with accurate diagnosis and an ability to differentiate between the various Bipolar Disorders. Treating bipolar depression is tricky, since antidepressants can cause a sufferer to switch to a manic state. Atypical depressive symptoms, psychosis, and a history of bipolar disorder, are key indicators of bipolar depression (Preston, et al, 2013). Understanding the severity of a client’s manic and depressive episodes, and the frequency of “switching” is important. Preston, et al, (2013) state that Lithium is the first drug of choice for mania. Additionally, a clear “rational for inclusion of anticonvulsants and 2nd Generation antipsychotics,” (Preston, et al, 2013, p198), is vital. Understanding and managing side effects is important alongside psychotherapy. Finally, as stated earlier, close monitoring of Lithiums every few months is important
Accurate diagnosis and understanding of a client’s symptoms is critical for effective treatment. SSRI’s and SNRI’s are the first choice as treatments for depression. It is important to notify clients, that it may be a several weeks before they experience a reduction in symptoms. Finally, while NRI’s and CRF blockers are newer, Tetracyclics and MAOI’s have severe side effects to be wary of, (as mentioned earlier). Rationale for the use of these medications should be clearly thought out, and therapists should closely monitor a client’s response to this medication regimen.
Regarding the choice of meds, the textbook mentions starting with examining a client’s responses to previous medications and re-examining their symptoms. Are there any other unexplained symptoms or comorbidities to consider? Additionally, it is important to ensure clients have had an adequate exposure to the medication (8-12 weeks), to ensure their response to treatment is fully evaluated (Preston, et al, 2013). Finally, since these clients are highly prone to discontinuing medication, psychoeducation and close monitoring are important.
Broadbear, J.H. Winger, G., Rivier, J.E. Rice, K.C. & Woods, J.H. (2004). Corticotrophin-releasing hormone agonists, asstressin B and antalarmin: Differing profiles in rhesus monkeys. Neuropsychopharmacology, 29(6), 1112-1121.
Grunze, H.R. (2010). Anticonvulsants in bipolar disorder. Journal of Menatl Health, 19(2), (127-141).
Howland, R. H., M.D. (2006). MAOI antidepressant drugs. Journal of Psychosocial Nursing & Mental Health Services, 44(6), 9-12. Retrieved from
NERD ALERT!!! – This post is a review of old assignments & papers that all focus on a specific diagnosis. The goal of this exercise is to become more familiar with mental health diagnoses…
Anxiety Disorders – Developmental Considerations…
The anxiety disorders section of the DSM-5 Manual is arranged developmental by age of onset. This paper focuses on a review of information from a papers on Childhood Anxiety Disorder. Developmental delays are a key issue with childhood anxiety disorders since states of excessive anxiety can divert attention from key developmental tasks, causing problems later in life. For example, delayed social skills, low self-worth, distorted thinking patterns, and poor emotional regulation, are common problems associated with these disorders (Ginsberg, 2007). When you consider that some estimates of prevalence for anxiety disorders in adolescents are as high as 20% this is clearly an issue that needs to be addressed (Ginsberg, 2007; Wood, et al, 2003). Despite this fact, a clear and easy solution isn’t available. One resource for this paper indicates that childhood anxiety disorders develop within a chaotic environment and parental symptoms of anxiety (Murray & Cooper, 2006). Temperament, and parenting styles are also key factors often mentioned predisposing children to a higher likelihood of developing these disorders (Wood, et al, 2003). Addressing all these associated factors would be essential.
So what is anxiety and exactly when does it become problematic?
According to Morrison, (2014) fear in general can be an adaptive response to danger and reflects a fight-or-flight response. However, while fear in general is an emotional discomfort to perceived danger, anxiety is the “anticipation of a future threat” (American Psychiatric Association, 2013, p. 189). Finally, the DSM-5 manual “anxiety disorders differ from developmentally normative fear or anxiety by being excessive or persisting beyond developmentally appropriate periods…[involving an] overestimation of anxiety” (American Psychiatric Association, 2013, p. 189). In other words, trait anxiety my be a transitory worry, the disordered variety can involve an overestimation of threat over a prolonged period of time that impedes one’s daily function. (Craske, 1999).
If one thing is clear, it is that developmental delays are a key issue with anxiety disorders.
States of excessive anxiety in childhood divert attention from key developmental tasks, causing problems later in life. For example, delayed social skills, low self-worth, distorted thinking patterns, and poor emotional regulation, are common problems associated with these disorders (Ginsberg, 2007). When you consider that some estimates of prevalence for anxiety disorders in adolescents are as high as 20% this is clearly an issue that needs to be addressed (Ginsberg, 2007; Wood, et al, 2003). Despite this fact, a clear and easy solution isn’t available. It appears, that many childhood anxiety disorders develop within a chaotic environment and parental symptoms of anxiety (Murray & Cooper, 2006). Temperament, and parenting styles are also key factors often mentioned predisposing children to a higher likelihood of developing these disorders (Wood, et al, 2003). Addressing all these associated factors would be essential.
In the following sections is a discussion of etiologies and treatments for reactive attachment disorder, separation anxiety, and selective mutism.
Reactive Attachment Disorder.
The development of early attachments are critical from the standpoint of future personality and brain development (Cornell, et al. 2008; Hardy, 2007). Key schematic frameworks regarding perceptions of self, and the reliability of others, develop as early in infancy. Additionally, as research has shown, these understandings, define many of our future relationships (Cornell, et al, 2008). Our attachment relationships develop as a history throughout our lives.
John Bowlby’s early work on attachment theory appears to provide a good share of our theoretical understanding on this issue. Based on his observations of a child’s relationship with caregivers, he was able to predict future personality development (Hardy, 2008). Additionally, his research provided a description of four key attachment styles: disorganized, ambivalent, avoidant, and secure (Hardy, 2008). His observations of body language, social cues, level of interactional reciprocity, and caretaker behavior provide a clear description of these styles (Cornell, et al, 2008). Underlying these observations are key differences in a child’s perception of self in relation to others. As one article aptly puts it: “the paradoxical experience of separateness and connectedness is enduring. Indeed, human beings struggle throughout their lives with balance thing need to be alone with others.” (Corbin, 2007, 542).
According to the DSM-IV-TR describes Reactive Attachment Disorder as follows: “Markedly disturbed or developmental inappropriate social relatedness in most context evidenced before age 5 years evidenced by either (1) persistent failure to initiate and respond to most social interaction or…(2) indiscriminate sociability with marked inability to exhibit appropriate selective attachments” (Hardy, 2007, 30). Additionally, the DSM-IV-TR, goes on to say, that this criterion alone doesn’t necessarily warrant a diagnosis of Reactive Attachment. Observations of pathogenic care as observed by persistent parental disregard for child’s basic needs (Hardy, 2007). Interestingly, while both the DSM, and psychological theory provide a good basis of understanding for attachment issues, current literature doesn’t address how their observations correlate (Cornell, et al, 2008). Further work is needed to clearly define the relationship between the DSM’s discussions of attachment issues, and relevant attachment theory. (Cornell, et al, 2008).
“A variety of biopsychosocial conditions are affected by the processes surrounding attachment” (Corbin, 2007, 539). The associated factors that underlie the development of reactive attachment are complex and integrated. These etiological factors include child temperament, genetics, the absence of key attachment figures, and maltreatment (Cornell, et al, 2008). Research for this paper discussed two key categories of factors which are each discussd below.
Biological Causes. In addition to the discussion of genetic inheritance as a key factor, deviations in the brain’s structure also provide a etiological explanation (Corbin, 2007). For example, our textbook mentions key structures in the brain, associated with the development of fear-based disorders, (Blaney & Millon, 2009, 126). While the amygdala is responsible for attending to the emotional significance of experiences, the hippocampus is vital in the development of long-term memory (Blaney & Millon, 2009). Dysfunction in these key structures may provide an etiological understanding of this disorder.
The Parenting Relationship. According to one resource for this paper, several theoretical perspectives exist to provide an understanding of the attachment process (Hardy, 2007, 28). On the one hand, developmental psychology points toward the development of internal working models (Hardy, 2007, 28). Other perspectives add to this, by pointing towards key alterations in brain development as a result of infant and caregiver interaction. A caregiver’s ability to influence and maintain an infant’s affective state influences this developing brain. From this perspective, education and parenting training are most effective.
Key interventions often proposed include cognitive behavioral interventions, addressing the attachment relationship, and social support (Hardy, 2007). Direct interventions focused on children can work to improve any impaired social relationships, and increase functioning as well as self esteem. Education and training for parents can help provide a better understand of the disorder with tools for managing it (Hardy, 2007). These psychoeducational models provide a therapeutic coaching experience for parents of RAD children. In addition to providing practical understanding, helping parents more effectively relate to RAD children are also helpful. (Cornell, 2008).
RAD vs. Separation Anxiety
While RAD is associated with a history of insufficient and neglectful care alongside emotionally withdrawn behavior (American Psychiatric Association, 2013). In contrast, Separation Anxiety Disorder (SAD) involves a recurrent distress and worry when anticipating separation (Orvashel, et al, 2001), In other words, SAD is related to fear of abandonment, and RAD involves an inability to form attachments.
RAD vs. School & Social Phobias
Orvashel, et al, (2001) describe school and social phobias in chapters nine and ten. School phobia is related to school refusal behavior and, at times, a failure to attend school consistently. In the case of social phobia the child instead has a fear of social situations and potential embarrassment. On one hand, school and social phobia are associated with a fear of a specific activity or event. On the other hand, RAD is not associated with a fear of a specific event or thing. Instead, the unresolved fear exists to an inability to connect with others and form meaningful attachments with caregivers.
RAD vs. GAD
GAD is associated with an excessive and uncontrollable worry associated with an array of symptoms including irritability, sleep problems, and restlessness (American Psychiatric Association, 2013). In contrast, excessive worry is not present in RAD, instead they are either emotionally withdrawn, or acting on unresolved fear or anger.
OCD vs. RAD
Orvashel, et al, (2001) describe OCD as involving intrusive and persistent thoughts that cause marked anxiety. In an effort to resolve this anxiety, individuals engage in repetitive acts as a response. RAD does not involve either of these issues.
Suggestions for Accurate Diagnosis
Information multiple sources and contexts is important, including the child’s primary caregivers and teachers. Through case histories including academic and medical files can also provide important information. Finally, a through longitudinal assessment of symptoms is also important. As I recall from the DSM class, all diagnoses temporally specific criterion. Additionally, the differential diagnosis appears to be based upon a careful contextualization of observations. In other words, what is the potential reason or context in which we can best understand the observed behavior?
It seems that with RAD, the underlying cause is a history of abuse and neglect. On the basis of this insight, an array of developmental considerations is worth examining. Does the child have any physical or academic delays as a result of this history? What is the nature of the child’s trauma, is a PTSD diagnosis warranted? Last, but not least, it would be important to examine the child’s parents, and home environment so these factors could be included in a treatment plan as well.
Definition & Diagnosis.
“Selective mutism has been defined as the consistent failure to speak in specific social situations, in which there is an expectation for speaking” (Beare, et al, 2008, 248). The specific criteria for the DSM-IV diagnosis are as follows:
A refusal to speak in certain social situations (Kumpulainen, 2002, 176).
Negatively impacted social communication and attachments (Kumpulainen, 2002, 176).
Presentation of symptoms for a minimum of one month, not explainable by other associated psychiatric disorders (Kumpulainen, 2002, 176).
In an article titled “Selective Mutism: Causes and Interventions” by Alan Hultquist, there is an overview of literature that describes subgroups (Hultquist, 1995). Based on an assortment of audiovisual and written observation, four types of selective mutism were discussed (Hultquist, 1995). While an in-depth discussion of this typology is beyond the scope of this paper, one thing may be noted. Underling this typology are associated etiological factors associated with each. Unhealthy symbiotic relationships with maternal figures, an extreme social phobia, passive-aggressive tendencies, or reactive post-trauma are just a few causes gleaned from this typology.
Still other research for this paper, proposes factors such as displaced hostility, an attempts to protect self-image, or socialization failures as added issues (Kumpulainen, 2002). Interestingly, these set of factors, include the interaction of child temperament with peer relationships and school officials as another observed etiological factor.
A variety of direct interventions are described in literature for this paper, including. Involving direct contact with the child, these interventions include both individual and group therapies. While group therapies involve play sessions with other children and therapists, individual direct therapy for children can include psychoanalytic therapy (Hultquist, 1995). Still, it must be noted, that psychoanalytic interventions, appear to have fallen into disfavor, due to the length and ineffectiveness of this approach (Hultquist, 1995; (Kumpulainen, 2002).
The most commonly cited successful form of therapy for this specific disorder, includes behavioral modification. Implemented in home and school environments, it includes interventions such as “stimulus fading, desensitization, extinction, and self modeling” (Hultquist, 1995, p103), just to name a few.
Cooperation with family members is essential to adjust the environmental factors to improve chances of recovery, (Kumpulainen, 2002). This process will need to start with an education on the nature of the disorder, (Kumpulainen, 2002). Additionally, a thorough assessment with all family member relationships will be vital to better understand the relational dynamics in the household (Hultquist, 1995). This can provide a clearer understanding of this disorder as occurring from within a specific familial environmental context (Hultquist, 1995). Interventions can then be provided and implemented accordingly.
School Based Interventions.
Finally, brief mention must be made, on the critical need to include the school system. Providing educational and interventional resources for key personnel, are vital in promoting recovery.
Description & Diagnosis
From a laymen’s perspective, separation anxiety, seems more of a normal reaction for infants and young toddlers. How can one differentiate normal reactions to separation with those instances in which it can be considered a disorder worthy of a DSM-based diagnosis? According to one resource for this paper, a Separation Anxiety Disorder can be defined as follows:
“Separation anxiety refers to developmentally appropriate distress regarding separation from significant disorders….Separation anxiety disorder (SAD) refers to developmentally inappropriate distress for at least 4 weeks regarding separation. A diagnosis of SAD requires three of nine symptoms and interference in daily functioning.” (Tillotson, 2003, 593).
The severity of symptoms associated with SAD are highly varied from an “anticipaitory uneasiness to full-blown anxiety” (Masi, et al, 2001, 94). Additionally, this disorder often spontaneously remits, and is associated with a high occurrence of co-morbidities. It is on the basis of these facts, that one research article describes SAD as a highly unstable diagnosis (Tillotson, 2003, 596).
A complex interplay of biological and genetic vulnerability, temperamental qualities, negative environmental influences, attachment experiences, and parental psychopathology…may induce the appearance of the disorder and influence its clinical severity. (Masi, et al, 2001, 94).
On the one hand early presentations of this disorder are said to reflect a strong biological disposition (Tillotson, 2003, 597) On the other hand, a problematic family environment and relationships are often found in those cases occurring in later childhood (Tillotson, 2003, 597). Additionally, parental psychopathology in the form of anxiety disorders can perpetuate and reinforce the condition (Masi, et al, 2001, 94). Finally, research points toward a strong association between family disharmony and parental inconsistency as key factors associated with this disorder. (Tillotson, 2003, 597).
Psychoeducational intervention in the form of family therapy, and parenting classes are essential. A through assessment of the family relationships and overall home environment are warranted. Providing parenting classes along with an explanation of the disorder and its symptoms, also helps to mange this disorder.
Finally, a discussion of interventions can’t go without a mention of cognitive behavioral therapy. As the most often-mentioned technique for childhood anxiety disorders, it is helpful addressing faulty cognitions associated with the anxieties. Additionally, behavioral modification techniques also prove helpful in addressing key symptoms associated with this disorder.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington D.C.: Author.
Blaney, P., & Millon, T. (Eds.). (2009). Oxford textbook of psychopathology, 2nd ed. Oxford, U.K.: Oxford University Press. ISBN 978-0-19-537421-6. (BM)
Corbin, J. R. (2007). Reactive attachment disorder: A biopsychosocial disturbance of attachment. Child & Adolescent Social Work Journal, 24(6), 539-552. doi:10.1007/s10560-007-0105x
Cornell, T., & Hamrin, V. (2008) Clinical interventions for children with attachment problems. Journal of Child and Adolescent Psychiatric Nursing. 21(1), 35-47.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM–5. Washington, D.C: American Psychiatric Association
Ginsburg, G. S., & Julie, N. K. (2007). Evidence-based practice for childhood anxiety disorders. Journal of Contemporary Psychotherapy, 37(3), 123-132. doi:10.1007/s10879-007-9047-z
Hultquist, A. M. (1995). Selective mutism: Causes and interventions. Journal Of Emotional & Behavioral Disorders, 3(2), 100.
Kumpulainen, K. (2002). Phenomenology and treatment of selective mutism. CNS Drugs, 16(3), 175-180.
Masi, G., Mucci, M., & Millepiedi, S. (2001). Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management. CNS Drugs, 15(2), 93-104.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians, 2nd ed. New York: The Guildford Press.
Murray, L., Creswell, C., & Cooper, P.J. (2009). The development of anxiety disorders in childhood: an integrative review. Psychological Medicine. 39, 1413-1423.
Orvaschel, H., Faust, J., & Hersen, M. (Eds.). (2001). Handbook of conceptualization and treatment of child psychopathology. Oxford, UL: Elsevier LTD.
Wood, J., McLeod, B., Sigman, M., Hwang, W., & Chu, B. (2003). Parenting and childhood anxiety: theory, empirical findings, and future directions. Journal Of Child Psychology And Psychiatry, And Allied Disciplines, 44(1), 134-151.
Bipolar spectrum disorder is best described as a longitudinal diagnosis that requires longer-term observation of mood swings, and other associated symptoms (Hirschfield, 2001). The abnormal mood swings associated with bipolar disorder include major depressive episodes, intermingled with manic and/or hypomanic states. Complicating the diagnostic process with this disorder, are several associated factors. In addition to the presence of six subtypes, the need for an observed presence of cyclical manic-depressive mood states, further complicates matters (Hirschfield, 2001). Finally, without a clear pathophysiological etiology, the diagnostic process rests largely on clinical judgment (Hirschfield, 2001).
With all these factors in mind, it is interesting to note the epidemiological increase in occurrence of bipolar disorder within both adult and child populations (Kaplan, 2007). For example, while previously viewed as “virtually nonexistent” (Harris, 2005) in the child and adolescent population, recent years have shown a sudden rise in prevalence. One resource for this paper, states this risen in prevalence as a “40-fold increase in the diagnosis of bipolar disorder in youth” (Xu, et al, 2007, 1). One can’t help but wonder how this may correlate with the conceptual broadening of this diagnostic category since the DSM-IV-TR was taken into effect. In the following sections, we outline the proposed causes of this “epidemic rise” (Bauer, 2005) with suggestions to improve the assessment and diagnosis for this population.
“As depressive episodes often precede the first clear-cut mania, it is almost inevitable that major depressive disorder (MDD) is by far the most frequent diagnosis…Of course, to some extent, the misdiagnosis of bipolar depression is unavoidable, because technically, the diagnosis cannot be made until an episode of mania or hypomania has occurred….There is at least a 10% chance that someone experiencing a first lifetime episode of depression actually will develop bipolar disorder. “ (Thase, 2005, 258).
One common reason, proposed for the increased rate of misdiagnosis for this population is the nature of the presenting complaints. Individuals suffering from bipolar diagnosis commonly seek help for treatment of symptoms of depression (Thase, 2005). Additionally, when help is sought to manage symptoms of mania or hypomania, it is commonly not the patient’s who do so but their family and/or legal system (Thase, 2005). When you add to this, the additional problem of a lack of continuity in care – an accurate diagnosis is frequently delayed (Kaplan, 2007).
Without a prior knowledge of the client’s history of mood swings, and the ability to engage in a longitudinal observation, a misclassification is common. Since the symptoms associated with a bipolar diagnosis overlap with other psychiatric disorders, this further complicates matters (Bauer, 2005). In fact, several resources lag time between symptom onset and accurate diagnosis, at somewhere between 7-10 years (Stensland, 2010, p 39; Thase, 2005).
A second key reason for increase prevalence and misdiagnosis of this disorder is the lack of a clearly understood pathophysiological etiology associated with this disorder (Kaplan, 2007). In fact without a clearly defined biological marker associated with this diagnosis, the process is a matter of clinical judgment (Xu, et al, 2007). With this in mind, the degree of imprecision associated with the diagnostic criteria for this disorder warrants close examination (Xu, et al, 2007, 246).
Juvenile Bipolar Diagnosis
Another key issue associated with the increase prevalence of bipolar diagnosis, is the lack of developmentally-based symptomatology (Harris, 2005). With a lack of universally acceptable criteria from an age-specific perspective, room for diagnostic misinterpretation exists (Harris. 2005). In fact, one resource for this paper poses the following question: “Are juvenile and adult bipolar disorder, the same disorder” (Harris, 2005, 529). In providing support for this possibility is the fact that symptoms present differently across the life span. What’s more, research has shown that a good majority of juveniles with bipolar disorder do not go on to exhibit the adult variety (Harris, 2005, 529).
Further complicating matters, are the associated pressures that can influence the diagnostic process (Harris, 2005, 531). For example, telling parents a child has a mental illness takes away the need to closely examine family interactions. Additionally, the government and insurance industry exert their own financial pressure that also influences diagnostic processes.
The perceived worthiness of the recipient may play a hidden role in the policy development. For instance, it is often easier for a child to get special educational services if the diagnosis is presumed to have a more biological basis. In many state programs, a child qualifies for services if the diagnosis is bipolar disorder but not if it is PTSD or disruptive behavior disorder. (Harris, 2005, 532)
Conceptual broadening of the bipolar spectrum disorders, is the most-cited reason underlying the increased prevalence of this diagnosis (Harris, 2005; Kaplan, 2007; Thase, 2005). In fact, it appears that further research to clearly understand the underlying etiology, and a refinement of diagnostic criteria are two key solutions to the issue of increase prevalence.
In a paper titled “The Road to DSM-V” is a discussion of the needed changes to the bipolar spectrum disorder description. The authors of this article provide the following assessment of the potential revisions to this category of disorders:
Useful Categorical Descriptors.
According to Colom & Vieta, three key descriptors of bipolar diagnosis remain quite useful. These key symptoms include, catatonic features; rapid mood cycling and depression with atypical features (Colom, et al, 2009). In fact, this article appears to call for further research to better understanding the nature of catatonia within bipolar disorder. Additionally, education to help medical professional’s understand how to better differentiate bipolar and unipolar depression is key (Colom, et al, 2009).
Areas of Revision.
While a more in depth discussion of suggested revisionary changes is beyond the scope of this paper, what follows is a brief listing of suggestions. These suggestions also come from the article titled “The Road to DSM-V” by Colom & Vieta:
Modification of seasonal pattern descriptor in bipolar diagnosis is warranted as research has proven this associated symptom to be inconclusively associated with the disorder itself. (Colom, et al, 2009).
Modifying and expounding upon levels of severity and/or degrees of remission would help provide further diagnostic clarity. While this resources states that a description of severity stages hasn’t been utilized in the field of psychiatry, it would be very helpful (Colom, et al, 2009).
Suggestion Descriptive Additions
Finally, two suggested additions are provide by Colom & Vieta, including addressing the juvenile variety of disorder, as well as varied degrees predominant polarities seen within patients.
Discussing the early onset forms of bipolar disorder, would involve a developmental age-related descriptor of symptomatologies across the life span. (Colom, et al, 2009).
Addressing the issue of predominant polarities, can provide clarity to research which reports high degrees in symptomatic presentation between predominantly hypomanic versus depressive patents (Colom, et al, 2009).
Bauer, M., & Pfennig, A. (2005). Epidemiology of bipolar disorders. Epilepsia, 46 Suppl 48-13.
Blaney, P., & Millon, T. (Eds.). (2009). Oxford textbook of psychopathology, 2nd ed. Oxford, U.K.: Oxford University Press. ISBN 978-0-19-537421-6. (BM)
Harris, J. (2005). Child & adolescent psychiatry: The increased diagnosis of “juvenile bipolar disorder”: What are we treating? Psychiatric Services, 56(5), 529-31. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/213096721?accountid=28125
Hirschfield, R. (2001) Bipolar spectrum disorder: Improving its recognition and diagnosis. Journal of Clinical Psychiatry. 62(14) 5-9.
Kaplan, A. (2007). Increase in bipolar diagnosis in youth prompts debates and calls for research. Psychiatric Times, 24(14), 1-1. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/204565230?accountid=28125
Netherton, S., Holmes, D., & Walker, C. (Eds.). (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, U.K.: Oxford University Press. ISBN 978-0-19-509961-4. (NHW)
Stensland, M.D., Schultz, J.F. & Frytak, J.R. (2010). Depression diagnoses following the identification of bipolar disorder: costly incongruent diagnoses. BMC Psychiatry. 10(1) 39-46.
Thase, M. (2005). Bipolar depression: issues in diagnosis and treatment. Harvard Review Of Psychiatry, 13(5), 257-271.
Xu, J., Rasmussen, I., Berntsen, E., Moss, K., Shnier, R., Lagopoulos, J., & Malhi, G. (2007). A growth in bipolar disorder?. Acta Psychiatrica Scandinavica, 115(3), 246-250.
NERD ALERT!!! This post consists of three papers on Autism…
Paper #1: Overview of Autism Symptoms…
Two Categories of Symptoms
Since the DSM-5 was published, Asperger’s is no longer an official diagnosis (American Psychiatric Association, 2013). It consists of two main categories of symptoms: (1) social deficits and (2) repetitive behaviors and/or limited interests. (American Psychiatric Association, 2013). These social deficits were described in one video as a form of “social dyslexia” (Diamonddave, 2007). A sufferer in another video, described this deficit as an inability to engage in any “theory of mind” conceptualization (Mike Peden, 2009). Keep in mind, the theory of mind concept pertains to an ability to attribute and discern the mental states of others (i.e. emotions, thoughts beliefs. The DSM-5 describes these persistent deficits as involving a range of difficulties in social communication and interaction (American Psychiatric Association, 2013).
The second main classification of symptoms involves repetitive behavior and restricted interests (American Psychiatric Association, 2013). In several assigned videos this week, these restricted interests were described as OCD-like (Diamonddave, 2007; Mike Peden, 2009). One sufferer noted that since this disorder encompasses limitations in social awareness, your mind is instead captured by predictable facts that are readily discerned from the physical world (Diamonddave, 2007). One individual described an avid interest in game shows as a young child due to the predictability of events (Diamonddave, 2007).
Symptoms Causing Parents to Seek Treatment
When reviewing the above list of symptoms, it is clear that underlying all these issues are limitations in the expression of empathy (Mike Peden, 2009). An inability to understand social cues, and emotions in others creates practical limitations in one’s ability to communicate and interact. An inability to grasp the “theory of mind” limits one’s information intake to information readily discernable in the concrete and visual world. As I have come to understand it, these limited interests reflect a desire to compensate for shortcomings, by focusing instead on something that made perfect sense. A great example of this, comes from a recent encounter I had with an elderly lady at work who had dementia. She would spend hours folding the same pile of towels. This activity kept her anxiety at bay, as her mind was able to focus on the task at hand. According to the videos assigned this week, three categories of issues most often capture the attention of concerned adults: (1) OCD-Like behaviors (2) limited communication and (3) restricted interaction (Diamonddave, 2007; Mike Peden, 2009).
The OCD-like behaviors referred to in these videos, reflect limitations in emotional understanding. As a result ASD sufferers display restricted and unusual interests such as, for example, a fascination with vacuum cleaners and their functionality. Repetitive behaviors associated with ASD, also have an OCD-like feel, due to their ability to allay anxiety and prevent temper tantrums.
Teachers and parents in both videos described a range of restrictions in communication (Diamonddave, 2007; Mike Peden, 2009). For example, one mother stated these concerns arouse when her daughter reached 18-months of age, but was unable to find help until she reached three (Mike Peden, 2009). Early intervention is helpful in narrowing the window of delayed development in communication ability for ASD children (Mike Peden, 2009).
I found it interesting that sufferers appeared to complain the most about limitations in social awareness (Diamonddave, 2007; Mike Peden, 2009). Outsiders, on the other hand, described a wider range of symptoms associated with this disorder (Diamonddave, 2007; Mike Peden, 2009). It appeared to me that these limitations in social awareness were conceptualized as a reason for their “differentness” (Diamonddave, 2007; Mike Peden, 2009). It was a key explanation for their struggles and the bullying/teasing they often endured growing up (Diamonddave, 2007; Mike Peden, 2009).
The Importance of Early Diagnosis
According to a video by Mike Peden (2009) ASD sufferer, two classifications of interventions are essential: (1) self-acceptance and understanding (2) self-improvement and skill building. Regarding the issue of self-acceptance and understanding, I was most struck by comments made by Mike Peden (2007), at the end of his video. Coming to a point of understanding what the nature of his disorder was critical in order to deal with it proactively. We see him developing to his utmost potential, rather than restricting himself to the limits of diagnostic expectations. Underlying this progress is an empowered attitude of self-acceptance. As a result, he was able to gain greater understanding of himself and able to address key deficits in communication, and social interaction.
Finally, it is important to note that early intervention is a critical determinant in the progression of this disorder throughout one’s life. Regarding the issue of human development, time is generally of the essence since the brain displays the greatest plasticity in early childhood. For example, Lopata, et al, (2006), states that significant improvements in social skills occurred as a result of their research based interventions. Bauminger, (2007), adds that their research participants displayed significant improvements in emotional knowledge, and socially oriented problem-solving, as a result of their interventions.
Paper #2: A Hypothetical Treatment Program for High-Functioning Autism…
The purpose of this paper is to design a hypothetical treatment program for individuals with high-functioning autism. The DSM-5 manual no longer includes Asperger’s as an official diagnosis (American Psychiatric Association, 2013). Instead, it is now included as a component of Autism Spectrum Disorder (ASD). Symptoms of ASD include social deficits, repetitive behaviors, and limited interests, (American Psychiatric Association, 2013). An interesting video assigned this week, provides unique insight on the inner world of a highly functioning autistic (Mike Peden, 2009). This video describes the social deficits associated with ASD as a form of dyslexia that pertains to an interpretation of social clues (Mike Peden, 2009). With no ability to engage in a “theory of mind” conceptualization, it is impossible to understand the emotions, thoughts or beliefs of others. The ASD sufferer’s world is limited to input that is readily discernible with the five senses. Objective and concrete facts from the physical world are a source information that readily captures the interests of an ASD sufferer. For this reason, I have come to understand ASD an issue of disordered empathy. All symptoms can be attributed to this underlying issue.
Targeted Symptoms & Population
Mike Peden (2009) points out two key areas of intervention that are most essential (1) self-acceptance, and (2) social skill building. This self-acceptance should encompass an awareness of one’s limitations alongside an empowering stance that acknowledges one’s potential (Mike Peden, 2009).. Developing social skills is useful in addressing a predominant complaint of highly functioning autistics in the assigned video (Mike Peden, 2009). Interestingly, suffers in this video pointed out social awareness as a source of differentness and personal struggle. In contrast, loved ones, reported a wider-spectrum of issues as a source of concern. Since all symptoms are a byproduct of limited social awareness and empathy, addressing this issue, is likely to provide the greatest benefit. This limited awareness can involve issues such as a difficulty maintaining friendships, lack of emotional reciprocity, and an inability to understand the rules of social interaction (Lopata, et al, 2006). Finally, in order to define the parameters of this program further, it will be geared toward school-age, highly-functioning autistics.
A cognitive-behavioral orientation will be utilized for the purposes of this hypothetical treatment program. Cognitive-behavioral therapy (CBT) encourages us to adjust our thinking in order to produce changes in mood that will influence our behavioral reactions. (Metcalf, 2011). It combines behaviorism with a cognitive perspective which focuses on our judgments of life events as sources of influence over feelings and behaviors (Metcalf, 2011).
An article I found in the library’s database provides an overview of the only empirically supported social skills CBT approach to autism (Lagueson, et al, 2014). The program reviewed in this article is titled “The Program for the Education and Enrichment of Relational Skills” (Lagueson, et al, 2014). Modifications to the CBT approach for this treatment program include a predictable structure in all sessions with visual supports and explicit verbal feedback (Lagueson, et al, 2014). Additionally, it will be important to give participants repeated opportunities to practice the skills they learn (Lagueson, et al, 2014).
Setting & Mode of Therapy
An ecological systems perspective will also provide guidance for this hypothetical social skills training program. An ecological perspectives views a children’s environment as a causal factor underlying presenting symptoms. The ecological model, describes zones of influence over one’s well-being including: mental, psychological, biological, interpersonal, familial, cultural perspectives (Bauminger, 2007a; Bauminger, 2007b). Adding to this ecological perspective, is insight from systems theory which utilizes a unique systemic, interpersonal viewpoint (Metcalf, 2011). According to this theoretical orientation, the family is considered a system, with a set of governing rules and structure, that provide an interactional homeostasis.
In keeping with these insights, a multimodal treatment design will be utilized. Individualized treatments, described in the “PEERS Treatment Program” (Lagueson, et al, 2014) will be used. These individualized therapy sessions will involve a predictable and structured psychoeducation. Acting as an educator, the therapist’s goal is to foster greater awareness of their behaviors, thoughts, and feelings (Lagueson, et al, 2014). Modeling these skills in a series of role-play demonstrations with other staff is also essential. Concrete steps defining a social task can be provided, with homework for practice elsewhere (Bauminger, et al, 2007b). Working through these skills with an underlying goal of self-understanding will be critical. Incorporating the family’s participation can allow participants an opportunity to practice these assigned skills at home. Finally, where applicable, it will also be useful to provide opportunities to practice these skills at school. Recruiting peer and staff support and participation will be essential.
Lopata, et al, (2006) describes a “Skillstreaming Curriculum” in its research on CBT methods for social skills training with ASD youth. Skills taught in this curriculum include concepts such as basic listening, starting a conversation, complementing, and handling stress (Lopata, et al, 2006). The procedure in the “Skillstreaming Curriculum” include a structured process that involves: (1) defining and modeling skills (2) conducting a role play sessions, (3) providing feedback, and (5) assigning homework (Lopata, et al, 2006). In this respect, it will work well alongside the individualized therapy methods from the PEERS treatment model. Since both treatment models utilize a similar design, participants are provided several opportunities in which to learn and practice the same set of skills.
Multiple Modes of Practice.
As stated earlier, it is important to provide participants several opportunities to practice social skills. For this reason, individual and group therapy will be utilized to provide multiple opportunities to receive social skills training. Finally, providing opportunities for practicing social skills across all elements of a participant’s life can provide reinforcement. For example, in addition to a therapy environment, it would also be useful to allow opportunities for practice in home and at school. Including the participation of family, peers, therapists, and school officials, where possible, can provide an understanding of these skills from multiple perspectives.
The goal of interventions utilized in this hypothetical treatment program includes the development of social understanding and problem solving skills (Bauminger, 2007a; Bauminger, 2007b). Social understanding can be seen in a greater attention to social and emotional cues with a correct interpretative response to this information (Bauminger, 2007a; Bauminger, 2007b). Improvements in social problem-solving skills involve an ability to accurately assess the social task at hand, generate behavioral responses, and examine their consequences (Bauminger, 2007a; Bauminger, 2007b).
Instruction & Feedback.
All interventions will utilize a systematic and predictable structure with repeated opportunities for receiving skills training. Feedback will involve a behavior reward system, in which participants gain and loose privileges based on their ability to follow rules (Lopata, et al, 2006). Naturalistic responses provide a secondary form of feedback through a participant’s life from family members, therapist, peers and school staff.
Examples of Interventions.
Examples of interventions that could be utilized in this hypothetical treatment program can be found from the Skillstreaming Curriculum, (Lopata, et al, 2006), and Peers Program Laguson, et al, (2014). For instance, Lopata, et al, (2006) describe facial expression activities and cooperative games useful in a group therapy setting. An example of a cooperative activity includes participants working together to build objects with the use of one hand (Lopata, et al, 2006). Facial recognition activities involve participants working on correctly identifying the emotions on face pictures (Lopata, et al, 2006). Activities from the Peers Program can provide a cognitive and role-playing interventional component (Lagueson, et al, 2014). For example, Lagueson, et al, (2014) describes a role playing scenario that involves opportunities for learning both positive and negative displays of social behavior. In contrast, cognitive strategies can involve teaching participants how to read social cues, engage in perspective taking exercises, and develop social problem solving skills (Lagueson, et al, 2014). While well-beyond the scope of this paper, I was very impressed with how this program delineates specific skills instructions in a way that is easy to comprehend for ASD sufferers.
What are the expected outcomes of these interventions? A review of research for this paper provides an idea of the long-term outcome for participants. Lopata, et al, (2006) states that participants of the Skillstream Curriculum displayed significant improvements in social skills according to staff and parent report. Lagueson, et al, (2014) also confirms the utility of the Peer program citing improvements in social skills, and increased frequency of peer interaction amongst participants. Finally, research by Bauminger (2007b) indicates the utilization of CBT interventions produced improvements in emotional knowledge, and problem solving ability.
Paper #3: Older Paper Comparing Aspbergers & Autism…
Autism & Aspberger’s
This week’s paper assignment takes a close look at individuals with autism and Aspberger’s. On the one hand, the DSM and ICD-10 both define these two disorders as separate entities. On the other hand, disagreement appears to exist as to whether or not these disorders are separate in nature or ends of a spectrum within a specific disorder. Either way, these diagnoses fall within a classification of “Pervasive Developmental Disorders” (Netherton, et al; 1999, p76). Characterized by symptoms such as communication and language impairment, social and interactive skill disability, and stereotyped behavioral interests: how exactly do these disorders differ (Netherton, et al, 1999, p76)? After all, as per MTV’s True Life segment “I Have Autism” (MTV, 2007) these disorders do appear to present with a highly varied spectrum of symptoms. What follows is a brief description that can help to differentiate between autism and Aspberger’s.
First described by Leo Kanner in the 1940’s, autism was first noted as a disorder of extreme isolation and “aloneness” (Netherton, 1999, p77). Displaying an interactive and social inaccessibility and communicational deficit, these individuals instead displayed greater fascination for abstract objects alongside unusual behavioral deficits.
The huge take-away in watching the assigned video for this week is what seems to be an extreme vacillation between two sets of symptoms (MTV, 2007). It appears these individuals have difficulty sorting through sensory information in an organized way. As a result, while highly sensitive to sensory information, they also appear to be in their own world. Additionally, while these displaying varying degrees of cognitive deficits they are also quite intelligent.
In fact, it appears, they are often aware of the world around them, and have a world of feeling, only unable to express it clearly to others. The world within their minds is different than their external behavioral displays might lead you to believe. With all this said, what is least known about this disorder is its underlying cause. While genetic factors, brain structure abnormalities, chemical imbalances, and viral infections are proposed causes research continues to provide a more definitive explanation (Netherton, et al, 1999).
Based on the textbook’s description and assigned video Aspberger’s appears to be a less-severe form of autism. As stated earlier, while the DSM currently defines it as a separate disorder, there is currently disagreement as to whether it is actually a milder variation along the autistic spectrum (Netherton, et al, 1999; MTV, 2007).
Key differences between Aspberger’s and Autism are readily seen in the levels of functionality displayed. In individuals with Aspberger’s speech onset is rarely delayed, yet more limited than the general population. Additionally, while nonverbal behaviors and social interactions are impaired as compared to the general population, this impairment is generally much less severe. Able to more readily express themselves and interact with the world around them, they display a greater level of functionality and independence. With behavioral symptoms less intrusive, fewer interventions are needed, with an ability to live independently.
So with this overview of the key differences out of the way, what are some key challenges these individuals face daily? What follows is an overview of relevant considerations.
Challenges and Considerations
In an assigned video for this week, we witnessed first-hand some key challenges for those with autism and Aspberger’s. Based on this video, it is clear that individuals suffering from these disorders display a wide range of symptoms that do appear to exist along a continuum. What follows are observations, and considerations to be kept in mind when counseling those with autism.
Jeremy – A Severe Nonverbal Autism
The first story shared in the MTV video titled “I Have Autism”, was of a nonverbal autistic boy named Jeremy. What makes his story unique is the severity of his language impairment. As a nonverbal autistic, his ability to connect with the world around him has been a huge life-long struggle. In fact, the introduction to this video shows him using a “litewriter” device with his mother. When using this device, he can type in his thoughts, and the machine will dictate them back verbally. Prior to the usage of this device, he relays the fact that his world was lonely and frustrating. Unable to express and share his feelings with others, he is saddened by this memory. It is clear, he wants to open up to the world around him, but he is overwhelmed by an array of sensory data, he is incapable of moving beyond.
So what are some key observation’s to note? Firstly, it appears obvious that Jeremy will require lifelong care, and will never be able to live independently. With this in mind, what notable facts regarding Jeremy’s needs and challenges can help those providing his care? Providing an environment that can allow him to remain engaged with the world around him is key. This can empower him to meaningfully relate to others and cement friendships with those around him. Also important in his case, are coping skills to help him handle the occasional stressful sensory overloads. All this, of course, will need to occur within an environment in which he can be assisted in safely engaging in his ADL’s as independently as possible.
Jonathan – Autism with A Savant Component.
The second case study of Autism in the MTV video titled “I Have Autism” is that of Jonathan. In contrast to Jeremy, Jonathan appears to display a less severe communicative and speech impairment. Instead, in Jonathan’s case, his impairments appear to involve a difficulty understanding abstract thoughts, and limited conversational ability. Finally, with an increased tendency toward emotional labiality, he is prone to occasional outbursts. This appears to occur whenever he is overwhelmed from a sensory and/or emotional standpoint.
Key challenges in Jonathan’s case, in addition with assistance with basic ADL’s include management of occasional sensory/emotional overloads. What is clear in Jonathan’s case is his desire to manage the occasional outbursts that come with this. Techniques such as the usage of headphones to lessen sensory input, and assistance in managing emotions are key. Finally, holding a unique artistic savant, our textbook mentions this special skill can “become a useful treatment tool as a conduit toward normalization.” (Netherton, et al, 1999, p89).
Elijah – Asperber’s Disorder
Most readily described as a less severe form of autism, Elijah appears to be the most highly functioning of all individuals in this video. With some speech delays, and motor dis-coordination, he also appears to be somewhat impaired in the context of social interactions. What is notable in Elijan’s case, is how the lesser degree of severity, changes the nature of the interventional considerations. Not needing assistance any meaningful assistance with ADL’s, Elijah can easily live independently as an adult.
So what considerations should be taken in Elijah’s case? Our textbook mentions education and vocational training with a goal towards independent living arrangements (Netherton, 1999, p94). Additional considerations to address in cases such this can be seen in reviewing Elijah’s struggles more closely. In particular, it seems he fears sharing his diagnosis of autism with others, for fear of stigmatization and negative judgments from others. He is somehow aware of his disorder, and how it differentiates him from others. Learning how to accept and handle this key issue. Doing so will be a critical factor in his degree of adeptness in traversing the world around him. Assistance in handling the emotions surrounding this issue, with additional social skill education, can make a world of difference
American Psychiatric Association. (2013). Diagnostic and statistical manual for mental disorders (5th ed.). Washington D.C: Author.
Bauminger, N. (2007a). Brief report: Group social-multimodal intervention for HFASD. Journal of autism and developmental disorders, 37(8), 1605-1615
Bauminger, N. (2007b). Brief report: Individual social-multimodal intervention for HFASD. Journal of autism and developmental disorders, 37(8), 1593-1604.
Lagueson, E.A., Park, M.N. (2014). Using a CBT approach to teach social skills to adolescent with autism spectrum disorder and other social challenges: The Peer’s method. Journal of rational-emotive & cognitive-behavioral therapy, 32(1) 84-91.
Lopata, C. Thomeer, M.L., Volker, M.A., & Nida, R.E. (2006). Effectiveness of a cognitive-behavioral treatment on the social behaviors of children with Asperger’s disorder. Focus on Autism and other developmental disabilities. 21(4), 237-244.
Metcalf, L, (2011). Marriage and family therapy: A practice oriented approach. New York: Springer Publishing Company
Lopata, C., Tohomeer, M.L. Volker, M.A., & Nida, R.E. (2006). Effectiveness of cognitive-behavioral treatment on the social behaviors of children with Asperger disorder. Focus on autism and other developmental disabilities, 21(4), 237-244.
During a discussion with my therapist recently I learned that some of my symptoms are reflective of Generalized Anxiety Disorder. Until she mentioned this, it hadn’t occured to me. However, I must admint, she does have a point. I’ve always been a worry wart, and find my anxiety the most difficult to manage on a daily basis. Anxiety urges us to action perceived in that moment as a solution to our concerns and fears. When overcome with anxiety, I try my best to “keep it in check”. However, sometimes it does get the better than me, and I react in an irrational and/or poorly-thought-out manner. What follows is a quick review of research that provides interesting causal explanation for G.A.D….
Beliefs & G.A.D.
Koerner, et al, (2015) note that certain beliefs about worry correlate with Generalized Anxiety Disorder, including “negative beliefs about uncertainty, and schemas reflecting unrelenting standards…the need to self-sacrifice…and less positive views of other people and their intentions” (p. 441). Additionally, how we view worry effects the way we handle and mange this emotion. “When individuals encounter a threatening situation, positive beliefs about the usefulness of worry are activated, which in turn initiate worrying as a coping strategy” (Koerner, et al, 2015).
Stressful Life Events & G.A.D.
Life events play a role as precipitating factors in the onset of generalized anxiety disorders and panic disorders….The objective of this study was to investigate the frequency, specificity and typology of stressful life events occurring in patients with generalized anxiety disorder and panic disorder…A significant proportion of patients in both groups reported stressful life events occurring in the year before the onset (87.5% in the group with generalized anxiety disorder and 76.3% in the group with panic disorder). More patients in the panic disorder group have reported events of the “loss” type and at least one event considered to be severe and very important compared to the generalized anxiety disorder patients. A significant proportion of patients in both groups have reported conflict and events involving threats. (Romosan, et al, 2004, p. 36).
Theoretical Interpretations of G.A.D.
A Psychoanalytic Perspective…
“According to psychoanalytic theorists, individuals with anxiety experienced difficult early relationships with unavailable and unresponsive caretakers In psychodynamic models, psychopathology is understood to occur as a result of excessive defenses against anxiety and guilt-producing, mixed feelings toward loved ones.” (Greenberg & Watson, 2017, p. 20-21)
From a learning theory point of view, people are anxious and fearful of feelings that are associated with negative outcomes. Learning theory approaches to GAD have suggested that uncontrollable and unpredictable aversive events may play an important role in the devel- opment of GAD (Greenberg & Watson, p. 21)
“Cognitive behavioral worry is a result of problems with affect regulation, including (a) heightened intensity of emotions, (b) limited understanding of emotions, (c) negative responses to current emotions, and (d) unhelpful management of emotions. According to this view, GAD results from deficits in affect regulation with an over reliance on worry to manage diffiult emotional experiences” (Greenberg & Watson, 2017, p. 23)
“Rogers suggested that anxiety occurs when the needs of the organism are in conflict with introjected conditions of worth from signi cant others. Fully functioning people do not need to distort experience…with introjected conditions of worth” (Greenberg & Watson, 2017, p. 24)
Existential theorists see anxiety as a core part of the human condition and as an unavoidable component of life. In their view, anxiety results from individuals having to face choices without clear guidelines and without knowing what the outcomes will be, and from being aware that they are ultimately responsible for the consequences of their actions…existential view sees anxiety as stemming from the inability to cope with the challenge of living and to choose to live in a healthy and productive way.” (Greenberg, & Watson, 2017, p. 24)
Repeated exposure to threatening, painful, and negative life events…without adequate protection, soothing, and nurturing compromises people’s emotional processing and affect regulation capacity, as well as their identity formation…If needs for connection and protection go unmet, individuals become distressed and their feelings of fear, sadness, and shame remain inadequately symbolized and soothed….These children feel solely responsible for their well-being. The lived experience plus the harmful situation are coded in emotion schematic memory. Thus, from an EFT perspective, an important contributor to GAD is the inability of people to process their emotions and soothe, comfort, and protect themselves when experiencing distress so as to return to a state of peace and calm.” (Greenberg & Watson, 2017, p. 25).
(((I am currently studying for a licensure exam & completing an internship. This blog post is intended as a study exercise.)))
What is GAD?
The DSM-5 Manual describes Generalized Anxiety Disorder (GAD) as a “persistent or excessive anxiety…about various domains…that the individual finds difficult to control” (American Psychiatric Association, 2013, p190). Additionally, the persistent worry associated with GAD includes symptoms of restlessness, perpetual fatigue, irritability, and difficulty concentrating (American Psychiatric Association, 2013). GAD involves a generalized anxiety that is unrelated to a specific stressor and is psychogenic in nature (Lambert & Kinsley, 2011; Preston, et al, 2013). In this respect, while GAD’s symptoms have a neurochemical basis, they are a byproduct of nonspecific and imagined threats (Lambert & Kinsley, 2011; Preston, et al, 2013).
Therapy for GAD
It is important to understand that the mental state of GAD involves a chronic anxiety that involves an ongoing prediction that life events are unpleasant and potentially threatening. For this reason, CBT, meditation, and motivational interviewing techniques are helpful in individuals with GAD (Greene, 2013; Preston, et al, 2013). This can a allow clients to overcome any ambivalence while developing tools for self-soothing and learning how to rethink about one’s situation (Greene, 2013; Preston, et al, 2013).
Medications for GAD
Medications for GAD can include SSRI’s, Benzodiazepine, Busprione, and Gabapentin (Greene, 2013; Preston, et al 2013). Benzodiazepine acts on GABA receptors that cause the opening of calcium channels, and inhibition of the neuron (Preston, et al, 2013). Busprione, in contrast acts on serotonin receptors, and while less addictive than Benzodiazepine, its action is delayed (Greene, 2013). Finally, the anticonvulsant Gabapentin is also used for anxiety. Originally designed to mimic GABA, Gabapentinis thought to prevent the release of monoamines (Greene, 2013).
Preston, et al, (2013) suggest that since the half-life of anxiolytics tends to be short, the tendency for withdrawal is high. Additionally, some of these medications have a high risk for addiction. Patient education of these risks and other potential side effects, is important. Finally, in order to minimize withdraw, it is important to closely monitor a client’s response to the gradual tapering of dosage levels (Preston, et al, 2013).
In the first week of class, we read several resources that discussed the importance of a multidimensional, biopsychosocialperspective of mental health. In addition to attaining a comprehensive experiential background, it will be important to collaborate one’s efforts with individuals in other mental health fields For example, while therapist’s do not prescribe medication, they will need to be aware of what the client is taking. An understanding of the effects of these medications is essential for properpsychoeducation and their effects on a patient’s overall well-being is also important. In the case of the anxiolytics, Preston, et al, (2013), suggests that they work best as a short-term solutions. For this reason, a therapist’s role will involve many of the therapeutic techniques listed above while simultaneously monitoring response to medications.
A Day in my Life
I am a married mother to two boys, ages 14 and 8. I work full-time job as a C.N.A. for a large hospital-system float pool. I work three back-to-back 12-hour night shifts, Friday-Sunday, 7:00 p.m. to 7:00 a.m.. I have Monday thru Thursday off and spend the majority of this time on school work and family-related duties. My days vary greatly depending on whether it’s a weekend or a weekday. However, one constant issue in my life is jet-lag, due to an ongoing rotation between day-time and night-time sleep. Additionally, since my husband works 8:00 a.m. through 5:00 p.m., Monday-Friday, we rarely have a whole day to spend together. I make the most of the family time I do have in the morning and evening.
On the weekends when I work, my husband is home with the kids. I usually arrive home at 8:00 a.m. and have a quick breakfast with the family. I make it a goal to sleep between 9:00 a.m. and 4:00 p.m. The sleep is usually inadequate since my kids can be noisy and frequently have friends over. When I wake up, I work on my discussion board post responses and have dinner with my family before leaving for work around 6:30. Since I work for a hospital system float pool, the work varies greatly. Nonetheless, it is usually physically and mentally exhausting. The floors have been short-staffed quite a bit lately. This doubles my patient load from approximately 10 to 20 patients. I often get one break during the middle of my shift at about 1:00 a.m., otherwise I’m on my feet constantly
On my weekdays off, my main goal is to recover from the weekend as quickly as possible. I reserve Monday for this purpose and don’t get much done. I wake up in the morning Tuesday, thru Friday, around 7:00 a.m. and make breakfast then get my kids to school. Since I’m home alone during the day, I try my best to complete homework, but often require a nap. I pick my kids up around 3:00 p.m., make a snack, and get dinner ready. I do my homework on the dining table while my kids after we eat. I try to get to bed between 10-11 p.m.
A Day in My Life with GAD
GAD & SWSD: A Double Whammy
The DSM-5 Manual describes Generalized Anxiety Disorder (GAD) as a “persistent or excessive….worry about various [life] domains…that the individual has difficult to control” (American Psychiatric Association, 2013, p190). Symptoms of anxiety include restlessness, perpetual fatigue, irritability, sleep disturbance, and difficulty concentrating (American Psychiatric Association, 2013). Interestingly, symptoms of GAD are fairly similar to “Shift Work Sleep Disorder” (SWSD), an issue common in night shift workers (Brett, 2005). Symptoms associated with Shift Work Sleep Disorder include: insomnia, fatigue, and difficulty concentrating (Brett, 2005). Additionally, individuals dealing with this issue are at increased risk of heart disease, obesity, anxiety and depression (Brett, 2005). Adding a GAD to my life would significantly exacerbate the sleep disorder issues I currently deal with. Right now, I’m able to manage effectively by making adequate self-care a priority. As an individual who spends the majority of her time caring for others, I’ve had to learn to put myself first. I try my hardest to get a full 6-8 hours sleep daily. With GAD, this may become an impossible feat, and would require a simplification of my life. This would include either working less or quitting school.
Life Through The Lens of Anxiety
The important thing to note about anxiety, is that it exists independent of logic. You can’t talk or reason your way out of it. While I don’t have an anxiety, I already have a very stressful schedule. In this respect, I can imagine its effects. For example, when I’m tired, I have difficulty utilizing my prefrontal cortex to think logically about things. As a result, the stress takes over, and I can become irrational when exhausted. I find I’m thinking with my emotions rather than through them. With Generalized Anxiety Disorder, this might occur in a more pronounced manner as the lens through which I experience life. Anxiety would become the mode of being that defines my existence. Every element of my life would become that much more unmanageable. For example, anxiety may cause me to worry about the effectiveness of my role as a mother. Since my son has a heart condition, and my youngest came only after a miscarriage, these experiences could exacerbat GAD. I would worry about their well-being every minute of the day. The guilt I would feel about the fact that they eat too much junk food and stay up too late, may incapacitate me. Adding the responsibilities of a full time C.N.A. position and school work may prove overwhelming. Honestly, I’m not sure if I would be able to function in my current life circumstances.
Overall, eliminating some responsibilities from my life would be the easier solution. This would involve working less or quitting school, which I would happily do for the sake of my well-being. The difficult issue regarding GAD pertains to its affect on relationships and the ability to enjoy life. My husband wouldn’t have the partner he does currently, and would need to shoulder greater responsibilities. Everybody would also have to accommodate my GAD symptoms. Most importantly, I would be trapped inside a mind filled with anxiety while living a life defined by worry.
Raising a Child with GAD
The final question posed in this assignment is how different it might be to parent a child with GAD. As a parent to a child with a congenital heart defect, I have some insights worth mentioning. My oldest son has a congenital heart defect (CHD) called pulmonary atresia. Individuals with heart defects have what can be thought of as a “hidden disability” (CITE). While not readily visible upon initial inspection, the influences of a heart defect do require special consideration. In addition to the obvious physical limitations, there are also less obvious concerns. Social delays in males with CHD result from an inability to participate in sports, alongside prolonged stays in the hospital (Berant, et al, 2001; Horner, et la, 2000). Emotional developmental delays result from the parent-child relationship that occurs when a child is faced with a serious life-threatening illness (Berant, et al, 2001; Horner, et la, 2000). The most difficult thing about the experience, isn’t just the heightened anxiety and worry, but also the judgment from others (Berant, et al, 2001; Horner, et la, 2000). It requires time to recover from such a trauma, and your relationship with the child is changed. Children with CHD spend a significant time fighting for their life, and don’t have the same opportunities to engage in the normal childhood developmental process. Nonetheless, people may not realize this and simply notice deviations in a child’s level of emotional regulation that are generally expected at a certain age. The hardest part is the idea of wanting to support your child by giving what they need developmentally, in a world that judges them for unpalatable behavior. While this issue, doesn’t compare to parents of children with a serious mental health issue, this experience has enabled me to develop greater understanding and compassion.
American Psychiatric Association. (2013). Diagnostic and statistic manual of mental disorders. (5th ed.). Washington, D.C.: Author.
Berant, E., Mikulincer, M., & Victor, F. (2001). The association of mothers’ attachment style and their psychological reactions to the diagnosis of infant’s congenital heart disease. Journal =of Social and Clinical Psychology, 20(2), 208-232.
Brett, A. S. (2005). Modafinil for shift-work sleep disorder. NEJM Journal Watch General Medicine, doi:http://dx.doi.org/10.1056/JW200508260000004
Horner, T., Liberthson, R., & Jellinek, M. S. (2000). Psychosocial profile of adults with complex congenital heart disease. Mayo Clinic Proceedings, 75(1), 31-6.
Lambert, K., & Kinsley, C.H. (2011). Clinical neuroscience: The neurobiologicalfoundations of mental health. 2nd Ed., New York, NY: Worth Publishers
Preston, J.D., O’Neal, J.H., & Talaga, M.C. (2013). Handbook of clinical psychopharmacologyfor therapists (7thEd.) Oakland, CA: New Harbinger Publications, Inc
Vrijmoet-Wiersma, ,J.C.M., Ottenkamp, J., van Roozendaal, M., Grootenhuis, M. A., & Koopman, H. M. (2009). A multicentric study of disease-related stress, and perceived vulnerability, in parents of children with congenital cardiac disease. Cardiology in the Young, 19(6), 608-14.
(((I am currently studying for a licensure exam & completing an internship. This blog post is intended as a study exercise. In it, I review information from two papers, one defines the subject of psychopathology and the other is a brief overview of DSM diagnosis. It is not intended as a substitute for mental health counseling or diagnosis…)))
An Overview of Perspectives
If there is one thing that can be taken away from this week’s readings it is that a simplified definition of psychopathology is difficult to come by (Maddux & Winstead 2008; Patrick, 2012). What one conceives of as a mental disorder actually depends upon how one differentiates between normal and abnormal behavior. While abnormal can be understood as anything that deviates from what is considered “normal”, psychopathology refers to deficits in mental functioning. These deviations from a norm, require us to first examine how this standard is define. “Upon what basis is a diagnosis of psychopathology made?”
A social constructionist perspective abnormal might be defined as a deviation from social expectations and cultural norms. The problem with this perspective is that it does not take into account cross-cultural differences, or even longitudinal changes within an individual culture. With this in mind, it is worth noting that the DSM manual has been written from a very westernized cultural perspective.
Vernacular criteria, on the other hand, reflect’s a laymen’s perspective that reflects popular opinion, especially within the media. This viewpoint of psychopathology is often quite disparaging and riddled with stereotypical labels like “crazy”, “nuts”, or “psycho”.
Legally, psychopathology is concerned with the issue of mental competency and criminal responsibility. This perspective here is guided by whether an individual’s psychopathology allows for the use of an insanity defense.
Finally, the Diagnostic and Statistical Manual (DSM-5) utilizes a medical definition of mental health. Overall, this perspective might be useful to asses an individual’s ability function comfortably on a daily basis. In sum, mental health from this perspective can be thought of as an ability to deal with reality on “reality’s terms”.
A Medical Perspective of Psychopathology
The Nature of Psychopathology
Inherent, in our definition of normalcy is a valuation statement of who falls within these parameters (Maddux & Winstead, 2008; Patrick 2012). A few notable aspects of psychopathology’s nature are worth mentioning.
What is “Abnormal” Anyway?
Acording to Maddux, et al. (2008), “Abnormal literally means away from the norm. The word norm refers to what is typical average.” (p 4). This implies a comparison of individuals against a standard that dictates what t characterized are considered typical ina society. In his article titled “The Perils of ‘Adjustment Disorder’ as a Diagnostic Category”, John Daniels states that a “Disorder is a term that names any variation, perversion, or dysfunction outside the normal order, which is regarded as a proper composition of parts according to the classical scientific paradigm” (p79).
A balanced consideration of general and particular.
Mental health diagnosis involves an assessment of individual characteristics against an objective standard. However, behavior cannot be truly understood when separated from the perceptual meaning system of the individual. While scientific and socially relevant standards are essential for diagnosis, a holistic perspective of the individual from within their standpoint of understanding is also needed. (Gorostiza & Manes, 2011, p211). This balance seems at times to reflect a Hegelian dialectic.
In reality, the issue of psychopathology is quite complex, involving an array of internal and external variables. Understanding the issue in absence of the social context is a disservice to patients. (Maddux & Winstead, 2008, p12). Multicultural competency is of ever-increasing importance in the global society we live in.
The final thing to note about psychopathology, is it is not a static concept readily observed objectively. Instead, it is a continually evolving issue that develops as a result of a complex array of factors. This creates a problem for a medical perspective that perceives symptoms, as being related to readily understood causal factors (Gorostiza & Manes, 2011, p211). In reality, the issue of cause and effect within the realm of mental health is much more complex (Gorostiza & Manes, 2011, p211).
Psychopathology – A Medical Definition.
According to the medical field, psychopathology can be defined as an inability to function on a daily basis. Diagnosis is based on observed behavioral and psychological symptom patterns. (Maddux & Winstead, 2008). From a medical perspective, two key requirements are essential for understanding psychopathology: “(1) concepts must unambiguously refer to observed clinical phenomena, and (2) symptoms, understood as conceptualized clinical data, must be stabilized by a causal account” (Gorostiza & Manes, 2011, p205).
When considering the issue of psychopathology from this perspective the problem of contextual blindness is immediately apparent (Daniels, 78). On the one hand, psychopathology can be best thought of as a mental construct based on personal meaning systems that are highly fluid and complex in nature (Gorostiza & Manes, 2011). On the other hand, a medical perspective very objective and rigid in focus (Gorostiza & Manes, 2011). This contextual blindness has deep historical roots in the origins of medical science. In reality the concept of psychopathology, extends beyond the limited confines of a medical perspective (Daniels, 1009; Gorostiza & Manes, 2011; Maddux & Winstead, 2008). To ignore this fact is to miss key “pieces of the puzzle” In reality, “mental phenomena are referentially open” (Gorostiza & Manes, 2011, 214) as active processes that result from a dynamic interplay of complex factor. It is in this respect that counseling is a much-needed counterpoint to the medical perspective that predominates mental health.
Mental Health Diagnosis
Initial Thoughts & Reactions
My beliefs about mental health diagnosis have been greatly influenced by observations in acute mental health settings. Overall, I’m pleasantly surprised by the changes made in the new DSM-5 Manual. My assumptions and beliefs about diagnosis are listed below.
Diagnosis is a Messy Process
“In the real world, patients, like Shakespeare’s sorrows, tend to come not as single spies but battalions” (Morrison, 2014, p. 8). I love this quote from our textbook, because it summarizes my observations about mental health diagnosis. In acute care settings there is often an insufficient amount of time to gather all necessary information for a full evaluation. Currently, the idea of sorting through information in such a context seems daunting. My goal for this class is to develop a good picture of the process overall as it should occur in an ideal setting. Realistically, learning to apply it in a real world context will come with have to come with practice.
Cultural Relativism Matters
As an individual who was raised in culturally diverse setting, I believe culture permeates every facet of our development. Culture influences not only our values and beliefs, but also how we think, behave, and feel. An assigned reading in my Social and Ccultural Diversity class provides interesting commentary relevant to this discussion. Johnson, (2013) states, “Cultural factors can influence the expression and interpretation of signs and symptoms. For example, practitioners commonly perpetuate racial biases…some examiners using the DSM-5 may function with unexamined assumptions or inadequate training.” (p. 20). On the basis of these observations, I believe it is critical for therapists to consider the influence of culture in their assessments.
Objectivity Trumps Subjectivity
In an acute care setting, diagnosis occurs according to Morrison’s (2014) observation that “signs trump symptoms” (p. 9). For example, clinical observations are used to contextualize a patient’s story. One criticism I have is the over-reliance of this viewpoint in acute care settings. Managing behaviors and assuring safety in this setting is the priority over other concerns. Patient’s thoughts and feelings are contextualized in terms of a diagnosis. I feel when interacting with patients, time must also be taken to see beyond this diagnosis. As our textbook notes, a client’s “back story…provides meaning that illuminate(s) motives, actions, and emotions” (Morrison, 2014, p7). While objectivity is important acknowledging a client’s subjective experiences is also critical.
Open-Mindedness is Important
One final assumption I have about diagnosis and assessment is that they exist as a process and not an event. In this respect, I feel it is important to keep an open mind. Morrison, (2014) confirms this assumption with the following statement: “I want to encourage you to avoid a trap that any clinician can fall into: rushing headlong into diagnostic closure before having all the facts” (xii).
The Process of Diagnosis….
Diagnosis requires an understanding of etiology, the process of development, and possible treatment regimen. Underlying this information is empirical research and “evidence-based” practice. First in my old DSM class are notes on a plan of attack….
“The Plan of Attack”
The first step is your initial diagnostic impressions. This involves creating groupings of symptoms into syndromes and simply listing them. This is allows you to form an initial diagnostic impressions, containing a potential list of relevant diagnosis.
The second step is a differential diagnosis. Here, we narrow down our list of potential diagnoses. To accomplish this compare you compare observable symptoms with diagnostic criteria. This will help you decide which disorder (or disorders) best account for the symptoms. In class, we are asked to explain why we keep and reject a specific disorder and the logical underlying our decisions.
The last step is a final diagnosis. Your final diagnosis reflects the decision you made, the diagnosis you feel most accurately accounts for the symptoms presented. The actual format for recording your final diagnosis will vary some depending upon the agency, insurance requirements, etc. However, at a minninum the final diagnosis should be reported with the correct code number, title (capitalized), and any necessary specifiers. Most disorders have coding notes and instructions for what specifiers are needed at the end of the Diagnostic Criteria section.
Suggestions from Morrison
Last week’s readings provided an overview of the process of diagnosis. The initial steps of this process include gathering information and identifying syndromes (Morrison, 2014). With this information in hand, therapists must construct a list of potential alternatives and determine an initial diagnosis (Morrison, 2014). A differential diagnosis “is a comprehensive list of conditions that could account for a patient’s symptoms” (Morrison, 2014, p14). Strategies that can aid in the construction of a differential diagnosis were discussed in this week’s readings (Morrison, 2014). These strategies are helpful in sorting through a complexity of symptoms as well as preventing therapists from diagnostic conclusions prematurely.
Morrison, (2014), suggests placing a list of potential diagnoses for consideration in a safety hierarchy. At the top of this hierarchy, are conditions that require urgent treatment and are likely to respond well (Morrison, 2014). Additionally, disorders due to physical disease or substance abuse should also be placed on top (Morrison, 2014). At the bottom of the list are conditions that are hard to treat with difficult outcomes.
An example from my own life experiences proves the utility of this strategy. As an infant, my son went into shock at home. This is a medical condition in which there is a lack of blood flow throughout the body. Causes of shock include: hypovolemic shock, cardiogenic shock, anaphylactic shock and septic shock. When I rushed him to the hospital, doctors recognized the condition immediately. They utilized a safety hierarchy similar to what is discussed in our textbook. Starting with the easiest to treat diagnoses, they assessed for dehydration and infection. After ruling out all possible alternatives it was finally determined my son had a congenital heart defect and required surgery. This process very much falls in line with the logic utilized in our textbook.
Another strategy for differential diagnosis includes the decision tree. “A decision tree is a device that guides the user through a series of steps to arrive at some goal, such as diagnosis or treatment” (Morrison, 2014, p19). While not included in the DSM-5, the differential discussion sections under each diagnosis provide a similar logic. For example, the DSM-5 states the following regarding major neurocognitive disorder:
“[cognitive] difficulties must represent changes rather than lifelong patterns…[therapists must also] differentiate between [cognitive deficits] and motor or sensory limitations” (American Psychiatric Association, 2013, p608)
This insight suggests therapists must ask if observe deficits are the byproduct of recent events or symptoms of lifelong developmental patterns (American Psychiatric Association, 2013). Additionally, can cognitive deficits be explained by any sensory limitations, (American Psychiatric Association,
The final bit of information I’d like to remember for future reference pertains to the issue of diagnostic uncertainty. What follows are suggestions from our instructor in class:
First you have “Rule Out”
There is not a code for this but you write out “Rule Out” followed by a specific disorder. This means you have some evidence to suggest there could be a specific disorder, but not enough information to confirm or deny. For example, if parents suspect their son is using marijuana, you could record “Rule out Cannabis Use Disorder”. This essentially says you should be on the look out for more information. I would list something as “rule out” in my final diagnosis if questions still remain after going through the differential process.
Then you have “Provisional Diagnosis”.
This is given when you have a clear theory about a specific disorder, but need additional information to confirm. This would be appropriate if you need results from a specific test (blood levels to see if it is medication induced) or a physician’s verification of a physical condition. Perhaps you suspect substance use and the individual was not very cooperative, you may have a pretty good idea that they have a substance use disorder, but want this confirmed by another source such as a urine analysis. With Rule Out I am not as confident about the disorder, but there is some evidence to suggest it should be explored.
Finally There is “Other/Unspecified”
This is an actual diagnosis with the number determined by the class of disorders indicated. These cases are tricky and rely heavily on clinical judgment. “Other specified” is used when the presentation does not meet official criteria for a specific disorder within a specific a diagnostic class, but the clinician communicates or “specifies” the specific reason why this is the case. “Unspecified” also means the diagnosis does not meet the specific criteria but allows the clinician to choose not to explain the reason(s) why criteria are not met. The unspecified/other diagnoses are given when you have enough information to be confident that the client has a disorder in a specific class. This may occur because you do not have the complete picture of the symptoms or it may just be that this individual is experiencing the disorder in an atypical way so their pattern of symptoms does not quite match up. The key is that the symptoms clearly indicate a class of disorders. If you want to specify why they don’t quite match then use “Other specified”, if you don’t want to explain or cannot give a clear explanation then use “Unspecified”. However, please understand that you are giving a diagnosis with a code when you do this. You are saying they have a disorder.
Daniels, J. (2009). The perils of ‘adjustment disorder’ as a diagnostic category. Humanistic Counseling, Education and Development. 48(1). 77-90
Gorostiza, P.R. & Manes J.A. (2011). Misunderstanding psychopathology as medical semiology: An Epistemological inquiry. Psychopathology. 44, 205-215. doi: 10.1159/000322692.
Johnson, R. (2013) Forensic and Culturally Responsive Approach for the DSM-5: Just the FACTS. Journal of Theory Construction & Testing, 17(1), 18-22.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental healthclinicians, 2nd ed. New York, NY: The Guilford Press.
Maddux, J. & Winstead, B. (Eds.). (2008). Psychopathology: Foundations for a contemporary understanding (2nd ed.). New York, NY: Routledge. ISBN 978-0-8058-6169-3. (M&W)