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Download Distress Disorder and Psychosomatic Disorders Dr James Rodger
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Producing a Formulation, Differentiating between Distress and Disorder, Psychosomatic Disorders Dr. James Rodger Consultant Child & Adolescent Psychiatrist, South Devon CAMHS Overview • Differentiating distress from disorder – what the manuals tell us • Beyond impairment – models of disorder • Validity of mental disorder • Formulation • Somatisation Differentiating between Distress and Disorder “Correct answer”? • DSM-IV-TR – polythetic symptom criteria – episode fit (is there a better fit?) / developmental criteria / duration criteria – causing clinically significant distress or impairment (educational, occupational, social, family life) – D: diagnostic fit (superordinate diagnosis, organic causes excluded?) Case example - ADHD • The DSM criteria - two groups: – Inattentive (9) and hyperactive-impulsive (6+3) symptoms (inconsistent with developmental level) • Six of the nine symptoms in each section must be present for a ‘combined type’ diagnosis of ADHD. • if insufficient symptoms for a full diagnosis – predominantly inattentive (ADHD-I) – predominantly hyperactive (ADHD-H) • Supported by factor-analysis studies – most studies supporting a two-factor model of symptom “clustering” (as above) DSM-IV-TR – symptoms must be chronic (> 6 months) and present before age 7 – symptoms present in 2 or more settings but evidence of significant impairment required in only one setting (social, school or work) – not occuring exclusively in context of PDD or psychosis, not better accounted for by another disorder (e.g. Anxiety, ?RAD) ICD-10 hyperkinetic disorders • Almost identical symptom list but need symtom count in all 3 domains accross >2 contexts: – 6/9 inattentive – 3/5 hyperactive – 1/4 impulsive • Significant distress or impairment 1 or more contexts • More rigourous exclusion (psychosis, PDD, mood, anxiety) • Prevalence rates much lower (<50%) using ICD Prevalence - UK • British Child and Adolescent Mental Health Survey 1999 (n>10,000) – parents / teachers + impairment (clinical process) – 3.62% of boys and 0.85% of girls had ADHD – 4.25:1 M:F. • more restricted diagnosis ICD10-hyperkinetic prevalence = 1.5% for boys (primary school) Natural Rates of ADHD! • UK prevalence estimate up to 16% (Taylor 1991) • In USA prevalence estimates 8-25% • Worldwide high variability (DSM-IV) – Low: Australia 2.4 – 10% (DSM-IV – High: Brazil, Colombia, Germany, Ukraine 15-20% • majority of variability methods used – – – – Criteria Rating scales vs. more in depth interview Impairment Sources of information (single / multiple) • minor differences worldwide (NICE) ~ 5.3% Impairment • Fundamental to diagnostic validity (as ADHD symptoms on spectrum with normal population) • Without criterion of impairment 2x prev • Newcastle (McArdle et al., 2004). – – – – 11% if no impairment 6.7% moderately low impairment 4.2% for moderate impairment 1.4% for severe pervasive impairment Is distress and/or impairment enough? • Being gay can be very distressing, if you, or your family, or wider society don’t want you to be – but we don’t call homosexuality a…. err… burn the previous editions • Roland Littlewood a psychiatrist and anthropologist describe a woman in her 30s, who by our standard would have met all several criteria for schizophrenia, but was not distressed, and formed a new religious movement “Mother Earth” with many followers therefore no dsyfunction? Biomedical Definitions • “biological disadvantage” (Scadding 1967) – that it must at least encompass reduced fertility and life expectancy (Kendell (1975) • Are we happy for this to be our primary evaluative criterion for thinking about the value of human life? – Life style choices, homosexuality, and life within religious orders, may all be patholgised by such a definition! • Illogical consequences when applied to thinking about mental disorder – Many milder conditions such as phobias as well as disorders with onset after the prime reproductive years would fail to qualify as disorders and may not affect lifeexpectancy either – Conduct disorder may confer evolutionary advantage! Biomedical Disadvantage = Failure of Evolutionary Design? • dysfunction - failure of a biological mechanism to perform a natural function for which it had been designed by evolution (Wakefield 1992) – Too little known about the evolution of most of the higher cerebral functions • Mood states such as anxiety and depression may have evolved as biologically adaptive responses to danger or loss • Paranoia ,hearing voices & OCD, may have conferred evolutionary advantage, during EEA (Pleistocene: 1.8million – 12,000 years ago) • Some cognitive abilities, like reading, have been acquired too recently to be plausibly regarded as natural functions designed by evolution Can dysfunction be defined without reference to evolution or disadvantage? • “too little is known about the cerebral mechanisms underlying basic psychological functions, such as perception, abstract reasoning, and memory, for it to be possible in most cases to do more than infer the probable presence of a biological dysfunction”?? – i.e. need a frame of reference to say whether “pathology” • “Furthermore, rejecting both the evolutionary and biological disadvantage criteria may open the way to regarding a wide range of purely social disabilities (such as aggressive, uncooperative behaviour or an inability to resist lighting fires or stealing) as mental disorders”. – Is this already happening? Sociopolitical Definitions • “disease is simply what doctors treat”! • Although rarely advocated by physicians - treatability is often a crucial consideration underlying their decisions to regard individual phenomena as diseases • despite the advocacy of Thomas Trotter and Benjamin Rush at the beginning of the nineteenth century and a sustained campaign by Alcoholics Anonymous in the 1930s, the medical profession firmly resisted the proposal that alcoholism should be regarded as a disease until disulfiram (Antabuse) was introduced in the late 1940s • As for Ritalin and ADHD >late 1960s? Sociopolitical Definitions • “Condition is regarded as a disease if it is agreed to be undesirable (an explicit value judgment) and if it seems on balance that physicians (or health professionals in general) and their technologies are more likely to be able to deal with it effectively than are any of the potential alternatives, such as the criminal justice system (treating it as crime), the church (treating it as a sin), or social work (treating it as a social problem)”. • essentially pragmatic or utilitarian. • given condition might be a mental disorder in one setting but not in another - depending on the relative efficacy of medical and other approaches to the problem in those different settings… Sociopolitical Definitions • whether restless, overactive children with short attention spans are regarded as having attention-deficit/hyperactivity disorder or simply as being difficult children would depend on whether child psychiatrists were better at ameliorating the problem than parents and teachers Combined biomedical and sociopolitical definition • concept of mental disorder necessarily involves both a scientific or biomedical criterion (dysfunction) and an explicit value judgment or sociopolitical criterion “harm” (Wakefield 1992/99) or “handicap” (WHO) – meets the main requirement of both the sociopolitical and the biomedical camps – seems to reflect the often intuitive ways in which physicians make disease attributions for physical disease – value judgements may vary accross cultures, and would be important even if concrete biological substrates discovered • Nailing down assured biological dysfunction, may still be elusive, and definition may slide towards purely sociopolitical definitions, masked by pseudo-science? – ODD...CD.... .....(ADHD?) – Also c.f. Neurodiversity Movement ADHD as a case example: controversies • ‘‘ADHD is total, 100 percent fraud’’ Fred Baughman - Pediatric neurologist (2006) • ‘‘ADHD is real, a real disorder, a real problem, often a real obstacle’’ Russell Barkley, leading ADHD researcher (1995) • “you ask me, any kid who would rather go outside and play, than to sit in school all day sounds pretty normal to me” (Yahoo Questions 2008). The place of values Who is it a problem for? • cultural differences in the level of activity and inattention that is regarded as a problem (Sonuga-Barke et al., 1993) • teachers and parents tolerance and ability to cope may determine whether the hyperactivity is presented as a problem • Children with hyperactivity rarely ask for help themselves Male – Female • Clinic referred – 10:1 • Community referred – 3:1 • Disruptive behaviour drives referrals? An “androgenist” critique • Quantified Observation – ethological observation and activity monitoring confirmed that teachers more likely to attribute symptoms of ADHD to boys than girls after correction for actual behaviour differences (Brewis et al. 2003) – Mothers and female teachers statistically more likely to initiate process of diagnosis and treament for ADHD, than fathers / male teachers who may view behaviour as more normative Case Study: homosexuality • Sexual Orientation Disorder (DSM-II revision 1974) / Ego-dsytonic homosexuality (DSM-III 1980) – located the problem within the psychologies of gay people, rather than within the society who stigmatised and discriminated against them • DSM-IV (1994) ego dystonic homosexuality dropped, but included "sexual disorder not otherwise specified" which could include "persistent and marked distress about one’s sexual orientation." Challenges to this definition: • Therapeutic challenges – Recovering subjugated narratives of strength – Explicating social causes of suffering (poverty, discrimination etc.) • Diagnostic challenges – Relational Disorders in DSM-V but limited scope (e.g. domestic violence, post-partum depression) • Political challenges – Neurodiversity – Critical Psychiatry Ostensive Definition • Impossible, even in principle, to provide a “semantic” or “operational” definition of the global concept of mental illness or disorder, only of individual illnesses or disorders” (Lilienfeld and Marino 1995) • The only criterion available is whether putative or candidate disorders are sufficiently similar to the prototypes of mental disorder (e.g. schizophrenia and major depressive disorder) • The best definition – remains a circular one!? Levels of Explanation • Even physical disease cannot be defined by one overaching definition – – – – – Clinical syndrome: migraine and torticollis Morbid anatomy: mitral stenosis Histopathology: tumours Chromosomal architecture: Down syndrome Molecular structures: thalasemmias • what is the most useful level of explanation (utility!) yielding the most useful information for action for a given presentation – May be reciprocally influenced by treatment available. Current treatments for torticollis don’t demand a molecular level understanding, even if this was available Why are different levels of explanation required? • more a particular presentation looks similar to others but responds differently - the more complex the level of explanation needs to be? • Most psychiatric disorder still defined by clinical syndrome – current drug treatments don’t justify a more complex biological description • But they do justify a more complex psycho-social / systemic description e.g. diffential explanations for symptoms of hyperactivity and inattention What do we mean by validity? • “valid” – validus = strong – defined as “well founded” and applicable; sound and to the point; against which no objection can fairly be brought” – Logic: validity is the characteristic of an inference that must be true if all its premises are true. • there is no single, agreed upon meaning of validity in science, although it is generally accepted that the concept addresses “the nature of reality” – its definition is an “epistemological and philosophical problem, not simply a question of measurement” • diagnostic vs. nosological validity Establishing Validity: Feigner Criteria • Robins & Guze (1970) / Feighner (1972) – Clinical description – Labaratory Studies (i.e. to show biological dysfunction – includes cognitive profile?) – Delimitation from other disorders (c.f. zone of rarity – Kendell 2003) – Follow-up studies (diagnostic stability & response to Rx and outcome) – Family studies Diagnostic Validity (According to NICE) • Do Symptoms of inattention, hyperactivity “cluster together” • Can they be distinguished from normal variation in the population? • Are they distinguishable from other disorders • Are symptoms asociated with significant clinical and psychosocial impairments? • Are there characteristic outcomes? • Is there consistent evidence of genetic, environmental or neurobiological risk factors? – Risks overlap / confluent with risks in normal population depending on method used Different Validators = Different Answers • a hierarchy of validators must first be chosen for a given nosologic question – involves a value judgment and cannot be directly addressed by empirical inquiries – “What is the core feature of schizophrenia—that it has a poor outcome, its Sx or that it runs in families?” – This is not a scientific question. • only once nosological question is set, can task of formulating maximally valid diagnostic criteria even begin to occur – Could compare different diagnostic criteria for utility, in different contexts – DSM-V may rate relative validity of different diagnosis but based on what? Validity vs. Utility (Kendell & Jablensky 2003) • Few psychiatric diagnosis can claim nosological validity, according to Feighner criteria (especially hard for laboratory studies & delineation from other disorders) • Moving to validity for specific questions, or contextbased, moves away from notion of universal “truth” to notion of “utility” • Psychiatric diagnosis cannot claim to be valid, but can claim to be useful – in certain contexts The Case for Dimensional Classification • Most disorders lack a “zone of rarity” • Genetic and environmental risk cut accross diagnoses, as do symptoms, and treatments (e.g. depression – anxiety – somatisation / psychotic – bipolar) • Would circumvent need for multiple diagnoses, of unclear validity or utility (treat all?) • Clinicians less pressured to make Procrustean decisions forcing diverse presentations into “best fit” categories – Less information is lost – Particularly helpful for trans-cultural work, where diagnostic categories perceived even more problematic • Emerging ideas in pharmacotherapy, suggest medication may target symptoms, not syndromes – response easily measured • Reduction of stigma, through normalisation with general population, and lack of labelling ADHD – validity according to Feighner criteria • Clinical description – symptom clusters • Impairment – culture-context specific? • Laboratory Studies – Neuroimaging studies (structural & functional) not drug naive (even if unmedicated at time of imaging) – Functional imaging also tautologous! – Distinguishes from other conditions, including effects of maltreatment? • Not well delimited from other disorders, e.g. paediatric bipolar, emerging emotional unstable personality disorder (impulsive subtype) and RAD ADHD – validity according to Feighner criteria • Does high heritability cannot distinguish environment from genetic influence? – Twin studies wrongly assume equal environment (DZ vs MZ)? – Adoption studies methodologically weak – often unblinded, lack adoptee control group (confounds attachment problems), and do not account for preadoption / pre-natal experience – Individual genes weak effect, non-specific - “how to inherit multiple genes of small effect” – DRD4-7 repeat (one of the highest RR 1.45) also linked with attachment disorganisation, but only in presence of unresolved maternal loss / trauma • Follow-up – highly variable, depending on other contextual factors OUTCOMES • persistence of symtpoms / impairment – better prognosis if problem is inattention alone • poor school achievement – 32% fail to complete high school • higher rate of disruptive behaviour disorders • lack of friends / peer problems – lack of constructive leisure activities OUTCOMES • • • • • unemployment (67% vs. 40% controls) antisocial / personality dysfunction substance misuse criminality (juvenille and adulthood) road traffic violations and RTAs – POOR OUTCOMES MEDIATED / MAGNIFIED BY DEVELOPMENT OF CONDUCT PROBLEMS • seperate but correlated factors in factor analysis seperate dimensions / traits of the disorder Adult ADHD • Recognition of persistence into adult life – 15% of those diagnoses still meet full criteria by age 25 prevalence 0.6-1.2% (childhood 4-8%) – 65% persistence of some Sx (DSM “partial remission”) • criteria may be biased towards younger developmental stages • Inattention may and attention span usually will usually with age – lag behind that of unaffected people and that necessary / expected for attainment. Adult ADHD • Evolution of Sx – in pre-school child: incessant and demanding extremes of activity – during school years child may make excess movements during situations where calm is expected rather than on every occasion – in adolescence hyperactivity may present as excessive fidgetiness rather than whole body movement; – in adult life it may be a sustained inner sense of restlessness. Establishing Validity: Feigner Criteria • Robins & Guze (1970) / Feighner (1972) – Clinical description – Labaratory Studies (i.e. to show biological dysfunction – includes cognitive profile?) • Largely non-specific – Delimitation from other disorders (c.f. zone of rarity – Kendell 2003) • Few disorders truly seperate – Follow-up studies (diagnostic stability & response to Rx and outcome) • Highly variable for many disorders – Family studies • Disorders overlap Producing a Formulation “A key advantage of formulation over diagnosis is that it can be used to predict how an individual might respond in certain situations and to various psychotherapies [or other interventions]” Standard textbook approach • • • • • • Socio-demographic summary Presentation Diagnoses / differentials Presumed aetiologies Management plan Predicted response – implicitly linked to accuracy of formulation DSM-IV Multi-axial evaluation • • • • I: Clinical disorders II: Personality disorders / learning disability III: General medical conditions IV: Psychosocial and environmental problems, inc: – problems related to “primary support group” – Educational problems – Problems with housing / economic / social environment • V: Global assessment of functioning score ICD-10: Multi-axial diagnostic formulation • I: clinical disorders (mental and general medical conditions) – include personality & developmental dimensions • II: disabilities (in personal care, occupational functioning, functioning with family, and broader social functioning / social roles); • III: contextual factors (interpersonal and other psychosocial and environmental problems); • IV: quality of life (primarily reflecting patient's self-perceptions, including spiritual – culturally informed). DSM-V Cultural Formulation • “What problems or concerns bring you to the clinic?” & “what troubles you the most about your problem?” • How would you describe to others [not doctors]? Is there a particular term / “cultural label”? • “Why do you think this is happening to you? What do you think are the particular causes of your” • “What have your family, friends, and other people in your life done that may have made your [PROBLEM] better/worse?” • “ Is there anything about your background, e.g. your culture, race, ethnicity, religion or geographical origin that is causing problems/ helping in your current life situation?” – REFLECTING ON CULTURAL IDENTITY AS SOURCE OF STRENGTH OR OTHERWISE DSM-V Cultural Formulation • Clarify self-coping for the problem & listen for mental health treatment, medical care, support groups, folk healing, religious or spiritual counseling, or other alternative healing. • Barriers to help-seeking, access to care, and problems engaging in previous treatment. – “Is there anything about my own background that might make it difficult for me to understand or help you with your [PROBLEM]?” • Establish goals and treatment preferences SIRSE framework (from Child Psychiatry, 2nd Ed Goodman and Scott) • Symptoms – Emotional – Conduct – Developmental (include: attention-activity levels-impulsivity, speech/language, play, motor, toilet training, learning – literacy / numeracy) – Social relatedness: peers, family, authority, strangers • Impact (how much distress or impairment does it cause?) • Risks – Bio-psycho-social – Predisposing / precipitating / perpetuating / protective factors • Strengths – What assets are there to work with? • Explanatory model An additional framework Rutter, Taylor & Hersov –CAAP, Modern Approaches • Does the child have a psychiatric disorder? • If there is a disorder does the clinical picture fit that of a recognized clinical syndrome? • What are the various roots of that disorder in terms of intrapsychic, family, sociocultural and biological factors; and what are the relative strengths of each of these root causes in this particular patient? • What forces are maintaining the problem? • What forces are facilitating the child’s normal development? • What are the strengths and competencies of the child and of the family • Untreated what is the likely outcome of the child’s disorder(s)? – Is intervention necessary in this case? • What types of intervention are most likely to be effective? Should formulation include impact of diagnosis itself? • Theoretically we can hold multiple levels of explanation in mind simultaneously – in practice it can be difficult not to privilege one level (hard for professionals, even harder for families?) – different levels may have contradictory implications for action • Whether intended or not, classification reifies disorder as a fixed, and real entitiy, located within the individual – a problem in psychiatry because psychiatric illness, may be more responsive to changes in meaning and social context, than physical illness • Impact of diagnosis, and contingent social stigma on self-identity (which may already be less developed and robust) Case: KB • 8 yr old – presenting “Sx ADHD / ODD” • Mum victim of CSA • CP chronology reveals pervasive Hx of neglect, emotional and physical maltreatment and exposure to DV – Impact on children minimised by mother • Significant Speech & Language difficulties – Receptive (ToM) and expressive (internalised dialogue) • Would meet DSM-IV criteria for ADHD – Would this be hlepful to give? Formulation • A hook to hang it all on! • A cook-book / symptom checklist approach to diagnosis may lead to multiple medications (c.f. Louis Theroux in America!) and have catastophic consequences – e.g. Labelling a child who is victim of CSA with ADHD Case HW • 14 yr m • Voice hearing (“command” violence – self/other) – involved relationship with voices – Triggered by hearing G/F tell him of physical abuse – Some prior drug use – Sees himself as “black sheep” – family withdrawal longstanding (prognostic / Rx significance) – Peers – streetwise, but non-confiding • Voices reminiscent of protracted bullying – evolves into protector – “rules of living” – Cf. Steiner “psychic retreats” Psychotherapeutic Formulation • Psychodynamic • Attachment • Systemic (include cultural) Systemic Formulation • • • • • Cybernetics – homeostasis / feedback Structural – hierarchies / boundaries Transitions / family life cycle Functional – what cause is the Sx serving? Beliefs and communication – difference and how this is understood and communicated • Narrative – how the problem is talked about is part of the problem 3 column systemic formulation (Carr 2006) Contexts Belief systems Family of origin issues Beliefs about change Social – educational – professional networks Acknowledged and hidden strengths (“subjugated narratives” – Foucault) Constitutional factors - Can include medical Disorder, deficit, disability – reframing, externalising Behavioural patterns Attachment: From Behaviour to Representation Attachment classification SST / AAI Strange Situation Test (SST) Adult Attachment Interview (AAI) Secure / Autonomous Cries briefly on separation, Coherent and relevant, happy on reunion, secure base appropriate examples, able to from which to explore acknowledge episodes of distress without overwhelmed Anxious-ambivalent / preoccupied - enmeshed Distraught on separation, clingy-inconsolable on reunion, cannot explore Anxious-avoidant / dismissing Indifferent on separation and overly brief, keen to move reunion, focused on inanimate onto next question, poverty of object-play description, idealisation without evidence to back up. Disorganised / unresolved Freezing, oscillation approach- Hard to follow narrative, avoidance, anamolous jumping from past to present, or speaking about past “as if” Bound up in feeling, stories and relationships from the past, winding, overlapping stories, without clear resolution Hypothesized Parenting Styles • Secure: attuned, able to think about child’s needs separate from their own, flexible but able to set boundaries • Dismissing: harsh, unreflecting, parenting style, parents unable to attend to child’s emotional needs (or their own), child learns to “not feel” • Preoccupied: parent may be intermittently available but inconsistently so – child learns to amplify distress to get their needs met • Unresolved: frightened or frightening parent – may be linked to parental unresolved grief or maltreatment Family (& cultural) scripts • Characteristic modes of relating and communicating distress that run in families – Risk taking – Dramatic – histrionic – Medicalising / somatising • Cultural “idioms of distress” and CBS – Overdosing (Western – shunned in “traditional soc”) – Somatisation – Spirit possession / sorcery / “psychotic behaviour” • Symptoms as attachment strategies – eliciting care Psychosomatic Disorders Formulations of somatic Sx • Family / cultural script – may also be universal characteristic of moodanxiety states, selected or de-selected from awareness by culturally influenced cognitive processes (automatic somatic-scanning) • Children less enculturated – therefore somatic complaints more common – May include cultural understandings of “what doctors want to hear” • Somatisation disorder / Sx much more commonly reported and Dx by physician interviewer • Children, less educated / illiterate persons, or those with LD may have more naïve notions of medicine Conscious or unconscious? • Conscious – Fictitious (or “malingering” (sic)) – Induced (by child or parent, or “for” parent) • Unconscious – Dissociative conversion (Freud – “hysteria”) • Intrapsychic conflict (aggressive / sexual impulses) • Symbolic resolution (unable to walk – fear of own aggression? Blindness – a refusal of desire?) • Naïve notions of neurology (children, uneducated, LD) • Conforming to perceived expectation of parent / doctor! “Unconscious” (cont..) • Traumatic dissociation (Janet) – Flashbacks, intrusion of visual memory – Pain, intrusion of somatic memory – Emotional numbness, emotions “split off” in dissociated self – Sensory loss, ongoing pain or memory off “split off” in dissociated self • Functional (systemic hypothesis) – Symptom serving a function within wider family system: e.g. to unite parents, derail conflict • Attachment / scripts / conscious - unconscious Case: KK • • • • • 17 yr F CAMHS 15 – depression / anxiety Hx domestic violence exposure +? “Hit and run” RTA PTSD Litigation Enmeshed relationship with mother: codependent (separation anxiety driven by?) • Ongoing Sx – PTSD & physical pains • Ambivalent engagement – Attachment script / pattern – secondary gain – fear of change? Disorders of somatisation relevant to childhood / adolesence • • • • • Somatisation disorder (roots in adolescence) Undifferentiated somatoform disorder Hypochondriasis Body dysmorphic disorder Conversion disorder (but dissociation ?normative in younger children)