DSM-5

Generalized Anxiety Disorder

(((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).

Therapist’s Role

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

The Overview

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.

Work-Day Weekends

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

Weekdays Off

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.

References

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
Greening, L. (2013). Generalised anxiety disorders. The Dissector, 41(2), 30-32. Retrieved fromhttp://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/1462047083?accountid=28125
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 neurobiological foundations of mental health. 2nd Ed., New York, NY: Worth Publishers
Preston, J.D., O’Neal, J.H., & Talaga, M.C. (2013). Handbook of clinical psychopharmacology for therapists (7th Ed.)  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.

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Psychopathology & DSM Diagnosis.

(((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?”

  1. 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.
  2. 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”.
  3. 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.
  4. 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.

Multicultural Competency.

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.

Causal complexity.

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”

  1. 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.
  2. 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.
  3. 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.

Safety Hierarchy

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.

Decision Tree

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,

Diagnostic Uncertainty

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.

References

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)
Patrick, C (2012). Bellevue University – Defining Abnormality Video. Available from: https://cyberactive.bellevue.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_278013_1%26url%3D
Warren, J. (2012) Psychopathology defined in context. [Class handout, HS-513, Dr. Jane Warren, Bellevue, University]

 

 

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Accurate Diagnosis of Psychosis

(((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 a paper on the accurate diagnosis of psychosis.  It is not intended as a substitute for mental health counseling or diagnosis…)))

Key features of schizophrenia and other psychotic disorders are: (1) delusions; (2) hallucinations; (3) disorganized thinking and speech; (4) disorganized behavior, and; (5) negative symptoms such as anhedonia (American Psychiatric Association, 2013).  This accurate diagnosis of psychotic disorders requires a thorough assessment of longitudinal and cross-sectional information. Many of these disorders are associated with time-related criteria that require close longitudinal observation. For example, brief psychotic disorder has a requirement that symptoms occur between one day and one month (American Psychiatric Association, 2013). Additionally, Schizophreniform disorder has a one to six month requirement, while schizophrenia applies to cases in which symptoms are present for at least six months (American Psychiatric Association, 2013). Other considerations confounding the diagnostic process include an array of comorbid diagnoses that must also be ruled out. For example, in order differentiate between schizoaffective disorder and a mood disorder with psychotic features, the temporal relationship between psychosis and mood is important (American Psychiatric Association, 2013). Finally, since substance use and medical diagnoses produce psychotic symptoms, they must also be ruled out (American Psychiatric Association, 2013). What follows are a list of considerations that can aid in the accurate diagnosis of schizophrenia and other psychotic disorders.

Information Required

There are two important considerations when accurately diagnosing psychotic disorders. Firstly, cross-sectional information and longitudinal observations should be thoroughly gathered (Morrison, 2014). Secondly, diagnostic principles can aid in the effective utilization of this information when sorting through differential diagnoses (Morrison, 2014). This section provides an overview of information necessary for the diagnosis of psychotic symptoms.

Cross-Sectional Information

Utility of the MSE.

Morrison, (2013) describes the Mental Status Exam (MSE) as a cross-sectional snapshot of an individual’s mental status at a particular point in time (p119). With this in mind, it is important to note the limitations of a MSE from a diagnostic perspective. Individually, MSE’s provide little temporally relevant data, vital to the accurate diagnosis of psychotic symptoms (Morrison, 2013). Nonetheless, several MSE’s over period of time can indicate the temporal occurrence of various symptoms as it pertains to diagnostic criteria. Additionally, an individual MSE provides “red flags” that indicate potential issues that require further assessment (Morrison, 2013; Robinson 2002). For example, symptoms in an MSE indicative of psychosis include: (1) hallucinations, (2) delusions, (3) disorganized speech (4) bizarre behavior, and (5) negative symptoms (American Psychiatric Association, 2013).   The utility of these symptoms as a “red flag” for psychosis are supported in Morrison’s (2013) “Diagnostic Tree For Psychotic Symptoms”. In this tool, Morrison (2013) excludes normality as a potential consideration by noting that “even the briefest psychoses warrant some sort of diagnosis” (p187).

Collateral information.

Alongside data from a MSE, collateral information such as a client’s medical history and interviews with family members, are also essential (Morrison, 2014). This collateral information provides a background against which to contextualize observations gathered in a MSE. This aids in the development of a differential diagnosis list that will guide the longitudinal observations required for final diagnosis of a psychotic disorder.

Longitudinal Observations

As stated earlier, the cross-sectional information discussed above, provides “red flags” that indicate potential issues in a client’s underlying symptomatology (Morrison, 2014; Robinson, 2002). Longitudinal observations are also vital to the diagnosis of the psychotic disorders since these diagnoses comprise temporally specific diagnostic criteria (American Psychiatric Association, 2013). What follows is a discussion of key considerations relevant to the longitudinal observations required in the diagnosis of psychotic disorders.

Differential Diagnosis.

The information described earlier, is useful in providing an overall impression of key issues present in a client’s underlying symptomatology (Weigel, March 30, 2015). Utilizing these concerns, a therapist can review diagnostic criteria for various diagnoses to produce a list of differential diagnoses (Weigel, March 30, 2015). These differential diagnoses are helpful as a guide in the longitudinal observations required for psychotic symptoms (Morrison, 2014). This differential diagnosis process begins from an inclusive perspective, as therapists consider “all alternative explanations” (Morrison, 2014, p14).

Assessing Negative Symptoms.

Morrison defines negative symptoms as observable functional deficits in individuals with a psychotic disorder (2014). These negative symptoms include: (1) diminished interests, (2) social isolation, (3) lack of motivation, (4) flattened affect, (5) diminished communication and (6) psychomotor activity (American Psychiatric Association, 2013). It is important to monitor negative symptoms on an ongoing basis since psychotic disorders are associated with a higher risk for depression and substance use (Morrison, 2014). Additionally, this information can aid in the assessment of comorbid diagnoses that alter the long-term prognosis of these patients (Morrison, 2014).

Onset & Duration of Symptoms.

Observations regarding the onset and duration of psychotic symptoms are helpful in differentiating between various psychotic disorders.  For example, while schizophrenia develops slowly, schizophreniform psychosis is associated with a rapid onset (Morrison, 2014). Additionally, while schizophrenia tends to emerge in late teens and twenties, psychotic disorders due to a medical condition aren’t associated with an age of onset (American Psychiatric Association, 2013). Finally, the duration of psychotic symptoms is also useful in differentiating between psychotic disorders.   As stated earlier, many psychotic disorders contain temporally specific criteria that aid in their differentiation (American Psychiatric Association, 2013).

Temporal Relationships.

The observation of temporal relationships between psychosis and other factors can also help rule out disorders in a list of differential diagnoses (Morrison, 2014). For example, differentiating between schizoaffective disorder and a mood disorder with psychosis, requires a careful observation of the relationship between psychosis and affective symptoms (Morrison 2014). Additionally, in order to determine if substance use underlies a psychotic episode, the causal relationship between these factors must be determined (Morrison, 2014). This can occur by simply observing if psychotic symptoms occurring independently of exposure to a substance.

Utilizing Information Diagnostically

In addition to gathering the information described above, knowledge of a few key principles and tools can aid in the accurate diagnosis of psychotic disorders. I briefly discuss these principles and tools described next.

The Diagnostic Tree

Morrison, (2014) provides a diagnostic tree for patients with psychotic symptoms that I found very beneficial in clearing much of my confusion (p189). The logic, which underlies the steps in this diagnostic tree, can help sort through observations diagnostically. A thorough review of this tool is beyond the scope of this paper.   Therefore, I will only review the initial steps in this tool to highlight the inherent logic within it.

  1. STEP ONE – Step one of Morrison’s (2014) diagnostic tree first suggests ruling out psychotic symptoms caused by underlying medical diagnoses (p189). This step relates to a diagnostic principle discussed by Morrison (2014), that states: “Physical symptoms and their treatment can produce or worsen mental symptoms” (p16).
  2. STEP TWO – Step two suggests therapists assess for a history of substance use in order to rule this out as an underlying cause of psychosis (Morrison, 2014). This suggestion relates to the fact that a substance induced psychotic disorder can appear cross-sectionally similar to psychosis (American Psychiatric Association, 2013).
  3. STEP THREE – The DSM-5 manual states that many neurocognitive disorders can present with behavioral disturbances that have psychotic features (American Psychiatric Association, 2013). In light of this fact, the diagnostic tree suggests looking out for a history of dementia or delirium and rule out differential diagnoses accordingly (Morrison, 2014).
  4. STEP FOUR – Morrison (2014) states that “somatizing patients report hallucinations or delusions that superficially resemble those of schizophrenia” (p188). The DSM-5 states that differences in the relative strength of these symptoms can help differentiate psychotic disorders from somatizing symptoms (American Psychiatric Association, 2013).   In light of these facts, the diagnostic tree suggests considering somatic symptoms when attempting to rule out disorders in a differential diagnosis list (Morrison, 2013).

Diagnostic Principles  

Other principles can be found in the DSM-5 that can help in utilizing information effectively from a diagnostic perspective.   The DSM-5 states that clinicians should first consider “diagnoses that do not reach full criteria for a psychotic disorder or are limited to on domain of psychopathology” (American Psychiatric Association, 2013, p88). After these diagnoses are ruled out, the DSM-5 then suggests that time-limited conditions be considered next (American Psychiatric Association, 2013). Finally schizophrenia is determined only after all other possibilities have been excluded (American Psychiatric Association, 2013). This insight reflects an early observation of the DSM-5 that much thought has gone into the organization of diagnoses in each chapter.

Assessment Plan for Substance Use & Psychosis

The final question posed for this assignment asks us to consider how we would assess individuals with psychotic symptoms and a substance use history. What follows is an overview of important considerations that can aid in this process.

Understanding The Problem

            Several facts shed light on the importance of assessing for a substance use history in individuals with psychotic symptoms. Firstly, rates of comorbidity for substance use are high in individuals with a diagnosis of schizophrenia (Morrison, 2014). Additionally, substance use is associated with a poorer prognosis for individuals with a psychotic disorder (Rosenthal & Miner, 1997; Schanzer, 2006). Finally, inappropriate treatment regimens are often the consequence of a failure to recognize a substance use issue (Rosenthal & Miner, 1997; Schanzer, 2006). These problems are also frequently exacerbated by the fact that these co-occurring symptoms are difficult to sort through emergently (Schanzer, 2006).   This is especially concerning since 17-37% of individuals with a first-episode of psychosis are found to have symptoms of substance use (Schanzer, 2006).

Developing a Solution

Creating a differential diagnosis list that addresses all presenting concerns can be helpful in addressing the issues discussed above (Morrison, 2014). As stated earlier, many psychotic episodes in patients with a substance use disorder appear cross-sectionally similar to psychotic disorders (American Psychiatric Association, 2013). This fact sheds light on the importance of carefully assessing an individual’s substance use history from the outset. In addition to obtaining a substance use history from the client, collateral data from medical records and family members can aid in the clarification of matters.   Following these clients closely and noting the temporal relationship between psychotic features and substance use aid therapists in determining a final diagnosis (Morrison, 2014; Rosenthal & Miner, 1997; Schanzer, 2006). In the interim, diagnostic uncertainty can be addressed by listing substance use concerns either as a provisional diagnosis, or disorder to rule out (Weigel, March 30, 2015). This can ensure a patient receives the substance abuse treatment they need, while a final diagnose is determined (Weigel, March, 30, 2015).

Understanding Diagnostic Criteria  

One final consideration that can aid in a plan to assess the co-occurring substance use and psychosis symptoms, is a thorough review of all relevant diagnostic criteria.   A review of insights from the DSM-5 pertaining to the assessment of substance use and psychosis is next (American Psychiatric Association, 2013). Overall, longitudinal observations are vital to determining the temporal relationship between substance use and psychosis (Morrison, 2014).

  1. Substance/Medication-Induced Psychotic Disorder (SMIPD): This disorder is indicated when hallucinations and delusions occur upon ingestion of a substance with resolution of symptoms after withdrawal (American Psychiatric Association, 2013). Atypical features, not generally associated with a psychotic disorder can also be supportive this diagnosis (American Psychiatric Association, 2013).
  2. Substance Abuse & Withdrawal: Altered perceptions are commonly associated with substance abuse withdrawal. Nonetheless, this issue is differentiated from SMIPD and psychosis due to the presence of reality testing abilities during the experience of altered perceptions (American Psychiatric Association, 2013).
  3. Dual-Diagnosis (Vern & Ted): Morrison, (2014), provides two case studies that show how a dual diagnosis can be differentiated from either SMIPD or substance withdrawal. In the case study of Vern, there exists a long-term history of schizophrenia that has been well managed. A sudden worsening of psychotic symptoms is observed alongside a known ingestion of substance. In contrast, the case study of Ted shows an individual with a long substance use history alongside a recent diagnosis of schizophrenia. After reviewing these cases, Morrison, (2013), stresses the importance of addressing all symptoms. Dr. Weigel, (April 10, 2015), states that if symptoms are “left over” from one diagnosis and unaddressed then comorbidity is indicated and a dual diagnosis should be considered.

References

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.
Robinson, D (2002). Mental Status Exam Explained, 2nd ed. Rapid Psychler.
Rosenthal, R. N., & Miner, C. R. (1997). Differential diagnosis of substance-induced psychosis and schizophrenia in patients with substance use disorders. Schizophrenia Bulletin, 23(2), 187-193.
Schanzer, B. M., First, M. B., Dominguez, B., Hasin, D. S., & Caton, C. L. M. (2006).  Diagnosing psychotic disorders in the emergency department in the context of substance use. Psychiatric Services, 57(10), 1468-73. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/213086869?accountid=28125
Weigel, S. (March 30, 2015). First set of cases [Online Forum] Retrieved from:  https://cyberactive.bellevue.edu/webapps/discussionboard/do/message?action=list_messages&forum_id=_1439057_1&nav=discussion_board_entry&conf_id=_391549_1&course_id=_333876_1&message_id=_27780353_1#msg__27780353_1Id
Weigel, S. (April 10, 2015). Re-using symptoms [Online Forum] Retrieved from:  https://cyberactive.bellevue.edu/webapps/discussionboard/do/message?action=list_messages&forum_id=_1439060_1&nav=discussion_board_entry&conf_id=_391549_1&course_id=_333876_1&message_id=_27847648_1#msg__27847648_1Id

 

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Childhood Onset Schizophrenia

(((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 papers I’ve written on childhood onset schizophrenia. It is not intended as a substitute for mental health counseling or diagnosis…)))

COS is characterized by an onset of psychosis prior to the age of thirteen (Khurana, et al, 2007). According to the DSM-5 Manual the characteristics of schizophrenia are identical in children and adults (American Psychiatric Association, 2013). However, while childhood-onset schizophrenia has a similar set of symptoms, its psychopathology is unique.   For this reason, it is much more difficult to diagnose. Hallucinations and delusions are often confused with fantasy play and difficult to distinguish from childish, idiosyncratic thinking (American Psychiatric Association, 2013; Khurana, et al, 2007). Disorganized cognition is often confused with autism or ADHD, and negative symptoms are frequently confused with bipolar disorder or developmental delay (Khurana, et al, 2007; Orvaschel, et al, 2001). Adding to this complexity is the fact that the onset of COS is gradual. Premorbid symptoms, such as minor neurological deficits, motor delays and social withdrawal are difficult to attribute to a clear cause for this reason (Khurana, et al, 2007).

Diagnostic Criteria

Criterion A for Schizophrenia requires the presence of delusions, hallucinations, and disorganized speech for at least one month (American Psychiatric Association, 2013).   Other criterion, include diminished functioning and continuous signs of disturbance for six months, including residual and prodromal periods (American Psychiatric Association, 2013). Due to the temporally specific criteria, longitudinal observation is critical for accurate diagnosis. Morrison’s (2014) diagnostic tree for psychosis suggests first ruling out medical diagnosis as an underlying cause for psychotic symptoms. Addressing neurocognitive deficits then requires considering developmental disorders or psychosis as an explanation (Morrison, 2014). The timing psychotic and depressive symptoms can then help differentiate a bipolar disorder and a psychotic disorder (Morrison, 2014). Finally, observing the length of time psychotic symptoms can be helpful when differentiating between the psychotic disorders (Morrison, 2014).

While the essential characteristics of schizophrenia are identical in children, developmental considerations make it more difficult to diagnose (American Psychiatric Association, 2013; Orvashel, et al, 2001). For example, hallucinations and delusions are often less complex, and need to be differentiated from imaginative and fantasy play (American Psychiatric Association, 2013; Orvashel, et al, 2001). Additionally, the DSM-5 manual cautions against attributing disorganized speech and thought to schizophrenia in children without first considering more common issues (American Psychiatric Association, 2013).  In order to account for these developmental differences, adjustments must be made to the process of diagnosis. For example, collaborative information from significant adults in the child’s life, are essential when assessing symptoms associated with this disorder (Patterson, et al, 2009). Additionally, a systems perspective can be helpful when considering the impact of the family situation on presenting symptomatology (Patterson, et al, 2009). Orvashel, et al, (2001) state that treatments must also be adapted to a child’s developmental needs. For example, psychosocial treatment methods can help address the effects of interpersonal relationship issues on adjustment and progression of schizophrenia (Orvashel, et al, 2001).   Additionally, these treatment methods might be helpful for child’s family who is trying to cope with the complex symptoms associated with this disorder (Orvashel, et al, 2001)

Assessment Considerations

Longtudinal Observation of Symptoms

The core issue of COS is an impaired reality testing ability, which produces many of the positive symptoms it is known for (Orvaschel, et al, 2001). As a severe form of schizophrenia with a guarded prognosis, COS is difficult diagnose without an understanding of childhood development and schizophrenic psychopathology.   The logic underlying this DSM-5 diagnosis is phenomenological and no clear cause has yet been determined (Velligan & Alphs, 2013). Instead, COS is a byproduct of an interaction between environmental stressors (i.e. dysfunctional family environments) with individual vulnerabilities (i.e. brain abnormality), (Patterson, et al, 2009).   Consequently, a judicious and longitudinal assessment of symptoms is critical which includes information from multiple sources (the school system, the family, and the child). Thorough medical and neuropsychological assessments are also important to rule out this as a cause for symptoms of psychosis.

Developmentally Appropriate Assessment

Assessment of COS requires an array of collaborative information and developmental considerations. Due to developmental deficits, young children will have difficulty verbalizing abstract verbal concepts. As a result, adjustments must be made throughout the assessment process (Orvaschel, et al, 2001). Caution should be taken when assessing delusions and hallucinations (Orvaschel, et al, 2001). Delusions tend to exceed the imaginative thinking common in child.   Instead they involve fixed and erroneous beliefs that are frequently terrifying, compelling suffers to engage in irrational behavior (Khurana, et al, 2007).   Additionally, while phobic hallucinations are common in anxiety-related disorders during childhood, the majority of children reporting hallucinations do not have COS (Khurana, et al, 2009; Orvashel, et al, 2001). Play therapy techniques can provide effective solutions to assessing disordered thinking. For example, one resource for this paper described a “Formal Thought Disorder Story Game” (Orvashel, et al, 2001, p419), as a useful assessment of this symptom. Negative symptomatology, (including blunted affect, anhedonia, lack of motivation, and depression) should also be monitored. Several resources for this article stated that suicide ideology is especially common in COS suffers (Khurana, et al, 2007; Velligan & Alphs, 2013

A Systems Perspective

Before concluding this paper, I feel it is important to briefly mention the importance of a System’s Perspective. Common in Marriage & Family Therapy, this theoretical viewpoint sees cause as a circular, rather than linear concept (Patterson, et al, 2007). Utilizing this perspective, a therapist is forced to ask how multiple systems affect the child’s presenting symptomatology (Patterson, et al, 2007).   How does the home environment affect the child? How are the school systems and child’s peer relationships, affecting their academic achievements? Asking questions such as these will require a strong collaborative relationship with the parents and the child so that all information can be gathered.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author
Greenstein, D., Kataria, R., Gochman, P., Dasgupta, A., Malley, J. D., Rapoport, J., & Gogtay. (2014). Looking for childhood-onset schizophrenia: Diagnostic algorithms for classifying children and adolescents with psychosis. Journal of child and adolescent psychopharmacology, 24(7), 366-373.
Khurana, A. (2007). Childhood-onset schizophrenia: Diagnostic and treatment challenges. Psychiatric times, 24(2), 33.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians, 2nd ed. New York: Guilford Press.
Orvaschel, H., Faust, J., & Hersen, M. (Eds.). (2001). Handbook of conceptualization and treatment of child psychopathology. Oxford, UL: Elsevier LTD.
Patterson, J., Williams, L, Edwards, T., Chamow, L. & Grauf-Grounds, C. (2009). Essential Skills in Family Therapy: From the First Interview to Termination. New York: Guilford Press.
Velligan, D.I, & Alphs, L.D. (2013). Negative symptoms in schizophrenia: The importance of identification and treatment. Psychiatric Times, 30(5), 24-26.

 

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Schizophrenia

(((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 papers I’ve written on the subject of schizophrenia.  It is not intended as a substitute for mental health counseling or diagnosis…)))

Schizophrenia is an illness associated with disabling symptoms & a distorted view of reality (Blaney & Millon, 2009). Symptoms associated with this diagnosis include, hallucinations, delusions, disorganized speech and thoughts as well as catatonic behaviors, and negative symptoms such as anhedonia (Beck & Rector, 2005).

Positive Symptoms

Definition & Explanation

Positive symptoms of schizophrenia include issues most readily associated with psychotic disorders that are noticeably absent in the unaffected population (Morrison, 2014; Schizophrenia Symptoms, 2008). In contrast to negative symptoms, positive symptoms add vivid descriptive detail to the clinical picture of Schizophrenic and Psychotic Disorders (Morrison, 2014; Robinson, 2002). What follows is a list of positive symptoms of schizophrenia (Andraesen, 1984a; Morrison, 2014; Robinson, 2002; Schizophrenia Symptoms, 2008):

  1. Hallucinations
  2. Delusions
  3. Disorganized & Bizarre Behavior
  4. Formal Thought Disorder
  5. Disorganized Mood & Affect

MSE Assessment.

While negative symptoms contribute more to the functional outcome and quality of life for schizophrenia, positive symptoms receive significantly greater attention (Velligan & Alphs, 2014). The primary reason is that positive symptoms are easier to diagnose and recognize, for clinicians as well as suffers (Velligan & Alphs, 2014). As a result, there currently exists a wider array of treatment for positive symptoms (Velligan & Alphs, 2014). This week’s readings provide a great overview of how to assess positive symptoms in a MSE:

  1. Appearance – Psychotic Disorders are commonly associated with an unkempt and disorganized appearance (Morrison, 2014; Robinson). Additionally, Morrison (2013) mentions a list of factors that can help differentiate between diagnoses in this category, including age, marital status, and age of onset (p214)
  2. Behavior – Positive symptoms are most readily associated with the presentation of disorganized and bizarre behavior. Other positive behavioral symptoms can include psychomotor retardation, movement abnormalities and negative symptoms (Robinson, 2002).
  3. Cooperation & Reliability – Morrison (2014) suggests that client reliability and cooperation may vary greatly within this diagnostic category. As a result, it is especially important to attain collateral information from family and the patient’s history.
  4. Speech – Incoherent speech characterized by loose association and derailment, can also represent positive symptoms of paranoid disorders assessed in a MSE (Morrison, 2014)
  5. Thought Form/Process/Content – Delusions can be found when assessing thought form and content in a MSE (Morrison, 2013; Robinson, 2002). Loose associations, and thought derailment can be found when assessing how thoughts are organized (Morrison, 2013; Robinson, 2002).
  6. Mood & Affect – Incongruency between mood and affect is a positive symptom of psychotic disorders that can also be assessed in a mental status exam (Morrison, 2013)
  7. Perception/Insight & Judgment – Hallucinations are a positive symptom of schizophrenia spectrum and psychotic disorders that can be assessed in a MSE (Morrison, 2013; Robinson, 2002). Additionally deficits in insight and judgment are also common in these disorders.

Negative Symptoms

Definition & Examples

Negative symptoms refer to deficits in an individual’s clinical presentation when compared to the unaffected population (Morrison, 2014; Robinson, 2002). In other words, while positive symptoms refer to psychotic symptoms, negative symptoms refer to functional deficits (Morrison, 2014; Robins, 2002).   Negative symptoms include primary and secondary subtypes (Velligan & Alphs, 2013). Primary negative symptoms are associated with “core pathology of schizophrenia” (Velligan & Alphs, 2013, p24) and are present from a disorder’s onset. Secondary negative symptoms occur later as a byproduct of issues, such as medication side effects, environmental factors, and disease processes (Velligan & Alphs, 2014).   This differentiation is vital because it points at an underlying etiology. For example, social isolation resulting from paranoia is a primary negative symptom, whereas akinesia resulting from antipsychotic medication is a secondary negative symptom (Velligan & Alphs, 2014). As a collectivity, primary negative symptoms are referred to as a “Deficit Syndrome” (Velligan & Alphs, 2014). Examples of negative symptoms include the following (Andraesen, 1984b; Morrison, 2014; Robinson, 2002; Velligan & Alphs, 2014):

Decreased eye contact

  1. Inattentiveness
  2. Avolition, Apathy & Anhedondia
  3. Alogia – Poverty of Speech
  4. Inattentiveness, & Inactivity
  5. Diminished Interests
  6. Increase in Cognitive Deficits
  7. Social withdrawal
  8. Lack of Motivation

MSE Assessment

Negative symptoms contribute significantly to the morbidity and prognosis of schizophrenia and related psychotic disorders (American Psychiatric Association, 2013; Velligan & Alphs, 2014). Nonetheless, they are much less prominent and more difficult to diagnose (American Psychiatric Association, 2013; Velligan & Alphs, 2014). Sufferers are frequently unaware of the presence of negative symptoms and rarely report them (Velligan & Alphs, 2014). Additionally, negative symptoms frequently receive significantly less attention in treatment diagnosis and treatment (American Psychiatric Association, 2013).   Morrison’s (2013) case study of Jeannie, an individual with a dual diagnosis of depression and schizophrenia, highlights the importance of addressing these issues. The biggest lesson from this story is the idea that we thoroughly address all symptoms in the diagnostic process.

Since many sufferers of schizophrenia and other psychotic disorders are largely unaware of negative symptoms, it is important to specifically ask about them. For example, Velligan & Alphs, (2014) suggest starting with the following question: “Starting from the time you get up, could you tell me how you have spent a typical day?” (p25) Observing a client’s response to such a question, can aid in the assessment of negative symptoms in a MSE. Velligan & Alphs (2014) provide a great list of negative symptoms that can be observed in a MSE (p24). It is useful in contrast to the above description of positive symptoms also found in a MSE.

  1. Communication – Negative symptoms are associated with the production of very little speech and require prodding and cueing throughout an interview (Velligan & Alphs, 2014).
  2. Emotion/Affect – Negative symptoms also include blunted and flat affect. These symptoms can be seen in the form of a limited range of emotional response, alongside the expression of feelings of anhedonia (Velligan & Alphs, 2014).
  3. Social Activity – Significantly limited interests, social isolation alongside a diminished interest in relationships are another negative symptom that can be assessed in a MSE (Velligan & Alphs, 2014).
  4. Motivation – A lack of motivation can be associated with deficient grooming, and overall attitude disinterest (Velligan & Alphs, 2014).
  5. Psychomotor Activity – The reduction and/or absence of psychomotor activity is also associated with negative symptoms of psychotic disorders (Velligan & Alphs, 2014).

Understanding the Cause: A Diathesis Stress Model

Lambert & Kinsley, (2011), briefly mention a diathesis stress model of schizophrenia which suggests that it a result of the interactive effects of a person’s makeup and environment stressors.   In an article titled “Cognitive Approaches to Schizophrenia”, Aaron Beck and Neil Rector provide insight into the pathogenic development of this disorder (Beck & Rector, 2005). In some individual’s, pre-existing neurocognitive impairments cause them more prone to this disorder. When encounter problematic life events, “highly stressful conditions [can] lead to dysfunctional beliefs and, consequently, dysfunctional cognitive appraisals and maladaptive behaviors.” (Beck & Rector, 2005, p579).  As time progresses the dysfunctional beliefs and cognitive distortions lead to more stressful life experiences and heightened pathophysiological stress in response to them.  These stresses, then cause further neurological impairments in a feedback-loop fashion.  “The repeated cycling of these psychological and physiological reactions lead to a cognitive decompensation and the clinical syndrome of schizophrenia” (Beck & Rector, 2005, p579).

Research has shown that early deficits can lead to later pathophysiological development, until schizophrenic symptoms finally arise (Preston, et al, 2013). The neurodevelopmental model of schizophrenia states that a series of abnormal processes are underway well before symptoms emerge.  Longitudinal epidemiological studies show a strong familial component in support of a biological predisposition. Environmental factors include low birth weight, prenatal infection and risk, as well as abnormalities in placental development and function (Rapoport, et al, 2012).  A history that includes childhood traumas, urban environments, also put individual at risk, indicating a stress-related factor in the development of schizophrenia (Rapoport, et al, 2012).

Neuroimaging Studies

Neuroimaging studies indicate that gray mater loss is specific to individuals with early childhood onset schizophrenia (Rapoport, et al, 2012). In contrast adult-onset schizophrenia is associated with small thalamus volume and enlarged ventricles (Rapoport, et al, 2012). Individuals who are at highest risk for schizophrenia show a less white matter in the fronto-occipital area (Rapoport, et al, 2012).

Pre-Symptomatic Indicators

In support of the pruning model of schizophrenia, several studies show that an effective growth and pruning process occurs in early brain development (Rapoport, et al, 2012). Additionally, brain abnormalities are noted in children that predate the onset of an illness such as brain cortical thinning (Rapoport, et al, 2012). Additionally, early onset schizophrenia is most strongly correlated with genetic error (Rapoport, et al, 2012).

Post-Mortem Studies

Post-mortem studies appear to provide further support for the notion of ineffective pruning (Rapoport, et al, 2012). Additionally, post-mortem studies also indicate that ineffective DNA transcription may underlie the developing schizophrenic brain (Rapoport, et al, 2012). Finally, this article mentions several studies that point at defects GABA neurotransmission as highly correlated with schizophrenia (Rapoport, et al, 2012).

Medication & Stages of Schizophrenia

Schizophrenia has three stages: a prodromal phase, active phase, and residual phase (Lambert & Kinsley, 2011; Preston, et al, 2013). Symptoms vary greatly depending on the specific stage of the disorder. Treatment considerations vary greatly depending on the stage of schizophrenia, the client is exhibiting.

Prodromal Phase

“During the prodromal phase, patients show a deterioration in their level of functioning” (Preston, et al, 2013, p130). During this phase, no positive symptoms of psychosis appear: including delusions, hallucinations, bizarre behavior (Lambert & Kinsley, 2011; Preston, et al, 2013). If these symptoms occur at all, they are much less intense like “misperceptions and…subdelusional changes” (Lieberman, et al, 2012, p58). Instead, prodromal phase symptoms involve distractibility, loss of motivation, depression, blunted affect, and declining functionality (Lieberman, et al, 2012; Preston, et al, 2013). Currently antipsychotic medications are geared toward active phase symptoms, and no treatment regimen exists to prevent psychosis. However, research shows a kindling effect at hand with each successive psychotic episode, as noted by brain changes and declining function (Lambert & Kinsley, et al; Preston, et al, 2013).

Treatment during the prodromal phase requires family education and management of negative symptoms. This family education can involve helping with the recognition of symptoms, such as “subdelusional changes….attenuated hallucinations” (Lieberman, et al, 2012, p59) that indicate a risk for an upcoming psychotic phase. Velligan & Alphs, (2013), mention that while negative symptoms contribute more to a person’s overall functioning and quality of life, few treatments exists. An adjustment in the client’s antipsychotics may be in order, where they produce negative symptoms. Antidepressants are useful in addressing a client’s negative mood and amotivational state. Finally, addressing other side effects of antipsychotics may require the use of antiparkinson medications, and propranolol (Preston, et al, 2013).

Active Phase

During the active phase of schizophrenia, all the classic symptoms of psychosis are present, including delusions, hallucinations, bizarre thoughts and behaviors (American Psychiatric Association 2013). Antipsychotic medications are useful in the treatment of active phase symptoms. First generation psychotics such as Thorazine are designed to address these positive symptoms by blocking the reuptake of Dopamine (Preston, et al, 2013). However, these medications produce a wide array of neurochemical effects throughout the brain and cause an array unpleasant side effects. These side effects include akathisia, depressive symptoms, and extrapyramidal side effects. Addressing these side effects with medication will also be required.
As an alternative, second generation antipsychotics, may be a better choice for clients due to their ability to address both positive and negative symptoms (Preston, et al, 2013). These medication block the reuptake of serotonin, and have fewer unpleasant side effects. Finally, it is important to note that often patients, over time, will require proper psychoeducation to better understand and recognize psychosis when it happens. This can, in time, allow them to better appreciate the actual extent of how these symptoms may hamper their overall functioning.

Residual Phase

In the residual phase of schizophrenia, a patient’s positive symptoms of psychosis are in remission (Lieberman, et al, 2012). Nonetheless, in order to prevent relapse, it is likely the patient will be required to take antipsychotics. “In the residual phase, the patient continues to be impaired but without psychotic symptoms. Social isolation and peculiar affect…may persist” (Preston, et al, 2013, p130). Preventing relapse and addressing negative symptoms are two key priorities during the relapse phase. Lieberman, et al, (2012) state that recovery is increasingly problematic with each successive psychotic phase, and neurodegneration is often the result. In addition to the antipsychotics, as mentioned in the active phase, it will be important to address both side effects and negative symptoms. This can be addressed with medications such as: antidepressants, antiparkinson drugs, benzodizapenes, lithium, and propaolol (Preston et al, 2013).

Other Treatment Considerations….

Advocacy – Addressing the Treatment Gap

In an article titled “The Treatment Gap in Mental Health Care”, by Richard Kohn, is the introduction of an intriguing concept relevant to the discussion:

“If (mental) disability is to be reduced, a bridging of the ‘treatment gap’ must occur. The treatment represents the absolute difference between the true prevalence of a disorder and the treated proportion of individuals affected by the disorder.   Alternatively, the treatment gap may be expressed as the percentage of individuals who require but do not receive treatment.” (Kohn, et al, 2004, p859).

This notion, adds to a relevant insight from the assigned videos this week that illuminates the fact that a majority of schizophrenia patients don’t receive the care they need. (Film Media Group, 1998; Film Media Group, 2003). Proposed causes for this gap in treatment are associated with an array of factors, including (1) a limited availability of services; (2) cost-prohibitive barriers; (3) delays in seeking treatment; (4) social stigma and lack of knowledge. When taking all these factors, alongside the nature of schizophrenia, it is clear that this population has difficulty advocating for its own needs. It is therefore of primary importance that mental health professionals, caring for this population, do so.

Mind you, these advocacy efforts would ideally occur at multiple levels. Firstly, this advocacy can involve assisting patients who are seeking outpatient and community based services. Knowing the available services for these clients, and helping them attain access to these services will be important. Secondly, other suggested advocacy efforts could involve community-based work.   This might mean, educating the public on the nature of the disorder as well as campaigning for the availability of funds and services.

Family-Based Psychosocial Education.

As is clear, from the assigned videos this week, schizophrenia doesn’t appear to just affect the individual, but everyone in their lives as well (Film Media Group, 1998; Film Media Group, 2003). Additionally, it seems the ability to function effectively in the real world is determined to a great degree by the nature of the home environment, interpersonal relationships (Film Media Group, 1998; Film Media Group, 2003).   With this in mind, it is clear that psychosocial education for the individual as well as their family is an essential component in the treatment and care of this group. What follows is a brief listing of suggestions to help provide family-based psychosocial education for schizophrenia patients.

Assessing The Situation.

Assessing the quality of a client’s relationship with loved one’s is important, as is the level emotional dynamics of the home environment. Additionally, alongside an assessment of the patient’s current level of functioning, it would be useful to examine how this affects family members. How have the coped, and what is their understanding regarding the client’s illness?

Developing Collaborative-Relationship.

With this assessment in place it will be vital to begin developing a collaborative relationship with family members. This can involve communicating with them the nature of the illness and how it is influenced by family dynamics and relationships (McFarlane, et al, 2003, 224). Working with the family over the long term to address these factors would ideally mean helping them understand the disorder, and how specific interactions can influences symptoms. Getting the family involved in the process of psychosocial rehabilitation for the sake of the client will be essential (McFarlane, et al, 2003, 224).

Family Based Education.

Helping the family understand the nature of the disorder is a related issue that also appears crucial. As was clear in the videos assigned for this week showed, outcomes appeared to be correlated with the family’s awareness and understanding of the disorder.

Access to Community Support Networks.

Addressing the family’s coping with the patient’s illness is a vital component of the treatment process. In addition to participating in therapy, helping family members access community social support networks is helpful. It can provide them with another useful outlet, if for no other reason than helping them understand they aren’t alone.

Cognitive Behavioral Interventions.

In an article titled “Cognitive Approaches to Schizophrenia” by Aaron Beck is important interventional strategies to help those with this disorder.   From the standpoint of Cognitive Behavioral Therapy, a few key issues appear to stand out for Beck. Firstly, he makes a point to note the deficits in “reality testing” that come with notions and ideas that have a highly emotionally charged component (Beck & Rector, 2005, p581). This unwillingness to test reality appears to prevent them from being able to consider wrongness in their notions or beliefs. Secondly, of note to Beck is the idea that delusions may be characterized as a unique and problematic cognitive pattern (Beck & Rector, 2005 p583). From the standpoint of Beck’s explanation, these delusions appear to be based on “idiosyncratic beliefs” (Beck & Rector, 2005 p583).   With these idiosyncratic beliefs in place, impervious to reality testing, it appears their perceptions and personal world is defined largely by their nature. With this in mind, what brief listing of interventional techniques might Beck suggest?

As a structured and time-limited approach, Beck’s approach appears to be aimed at first developing a trusting relationship upon which guided discovery can take place (Beck & Rector, 2005 p598). Alongside a formal assessment of client’s symptoms, an educational process about the nature of their illness will be vital.   With a trusting relationship in place, a normalization process occurs, in which a client’s sharing of symptoms are explained in terms of relevant diagnosis (Beck & Rector, 2005 p598).   The goal of this, according to Beck, is a reducing in Stigma, and further building of trust in the therapeutic relationship.   Later in the therapeutic process, the guided discovery process may occur in which therapists help clients understand relationship between feelings, thoughts and behaviors. With a gradual development in understanding of this from the client’s point of view, a Socratic dialogue may take place.

“Therapists questioning mode provides the context for patients to generate a range of alternative explanations for their experiences. With repeated practice in generating alternative explanations in the therapists’ office and then routinely in homework sessions, the patient can begin to respond to life events ore flexibly and thus reduce the delusional beliefs. In addition to verbal strategies, the cognitive therapist aims to institute change in delusional thinking by setting up behavioral experiments to test the accuracy of different interpretations. “ (Beck & Rector, 2005, p599)

Skillful Pharmacological Management.

While outside the scope of a therapists practice, it warrants mention that several resources of this article pointed towards inadequate pharmacological management as a key issue (Razali, et al, 2000; Ryu, et al, 2006). There are several reasons cited for this. Firstly, mention was made to the poor coordination of services that exists as one underlying cause. Secondly, other reasons for this include, a lack of attentive care to the responsiveness to therapies. Failing to carefully examine a clients responses to medication and assessing this is another problem.

Again, while this isn’t something a therapist may be involved in, it might be useful to note again the therapist’s role as an advocate for the patient. Helping to coordinate the many services and providers the client sees, is vital. Additionally, observing a client’s reaction, presenting symptoms, and communicating this to the psychiatrist may be useful.   Working to create a coordinated treatment effort, can be yet another vital role for the therapist in these cases. 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author
Andreasen, Nancy C. (1984a) Scale for the assessment of negative symptoms. Iowa City: University of Iowa.
Andreasen, N. C. (1984b). Scale for the assessment of negative symptoms. Iowa City: University of Iowa.
Beck, A.T.; & Rector, N.A. (2005) Cognitive Approaches to Schizoprhenia: Therory & Therapy. Annual Review of Clinical Psychology. 1 577-606.
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)
Films Media Group. (1998). Schizophrenia: New definitions, new therapies [H.264]. Available from  http://digital.films.com/PortalPlaylists.aspx?aid=2914&xtid=10045.
Films Media Group. (2003). People say I’m crazy [H.264]. Available from http://digital.films.com/PortalPlaylists.aspx?aid=2914&xtid=37647
Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004). The treatment gap in mental health care.
Lambert, K., & Kinsley, C.H. (2011). Clinical neuroscience: The neurobiological foundations of
mental health. 2nd Ed., New York, NY: Worth Publishers
Lieberman, J.A., Stroup, T.S., & Perkins, D.O. (2012) Essentials of Schizophrenia. Arlington,
VA, USA: American Psychiatric Publishing.
McFarlane, W.R.; Dixon, L; Lukens, E.; & Lucksted A. (2003). Family psychoeducation andschizophrenia: A review of the literature. Journal of Marital and Family Therapy. 29(2).223-245.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians, 2nd ed. New York: The Guildford Press.
Netherton S.D., 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)
Preston, J.D., O’Neal, J.H., & Talaga, M.C. (2013). Handbook of clinical psychopharmacology
for therapists (7th Ed.) Oakland, CA: New Harbinger Publications, Inc
Rapport, J.L., Giedd, J.N. & Gogtay, N. (2012). Neurodevelopmental model of schizophrenia: Update 2012. Molecular Psychiatry 17, 1228-1238.
Razali, S; Hasanah C; Khan, U; Subramaniam, M. (2000). Psychosocial interventions for schizophrenia. Journal of Mental Health 9(3). 283-289.
Robinson, D (2002). Mental Status Exam Explained, 2nd ed. Rapid Psychler.
Schizophrenia symptoms. (2008, Oct 23). The Spectator. Retrieved from: http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/270336975?accountid=28125
Velligan, D.., & Alphs, L.D. (2013). Negative symptoms in schizophrenia: The importance of
identification and treatment. Psychiatric Times, 30(5), 24-26.
World Health Organization. Bulletin of the World Health Organization, 82(11), 858-66. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/229637504?accountid=28125

 

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Dexter Morgan

FYI – This is an assignment from a class in which we are required to create a treatment plan for a television or movie character.  I’m not sure how on point this is, but thought it was a fun exercise and worth posting…

“Dexter Morgan is a forensic analyst specializing in blood spatter [analysis] who [also] happens to be a…serial killer devoted strictly to the murder of other killers…Born in 1971, as a child Dexter witnessed the violent murder of his mother Laura Moser and…remained in the shipping container for days, surrounded by the carnage…[as a result a] ‘Dark Passenger,’or psychopathic need to kill [existed inside]…This desire was…channeled by his…adoptive father, Harry Morgan…Dexter eventually incorporated ‘Harry’s Code’ into his life.” (Heueristic, n.d.).

In light of this complex biography, utilizing Dexter Morgan as the focus for this paper presents a unique challenge. As stated earlier, the purpose of this assignment is to apply key concepts discussed in this weeks readings on assessment, diagnosis, and treatment planning. Important ethical ramifications exist surrounding the notion of providing therapy to a prolific serial killer.   It will be the assumption throughout this hypothetical exercise that mental health services will be provided to Dexter Morgan, as an inmate in a correctional facility.   Accepting responsibility for his actions is not only ethically necessary, but essential for well-being and improved mental health. It would be impossible to consider this situation otherwise.

Assessment & Diagnosis

Assessment in the context of counseling practice can be thought of as involving data gathering with the underlying goal of better understanding treatment needs. (Prout & Wadkins, 2014)  Prout & Wadkins (2014) discuss testing, behavioral assessment, mental status exams, and collateral data as useful for case conceptualization in this respect. Whereas these assessments are useful in better understanding client symptoms, a DSM-5 diagnosis is essential for purposes of diagnostic classification (Prout & Wadkins, 2014, p187).   With this key differentiation in mind, assessment and diagnosis are discussed separately below.

Mental Health Assessment

            In bringing up Dexter Morgan in a conversation with any mental health worker this week, the concept of psychopathy often arose. Discussed in greater depth later, what follows is a discussion of insights from Dexter Morgan from within a mental health assessment framework.

Mental Status Exam. “A mental status exam is an interview screening evaluation of the most important areas of a patient’s emotional and cognitive functioning.” (Thomas & Hersen, 2007, p49). (((While by no means thorough what follows are just a few quick insights of this character from within the parameters of a mental status exam))))
  1. General Appearance & Behavior – The client is well-groomed preferring business casual clothing and is cooperative and focused throughout the exam. Displaying direct eye contact throughout the interview, he is very articulate with speech normal in rate and volume.
  2. Orientation & Concentration – Fully-oriented to time, place, and person, this client is able to successfully complete tests of concentration and memory.   It must also be noted that he provides a very insightful personal history, indicative of years of professional training.   It is felt this has also aided him in the concealment of his troubling symptomatology.
  3. Mood & Affect – The client’s affect at first meeting can be best described as a contrived attempt at friendly engagement. With his affect progressing to a bland demeanor later in the session he makes a point to mention his inability to understand or experience emotion.   Most notable throughout the interview, is a heightened excitement observed when discussing observations from his crime scene investigations: “No blood, no sticky, hot messy, awful blood; no blood at all. Why hadn’t I thought of that? No blood what a beautiful idea.” (Dexter, 2006) It is felt this high degree of incongruence may be indicative (in part) of unresolved trauma concealed by dissociative defense mechanisms.
  4. Thought Process & Content – Thought processes are linear and logically goal-oriented. Until the client’s recent incarceration, thought content was focused strictly around a few key endeavors that consumed the majority of his time including: the investigation crime, the concealment of crime, as well as planning future crimes. The client reports the majority of his time is currently spent reflecting upon such experiences and finding activities to occupy his time. Continuing to experience homicidal ideations he admits to an inability to control these impulses if he weren’t for the fact he was in prison.
  5. Cognition: Judgment & Insight – “This individual, like his [heroes is] a product of a subculture of violence in which socially shared constructions led to a climate permissive of…violent acts….” (Winter, 2007, p295). Living by an ethical standard described as the “Code of Harry” (Dexter, 2006), this individual’s judgment and insight are limited by a moral superiority and grandiose delusions (Martin, 2001, p1; Winter, et al, 2007).   This “Code of Harry” (Dexter, 2006), acts to limit his judgment to the exacting of revenge in the name of a defined code of justice.

Functional Behavioral Assessment.

Prout & Wadkins, (2014) state that a functional behavioral assessment is useful in understanding the nature of a behavior. This method would be useful to better understand the precipitating factors and motivational consequences of his crimes. (Prout & Wadkins, 2014, p181).  While obviously not very helpful in preventing these crimes it would prove beneficial, not only for the client, but research purposes as well.   Having said this, insights from what is known can be useful in guiding this process.

One such insight includes a history of suppressed trauma that contributed to his current state of mental health as an experiential precipitating factor. While this factor would take some time to explore due to its largely suppressed nature of Harry’s code might be a great place to start.   Described, as a “coping mechanism” for urges to kill, this ethical code existed as a standard around which this patient constructed his life.

DSM-5 Diagnosis.

The first that comes to mind when describing Dexter Morgan is the term psychopath.    “Psychopathy is commonly viewed as a personality disorder defined by a cluster of interpersonal, affective, lifestyle and antisocial traits and behaviors, grandiosity, egocentricity, shallow emotions, lack of empathy or remorse, irresponsibility, impulsivity and a tendency to violate social norms.” (Hare, & Neumann, 2009, p791). While not included in the DSM-5 Manual, an official diagnosis for this fictional character would include antisocial personality disorder with psychotic factors and possibly post-traumatic stress disorder with dissociative features.

Antisocial Personality Disorder with Psychotic Features.

“The essential feature of antisocial personality disorder is a pervasive pattern of disregard for and violation of, the rights of others that begins in childhood…also…referred to as psychopathy or sociopathy.” (American Psychiatric Association, 2013, p661). Alongside this underlying personality disorder, is belief in his own moral superiority, described in the DSM-5 Manual as a grandiose delusion (American Psychiatric Association, 2013, p91).

Post-Traumatic Stress Disorder.

In a scene, after which Dexter realizes that witnessing his mother’s death is correlated somehow with the dark passenger, he states following: “…and its like the mask is slipping…and things…people…who never mattered before are suddenly starting to matter. It scares the hell out of me.” (An Inconvenient Lie, 2007). This revelation helps to contextualizes observations from the client’s life in “present time” showing an absence of emotion. Dexter is observed throughout the series displaying many diagnostic criteria relevant for this diagnosis (i.e. exposure to a traumatic event and the presence of intrusive memories).  With this in mind, a diagnosis of post-traumatic stress disorder with dissociative features should also be considered.

Treatment Goals

What follows is just a brief suggestion of potential problems to address, based on the previous discussion.   A discussion then follows of potential treatment goals for possible consideration, pending review with the client. It is by no means comprehensive.

Creating a Problem List.

  1. Problem 1: Unresolved Trauma.
    1. As evidenced by: Flashbacks of childhood trauma.
    2. As evidenced by: The revelation of a previously unknown life history and new understanding of his personal hero, Harry Morgan.
    3. As evidenced by: A personal realization that the “dark passenger” he describes within him as a need to kill, exists in conjunction with this traumatic history.
  2. Problem 2: Persistent Alexithymia & Loss of Meaning
    1. As evidenced by: Frequent reports of an inability to both understand and experience emotion.
    2. As evidenced by: Frequent reports of needing to “act normal” as a person who has and understands feeling.
    3. As evidenced by: Recent incarceration and loss of employment.
  3. Problem 3: Poor Judgment & Insight
    1. As evidenced by: “The Code of Harry” (Dexter, 2006), as the sole measure of his judgment when engaging in criminal activity.
    2. As evidenced by Ability to eliminate from thought processes, anything that doesn’t coincide with “Code of Harry” (Dexter, 2006).
    3. As evidenced by: Displays of perceived moral superiority, and failure to consider his actions as the same sort of criminal behavior he punishes others for.

Developing Treatment Goals.

Problem 1: Unresolved Trauma.  The initial treatment goal to begin processing unresolved trauma is simply to share insights from flashbacks and missing memories as they are recovered.
  1. Objective One: Client will develop and maintain open dialogue with therapist.
    1. Intervention One: Client agrees to share any and all thoughts and feelings surrounding insights from uncovered memories as they arise.
    2. Intervention Two: Client will meet with therapist as per agreed upon schedule, and give advance notice if unable to attend.
  2. Objective Two: Process unresolved hurt and anxieties underlying trauma.
    1. Intervention One: Understanding and awareness of strategies to distance self from emotional trauma.
    2. Intervention Two: Discuss possibility of emotional exposure therapy & EMDR Therapies.
Problem 2: Persistent Alexithymia & Loss of Meaning. Due to recent incarceration, it will be important to find new activities and endeavors to discover a new meaning in life.
  1. Objective One: Consider participating in research to further understand psychopathology of serial killers.
    1. Intervention: Arrange time for researchers to review case file and meet with Dexter.
    2. Intervention: Utilize forensic background to share and contextualize details of personal history.
  2. Objective Two: Develop an awareness of dissociative defense mechanisms in relation to inability to experience emotion.
    1. Intervention: Client will work with therapist to complete functional behavioral assessment to better understand motivations and predisposing factors underlying criminal behavior.
    2. Client will report and discuss experiences of dissociation with therapist when they occur.
Problem 3: Poor Judgment & Insight  Repairing this client’s poor judgment and insight is a goal that may not be fully realized. Nonetheless, a reasonable first step exists in working through facts and underlying thought processes underlying faulty conclusions associated with grandiose delusions of moral superiority.
  1. Objective: Discuss originating factors underlying perception of moral superiority.
    • Intervention: Client will discuss the origins of the “Code of Harry”.
    • Intervention: Client will examine these origins and acknowledge any shortcomings as well as personal failings regarding lack of insight.
  2. Objective: Examine thought processes underlying grandiose delusions.
    1. Intervention: Client will discuss personal perceptions of criminal activity as an act of retribution.
    2. Intervention: Client will work with therapist to acknowledge faulty self-perception as a morally superior person.

Wellness-Based Considerations.

Prout & Wadkins (2014) discuss a Wheel of Wellness as yet another consideration in the development of a treatment plan. Based on Adler’s holistic perspective, the indivisible self is a central concept in the wheel of wellness, (Prout & Wadkins, 2014).   This multidimensional concept includes five components: a social self, an essential self, a physical self, a creative self, and a coping self (Prout & Wadkins, 2014). In light of this client’s incarceration several difficulties exist in utilizing this model.   In addition to the limitations in interventions available due to client incarceration, there exists an attitude predominant of individuals such as Dexter. In fact, “ psychologists in the criminal justice system [are often thought of] as ‘little more than high priced janitors hired to sweep the problems of the system under the rug.’” (Hilkey, 1988, p676) With this limitation in mind, a useful alternative is proposed in literature for such inmates utilizing Mazlow’s Hierarchy of needs (Hilkey, 1988). What follows is a listing of considerations based on this model:

Physiological & Safety Needs: A key consideration for incarcerated individuals includes basic physical needs and a sense of safety. While difficult to intervene in this hypothetical scenario, the therapist would need to monitor this. These basic aspects in Maslow’s need hierarchy seem to coincide with the physical and essential components of the self as discussed in the wheel of wellness (Prout & Wadkins, 2014; Hilkey, 1988).

Belonging & Self-Esteem Needs

These elements of Maslow’s need hierarchy coincide with the social self and the coping self from the wellness wheel discussed, (Hilkey, 1988; Prout & Wadkins, 2014). Providing a sense of belonging is naturally limited in this case, although creating a small community such as a self-help group could help. To improve self-esteem, ongoing participation in research with the client as subject could be helpful in providing a sense of purpose.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental  Disorders (5th ed.). Washington, DC: Author.
“An Inconvenient Lie” Dexter Morgan Showtime, California. October 14, 2007.
“Dexter” Dexter Morgan Showtime, California. October 1, 2006.
Hare, R.D., & Neumann, C.S., (2009) Psychopathy: Assessment and forensic implications. Canadian Journal of Psychiatry. 54(12) 191-802
Heueristic. (n.d.) IMBD Biography for Dexter Morgan. Retrieved from http://www.imdb.com/character/ch0026519/bio
Hilkey, J. H., PhD. (1988). A theoretical model for assessment of delivery of mental health services in the correctional facility. Psychiatric Annals, 18(12), 676-679. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/894251682?accountid=28125
Martens, W. H. J. (2014). The hidden suffering of the psychopath. Psychiatric Times, 31(10), 1.
Prout, T.A., & Wadkins, M.J. (2014). Essential Interviewing and Counseling Skills. New York: Springer Publishing Company.
Thomas, J.C. & Hersen, H. (2007) Handbook of Clinical Interviewing of Adults. Thousand Oaks, CA: Sage Publications.
Winter, D.A. (2007) Construing the Construction Processes of Serial Killers And Other Violent
Offenders: 2. The Limits of Credulity. Journal of Constructivist Psychology, 20(3), 247-275.
Winter d., Felxas, G., Dalton, R., (Jarque-Llamazares, L., Laso, El, Mallindine, C., & Patient, S.
(2007) Construing the Construction Process of Serial Killers and Other Violent Offenders: 1. The Analysis of Narratives. Journal of Constructivist Psychology, 20(1), 1-22

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Dissociative PTSD….

In this post, I’m reviewing a few old papers I’ve written on PTSD….

As this blog develops, I find it is serving two purposes.  The first is as a brain dump, where I can purge all the thoughts and feelings lurking in my mind after a long way.  The second function for this blog is as a study tool.  As a verbal processor, my greatest successes in retaining information comes through reading it and then summarizing information in a manner that makes sense to me.  That is the purpose of this post.

A Multifactorial Perspective…

Ultimately, therapists seek to make sense of human nature, one client at a time. As a PTSD sufferer, I have both a professional & personal interest on the subject of dissociative PTSD.  What follows is a gathering of all research I’ve done thus far on the subject.   In my studies, I am fascinated at how complex human nature truly is.  As I learn more, I become increasingly aware of my expansive ignorance is: there is much to learn.  The first conclusion I came to was that “making sense of human nature” requires a multidimensional perspective.

*For example, systems theory can help us understand individuals as byproducts of their family & community environment.  
*Eric Berne’s work is useful in making sense of complex social transactions. 
*Finally, DBT’s biosocial perspective can provide understanding of how our mental health exists as a byproduct of the interaction between one’s biology and environment. 

Lambert & Kinsley, (2011) describe this multidimensional perspective by noting that biological, developmental, environmental, interpersonal, psychological and cultural perspectives are all useful in this endeavor to study human nature.  From within each perspective is another unique piece of the puzzle.

Biomedical Perspectives

imagePreston, et al, (2013) state that “the brain is a complex ecosystem that depends on a large number of interrelated variables” (p8). For this reason, it is important for therapist to understand the influence of neurochemical, neuroanatomical, and neurophysiological changes on behavior and mental health (Lambert & Kinsley, 2011).  Therapists need an understanding of how brain anatomy correlates with various cognitive functions. A basic knowledge of brain physiology and underlying electrochemical processes are also vital.   For example, when helping an individual recover from a stroke, the nature of the injury is important. Whereas, right sided strokes result in higher emotional lability, left-sided strokes are correlated with compulsive behaviors and aphasia. Another useful example of this comes from recent research on dissociative PTSD.   Lanius, et al, (2010) state that dissociation is best understood as a defense mechanism to prolonged trauma.   Alterations in the brain function associated with some PTSD sufferers, include an overly-inhibited limbic system, and hyper-regulation in the prefrontal cortex (Lanius, et al, 2010). These changes correlate with the dissociative symptoms often found in PTSD sufferers. Examples such as these shed light on the importance of understanding the biological underpinnings to observed symptoms. This background of knowledge is critical in the development of effective treatment plans for clients.

Developmental Perspectives

Lambert & Kinsley, (2011) also mentions genetics and the importance of a developmental perspective as yet another critical point of understanding human behavior. Genetics is vital in determining’s one’s overall mental health predisposition. A developmental perspective is useful in understanding the influence of one’s early childhood experiences on their mental health. In reality, these perspectives are two sides of the same coin from a nature vs. nurture standpoint. For example, my oldest son has a congenital heart defect imagecalled pulmonary atresia. As a “hidden disability”, while my son appears physically normal, he has had to adjust to an array of developmental issues.  My mother is a retired Geneticist, and has provided a useful perspective on this matter.   She states that her job is best understood as a “G.P. of rare and unusual conditions”. Additionally, she notes that since her diagnoses have no cure, her biggest role is helping parents work through difficult information. Her advice has been that genetics only provides part of the picture.  How parents handle and adjust to this information greatly influences the developmental course of children with congenital defects. Applying my mother’s insight to personal research on this subject has provided confirmatory evidence of her advice.   For example, a study by Berant, et al, (2001) looks at the influence of mothers’ attachment styles on the development of infants with heart defects. Securely attached mothers are found to develop better coping methods in response to the prolonged stress (Berant, et al, 2001) Additionally, research on the long-term effects of congenital heart defects on psychosocial development indicate family coping styles have a huge impact on a child’s well-being (Brown, et al, 2008). While this is only one example, it provides a convenient illustration of the importance of nature and nurture in one’s overall lifelong development.

Evolution & Sociocultural Perspectives

Lambert & Kinsley, (2011), also briefly mention the importance of environment, evolution, and culture as key factors in understanding our clients. Together evolution and environment are useful in contextualizing how individuals adapt to their environment. Recent research on the brain has shown a surprising degree of lifelong neuroplasticity that allows us to adjust and adapt to our surroundings.   Culture provides an excellent example of how widely varied environments can be and their influence over our. For example, a book by Kathleen Taylor (2006) provides the following definition: “Brainwashing is characterized in wholly negative terms as a kind of mental rape…[the] intention is to destroy the victim’s faith in former beliefs to wipe the slate clean so that new beliefs can be adopted” (p4). This westernized perspective on brainwashing, is likely to be met with a divergent interpretation from collectivist societies. As Kathleen Taylor (2006) states individuals from China, tend to view this experience as “morally uplifting and harmonizing” (p5). While reading this, I was reminded of a recent conversation with my mother, who is from the Philippines. As a culture with a more collectivist background, she has stated that American individualism, can often appear as prideful and selfish to foreigners.  This convenient example, is also effective in illustrating the influence of culture. Culture is more than a set of beliefs and values. It defines our way of being in the world, by predefining our way of understanding it. In this respect, culture determines our emotional and cognitive responses to life events.

Conclusion

Preston, et al, (2013) state that “a single model for understanding and treating mental disorders is too narrow and simply inadequate” (p13).

In fact, in an attempt to better understand human nature, it is clear that the whole is not equal to the sum of its parts. We influence our world and are influenced by it in turn.  An understanding of human nature from a biomedical, sociocultural and developmental perspective are all critical. For example, a biomedical perspective is important in observing a client’s response to medications. In contrast, sociocultural competency and developmental psychology are important in understanding the effects of one’s environment and life experiences. In light of all this, a lifelong commitment to personal development is critical, since it appears we give to others on the basis of who we are.

Having described my approach to therapy, I’d like to discuss what I’ve learned do far about PTSD…

What is Dissociative PTSD?

In the new DSM-5 manual, PTSD is no longer classified as an anxiety disorder.  Instead it is classified under a new category titled “Trauma and Stressor-Related Disorders”, (American Psychiatric Association, 2013).  Gateway criterion for this disorder define trauma as an “exposure to actual or threatened death, serious injury or sexual violence” (American Psychiatric Association, 2013, p. 271).  Additionally, while PTSD’s traumatic stressors can include either direct or indirect, the requirement of “fear, helplessness and horror” (Friedman, 2013, p. 550) is no longer required.  Other symptoms include (1) a persistent avoidance of triggers, (2) alterations in mood and cognition, (3) flashbacks; and (4) alterations in arousal and reactivity (American Psychiatric Association, 2013).   Finally, two new subcategories of PTSD are included in the new DSM-5 Manual, including a developmentally relevant subcategory for children, and dissociative subtype.

Symptoms & Life Situation.

imageWhat is it like to experience symptoms of dissociative PTSD and what are their consequences for one’s daily life? Dissociation causes a fragmentation of one’s awareness and an inability to utilize cognitive processes to perceive the “real self” in relation to the environment (Armour, et al, 2014, Lanius, et al, 2012).  Dissociation includes symptoms of depersonalization and derealization.  Depersonalization is a feeling of detachment that is often described as an outer body experience.  In contrast, derealization results in the feeling that one’s world is unreal and dreamlike (American Psychiatric Association, 2013).  While PTSD is associated with emotional under-modulation and symptoms of hyper-arousal, the dissociative subtype is associated with persistent emotional over-regulation (Lanius, 2010).  A study by Griffin, et al, (1997), is helpful in understanding the consequences of this unique feature of dissociative PTSD.  In this study, 85 rape victims were interviewed and asked to discuss details surrounding the traumatic event (Griffin, et al, 1997).  Measures of heart rate and skin conductance were taken during the interview (Griffin, et al 1997).    Upon completion of the interview, participants filled out the PTSD symptom scale.  A subset of individuals was shown to have high levels of incongruence between their own report of distress in comparison to physiological measures (Griffin, et al, 1997).  Research like this supports the conclusion that dissociation is a defense mechanism of prolonged trauma, especially of a sexual nature (Armour, et al, 2014; Griffin, et al 1997; Lanius, et al 2012).  The following lasting consequences exist as a result of this maladaptive defense mechanism:

*Unmanageable disconnection:  Individuals with Dissociative PTSD describe an unmanageable disconnection well after trauma exposure.  While this dissociation is a useful defense mechanism during trauma, it prevents individuals from fully engaging in life.  For this reason, sufferers often experience anhedonia, diminished interests, and a higher rate of depression and anxiety (Lanius, 2012).
*Difficulty processing Trauma: Persistent avoidance and dissociation interfere with the habituation process that occurs during exposure therapy (Wabnitz, et al, 2013).  Until sufferers can begin woking through these experiences, they will have little insight how these past traumas have affected them.  Additionally, since dissociative PTSD is associated with prolonged trauma, the effects of underlying symptoms are profound.  This disorder is associate with high rates of divorce and job insecurity (Armour, et al, 2014; Griffin, et al 1997).
*Insecure Attachment & Perceived Hostility:  dissociative PTSD is associated with “exaggerated negative beliefs [and] expectations…of others” (American Psychiatric Association, 2013, p. 272).  Armour, et al, (2014), describes a hostile attitude, defined by distrust and an over-arching perception of ill intent, in sufferers of this disorder.  Additionally, sufferers of this disorder frequently exhibit dysfunctional attachment styles.  As a result, sufferers of dissociative PTSD have an array of belief systems that act as self-fulfilling prophecies in all relationships.  Until these issues can be worked through, they will continue to influence all present and future relationships in a “like-attracts-like” fashion.
*Anxiety & Persistent Avoidance:  Exposure to reminders of past trauma produce feelings of anxiety and hyper-arousal.  In order to prevent re-experiencing old traumas, sufferers will engage in a hyper-vigilant avoidance of anything that triggers these memories.  When this is not possible, dissociative symptomatology arrises as described earlier.

Controversies & Validity…

Support for Dissociative PTSD…

Research providing rationale for inclusion of Dissociative PTSD indicates that this disorder has a unique clinical presentation and responds differently to treatment.  Dissociative PTSD is associated with ‘”chronic child abuse, sexual abuse, and prolonged trauma” (Wabnitz, et al, 2013).  Early studies on prevalence rates indicate that 70% of PTSD sufferers fall into the re-experiencing category and 30% qualify for the dissociative subtype (Lanius, et al, 2012).  Additionally, while the re-experiencing group shows lower activity in the prefrontal cortex and hyperactivity in the limbic system, the opposite can be said of the dissociative subtype (Lanius, et al, 2012).  Finally, in support of the validity of dissociative PTSD, research shows a differential response pattern to conventional exposure therapy (Lanius, et al, 2012).

A  Continuum of Dissociation.

imagePrior to inclusion in the DSM-5 manual, dissociation has been considered to be a predictor of the development of PTSD (Wabnitz, et al, 2013).  Smptoms of dissociation found in the DSM-5 disorders can be arranged from simple to complex (Wabnitz, et al, 2013).  While the dissociation found within acute stress disorder has a simple presentation, it is much more complex within dissociative identity disorder.  In contrast, Dissociative PTSD, can be found at a midpoint between these extremes.  Currently, no research exists which has studied the varied presentation of dissociation within these diagnoses.  For this reason, critics question whether Dissociative PTSD is indeed a unique subtype or if it is a component of one’s adaptive responses to a trauma (Armour, et al, 2014; Wabnitz, et al, 2013).

Component vs. Subtype Models.

A wealth of research exists to support the connection between PTSD and experiences of dissociation (Armour, et al, 2014).  However, there is disagreement on the specific relationship between trauma and dissociation.  Armour, et al, (2014), describe two causal models with different proposed relationships between dissociation and trauma.  While both models conclude that dissociation is a defense mechanism to trauma, they disagree on whether research supports inclusion in the DSM-5 Manual (Armour, et al, 2014).   Supporters of the component model point at the varied presentation of dissociation across diagnoses and state they are simply co-occurring factors (Armour, et al, 2014; Wabnitz, et al, 2013).  In contrast, the subtype model points at the fact that heightened levels of persistent dissociation change the nature of PTSD symptoms (Armour, et al, 2014).  In an effort to encourage research to clarify the matter, dissociative PTSD has been included in the new DSM-5 Manual (Friedman, 2013).

Accurate Diagnosis….

 Gateway Criterion….

imageAs stated earlier, PTSD is no longer classified as an anxiety disorder.  This change reflects research that shows PTSD is not best understood as a fear-related issue (Friedman, 2013).  Instead, the updated version of PTSD  provides a diagnosis for the DSM-5 manual based on a cause (Levin, et al, 2014).  Changes to gateway criterion of PTSD no longer require a specific emotional response such as fear or horror (Friedman, 2013).  Instead, the definition of trauma has been expanded to aid diagnoses.  Based on these observations, Levin, et al, (2014) suggest a structured interview of an individual’s trauma history, is now vital for accurate diagnosis.  the clinician administered PTSD scale for DSM-5 (CAPS-5) is an example of a tool that can aid in this assessment (Bauer, et al, 2013).  Developed by the U.S. Department of Veteran’s Affairs, This tool is designed for use as a semi-structured interview (Bauer, et al, 2013).  In addition to clustering scores in accordance with DSM-5 criteria, it assesses the impact of symptoms on an individual’s overall functioning (Bauer, et al, 2013).  In this respect, subsequent administrations of this tool, are useful in assessing a client’s response to treatment.

Consequences of a Broad Definition.

While a narrow definition of PTSD simplifies diagnosis, a broad construct was designed to provide the most accurate clinical picture of PTSD (Friedman, 2013).  Levin, et al, (2014), note that this broad definition makes diagnosis much more complex.  Some symptom categories are difficult to assess objectively and require client self-report (Levin, et al, 2014).  This adds an extra layer of complexity to the diagnosis of dissociative PTSD (Levin, et al, 2014).  For example, criterion D refers to persistent belief of oneself in relation to others.  Dissociative PTSD is associated with a prolonged history of trauma, insecure attachment and a hostile perception of others (Armour, et al, 2014).  With low levels of insight into these issues, assessing Criterion D symptoms in dissociative PTSD sufferers is problematic. An accurate diagnosis of dissociative PTSD must account for its unique clinical presentation including the consequences of persistent emotional over-regulation.

Differential Diagnoses….

As stated earlier, dissociation is a symptom that can be found in varying degrees throughout the DSM-5 (Wabnitz, et al, 2013).  To avoid any confusion, it is important to note that not every exposure to trauam or extreme distress causes PTSD.  While a careful assessment of gateway criterion for this disorder is important, alone it is not enough.  In order to differentiate PTSD from other trauma-related diagnoses, a traumatic event should precede other PTSD symptoms (American Psychiatric Association, 2013).

imageAnother source of diagnostic confusion, is the need to differentiate personality disorders from criterion D of PTSD which describes a “persistent and exaggerated negative belief about oneself [and] others” (American Psychiatric Association, 2013, p. 272).  Personality disorders present interpersonal disturbances that reflect pervasive and lifelong patterns of beliefs, behaviors and inner experience (American Psychiatric Association, 2013).  It is also worth noting that personality is defined as a pattern of thoughts and behaviors, unique to an individual that define how they relate to others.  The interpersonal issues experienced by PTSD sufferers can be understood as a byproduct of unresolved traumatic events. They are coping responses and not evidence of one’s character.

A final source of confusion worth mentioning, is the difference between dissociative PTSD and DID, (dissociative identity disorder).  Dissociative symptoms in DID, involve a pervasive amnesia related to everyday events followed by flashbacks and a loss of time.  Additionally, DID includes a disruption of identity states that cause the compete loss of a personal sense of agency that is unrealted to trauma (APA, 2013).  In contrast Dissociative PTSD is associated with transitiry experiences of amnesia, falashback, depersonalization, adn derealization (American Psychiatric Association, 2013).

Final Comments on Diagnosis…

Diagnosis of dissociative PTSD must include an assessment of the severity of dissociative symptoms alongside relevant v-codes.  These diagnostic considerations are critical for treatment planning. For example, individuals with low levels of dissociation can show successful outcomes with cognitive therapy alone (Lanius, et al, 2012). In contrast, higher levels of dissociation require a stage-oriented approach that provides a form of DBT skills training, in emotional regulation, distress tolerance, and mindfulness for grounding purposes, prior to EMDR or exposure therapy (Lanius, et al, 2010; Lanius, et al, 2012).  Finally, it is also worth noting that sufferes with dissociative PTSD have complicated abuse and trauma histories.  This has a profound affect on one’s attachment style and interpersonal relationship habits.  Assessing this issue thoroughly and addressing it in family therapy may also be warranted (Armour, et al, 2014).

Treatment & Medication

Understanding Dissociation…

imageIn an article by Jepsen, et al, (2013), research was conducteed on the effect of dissociation and interpersonal dysfunction on the treatment of chronically sexually abused adults.  A group of 48 individuals were followed on a year-long treatment process.  results of this study indicate that pathological dissociation and interpersonal difficulties significantly affected treatment outcomes (Jepsen, et al, 2013).  Since dissociation is best understood as a defense mechanism to prolonged trauma it isn’t surprising.  Additionally, evidence such as this, indicates a careful assessment of dissociation is essential for effective treatment in cases of complex trauma.

Dissociation affects an individual’s arousal response to triggers.  In dissociative PTSD, the prefrontal cortex over-regulates the limbic system (Lanius, et al, 2010).  As a result the system is overly-inhibited and dissociative symptomatology is a result.  Dissociative symptoms, impede the effectiveness of interventions aimed at effective trauma processing.  The habitual learning processes associated with classical conditioning in these trauman processing techniques are also interfered with through dissociative symtomatolgoy.  Exposure therapy alone, is not effective for this reason.

Neurobiology of PTSD

“The human stress response is…a complex biological system…built around the capacity for rapid recognition of potentially harmful stimuli to mobilize the specific-specific defense response.” (Friedman, 2015, p9). In PTSD, this stress response is sustained longer, becoming maladaptive. A basic knowledge of the maladaptive neurobiology underlying PTSD is critical to understanding how medications can be utilized to treat and prevent this disorder.   What follows is a listing if biochemical alterations in the nervous system of individuals with PTSD:

  1. Thalamus: PTSD is associated with an impaired relay of information from the thalamus to cortex during arousal, causing symptoms of both dissociation and hyper-arousal.
  2. Amygdala: Receiving information from the thalamus, the amygdala provides information regarding any potential threat (Weiss, 2007). The emotional valance of a potential threat is a byproduct of messages sent from the amygdala to the HPA axis as well as the skeletal muscles (Friedman, 2015).
  3. Hypothalamic-Pituitary-Adrenal (HPA) Axis: The HPA axis, comprises the flight-or-flight response of the neuroendocrine system (Lambert & Kinsley 2011).   It is responsible for producing many of the physical symptoms associated with prolonged stress. Evidence of HPA axis dysregulation in PTSD is most readily evident in elevated levels of corticotrophin releasing hormone (CRH) and glucocorticoids (Friedman, 2015).
  4. Prefrontal Cortex (PFC): The PFC is responsible for making cognitive decisions about emotional responses, and acts as a regulator in this respect (Weiss, 2007). In PTSD, alterations in emotional regulation can be seen as correlating with maladaptive responses. Dissociation correlates with an overregulation of the limbic area by the PFC (Friedman, 2015). In contrast, hyperarousal is the result of under-regulation by the PFC of the limbic system (Friedman, 2015).
  5. Hippocampus: The hippocampus is responsible for establishing conscious experiences into memories. Trauma victims have been found to have smaller hippocampal regions (Weiss, 2007). It is felt this is related to symptoms of avoidance, dissociation, and numbing (Friedman, 2015).
  6. Neurochemical Alterations: Elevated levels of cortisol and epinephrine are related to flashbacks, hyper-arousal, and panic attacks (Weiss, 2007). Norepinephrine, effective in maintaining alertness, and focus, is associated with PFC impairment, and ineffective amygdala restraint (Friedman, 2015). Chronic serotonin activation, common in PTSD, is associated with symptoms of hyper-vigilance, irritability, and re-experiencing (Weiss, 2007). In contrast, altered Dopamine levels in PTSD are associated with dissociative symptoms as well as hyper-vigilance (Friedman, 2015).

History of Medications Utilized to Treat PTSD

imageChanges in the classification of PTSD and addition of new subtypes, indicate that the presenting symptoms for this disorder are likely to vary. Consequently, these “different phenotypes of PTSD…might be best addressed by different therapies” (Friedman, 2015). Research is currently ongoing that can provide a better understanding of the symptomatic variations for the PTSD subtypes.   Hopefully, in time, this can lead to medications that are specifically designed to address these varied PTSD subtypes more effectively. In the meantime, what follows of a review of treatments utilized currently in the treatment of PTSD symptoms.

Anxiolytics for PTSD

            In the 1980’s, when PTSD first appeared in the third edition of the DSM, Benzodiazepines were the preferred medication to treat this disorder (Bernardy, Souter & Friedman, 2015). These anxiolytics are effective in enhancing the inhibitory amino acid GABA by binding with benzodiazepine receptors, and enabling calcium channels to open more fully (Lambert & Kinsley, 2011). Initially thought to be effective in reducing symptoms of hyper-arousal, clinical practice guidelines no longer support the use of benzodiazepines for PTSD (Bernardy, Souter & Friedman, 2015). Side effects of benzodiazepines can include, drowsiness, stomach upset, cognitive impairment, memory loss, nightmares, and changes in heart rate (Preston, et al, 2013). Examples of benzodiazepines include Diazepam, Temazepam, and Lorazepam (Preston, et al, 2013). With a lack of support regarding their effectiveness in alleviating PTSD symptoms, benzodiazepines are associated with withdrawal, tolerance and dependence. Most notably, Research in support of this clinical standard notes that “benzodiazepines may interfere with the extinction of fear condition…[and] worsen recovery” (Bernardy, Souter, &, Friedman 2015, p78).

Antidepressants for PTSD

            Since the 1990’s great progress has been made in how to effectively treat PTSD, due to an understanding that symptoms overlap depression and anxiety (Bernardy & Friedman, 2015). Based on this insight, recent research has focused on the effectiveness of Selective Serotonin Reuptake Inhibitors (SSRI) for PTSD. SSRI’s, currently a first line treatment for PTSD, enhance the effectiveness of Serotonin by increasing the availability of this neurotransmitter. It addresses symptoms of irritability, depression, anxiety, avoidance, and numbing (Bernardy & Friedman, 2015). Examples of SSRI’s include Celexa, Paxil, and Zoloft. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s), are another first line treatment of PTSD, found equally effective in clinical trials, improve resilience in handling stress (Bernardy & Friedman, 2015). These medications increase the availability of norepinephrine and serotonin and include drugs such as Cymbalta and Effexor (Preston, et al, 2013). Occasionally, Tricyclics and Monamine Oxidase Inhibitors (MAOI’s) are utilized to treat PTSD, although they are not considered a first line treatment for this disorder due to a long-list of side effects (Bernardy & Friedman, 2015).

Atypical Antipsychotics & Anticonvulsants

            Recent research has shown mixed results regarding the effectiveness of SSRI’s in the treatment of PTSD (Bernardy & Friedman, 2015). Additionally, there are currently “limited medication options available for the treatment of PTSD” (Jeffreys, 2015, p89). For this reason, research is now focusing on broadening the list of secondary options for PTSD. Atypical antipsychotics and anticonvulsants have been studied as potential treatments for complex presentations of PTSD that include comorbid diagnosis and a history of substance use (Jeffreys, 2015). While atypical antipsychotics target serotonin, anticonvulsants inhibit GABA in the central nervous system.   Their effectiveness in research is mixed-at best, and only suggested in complex cases of PTSD as described above (Jeffreys, 2015). They are to be utilized with caution due to a wide array of associated side effects.

Medication Utilized to Prevent PTSD

A new wave of research has been underway that addresses the question of whether or not it is possible to prevent PTSD with early pharmaceutical interventions (Lambert & Kinsley, 2011).   The theoretical perspective underlying this innovative approach states that PTSD occurs in those cases in which the fear response to a traumatic event doesn’t extinguish fully and instead becomes habituated (Kearns, et al, 2012). Exposure therapy is effective in extinguishing a condition fear response associated with PTSD since it involves the activation of fear memories, and the incorporation of corrective information (Kearns, et al, 2012). Preventative treatments for PTSD are based on the notion that inhibiting the process of memory consolidation during a traumatic event can halt the development of this disorder.

Beta Blockers

Overview of Medication. One class of medications thought to be effective in the prevention of PTSD are beta-blockers such as Propranolol (Carter & Hall, 2007). Beta Blockers are medications useful in the treatment of high blood pressure, chest pain, and anxiety.   As anxiolytics, they are useful in treating “peripheral manifestations of anxiety (increased heart rate, sweating, tremor), but are not very effective at blocking the internal experience of anxiety” (Preston, et al, 2013, p217). Side effects include anxiety, irritability, hyperventilation, sleep difficulties, shakiness, restlessness, GI upset, and dry mouth (Preston, et. al, 2013).

Therapeutic Effects. The therapeutic effects of Beta Blockers in the prevention of PTSD are based on the notion that regulating catecholamine dysfunction can prevent PTSD symptoms. Research supporting this has indicated PTSD sufferers have decreased cortisol levels and elevated CRF, indicating an inability to regulate catecholamines (Searcy, et al, 2012). For example, one study compares the effects of Metopropolol, a noradrenergic antagonist with Yohimbine, a noradrenergic agonist on the recall of emotionally arousing events. Results showed that Yohimbine provided increased memory recall of emotionally arousing material, indicating that noradrenergic medications can modulate memory formation (Searcy, et al, 2012).

Research Evidence. In one study, participants were administered Propranolol within 2-20 hours after a motor vehicle collision (Searcy, et al, 2012). A follow-up of participants in this study showed that only one individual who received propranolol reported symptoms of PTSD (Search, et al, 2012). Another study, reporting similar effectiveness of Propranolol as a preventative, theorizes that this effect is due to a limited epinephrine-enhanced fear conditioning (Kearns, et al, 2012). However, despite this promising evidence, a thorough review of clinical evidence, shows mixed results in support of Propranolol (Searcy, et al, 2012).

Corticosteroid: Hydrocortisone

Overview of Medication. Another medication that may be effective in preventing PTSD, is the corticosteroid hydrocortisone. “Hydrocortisone is used to treat adrenal failure, shock, and inflammatory, allergic, and rheumatic conditions” (Hydrocortisone, 2014). All studies utilizing hydrocortisone as a preventative medication for PTSD in this paper were administered I.V.   The side effects of glucocorticoid treatment are too numerous to list and involve the GI system, cardiovascular system, immune system, central nervous system, and endocrine system (Schäcke, et al, 2002).

Therapeutic Effects. Glucocorticoids, such as hydrocortisone, play an essential role in modulating the behavioral and physiological responses to stress in order to maintain homeostasis (Zohar, et al, 2011).   Normally, in the aftermath of trauma, individuals work through a process of reconsolidation, in order to make sense of what has transpired, and develop an acceptable narrative of recent events (Glazer, 2011). Individuals at risk for PTSD, struggle in the aftermath of a trauma, to make sense of what has happened.   Neurobiological evidence of this difficulty can be seen in evidence of lower levels of cortisol after trauma, causing impairments in memory formation (Glazer, 2011). Hydrocortisone is thought to impact a person’s ability to reconsolidate memories through is effects on the hippocampus (Zohar, et la, 2011).

Research Evidence. Early studies on hydrocortisone as a PTSD preventative utilized rats and showed this medication modulated the fear response (Searcy, et al, 2012). Two subsequent studies involving human subjects involved the administration of IV Hydrocortisone to acutely ill ICU patients (Searcy, et al, 2012).   In both studies, this medication was very effective in reducing the incidence of PTSD symptoms of its subjects (Searcy, et al, 2012). In contrast, studies utilizing long-term sufferers of combat trauma, indicate a temporally based window of opportunity (Kearns, et al, 2012).   Studies such as these, which utilize long-term PTSD survivors, show a temporary reduction in symptoms that return over time (Kearns, et al, 2012).   To understand the neurobiological correlates of these therapeutic effects other research examines the neuroanatomy of animals with steroid-treated stress (Zohar, et al, 2011). “Steroid-treated stressed animals displayed significantly increased dendritic growth and spine density with increased levels of brain-derived neurotropic factor” (Zohar, et al, 2011, p796).

An Ethical Controversy

While there is scant evidence that other medications may prove effective in preventing PTSD, the Hydrocortisone and Propranolol, hold the greatest promise. The effectiveness of these drugs in preventing PTSD, are all based on their ability to affect on the establishment of long-term memory.   It is for this reason, that the utilization of these drugs is somewhat controversial. Carter & Hall, (2007), address this controversy by asserting that ethical objections of memory dampening medications such as propranolol, should be weighted against long-term negative consequences of PTSD.

Therapy for Dissociative PTSD???

In this final section, I set aside the research and speak from personal experience.  Therapy for my own process of recovery occured over the span of almost a decade.  It began when I entered individual therapy, and met an insightful therapist who encouraged me to enter a DBT skills group.  On completion, I began working toward utilizing these skills throughout my personal life.  Over the years, I came to understand how my entire existence became polluted by this issue.  I worked on my relationship with my kids, and how I parented them.  I addressed unhealed wounds within my family in the aftermath of the shared trauma of those “it years”.  Finally, once my therapist and I were certain my coping skills were strong enough, we did a some EMDR, for purposes of trauma processing.  The path was a long one, and took time, but well worth the effort…

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