Download Mental Health Diagnosis Training

Mental Health
Diagnosis Training
Anxiety
• Panic Disorder
– Agoraphobia
• Obsessive Compulsive Disorder
• Specific Phobias
• Separation Anxiety Disorder
• Posttraumatic Stress Disorder
• Generalized Anxiety Disorder
• Anxiety Disorder NOS
What Type of Anxiety?
• Marcus has come for a follow-up appointment at the SBHC.
He reported several anxiety symptoms during his
comprehensive risk assessment, and screened positively
for panic attacks during the Diagnostic Predictive Scales.
Marcus indicates that the panic attacks are triggered by a
fear of being called on in class. He experiences symptoms
of panic (heart palpitations, nervousness, sweating, etc) on
the way to school, while sitting in class, and even just
thinking about being in class.
Panic Disorder –
Diagnostic Criteria
I. Recurrent, Unexpected Panic Attacks
Criteria for Panic Attack: A discrete period of intense fear or discomfort, in which four (or
more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes
Panic Disorder –
Diagnostic Criteria
II. At least one of the attacks has been followed by 1 month
(or more) of one (or more) of the following:
1. Persistent concern about having additional attacks
2. Worry about the implications of the attack or its
consequences (e.g., losing control, having a heart
attack, "going crazy")
3. A significant change in behavior related to the attacks
What Type of Anxiety?
• Philip was referred to the SBHC by his mother, because
she has become increasingly concerned by his fears of
going outside. Upon interview, Philip reveals that after
being attacked by a neighborhood dog a few years ago, he
has developed a fear of dogs. His fear is getting worse, and
he is beginning to limit his outdoor activities. He reports
getting nervous even when seeing dogs on television, even
though he knows they cannot hurt him.
Specific Phobias
• Marked and persistent fear of a specific object or situation
with exposure causing an immediate anxiety response that
is excessive or unreasonable
• In children, anxiety may be expressed as crying, tantrums,
freezing, or clinging.
• Adults recognize that their fear is excessive. Children may
not.
• Causes significant interference in life, or significant
distress.
• Under 18 years of age – symptoms must be > 6 months
Specific Phobias
• Animal phobias most common childhood phobia.
• Also frequently afraid of the dark and imaginary creatures
• In older children, fears are more focused on health, social
and school problems
What Type of Anxiety?
• Sally is brought to the SBHC by her parents, who are
worried about her poor attendance in school. Sally has had
some difficulty leaving her parents for the past several
years, but her concerns have grown increasingly more
intense. She reports having fears that if she goes to school,
her parents will abandon her or something very bad might
happen to them. She sometimes has dreams that they
have died, and she wakes up in a panic. Sally has come to
the SBHC several times in the past few months
complaining of headaches and stomachaches, requesting
that she be sent home.
Separation Anxiety Disorder
• Developmentally inappropriate and excessive anxiety concerning
separation from home or from those to whom the individual is
attached, as evidenced by three (or more) of the following:
1. Recurrent excessive distress when separation from home or
major attachment figures occurs or is anticipated
2. Persistent and excessive worry about losing, or about
possible harm befalling, major attachment figures
3. Persistent and excessive worry that an untoward event will
lead to separation from a major attachment figure (e.g.,
getting lost or being kidnapped)
4. Persistent reluctance or refusal to go to school or elsewhere
because of fear of separation
Separation Anxiety Disorder
5. Persistently and excessively fearful or reluctant to be alone or
without major attachment figures at home or without
significant adults in other settings
6. Persistent reluctance or refusal to go to sleep without being
near a major attachment figure or to sleep away from home
7. Repeated nightmares involving the theme of separation
8. Repeated complaints of physical symptoms (such as
headaches, stomachaches, nausea, or vomiting) when
separation from major attachment figures occurs or is
anticipated
Separation Anxiety Disorder
• Duration of at least 4 weeks
• Causes clinically significant distress or impairment
in social, academic (occupational), or other
important areas of functioning
What Type of Anxiety?
• James walks into the SBHC for an appointment. He reports
having great difficulty concentrating in his classes because
of his increased worrying. He cannot pinpoint his worries;
Rather, he reports being nervous about many things in his
life, including his relationships with peers, his grades, and
even his performance in basketball. His worries are
beginning to impact his sleep, and he is finding himself
becoming more irritable than usual.
Generalized Anxiety Disorder
• Excessive anxiety + worry for at least 6 months, more days than not
• Worry about performance at school, sports, etc.
• DSM IV criteria less stringent for children (Need only one criteria
instead of three of six):
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or
restless unsatisfying sleep)
What Type of Anxiety?
• Shelley’s teacher brings her down to the SBHC because he
is concerned that her grades have been declining, and he
has noticed that she has not been completing her
homework. Shelley reports that she is being plagued by
distressing thoughts of doing bad things, including hurting
herself and others. In order to get rid of the thoughts,
Shelley often has to engage in intricate routines, including
counting to 1000 and backwards, and touching her desk at
home in specific patterns. Although these routines
decrease her anxiety, they are causing her to skip
homework assignments and even lose sleep.
Obsessive Compulsive Disorder
• Presence of Obsessions
(thoughts) and/or
Compulsions (behaviors)
• Although adults may have
insight, kids may not
• Interferes with life or
causes distress
• One third to one half of all
adult patients report onset
in childhood or
adolescence
What Type of Anxiety?
• Ginny comes to the SBHC for a sports physical. During her
risk assessment, she reveals that her parents have a
history of domestic violence, and that she witnessed her
father attack her mother on several occasions. In the past
few months, Ginny has been having nightmares about the
abuse, and finds herself having flashbacks even during
class. Ginny has been avoiding certain rooms in her house
that remind her of the incidents. She also reports having
difficult sleeping and concentrating in class.
Post-Traumatic Stress Disorder (PTSD)
• The person has been exposed to a traumatic event in which both of
the following were present:
1. The person experienced, witnessed, or was confronted with an
event or events that involved actual or threatened death or
serious injury, or a threat to the physical integrity of self or
others
2. The person's response involved intense fear, helplessness, or
horror. (Note: In children, this may be expressed instead by
disorganized or agitated behavior.)
Persistent Re-Experiencing of Event (1+)
(1) Recurrent and intrusive distressing recollections of the event, including
images, thoughts, or perceptions. (Note: In young children, repetitive play
may occur in which themes or aspects of the trauma are expressed.)
(2) Recurrent distressing dreams of the event. (Note: In children, there may be
frightening dreams without recognizable content.)
(3) Acting or feeling as if the traumatic event were recurring (includes a sense
of reliving the experience, illusions, hallucinations, and dissociative
flashback episodes, including those that occur on awakening or when
intoxicated). (Note: In young children, trauma-specific reenactment may
occur.)
(4) Intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event physiological
reactivity on exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event
Avoidance and Numbing (3+)
(1) Efforts to avoid thoughts, feelings, or conversations associated with the
trauma
(2) Efforts to avoid activities, places, or people that arouse recollections of the
trauma
(3) Inability to recall an important aspect of the trauma
(4) Markedly diminished interest or participation in significant activities
(5) Feeling of detachment or estrangement from others
(6) Restricted range of affect (e.g., unable to have loving feelings)
(7) Sense of a foreshortened future (e.g., does not expect to have a career,
marriage, children, or a normal life span)
Increased Arousal (2+)
(1) Difficulty falling or staying asleep
(2) Irritability or outbursts of anger
(3) Difficulty concentrating
(4) Hypervigilance
(5) Exaggerated startle response
Post-Traumatic Stress Disorder (PTSD)
• At least one month duration.
• Causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning
• Note: Many students with PTSD meet criteria for another
Axis I Disorder (e.g., major depression, Panic Disorder) –
both should be diagnosed
Anxiety Disorder NOS
• Disorders with anxiety symptoms BUT do not meet criteria
for any specific Anxiety Disorder, Adjustment Disorder with
Anxiety, or Adjustment Disorder with Mixed Anxiety and
Depressed Mood
• Example: mixed anxiety-depressive disorder
• Also used in situations in which clinician has concluded that
an anxiety disorder is present, but is unable to determine
whether it is primary, due to medical condition, or
substance induced
Depressive Disorders
• Major Depressive Disorder
• Dysthymic Disorder
Depression
Epidemiology
• 2.5% of children, up to 5% of adolescents
• Prepubertal-1:1/M:F; adolescence-4:1/F:M
• Average length of untreated MDD-7.2 months
• Recurrence rates-40% within 2 years
Genetics
• Most important risk factor for the development of
depressive illness is having at least one affectively ill parent
What Type of Depression?
• Tonya has come for an initial appointment to the SBHC. During
the risk assessment, Tonya reports a number of depressive
symptoms, including suicidal ideation. Tonya seems to display a
lot of negative thinking and cognitive distortions. For example,
she believes that “nobody” likes her and that s/he will “never” be
successful in school. Her math teacher often compliments her
work, but Tonya dismisses the teacher’s comments as him “just
trying to be nice.” Tonya has good grades in all classes except
for one, yet she only acknowledges her below average
Chemistry grade. Tonya has felt extremely sad for about three
weeks, which is a contrast from her usually happy disposition.
Major Depressive Disorder
• Major Depressive Episode:
• Five (or more) of the following symptoms have been present during the same twoweek period and represent a change from previous functioning. At least one
symptom is either (1) depressed mood or (2) loss of interest or pleasure.
– Depressed mood most of the day, nearly every day, as indicated by subjective report or based on
the observations of others. In children and adolescents, this is often presented as irritability.
– Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every
day
– Significant weight loss when not dieting or weight gain (change of more than 5% of body weight in a
month), or decrease or increase in appetite nearly every day
– Insomnia or hypersomnia nearly every day
– Psychomotor agitation or retardation nearly every day (observable by others)
– Fatigue or loss of energy nearly every day
– Feelings of worthlessness or inappropriate guilt nearly every day
– Diminished ability to think, concentrate, make a decision nearly every day
– Recurrent thoughts of death, recurrent suicidal ideation with or without a specific plan, or an actual
suicide attempt
Major Depressive Disorder
• Symptoms cause clinically significant distress or
impairment in social or academic functioning
• Symptoms are not due to the direct physiological effects of
a substance (drugs or medication) or a general medical
condition
• Although there is a different diagnostic category for
individuals who suffer from Bereavement, many of the
symptoms are the same and counseling techniques may
overlap.
Depression
Modifications in DSM- IV for children:
• irritable mood (vs. depressive
mood)
• observed apathy and pervasive
boredom (vs. anhedonia)
• failure to make expected weight
gains (rather than significant weight
loss)
• somatic complaints
• social withdrawal
• declining school performance
Adolescent Development
Adolescent Development
• Periods of transient milder problems with low selfesteem, anxiety, depressive feelings are quite
common.
• Needs to be differentiated from clinical depression!
Suicide
• Attempts- 3:1/F:M, Completions- 4:1/M:F
• Most common means of completed suicide: FIREARMS
• Most often associated with depressive disorder.
• Risk factors: Age, sex, presence of psychiatric illness,
family history, isolation from friends, substance abuse
Adolescents and Suicide
• In 1998, 4,153 young people, ages
15-24, committed suicide in the United States an average
of 11.3 per day.1
• Suicide is the third leading cause of death in this age
group following unintentional injury and homicide2
• Suicide accounts for 13.5% of all deaths in this age-group1
1
Murphy, SL, 1998
2
The Surgeon General’s Call to Action to Prevent Suicide, 1999
Mortality in Children
Ages 1-19 years
Suicide
Homicide
Accidents
Cancer
Congenital
Other
Source: CDC Wonder Mortality Statistics; Center for Disease Control and Prevention, 2001
What Type of Depression?
• Maria comes for a follow-up appointment to the SBHC. Her
risk assessment showed that she has felt sad or blue for at
least two weeks. Upon further inquiry, Maria reports that
she generally feels sad, and finds little enjoyment in
activities. She reports having felt this way for several years.
In fact, she can’t recall a time when she didn’t feel mostly
down. She denies suicidal ideation, and is doing pretty well
in school. She is not very social, but does have a few
friends.
Dysthymic Disorder
• Major difference between a diagnosis of Major Depressive
Disorder and Dysthymia is the intensity of the feelings of
depression and the duration of symptoms.
• Dysthymia is an overarching feeling of depression most of
the day, more days than not, that does not meet criteria for
a Major Depressive Episode.
• Impairs functioning and lasts for at least one year in
children and adolescents, two in adults.
Depressive Disorder NOS
• Disorders with depressive symptoms BUT do not meet
criteria for: Major Depressive Disorder, Dysthymic Disorder,
Adjustment Disorder with Depressed Mood, or Adjustment
Disorder with Mixed Anxiety and Depressed Mood
• Examples: premenstrual dysphoric disorder, minor
depressive disorder (at least 2 weeks, but < 5 symptoms)
• Also used in situations in which clinician has concluded that
a depressive disorder is present, but is unable to determine
whether it is primary, due to medical condition, or
substance induced
Disruptive Disorders In Children
• Attention Deficit Hyperactivity
Disorder
• Oppositional Defiant Disorder
• Conduct Disorder
• Disruptive Behavior Disorder NOS
What Type of Disruptive Behavior
Disorder?
• Joseph was referred to the main office by his teacher for
disrupting her class. Joseph’s teacher reported that she
cannot manage him in class because he is constantly out of
his seat and will not concentrate on work. He has a hard
time completing tasks, and is very disorganized. He talks
back to her occasionally when frustrated, but is not
frequently defiant. His peers are getting tired of him
constantly interrupting them, and he is losing friends
quickly.
Attention Deficit Hyperactivity Disorder
• Symptoms for at least six
months to a degree that it is
maladaptive and
INCONSISTENT with
developmental level
• Some symptoms present
prior to age 7 years
• Two or more settings
Attention Deficit Hyperactivity Disorder
Inattention
• Poor organization
• Does not seem to listen
when spoken to
• Loses objects
• Easily distracted
• Forgetful in daily activities
Hyperactivity/Impulsivity
• Fidget
• Leaves seat often
• Runs or climbs excessively
• Always “on the go”
• Talks excessively
• Blurts out answers
• Can’t wait turn, interrupts
others
Attention Deficit Hyperactivity Disorder
• Attention deficit disorder can occur WITH and
WITHOUT hyperactivity
• Hyperactivity is more common in boys than girls
Attention Deficit Hyperactivity Disorder
• ADHD can be a lifetime disorder with 30-50% having
symptoms as adults
• Learning Disabilities are frequently seen in children with
ADHD
• Behavior in a provider’s office does NOT always reflect the
situation at home or in school
What Type of Disruptive Behavior Disorder?
• The principal of your school has called you to a meeting
with Jonathon’s parents and his teachers, all of whom
complain that Jonathon has been “acting out” for over a
year, and refuses to listen to their direction. He is constantly
arguing with all authority figures, and will not take
responsibility for his actions. Jonathon’s teacher and
mother say that he is “always angry,” and that he lashes out
at everyone around him. He has been breaking more rules
at home and in school. He has not been drinking alcohol or
using drugs, not has he broken the law up until this point,
but his parents are worried that his behaviors are going to
grow steadily worse.
Oppositional Defiant Disorder
A pattern of negativistic, hostile and defiant behavior lasting greater than
6 months of which you have 4 or more of the following:
• Loses temper
• Argues with adults
• Actively defies or refuses to comply with rules
• Often deliberately annoys people
• Blames others for his/her mistakes
• Often touchy or easily annoyed with others
• Often angry and resentful
• Often spiteful or vindictive
Oppositional Defiant Disorder
(ODD)
• Prevalence-3-10%
• Male to female -2-3:1
• Outcome-in one study, 44% of
7-12 year old boys with ODD
developed into CD
• Evaluation-Look for comorbid
ADHD, depression, anxiety
&LD/MR
What Type of Disruptive Behavior Disorder?
• Matthew was referred to the social worker at the SBHC
because he has been “going down the wrong path for
several years,” according to his mother. Matthew’s negative
behaviors began before puberty, when he started hanging
out with negative peers. Matthew’s mother has caught him
hurting their family pet as well as other animals, and he
was recently arrested for vandalizing school property. He
has been getting into frequent fights at school without
apparent instigation. Matthew’s mother also realized that he
had stolen from her when she noticed $50 missing from her
purse and found it in his pocket.
Conduct Disorder (CD)
• Aggression toward
people or animals
• Deceitfulness or Theft
• Serious violation of rules
• Destruction of property
Conduct Disorder (CD)
• Prevalence-1.5-3.4%
• Boys greatly outnumber
girls (3-5:1)
• Comorbid ADHD in 50%,
common to have LD
• Course-remits by adulthood
in 2/3. Others become
Antisocial Personality
Disorder
Conduct Disorder (CD)
“You left your D__M car in the driveway again!”
Disruptive Behavior Disorder
NOS
• Disorders characterized by conduct or
oppositional defiant behaviors that do not
meet criteria for ODD or CD
• Still must have impairment in functioning
Substance Abuse
• Experimentation with substances is common, particularly
during adolescence.
• Teenagers use alcohol and drugs for a variety of reasons:
– curiosity
– to reduce stress
– to fit in with a peer group
– it feels good
• Difficult to determine which
youths will experiment and stop and
which will develop more serious problems
with substances.
Adolescent Brain Changes
• Earlier drinking more likely to result in alcohol dependence
independent of family hx (Grant 1998)
• Exposure of alcohol may indeed cause alterations in brain
chemistry…. There are studies indicating heaving drinking
during adolescence causes memory and
neuropsychological changes (Brown, et al)
• Animal studies show that early exposure to alcohol results
in longer term problems such as cognitive and behavioral
problems
Dependence vs. Abuse
Dependence: A maladaptive pattern of substance use, leading to clinically significant
impairment or distress, as manifested by three (or more) of the following, occurring at
any time in the same 12-month period:
I.
Tolerance, as defined by either of the following:
a) A need for markedly increased amounts of the substance to achieve
intoxication or desired effect or
b) Markedly diminished effect with continued use of the same amount of the
substance
II. Withdrawal, as manifested by either of the following:
a) The characteristic withdrawal syndrome for the substance or
b) The same (or a closely related) substance is taken to relieve or avoid
withdrawal symptoms
III. The substance is often taken in larger amounts or over a longer period than
was intended.
Dependence vs. Abuse
IV. There is a persistent desire or unsuccessful efforts to cut down or
control substance use.
V.
A great deal of time is spent n activities necessary to obtain the
substance (e.g., visiting multiple doctors or driving long distances), use the
substance (e.g., chain-smoking), or recover from its effects
VI. Important social, occupational, or recreational activities are given up or
reduced because of substance use.
VII. The substance use is continued despite knowledge of having a
persistent physical or psychological problem that is likely to have been
caused or exacerbated by the substance (e.g., current cocaine use
despite recognition of cocaine-induced depression, or continued drinking
despite recognition that an ulcer was made worse by alcohol
consumption).
Dependence vs. Abuse
Abuse: A maladaptive pattern of substance use, leading to clinically significant impairment or
distress, as manifested by one (or more) of the following, occurring at any time in the same 12month period:
1.
Recurrent substance use resulting in a failure to fulfill major role obligations at wok,
school, or home (e.g., repeated absences or poor work performance related to substance
use; substance-related absences, suspensions, or expulsions from school; neglect of
children or household
2.
Recurrent substance use in situations in which it is physically hazardous (e.g. driving an
automobile or operating a machine when impaired by substance use)
3.
Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly
conduct)
4.
Continued substance use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the substance (e.g., arguments with
spouse about consequence of intoxication, physical fights)
The symptoms have never been met the criteria for Substance Dependence for this class of
substance.
Dependence vs. Abuse?
• Martina was referred to the substance abuse counselor
because her teacher thinks she has been high during class.
Martina reported to the counselor that she has been
drinking alcohol and smoking marijuana for the past couple
of years, and that she is having to drink and smoke more to
feel the same effects that she used to. She notices that
when she does not drink, she has trouble sleeping at night.
Martina reports trying to stop drinking and smoking in the
past, but she never succeeded. She has recently been
cutting classes to purchase alcohol and drugs.
DEPENDENCE
Dependence vs. Abuse?
• During his sports physical at the SBHC, Samuel reported
that he has drank alcohol in the past several months. He
indicated that he only drinks on the weekend, and that he
usually drinks the same amount (a few beers) each
weekend. His family and his girlfriend have complained to
him that his drinking is causing problems in their
relationships, and have asked him to stop. Over the past
summer, Samuel was arrested for drinking while driving. He
also said that he has been late to work a few mornings
because he had stayed out late drinking.
ABUSE