Assessment; Intervention Planning; Diagnosis; Treatment Planning. Flashcards
What is Assessment?
The Assessment Process.
- It is a critical element in the treatment of a CT.
- Refers to the process of arriving at tentative conclusions about the nature of the CT’s situation, including problems and resources.
- It provides the basis for treatment planning.
- It should be an ongoing process.
What should Assessment focus on?
The Assessment Process.
- Internal: Biophysical functioning-?; Use and abuse of alcohol and drugs; Cognitive and perceptional functioning; Emotional functioning; Mental disorders; Behavioral functioning; Motivation; Degree of acculturation; Language fluency; Problem solving skills.
- External: Health and safety factors; Social support systems; Environmental needs of adults and children; Cultural norms; Educational support and needs; Precipitating events that brought the CT to seek SW services.
What is Intake (interview)?
The Assessment Process.
- The assessment process generally begins with the intake interview, where pertinent info is gathered.
- The intake interview more extensive social history is written, which leads to a statement of CT strengths and problem areas or to a diagnosis and then a treatment plan.
CT Interviewing and Observation, what is Gathering data via interviewing?
The Assessment Process.
- Problem areas- should be identified from the CT’s point-of-view. The most pertinent info is often obtained when the CT is most upset. Personal and environmental problem areas, including economic factors, that are having an effect on the CT’s psychosocial functioning should be explored and identified.
- Strengths- of the CT and CT’s support system need to be identified. Identifying CT strengths can provide encouragement and lead to CT believing he/she is the driving force in dealing with current problems. The CT’s coping mechanisms, both adaptive and maladaptive, should be assessed and can shed light on their effect on the CT’s presenting problems.
- Support system- is one of the most important aspects of the treatment process and needs to be throughly explored. That one support system increases the CT’s ability of resiliency. Support system includes family members, friends, religious affiliations, caretakers, pets, helping professionals, etc.
- The Attitude- of the CT needs to be assessed. A positive attitude about current situation and has the ability to see things as being able to get better, he/she will have a greater chance of dealing with the problem. A negative, defeatist, or persecutory attitude about his/her situation is generally not good. There are many treatment strategies and methods that focus on changing CTs attitudes.
- CT Motivation should be explored because a CT can have devious reasons for seeking therapy, such as wanting secondary gains. E.g. satisfying someone else’s request for the CT to obtain help or avoiding negative legal consequences. SW can ask the CT directly about his/her level of motivation or can assess the level of motivation based on the CT’s answers to questions that are asked.
- *Motivational interviewing- is a CT- centered method for addressing the CT’s ambivalence ( simultaneous and contradictory attitudes or feelings (such as attraction and repulsion) toward an object, person, or action) and eliciting the CT’s own motivation to change rather than imposing the change. According to Miller and Rollnick (1991), motivational interviewing is not a set of counseling techniques, but a way of being with the CT while assessing the CT’s motivation to change. It is useful in substance dependence, problematic gambling, dual diagnosis, brief intervention, mental disorders, parenting and in the court system.
- The CT’s Relationships are an essential component of the data gathering process. Interpersonal relationships frequently plays a key role in seeking treatment. The patterns of behavior that may be contributing to the presenting problem can be identified. Relationships in the CT’s work environment may contribute to the CT’s problems, so gathering information about the CT’s employment history is valuable.
- Use of Resources- both personal and environmental is important to the CT’s situation. SW should determine if the CT has used community resources in the past and his/her attitude toward seeking and accepting help. An assessment should be made for the CT’s personal resources, such as problem solving skills, faith or spirituality, cultural values, cognitive abilities, and dependance on his/her support system. An assessment should be made to the CT’s willingness to access personal and community resources in the future.
- Danger to Self or Others- should be explored in the initial interview. If the SW senses any indication that the CT is planning to harm him/herself or another person, SW should take immediate action.
CT Interviewing and Observation, what is Gathering data via observation?
The Assessment Process.
- SW should observe the CT over time and in multiple situations.
- Observation-based data gathering includes:
Appearance- of the CT, SW should note any condition relevant to understanding the CT, such as body weight, physical disabilities, apparent healthiness, facial affect, grooming, etc.
Health- Obtained through medical records. The impact of life stressors on the CT can often be seen in the physical and emotional health of the CT. Self-care, cognitive abilities, emotional functioning, and social skills can be observed. Drug use may also be considered a possibility when certain physical, behavioral, and cognitive elements are observed.
Life skills- are indicative of the CT functioning and may be deemed as strengths or limitations in the CT’s situation. Depending on the age and ability of the CT, factors to observe may include mobility, money management, cleanliness, personal hygiene, communication skills, organizational skills, social skills, problem- solving, self-care and work skills.
What is Referral for additional evaluations?
The Assessment Process.
- It may be necessary to obtain additional information through formal psychological testing, psychiatric evaluation, vocational testing, or medical evaluations. SW may need to refer CT to another mental health professional, medical doctor or agency. SW should tell the CT why this referral is needed and facilitate the referral process. The SW should then follow up with the individual with whom the CT was referred and use the information to complete the intake process.
What is Assessment of Problems Areas and Strengths?
Assessment Methods
- Biopsychosocial model of assessment considers three elements of the CE’s situation: (1) the biological component or how the body’s functioning may be contributing to the CT’s current problems; (2) the psychological component, or the emotions, the thinking process and behaviors of the CT; (3) the social component, or the role fo the environment, culture, socioeconomic status, poverty, and spirituality in the individuals’s health.
- After gathering all these information, SW then identifies the CT’s current level of functioning, strengths and weaknesses, mental health status (including previous problems areas), and the CT’s needs.
- The traditional Medical Model of assessment focuses on the CT’s pathology or what is “wrong” with the CT. In the process of gathering data and formulating a diagnosis, SW have traditionally identified problems areas, but sometimes w/o enough consideration of the CT’s strengths, resiliency, and positive life factors.
- The Strengths Perspective of assessment is based on the notion that CT strengths are essential ingredients in the healing process and that incorporating the strengths of the CT will aid in empowering the CT to reach the desired goal.
- Strength Perspective benefits are: empowers the CTs to solve their own problems; examines possible alternatives; teaches competencies; creates more equity between the CT and SW; builds self- confidence; helps CTs to see that problems are influenced by multiple factors, are interactive, and are ever-changing.
What does Social History include?
Assessment Methods
- Gathering data via interviewing and observation- is importation when writing the social history. The topic include problem areas, CT strengths, support system, attitude of the CT, CT motivation, CT’s use of resources, danger to self and others, appearance, health and life skills.
- Identification of presenting problem- information gathered initially should focus on why the CT (sometimes called the “identified patient”) was referred to the agency or setting. SW should find out the reason for the referral from the viewpoint of the agency, CT and the family but there will be one problem that will be considered the referral problem, which is the primary reason for seeking help.
- Family History- gathering family history can provide SW with valuable information about the CT’s past and can identify potential predicators of the CT’s future prognosis. Information can be gather by asking open-ended questions (e.g. “tell me about your family”) or direct questions (e.g. “Were you abused as a child?”). A CT’s response gives him/her a chance to identify what may be most important to them about their family, rather than the SW deciding what is most important. SW’s should always be attuned to cultural factors as they ask questions and interpret CT responses. SW should look for patterns of behaviors in families (e.g. poor decision- making, abuse, etc.) as possible predicators of how the CT may function. The position that the CT holds in the family constellation and his/her relationship w/ family members may also be important information needed to complete the social history. Medial and mental health history of CT and family should be assessed in relationship to their impact on CT’s current problems.
- Sexual History- is vital information to the treatment plan. The taking of sexual history may depend on the CT’s age and reason for treatment. SW’s should prepare CT that these types of questions will be asked. These question should not be asked until well into the assessment process. Questions can be open-ended or specific. It is vital to take a sexual history due to sexual offense, or if a history of sexual abuse or sexual perpetration. Sex offenders may be reluctant or unwilling to admit to sexual behavior and may become angry when confronted. When working with a child, the SW may want to engage the child in a play situation or having the child draw pictures and describe what he/she has drawn. SW can also ask parents about their child’s sexual knowledge, including whether the parent suspects that the child has been molested.
- Records pertinent to the CT and his/her situation, both current and past, are vital social history as they provide information that may not be readily attainable through the interview process. Relevant records to be obtained with CT permission, include school, medical, abuse and neglect, substance abuse treatment (psychiatric and medical) and criminal records. All records requests and evaluation should be in compliance with HIPPA regulations.
- Assessment instruments are necessary pieces of information for the formulation of a diagnosis and treatment plan for the CT. In general, SW are not trained nor licensed to administer or interpret psychological tests and are only allowed to use evaluation tools for which they are qualified to administer and interpret. With CT’s permission, SW can gather school test results, vocational testing, achievement tests, psychiatric evaluations, and psychological tests.
- Collateral contacts/ information- refers to data that is gathered from individuals who know or have had contact with the CT. They provide valuable information and often differing points of view with regard to the CT and his/her situation. Strengths of the CT and support system may also be identified when making collateral contacts. SW’s may interview relatives, neighbors, caregivers, school personnel, and co-workers. SW should inform CT that these contacts will be made and use caution and sensitivity in dealing with the CT’s feelings about these contacts.
- Suicide Risk- requires a timely assessment. It is important to take necessary steps to prevent harm. A “no harm” contract is sometimes created for those who are having suicidal ideation, but some research suggests that this is ineffective. If a CT have a specific plan, it is important to have the CT admitted to the hospital. If the CT refuses to voluntary admit him/herself it may be necessary to contact EMS and a family member or friend to assist with the process. Drastic changes in mood may also indicate a problem in a CT who has a history of suicide or is coming out of a major depression. A person who has formulated a plan to commit suicide may also display calmness and happiness and could have all of his affairs in order.
- Risk Factors for suicide may include: Previous suicide attempt; Family history of suicide; Mental disorders; Alcohol and substance use; Serious physical illness; History of abuse or trauma; Impulsiveness; aggressive tendencies; Feelings of hopeless; Significant losses; Isolation; no support system; Lack of mental health care; Easy access to weapons, drugs or other means.
- Protective Factors may include: No access to guns, lethal drugs, weapons; Strong support system; Religious and cultural beliefs about suicide; Problem- solving skills; Mental health care, including treatment for substance disorders.
Suicide chart- pg. 115- 116 - Violence Risk- or risk of harm to others is another category that requires a timely assessment. Risk cannot be entirely eliminated, is dynamic and depends on the circumstances. Some risk factors include: History of violence or harm to others; “Social restlessness” (e.g. frequent relocation, job changes, few relationships); Individuals with mental disorders (unreliable predicators of risk); Emotions related to violence: irritability, anger, hostility, suspiciousness, fear; Substance abuse; Poor compliance with treatment; discontinuing medications; Feeling persecuted or feeling that mind or body is being controlled by external forces; Evidence of recent severe stress or loss; Access to Victims.
The Indicator of Traumatic Stress and Violence entails?
Assessment Methods
- When assessing trauma, SWs can be attuned to the indicators of trauma by observing the behavior that occurs in the assessment interviews. The SW can ask the CT about physical complaints, sleep disturbances, and coping methods. Trauma can occur with one-time, multiple, or long- lasting repetitive events that effect each person differently. Some individuals develop PTSD while others exhibit brief symptoms or resilient responses. It is important for clinicians to remember that traumatic stress reactions are normal reactions to abnormal experiences/ circumstances. Immediate reactions to trauma vary in severity. Reaction include exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect (is a lack of affect more severe than restricted or constricted affect, but less severe than flat or flattened affect). More severe reactions may include continuous distress w/o periods of feeling calm or rest, severe dissociation and derealization symptoms, and intense intrusive thoughts. Delayed reaction may include persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety about flashbacks, depression, avoiding emotions, avoiding activities associated with the trauma.
- Trauma Impacts individuals in multiple areas of functioning: Emotional- reactions are significantly influenced by the individual’s sociocultural history. The individual may associate with strong feelings from the post trauma and the may feel emotionally out of control. Another common response is emotional numbness. (Numbing is a biological process in which emotions are detached from the thoughts, behaviors and memories).
- Emotional dysregulation: Generally there are two emotional extremes in reaction to traumatic stress. There is a feeling of being overwhelmed (too much) or little emotion (too little). Some trauma survivors may have difficulty regulating the expression of anger, anxiety, sadness, and shame (especially with trauma experienced at a young age.) In older individuals and those who functioned well prior to the trauma, the emotional dysregulation is generally short-lived and an immediate reaction. It is common that self-medication is used as a coping skill to regain emotional control.
- Physical: Common physical complaints include somatic symptoms, sleep disturbances, gastrointestinal, cardiovascular, neurological, respiratory and urological concerns (urinary tract infections, kidney stones, bladder control problems, and prostate problems). CTs are likely not aware of the connection b/w their emotions and physical symptoms. Focus on physical symptoms may help the person avoid emotion.- Hyperarousal and sleep disturbances: Hyperarousal is a biological mechanism to keep a person prepared for some event and is characterized by sleep disturbances, muscle tension, and a lower threshold for startle responses. These symptoms can persists for years after a trauma and can interfere with the ability to appropriately assess and respond to specific input from the environment (e.g. loud noises or sudden movements) which can lead to overreaction.
- Cognitive: Traumatic experiences can alter the way in which a person thinks and processes information. Trauma frequently alters core life assumptions- thoughts about self, the world, and regarding the future. E.g. of Cognitive changes: Cognitive errors such as misinterpreting a situation as dangerous because it resembles the previous trauma; Excessive or inappropriate guilt; assuming responsibility for the traumatic event or possessing survivor’s guilt; Idealization: inaccurate rationalizations, idealization or justification of a perpetrator’s behavior leading to traumatic bonding; Trauma- induced hallucinations or delusions which are congruent with the content of the trauma; Intrusive thoughts or memories: experiencing w/o warning, thoughts and memories associated with the trauma that triggers strong emotions and behavioral reactions.
- Behavioral: Individuals may use avoidance to reduce tension and stress; may indulge in self-medication; may exhibit compulsive behaviors (e.g. overeating), impulsiveness (e.g. high risk behaviors), self-injurious behaviors, and aggressiveness. A traumatized individual may subconsciously reenact aspects of the trauma (e.g. a child crashing a toy plane into a toy building after 911). Reenactment helps the individual to master the trauma.
What does Standardized Testing include?
Assessment Methods
- Unlicensed SWs are not allowed to administer tests such as: Psychiatric evaluations; Intelligence (IQ) test; Learning disabilities test; Communication disorder tests; Adult and children’s ADHD test; Personality test such as the MMPI.
- Depending on the SW’s level of training and scope of practice, SW may with some specific training, administer test such as depression inventories, behavioral checklists, personality inventories, alcohol use inventories, etc.
- Mental Status Examination- is part of a psychiatric clinical assessment to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. This exam can be used in outpatient and inpatient settings. It consists of informal inquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The domains examined are appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgement.
What does Standardized Testing and Specific domains include?
Assessment Methods
- Appearance- physical appearance includes a CT’s age, height, weight, and overall grooming.
- Attitude- refers to the CT’s interaction with the mental health professional. CT’s attitude may be described as cooperative, uncooperative, hostile, guarded, or suspicions.
- Behavior- includes general observation about the CT’s level of activity, specific abnormal movements, eye contact, and gait. E.g. of abnormal movements or tremor includes tics, Catatonia (detach from reality or oblivious to environmental stimuli), repetitive purposeless movements (head banging, rocking), odd mannerisms, restlessness, psychomotor agitation, or retardation.
- Mood and Affect- Mood is described by the CT in his/her own words; it is an internal emotional state. Types of mood states include neutral, euthymic (normal mood), depressed or dysphoric, euphoric, angry, anxious, indifferent (apathetic), or anhedonic (inability to experience pleasure). Affect is the emotion conveyed by the CT’s nonverbal behavior. The affect is evaluated by appropriateness, intensity, range, reactivity, and mobility. Types of affect include full range, restricted, blunted, flat, labile (tendency toward emotional flexibility freedom of a movement and abrupt changes in mood and effect.), congruent (in agreement or harmony.), incongruent, exaggerated, or dramatic. Affect is subject to cultural influences.
- Speech- is assessed by listening to the CT. The focus is on the production of speech rather than the content of speech (which is related to thought). E.g.s of speech include loudness, rhythm, pitch, articulation, quantity, rate, and spontaneity. It also includes the CT’s ability to name objects, produce specific words in a set time, and repeat short sentences. Abnormalities of speech may include stuttering, mutism, echolalia (repetition of another person’s words), palilalia (repetition of the individual’s own words), and neologisms (made-up words that have specific meaning to the individual).
- Thought process- refers to the quantity, rate, and form (logical or coherent) of thought. It cannot be directly observed, only inferred from the CT’s speech. Rate can be described as “flight of ideas” (i.e. thought are rapid and pressured.) Poverty of thought is a term used to described a reduction in the quantity of thought. Perseveration (the repetition of a particular response (such as a word, phrase, or gesture) regardless of the absence or cessation of a stimulus.) is noted if the CT keeps returning to the same limited set of ideas.
A formal thought disorder may be exhibited by thought blocking (where the CT’s thoughts seem to be interrupted w/o apparent causes; frequently mid-sentence), loose associations (thoughts appear unconnected unbeknownst to the speaker), tangential thinking (replying in an oblique or irrelevant way), derailment, and circumstantial (where the CT includes a great deal of irrelevant details and makes frequent diversions.) - Thought Content- identifies a CT’s delusions, phobias, obsessions, over-valued ideas, and pre-occupation. Abnormalities are measured through open-ended, conversational types of questions w/ the CT. Delusions (false ideas or beliefs that are not held by the CT’s educational, cultural and social background) are abnormalities of thought content. The content of delusions can be paranoid, grandiose (when the individual is convinced that he/she has a special talent or understanding of some phenomenon or that he/she has accomplished something of great importance), erotomanic (when the individual believes that another person, frequently of higher status, is in love with him/her), jealous, or delusions of reference (a common or action that is interpreted to have special meaning to the CT.)
Thought withdrawal is a belief that one’s thoughts are being withdrawn from one’s mind.
Thought insertion is belief that others are putting thoughts into one’s mind.
Thought broadcasting is a belief that one’s thoughts are broadcasted or heard by others. - Perception- is a sensory (sensation or physical senses) experience. The main perceptual distortion is a hallucination (i.e. sensory perception in the absence of any external stimulus.) These occur in any of the five senses. The most common type of hallucination is auditory- person hears voices or sounds that others cannot hear. Visual hallucinations involves seeing things others cannot see. Tactile hallucinations involve touch. Olfactory hallucination involve smell. Gustatory hallucinations involve taste and are generally unpleasant. Distortion of sense of time (e.g. deja vu); depersonalization distortion of sense of self; and derealization (distortion of sense of reality.)
- Cognition- assesses the CT’s level of alertness, orientation, attention, memory, language, and executive functions.
Alertness is assess by the individual’s level of consciousness (awareness of and responsiveness to the environment). The level of consciousness can be alert, drowsy, clouded, or stupor.
Attention and concentration is assessed by serial sevens (subtracting 7 from 100, 7 from 93, etc.) and digit span (ability to repeat numbers in a specific sequence.)
Memory is assessed on three levels: immediate recall (repeating words), short-term (recalling three items after a small time delay), and long-term (recollection of historical or geographical facts.)
Language is assessed through the ability to name objects, repeat phrases, and observing spontaneous speech.
Executive function can be assessed by asking about similarities, (e.g. “what do a ball an apple have in common?”) and proverbs (e.g. Ask the meaning of the proverb, “People in glass house should not throw stones”.) - Insight- refers to the individual’s understanding to his/her problems and treatment options. Insight is a continuum (e.g. good, poor, no insight).
- Judgment- refers to the individual’s ability to make sound, reasoned and responsible decisions. A typical question might be, “If you were in a movie theatre and smelled smoke what would you do?” or “What would you do if you won the lottery?”
What does Medical Terminology include?
Assessment Methods
- Alert and Oriented, aka oriented X3 is used to describe a CT that is aware and oriented to person, place and time.
- Complete Blood Count or CBC, aka Full Blood count is a very common test used to determine the chemistry in a person’s blood.
- Congestive Heart Failure is a condition in which the heart is unable to pump enough blood to the rest of the body. Common symptoms include lethargy (lack of energy and enthusiasm), extreme tiredness, swelling and fluid retention.
- Chronic Obstruction Lung Disease (COPD) is a chronic condition of the lungs in which chronic bronchitis and emphysema are the most common complaints.
- “SOAP notes- is a commonly used format for SW and behavioral health professionals to use in documenting progress in a CT’s record. SOAP- “Subjective”- observation, “Objective”- data, “assessment”, and “plan”.
- “BIRP notes” is another format used for documenting CT progress. BIRP- “behavior” of CT, “intervention” of the SW on behalf of the documented behavior, “response” to the intervention, and “plan”.
What does Medical Terminology include?
Assessment Methods
Commonly used acronyms include:
bid- 2x a day
tid- 3x a day
qid- 4x a day
@hs- at hr of sleep (bedtime)
prn- as needed
stat- immediately
f/u- follow up
hx- history
sx- symptoms
dx- diagnosis
nka- no known allergies
dc- discontinue or discharge
lmp- last menstrual period
rx- prescription
r/o- rule out
uri- upper respiratory infection
uti- urinary tract infection
wnl- w/in normal limits
mri- Magnetic Resonance Imagining.DSM Classification System consists of?
- 22 diagnostic categories (including Z Codes or Other Conditions That May Be A Focus of Clinical Attention). The disorders are organized by similarity in symptoms or etiology (underlying problem or disorder) and from a life span approach. E.g. disorders that first manifest in children are addressed first, such as Neurodevelopment Disorders. Then adolescence, early adulthood, and later adulthood such as Neurocognitive disorders. If there are diagnoses that manifest differently as the individual ages, DSM- 5 specifies the signs or symptoms that are present (e.g. Attention Deficit/ Hyperactivity Disorder). For disorders that do not meet the full criteria, the clinician uses “Other Specified (disorder)” or “Unspecified (disorder)”. If the disorder is associated with substance use or a medical condition, the terms “Substance/ Medication Induced (disorder)”, or “(disorder) Due to Another Medical Condition” are used.
- The DSM- 5 no longer uses the multi-axial formulation found in the DSM-IV-TR. Axes I, II and III are combined, making the formulation more consistent with ICD-9 and ICD- 10 Codes (International Classifications of Diseases.) Axes IV and V were also eliminated. Psychosocial stressors are accounted for by the expanded section in “Conditions that May be the Focus of Clinical Attention” (Z Codes).
- Specifiers- When diagnosing, the clinician may be requested to add “specifiers”. There are several types of specifiers: duration (e.g. first episode, multiple episodes, continuous), type specifiers (e.g. Delusional Disorder, jealous type), and severity specifiers (e.g. mild, moderate, severe; 1- 4). Severity specifiers are defined w/in diagnostic categories.
Examples of a Diagnostic Formulation includes?
DSM Classification System
F60.3 Borderline Personality Disorder
F34.1 Persistent Depressive Disorder, early onset, w/ anxious distress, moderate
Z62.811 Personal history (past history) of sexual abuse in childhood.
- Diagnostic codes written in parentheses denote code that are consistent with ICD Codes.
- Either diagnostic code is considered to be equivalent.
- Individuals are viewed from a bio-psychosocial perspective in which psychosocial stressors, medical conditions, strengths, daily functioning, and mental disorders all interact. SW may want to include any medical diagnosis of a chronic nature (e.g. diabetes, congestive heart failure) that impacts the individual’s ability to function. It is important to indicate where you obtained this information, such as CT report, prior medical records or family report.
- A co-occurring disorder is defined as a combination of disorders that an individual may experience (e.g. Borderline Personality Disorder and Post- Traumatic Stress Disorder; Major Depressive Disorder and Alcohol Use Disorder). Co-occurring disorder replaces the term dual diagnosis.
- Individuals with mental health disorders are more likely to experience a substance use disorder. The co-occurring disorder can be difficult to diagnose because of the complexity of symptoms. The disorder may vary in severity. Individuals with co-occurring disorders often experience chronic medical issues, social and emotional problems rather than if the individuals was diagnosed with either a mental health disorder or a substance use disorder. The are vulnerable to both relapse of substance use and psychiatric decompensation.
Symptoms of Neurologic and Organic disorders is?
DSM Classification System
- Organic disorder is a disease process due to a medical or physical condition that affects mental function. It may be temporary or long- term. Most organic disorders fall into the categories of delirium, dementia and amnestic. The specific disorder can be acute (e.g. delirium) or chronic (e.g. dementia). Other examples include: traumatic brain injury, hypoxia (is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level.), cardiac arrhythmias (also known as Arrhythmia, cardiac arrhythmia or heart arrhythmia, is a group of conditions in which the heartbeat is irregular, too fast, or too slow… Some types of arrhythmias have no symptoms. Symptoms when present may include palpitations or feeling a pause between heartbeats.), and degenerative disorders (e.g. Multiple Sclerosis, Parkinson’s Disease, Huntington’s Chorea, infections).
- A functional neurological disorder occurs when the brain’s structure is not damaged but it does not function correctly. Symptoms does not fall into specific diagnoses. The cause of a functional neurological disorder is unknown. Frequently symptoms are attributed to psychological factors such as emotional conflicts or stress.
- Common symptoms of functional neurological disorder include tremors, headaches/migraines, difficulty with memory, changes in personality, pain, sleep disturbance, inability to move arms or legs properly. Symptoms vary in intensity and may be constant or intermittent. The individual is not able to intentionally produce or control the symptoms.
What does Neurodevelopment Disorders include?
DSM-5
- Intellectual Disabilities
Intellectual Disability (Intellectual Development Disorder)- replaces the term "mental retardation". Intellectual Disability is characterized by both intellectual and adaptive functioning deficits that begin during the developmental period. It occur in reasoning, problem solving, planning, abstract thinking, judgement, academics and an inability to learn from experience. Intellectual functioning deficits are manifested by clinical observation and standard intelligence testing.
Adaptive functioning deficits are manifested in failure to meet developmental and sociocultural standards of personal independence and social responsibility. There are limitations in activities of daily living, communication, independent living, and social interactions across multiple situations (e.g. home, school).
The level of severity is defined by adaptive functioning rather than IQ. Severity indicates what level of support is required in academic, social and practical domains. DSM- 5 notes that IQ measures are less valid in the lower end of the IQ range.
- Global Developmental Delay- is reserved for children under the age of 5 when clinical severity cannot be reliably assessed through standardized testing. The child fails to meet expected developmental milestones in serval areas of intellectual functioning. R/A after a period of time is required.
There is no specific meds for Intellectual Disability Disorder or Global Development Delay. If there are specific symptoms, such as tics, meds may be prescribed for those symptoms. Treatment modalities focus on multidisciplinary interventions depending on the type of deficits the individual is experiencing. The goal is for the individual to function at his/her full potential. Use of social skills training is considered beneficial.What is Communication Disorders?
Neurodevelopment Disorders - DSM-5
- These disorders are identified in the DSM- 5 under four diagnoses. The communication difficulty must negatively impact academic or occupational achievement and/or interpersonal communication. Communication disorder tend to be common in males.
(1) Language Disorder is a failure to acquire and use spoken language, written language or sign language due to deficits in comprehension or production. Language difficulties are below those expected for a child of the same age. Associated defects significantly interfere with socialization, academic achievement or occupational performance and effective communication.
There are no meds currently prescribed.
Treatment focuses on the child working with a speech and language therapist.
(2) Speech Sound Disorder- is a new disorder that is defined as a persistent difficulty with speech sound production that interferes with the intelligibility of the individual’s speech. This disorder interferes with social interaction, academic achievement or occupational performance. Most intelligible speech occurs by the age of 3. Children with Speech Sound Disorder continue to use immature speech patterns past the age when other children can produce words clearly.
No meds for the treatment.
Most children respond well to treatment by a speech and language therapist and speech difficulties improve over time.
(3) Childhood- Onset Fluency Disorder (Stuttering) is diagnosed when a child fails to use age and dialect appropriate speech sounds. The average age of onset is by age 6, but the range can be between 2-7 years of age. The disorder causes significant anxiety related to speaking or limitations in effective communication. Stress and anxiety can exacerbate the disorder. The disorder interferes with the individuals’s achievement in academics, occupation, and interpersonal communication. The individual may avoid situations due to fear that stem from humiliation and embarrassment.
The symptoms consist of: sound distortions, substitutions or omissions; articulation problems; words produced with excessive physical tension; and monosyllabic word repetitions.
(4) Social (Pragmatic) Communication Disorder is a new order. The individual diagnosed with this disorder has persistent difficulties in the social use of verbal and nonverbal communication. The diagnosis is appropriate after the 4 or 5 when the child has adequate speech and language abilities. There is no evidence of restricted/ repetitive patterns of behavior, interests or activities as would be seen in Autism Spectrum Disorder. There is functional impairment in effective communication, social relationships, academic achievement or occupational performance. There are specific deficits in the following areas: communication for social purposes; impaired ability to change communication to match context or the needs of the listener (e.g. setting, speaking with an adult vs. a child); following rules of conversation (e.g. taking turns, rephrasing what has been heard); and understanding inferences, nonliteral or ambiguous meanings of language. Since Social (Pragmatic) Communication Disorder is new, there has not been specific research related to effective meds or treatment. However, since many of the communication issues are similar to Autism Spectrum Disorder, similar medications and treatment have been suggested including social skills training, speech and language therapy.
What is Autism Spectrum Disorders?
Neurodevelopment Disorders - DSM-5
- This is a new disorder under the DSM- 5. It consolidates the following DSM- IV disorders: Autistic Disorder, Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder and Pervasive Development Disorder NOS.
Symptoms of the disorder are represented in terms of severity in social communication/ interaction and restrictive behaviors/ interests/ activities. Symptoms include: reduced sharing of emotion and a failure of normal back and forth conversation; stereotyped or repetitive motor movements or speech; insistence on sameness; no flexibility in routines, ritualized patterns to sensory input. Severity is assessed separately for social communication and restricted, repetitive patterns of behavior.
** If symptoms are related only to social communication, then the clinician should look at the criteria for social (Pragmatic) Communication Disorder.
Meds are generally used to treat specific behavioral issues (e.g. aggression, self-injurious behaviors, and self-harm behaviors). Risperidone and Abilify are prescribed to treat these behaviors. Other medications have been prescribed for specific symptoms (e.g. anxiety, depression, obsessive- compulsive behavior, hyperactivity).
There are no single treatment for autism and requires an interdisciplinary team approach. Treatment is tailored to the individuals child’s needs. The main goals of treatment are to lessen associated deficits and family distress and to increase quality of life and functional independence. Many of the treatments utilized are related to Applied Behavioral Analysis (e.g. Intensive Behavioral intervention, Pivotal training-(PRT)- is a method of systematically applying the scientific principles of applied behavior analysis (ABA) to teach learners with autism spectrum disorders (ASD) functional social-communicative and adaptive behaviors within a naturalistic teaching format.). Speech therapy, physical therapy, and occupational therapy can address specific deficits in those areas.
What is Attention- Deficit/ Hyperactivity Disorder (ADHD)?
Neurodevelopment Disorders - DSM-5
- A clear pattern of inattention and/or hyperactivity not accounted for by an individual’s developmental stage. ADHD is more common in boys. Some symptoms are evident before age 12 and impairment must be significant and evident in at least two different settings. In preschool children, hyperactivity is the main manifestation. In school age children, inattention is more prominent. In adolescent, hyperactivity is less common and may be more related to fidgetiness, inner restlessness or impatience. In adulthood, impulsivity may remain problematic even when hyperactivity has diminished. In children, there must be at least six symptoms in either or both inattention and hyperactivity- impulsivity. In adolescents and adults ( over age 17), the individual must present with five symptoms.
- Three different types of ADHD:
Attention- Deficit/ Hyperactivity Disorder, Combined Type
Attention- Deficit/ Hyperactivity Disorder, Predominantly Inattentive Type
Attention- Deficit/ Hyperactivity Disorder, Predominantly Hyperactive- Impulsive Type
Treatment has typically focused on meds (e.g. psychostimulants such as Ritalin, Dexedrine, or Adderall.) These psychostimulants are often helpful in curbing hyperactivity and impulsivity, attention, and learning. Strattera is a non-stimulant that is prescribed for adults or children who do not tolerate psychostimulants. Tricyclic antidepressants are also effective in adults.
There are varies therapies utilized for individuals with ADHD. Psychotherapy allows the child to talk about upsetting thoughts and feelings, identify self-defeating behaviors, and learn alternative ways to handle these emotions and behaviors. Behavior therapy focuses on ways to deal with immediate issues and create behavior change (e.g. organizing schoolwork). Social skills training assists individuals with ADHD in maintaining good social relationships and understanding social cues. Psychotherapy and medication are the preferred treatment in adults.
What is Specific Learning Disorder?
Neurodevelopment Disorders - DSM-5
- The inability to learn or use academic skills as quickly or as accurately as other children of the same developmental age. The specific learning difficulties occur during school- age yrs and may not manifest until the demands of the school exceed the individual’s abilities. This disorder significantly impairs the person’s ability to perform activities of daily living or in academic areas. This disorder tend to be more common in males.
Specify type:
- with impairment in reading
- with impairment in written expression
- with impairment in mathematics
Specify severity: Mild, Moderate, or Severe.
There are no meds to treat Specific Learning Disorder.
Treatment is provided by an Education Learning specialist. It focuses on strengthening skills the child currently has, developing new learning strategies and use of multimodal teaching (e.g. using different senses) to take advantage of the child’s strength.
What does Motor Disorder entails?
Neurodevelopment Disorders - DSM-5
- Developmental Coordination Disorder- is characterized by marked impairment in developmental acquisition and execution of skills requiring motor coordination. It involves the following symptoms: significant developmental delays, substantial impairment in motor coordination and achieving normal motor milestones. These impairments significantly interfere with academic achievement or daily activities. None of the impairments are the results of a general medical condition.
There are no meds that are prescribed unless there is a significant tremor that interferes with motor function; in that circumstances beta-blockers may be prescribed.
There are no specific treatment designed for individuals with developmental Coordination Disorder. However, physical and/or occupational therapy are considered to be helpful.
Stereotypic Movement Disorder- is characterized by repetitive, motor behaviors that have no apparent useful purpose (e.g. body rocking, head banging). Head banging is more common in males, whereas self-biting is more common in females. The behavior (s) must be present for a minimum of 4 weeks. The behavior (s) are not the result or a compulsion or tic. The behavior (s) have the potential to cause physical injury requiring medical intervention. The disorder causes clinically significant impairment in daily activities.
In same cases, antidepressants such as Prozac, Zolof, and Luvox (selective serotonin reuptake inhibitors, or SSRIs) or Anafranil (a tricyclic antidepressant) may be helpful in treating Stereotypic Movement Disorder.
The goals of treatment are to ensure the child’s safety, as well as to improve the child’s ability to function. The child’s surroundings may need to be modified to reduce risk of injury.
Tic Disorder are defined in the DSM-5 (2013) as “… a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalizations. Although tics can include almost any muscle group or vocalization, certain tic symptoms, such as eye blinking, or throat clearing are common across patient populations. Tics are generally experienced as involuntary, but can be voluntarily suppressed for varying length of time.
Copropraxja- involves obscene gestures and words.
Palilalia- involves a repetition of one’s own sounds and words.
Echolalia- involves the repetition of the last sound or word of another individual.
Typical onset is between 4 and 6 yrs of age. Peak severity occurs between ages 10 and 12 with a decline during adolescence. Tics wax and wane in severity. They are not the direct result of a medical condition or a substance.
Tics Disorders are:
Tourette’s Disorder involves both motor tics and vocal tics over the course of the disorder. Onset is before age 18. Tics wax and wane in frequency, but have persisted for more than 12 months.
Persistent (Chronic) Motor or Vocal Tic Disorder involves either motor tics or vocal tics, but not both, over a 1-yr time period. Tics wax and wane in frequency. Onset is before age 18.
Provisional Tic Disorder is characterized by single or multiple motor and/or vocal tics that have been present for less than a year. Onset is before age 18. The individual must not have previously met the criteria for Tourette’s Disorder or Persistent (Chronic) Motor or Vocal Tic Disorder.
There are no specific meds for any of the Tic Disorders. Antipsychotic meds and anti-hypertensive agents are used to decrease tics when the tics cause significant distress or impairment.
Comprehensive Behavioral Intervention for Tics (CBIT) includes habit reversal training (HRT) education and life style changes. Habit reversal is intended to involve replacing a tic with a competing response (i.e. a more comfortable or acceptable movement or sound) when an individual feels a (pre)mon(i)(tory) urge building. Education teaches individuals to become more aware of tics and life style changes to reduce the occurrence of tics.
Schizophrenia Spectrum and Other Psychotic Disorders entails?
Neurodevelopment Disorders - DSM-5
The hallmark of Schizophrenia Spectrum and Other Related Psychotic Disorder is a significant distortion in the individual’s perception of reality. Individuals with this disorder show impairment in the capacity to reason, and behave rationally or spontaneously. Also impairment in the individual’s capacity to respond spontaneously with appropriate affect and motivation. These disorder occur in the absence of impairment of memory or consciousness.
Terminology-
Hallucination- are sensory distortions concerning the five senses that other do not observe. The most common type of hallucination is auditory (hearing sounds or voices). The next most frequently occurring are visual hallucinations such as seeing shadows or imaginary people. There may also be tactile (hallucinations of touch), olfactory (hallucination of smell), and gustatory (hallucination of smell)
Delusion: A delusion is a false belief that is not held by others of the individual’s culture. The individual cannot be dissuaded that the belief is untrue even when presented with evidence to the contrary. Disorganized Speech: is characterized by non-logical ideas. Examples of disorganized speech are: tangential speech, in which the individual moves from one topic to another with little association to the previous topic (“going off on a tangent”); Loose associations, in which there is no logical progression from one thought to another; or word salad in which no rules or grammar are used, and the words are jumbled. Negative Symptoms: are symptoms that include restricted, blunted emotional expression or flat affect. There is a lack of motivation that characterizes negative symptoms as if something has been taken away from the individual.
Schizophrenia- a psychosis not apparently the result of organic mental disorder or mood disorder that has lasted more than six months in which the active phase has begun before the subject is 45yrs.
Typical features- thought disturbance- misinterpretation of reality, misperception, loose association, delusion or hallucination.
Mood Changes- inappropriate affect, blunted emotion, inability to empathize and ambivalence.
Communication Problem- incoherence or poverty of speech content; Behavior patterns that may be bizarre, regressive or withdrawn.
Psychotropic drugs, Psychotherapy and help with social functioning enable most ppl to live fairly comfortable and somewhat independent.
What is Delusional Disorder?
Schizophrenia Spectrum and Other Psychotic Disorders
Neurodevelopment Disorders - DSM-5
This disorder is characterized by a minimum of one non-bizarre delusion and must be evident for a minimum of 1 month. It can be accompanied by tactile or olfactory hallucinations if related to the delusion. An individuals psychosocial functioning, apart from the delusions, is normal. Any concurrent mood episodes are brief relative to the duration of the delusions.
Types of Delusions Disorders:
Erotomanic Type- is diagnosed when the individual believes that another person, frequently of higher status, is in love with him or her.
Grandiose Type- is diagnosed when the individual is convinced that he/she has a special talent or understanding of some phenomenon or that he she has accomplished something of great importance.
Jealous Type: is diagnosed when the individual believes that his or her spouse or lover has been unfaithful based on faulty inferences.
Persecutory Type: is diagnosed when the individual believes that someone is conspiring, trying to poison, following him or her, etc.
Somatic Type: is diagnosed when the individual is convinced that one or more of his or her body openings emits noxious odor, that insects are crawling under the skin, that a parasite has invaded his/her body, or that one or more body parts are not functioning.
Mixed Type: is diagnosed when a specific delusional theme does not predominate.
Unspecified Type: is diagnosed when the SW is uncertain about the central delusional theme or when the delusion does not fall under any of the categories above.
Medications: are only marginally effective. Some antipsychotic medication may relieve delusional beliefs but only temporarily.
Individual therapy is usually the most effective modality for individuals suffering from Delusional Disorder. The most important factor is the quality of the CT-SW relationship where trust is the key issue. Early in the relationship is it important that the SW does not challenge the CT’s delusional beliefs and instead concentrate on realistic and concrete problems and goals within the individual’s life. Once a supportive relationship has been established the SW can begin reinforcing positive gains and behaviors the individual makes in his/her life, and then gradually and gently challenge the delusional beliefs.
What is Brief Psychotic Disorder?
Schizophrenia Spectrum and Other Psychotic Disorders
Neurodevelopment Disorders - DSM-5
This disorder is characterized by Schizophrenic symptoms that have been evident at least 1 day and no more that 1-month. A SW should specify With Marked Stressor (s) if symptoms seem to be caused by stressful event; Without Postpartum Onset if symptoms appear within 4- weeks postpartum; specify with Catatonia (detached from reality and oblivious to environmental stimuli) if he individual meets the criteria for Catatonia.
If symptoms are only minimally impairing the individuals functioning and if a specific stressor has been identified, removing the stressor should provide sufficient treatment. Brief hospitalization may be necessary for evolution and safety. Antipsychotic mediations may be necessary. After the acute episode is resolved, individual, family, and group therapy may be considered to cope with stressors, resolve conflict, and improve self-esteem and self-confidence.
What is Schizophreniform Disorder?
Schizophrenia Spectrum and Other Psychotic Disorders
Neurodevelopment Disorders - DSM-5
This disorder is different from Schizophrenia in two ways. One, the individual may or may not experience impairment in social or occupational functioning. Two, the individual should have symptoms of the disorder a minimum of 1-month and less than 6 months. If the disorder continues beyond 6 months, the diagnosis should be changed to Schizophrenia.
Medication and treatment are similar to those listed for Schizophrenia. Schizophrenia is a psychotic disorder characterized by a combination of specific positive and negative symptoms.
Positive Symptoms- includes hallucinations, delusions, disorganized speech, inappropriate affect, and disorganized behavior (absence of goal- orientation often manifested in failure to perform activities of daily living).
Negative Symptoms- include a flat or blunted affect (the absence or a severe restriction of observable emotion), avolition (a loss of willpower and decisiveness), alogia (a speech disturbance in Schizophrenia involving poverty of speech), decrease in the amount of speech or poverty of content of speech (speech that contains little or no meaningful information), and anhedonia (a loss of ability to experience pleasure).
There are three phases of Schizophrenia:
Prodromal Phase- is characterized by a decline in role functioning and precedes the active phase.
Active Phase- is distinguished by full-blown symptoms of Schizophrenia (e.g. delusions, hallucinations, severely disorganized speech, etc.)
Residual Phase- follows the active phase, in which the psychotic symptoms have improved but impairment continues.
There must be continuous signs of disorder of a minimum of 6 months to be diagnosed with Schizophrenia. Any mood episodes that may have occurred during the active phase of the disorder must have been relatively brief; otherwise, a diagnosis of Schizoaffective Disorder or Mood Disorder with Psychotic Features should be considered. The active phase must have lasted at least 1 month unless treatment led to a decreased in symptoms.
Medication management often requires a combination of antipsychotic, antidepressant, and anti-anxiety medications depending on the types of symptoms the individual experiences. Antipsychotic meds help to normalize biochemical imbalances that cause Schizophrenia. The biggest obstacle for individuals with Schizophrenia is medication compliance.
Treatment requires “wrap around services”. Such services include social skills training, education about the disorder, independent living assistance, case management, and medication compliance. Although psychotherapy is not a treatment of choice, is can be beneficial in providing encouragement, reassurance and reality testing. Group therapy is beneficial when it focuses on real-life plans, problems, social and work roles, relationships, medication compliance, and practical recreational or work activity. Family therapy can significantly decrease relapse rates and provide support for both the individual with Schizophrenia and family members. Self-help and community support groups (e.g. National Alliance for the Mentally Ill) are also beneficial.
What is Schizoaffective Disorder?
Schizophrenia Spectrum and Other Psychotic Disorders
Neurodevelopment Disorders - DSM-5
- This disorder has major depressive ( Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems), or Manic ( is an emotional state characterized by a period of at least one week where an elevated, expansive, or unusually irritable mood exists), episode in combination with symptoms of Schizophrenia. The mood symptoms are prominent feature of the disorder. There must have been a period of two or more weeks in the absence of mood symptoms during the lifetime of the illness.
Specify: Bipolar type or Depressive type with Catatonia (if applicable)
Antipsychotic medications are the treatment of choice for individuals diagnosed with Schizoaffective Disorder.
Individual therapy is the most common format for treatment. Supportive, CT- centered, non-directive psychotherapy is the modality often used. A problem- solving approach can also be very beneficial in helping the individual learn how to deal with issues more functionally and improve daily coping skills. With episodes of severe psychosis, inpatient hospitalization may be necessary.
What does Bipolar and Related Disorder entail?
Neurodevelopment Disorders - DSM-5
- Bipolar- also known as manic depression, affects mood and energy levels. Symptoms of bipolar include manic states of ecstatic nature, and depressive states of severe hopelessness. Extreme irritability, restlessness, and irregular sleep patterns are all signs of bipolar.
- Manic Episode is characterized by mood that is abnormally elevated, expansive, or irritable that persists for a minimum of a week. In addition, the individual has at least three of the following symptoms (four if mood is irritable):
- grandiosity or self-esteem that is inflated
- decreased need for sleep
- pressured speech
- racing thoughts
- easily distracted
- psychomotor agitation or persistently increased goal- oriented behavior
- excessive involvement in activities that are likely to result in negative consequences.
The symptoms cannot be the direct result of a substance or medical condition and must cause marked impairment in functioning.
- Hypomanic Episodes involves symptoms associated with a Manic Episode, but are less extreme. The symptoms must be present for 4 days and have been present most of the day, nearly every day. Even though the symptoms are accompanied by a change in functioning, the episode does not cause significant impairment in functioning. The symptoms are not the direct result of a substance or a medical condition.
- Major Depressive Episode is characterized by at least two weeks of depressed mood, or a loss of pleasure in most activities. Children and adolescents may present with irritability instead of sadness. The individual must have at least five of the symptoms listed below with a marked change in functioning. The symptoms should not be a direct result of a substance or a medical condition. The individual should not be experiencing normal bereavement.
Characteristics of Major Depressive Episode: - change in appetite or a significant loss of weight
- sleep disturbance, either insomnia or hypersomnia
- restlessness, agitation or motor sluggishness
- fatigue
- feelings of worthlessness; guilt- laden
- difficulty thinking, concentrating and making decisions
- recurrent thoughts of death
What does Bipolar and Related Disorder entail?
Neurodevelopment Disorders - DSM-5
- Bipolar I Disorder- involves a minimum of one Manic episode and Major Depressive Episode (although mania- an intense preoccupation with some kind of idea or activity. A state of agitation accelerated thinking, hyperactivity, & excessive elation seen in some major affective disorder-Affective disorders are a set of psychiatric disorders, also called mood disorders. The main types of affective disorders are depression, bipolar disorder, and anxiety disorder may be the first manifestation of the disorder).
- Bipolar II Disorder- involves a minimum of one Hypomanic episode and Major Depressive Episode (s).
Medications are an integral part of treatment for Bipolar Disorder (either I or II). Mood stabilizers (Lithium, Tegretol, Depakote) have been the first line of treatment in the past and are still used. Atypical antipsychotics (Geodon, Risperdal, Zyprexa, Abilify, Seroquel) are more frequently prescribed because they can provide greater symptom relief but have greater side effects and are more expensive. Antidepressants may be added during a depressive episode.
Both typical and atypical antipsychotics are dopamine antagonists, which means that they impede chemical messengers in the brain known as dopamine.
In conjunction with medication management, therapy is considered beneficial. The key components for treatment of Bipolar Disorders are:
- strong education about the disorder
- looking for and planning for signs of relapse
- illness acceptance
- regular sleep and activity patterns
- direct involvement with family
Some successful treatment have been Cognitive- Behavioral Therapy, Interpersonal Therapy with Social Rhythm Therapy, and Family- Focused Therapy.
Cyclothymic Disorder (cy-clo-thy-mic)- is characterized by mood shits between hypomanic and depressive symptoms that do not meet criteria for either episode. The hypomanic and depressive symptoms have been present for at least half the time. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must persist for a minimum of two years in adults, or on year in children and adolescents.
Generally speaking, meds is not the first line of treatment. Lithium carbonate can be tried to manage mood swings that are similar to those found in Bipolar Disorder.
There is no clear treatment of choice. Individual psychotherapy techniques may vary. Some clinicians have found a psychoeducational approach to be helpful. Since Cyclothymic disorder is a chronic condition, helping individuals to better predict their mood swings and increase their level of coping skills become vital.
What is Depressive Disorders?
Neurodevelopment Disorders - DSM-5
- Disruptive Mood Dysregulation Disorder- characterized by chronic, severe persistent irritability. The child has severe temper outbursts that are grossly out of proportion in intensity or duration for the situation and are not consistent with the child's developmental level. The outbursts occur regularly and when absent, the child's mood is persistently irritable and angry. Symptoms must be present for at least 12 months and manifest in at least two settings (e.g. home, school). The diagnosis cannot be made before age 6 or after age 18. The onset is typically before age 10. Disruptive Mood Dysregulation Disorder is a relatively new disorder, treatment and meds options are still under investigation. If the CT demonstrates depression and anxiety then SSRI meds-re a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder and anxiety disorders; by increasing levels of serotonin in the brain; and stimulants would likely be considered first. If the disorder is more related to bipolar disorder, then mood stabilizers or atypical antipsychotic agents might be the treatment of choice. Cognitive Behavior Therapy (CBT) and Behavior Therapy are considered to be the essential components of psychosocial intervention with individuals with this disorder.
- Major Depressive Disorder- involves a minimum of one Major Depressive Episode, and causes clinically significant distress or impairment.
Specify: single episode or recurrent episode.
Antidepressants are commonly prescribed for depression. There are several types of antidepressants: tricyclics, selective serotonin reuptake inhibitors (SSRI’s), MAO inhibitors (psychotic drug- reduces metabolism of monoamine oxidase) and atypical antidepressants (Trazodone, Wellbutrin), Electroconvulsive Therapy (ECT)- small electric current sent thru the brain triggering brief seizure; is a treatment of last resort for severe and chronic depressive symptoms.
Cognitive- Behavioral therapy is the most popular and typically the most effective in the treatment of depression. Emphasis is placed on discussing thoughts and behavior associated with depression. While emotions are a focus of treatment some of the time, dealing with problematic thinking and behaviors will more likely lead to a change in an individual’s emotional state.
Interpersonal therapy is another therapy utilized in the treatment of depression. The foci of this approach are the individual’s social relationships, more effective communication, appropriate expression of emotions and appropriate assertiveness in social and occupational situations.
Other approaches can also be used (e.g. Behavioral Therapy or Rational Emotive Therapy). Whatever the approach used, the emphasis is on the individual taking a proactive approach to treatment.
What is Depressive Disorders?
Neurodevelopment Disorders - DSM-5
- Persistent Depressive Disorder (Dysthymia- dys-thy-mi-a- persistent mild depression; defined as a low mood occurring for at least two years, along with at least two other symptoms of depression) is characterized by depressive symptoms that do not meet the criteria for a Major Depressive Episode. Symptoms have been present a minimum of tow years in adults and one year in children and adolescents in combination with other depressive symptoms. It is common for the individual to develop Major Depressive Episodes; however, once the episode clears the individual returns to the chronic state of dysthymia. The individual has two or more of the following:
- poor appetite or overeating
- insomnia or hypersomnia
- low energy or fatigue
- low self-esteem
- poor concentration
- feelings of hopelessness
Antidepressant meds is helpful in keeping the person’s energy level up and preventing depressed mood. SSRI’s are the most commonly prescribed meds.
The best treatment is a combination of psychotherapy and antidepressant meds. Cognitive therapy emphasizes change in faulty or distorted thinking and realistic, attainable goals in the individual’s life that assist the person in returning to a normal level of functioning. Interpersonal therapy focuses on an individual’s relationship with others and how to improve and strengthen existing relationships while also finding new ones. Solution- focused therapy looks at specific problems that persist in the individual’s life and how to best bring about change in the person’s behavior to solve these difficulties. Social skills training focuses on teaching new skills so that the individual can become more effective in social and work relationships. - Premenstrual Dysphoric-a state of unease or generalized dissatisfaction with life Disorder- is characterized by symptoms that occur during a majority of the woman’s menstrual cycle. The symptoms begin in the final week before the onset of menses-the time of menstruation and begin to improve within the few days after the onset of menses and become minimal or absent in the week post-menses. One or more of the first three symptoms and up to five additional symptoms must be present:
- significant affective lability (Emotional lability refers to rapid, often exaggerated changes in mood, where strong emotions or feelings (uncontrollable laughing or crying, or heightened irritability or temper) occur)
- significant irritability or anger or increased interpersonal conflict
- marked anxiety, tension, and/or feeling of being keyed up or on edge
- decreased interest in usual activity
- subjective difficulty in concentration
- lethargy, easily fatigued, or lack of energy
- significant change in appetite; overeating or specific food cravings
- hypersomnia or insomnia
- sense of being overwhelmed our out of control
- physical symptoms ( breast tenderness/ swelling, joint/ muscle pain, sensation of bloating or weight gain)
The symptoms cause clinically significant impairment and distress.
Serotonin Reuptake Inhibitors (SSRI’s) and Xanax (a benzodiazepinc) have been reported to be effective in treating Premenstrual Dysphoric Disorder although no treatment has been conclusively shown to be effective in well- controlled studies.
Cognitive Behavior therapy (CBT), light therapy, exercise, relaxation strategies and nutrition therapy are appropriate interventions although untested.
What does Anxiety Disorder entail?
Neurodevelopment Disorders - DSM-5
- a chronic or recurring state of tension, worry, fear, and uneasiness arising from unknown or unrecognized perception of danger or conflict.
Separation Anxiety Disorder
- It is distinguished by developmentally inappropriate excessive anxiety around separation from significant others (parents or spouse). Features include clinically significant (e.g. severe distress or impairment of function) symptoms of anxiety; unrealistic worries about the safety of loved ones; reluctance to fall asleep without being near the primary attachment figure; excessive distress, such as tantrums, when separation is imminent; nightmares with separation- related themes; and homesickness, such as a desire to return home or make contact with the significant other. Physical and somatic symptoms, such as dizziness, light headaches, headaches, nausea, stomachache, cramps, vomiting, muscle aches, or palpitations, may be present and problematic. In children and adolescents the symptoms must be present for at least 4 weeks and in adults 6 months. Symptoms cause significant impairment and distress.
- The medication fluoxetine (Prozac), the only selective serotonin reuptake inhibitor (SSRI) approved by the FDA in those younger than 18, is typically prescribed. This medication should be used when functional impairment is moderate to severe.
- The therapy focus on teaching children several major skills: recognizing anxious feelings regarding separation and identifying their physical reactions to anxiety; identifying their thoughts in anxiety provoking separation situations; and developing a plan to cope adaptively with the situation. In younger children who have difficulty expressing thoughts and feelings play therapy is beneficial.
Behavioral strategies such as modeling, role-playing, relaxation training, and reinforced practice are used. Children are taught to implement their coping skills while gradually facing anxiety producing situations. Children’s successes are praised highly by the SW and parents.
- Selective Mutism
This disorder is identified by a persistent failure to speak in certain situations with a demonstrated ability to talk as evidenced by doing so in other situations. It lasts a minimum of 1 month and cannot be evident only in the fist month of school. This diagnosis is not given if it is apparent that the person’s failure to speak is rooted in a lack of familiarity of or comfort with the language. - Occasionally, it is treatable with medication- Fluoxetine (Prozac), a SSRI. Treatment with medication is more successful in younger kids. Fluoxetine has been found to reduce the symptoms in about three-fourths of children.
- A number of different approaches have been used in an attempt to treat Selective Mutism. Behavior modification techniques may be used in which positive rewards for speech are given and then withheld when the individual is silent. Punishment is not recommended. Stimulus fading involves finding a motivating “stimulus” for the child to speak in a mute situation, which is typically a place that is intimidating and therefore speech is more difficult. A trusting parent is often a good “stimulus” to use. Stimulus fading has been found to be particularly effective when used in conjunction with positive reinforcement techniques.
- Specific Phobia
Is diagnosed when a specific object or situation causes excessive or unreasonable anxiety; avoidance behavior is often evident. Types of phobias include animal, natural environment, such as storms, blood-injection- injury, and “other types” that do not fall under one of the previous categories. The concerns are fear about harm from the object, concerns about embarrassment, or fear of consequences related to exposure. - Medications are not generally prescribed. Individuals who experience anticipatory anxiety may benefit from benzodiazepines (e.g. individuals who are afraid of flying might be able to control their fear with medication). Individuals whose phobia interferes with daily functioning may benefit from an SSRI (e.g. Paxil)
- Desensitization, in which the individual is exposed to graded doses of a phobic object or situation, is an effect technique and that the individual can practice outside of the therapy session. Emotive imagery helps to decrease the anxiety when the individual faces real life situation. (Emotive imagery- behavior and cognitive therapy, the CT imagines emotion arosuing scenes while relaxing and being comfortable and protected). Relaxation techniques are sued to manage anxiety symptoms.
What does Anxiety Disorder entail?
Neurodevelopment Disorders - DSM-5
- Social Anxiety Disorder (Social Phobia)
Is characterized by fear of embarrassing oneself in social situations or feeling foolish. Avoidance behavior is often evident and the condition is not due to a medical situation or substance. This disorder typically lasts for more than 6 months.
Imipramine (Tofranil among others, is a tricyclic antidepressant-are a class of medications that are used primarily as antidepressants) has been effective in blocking some Panic Attacks. MAO (are a class of drugs that inhibit the activity of one or both monoamine oxidase enzymes: monoamine oxidase A (MAO-A) and monoamine oxidase B (MAO-B)) inhibitors have also been helpful for some individuals. Some benzodiazepines ( Librium, valium) are effective in a phobic situation if they are taken in sufficient doses to produce relaxation.
Psychotherapy and behavioral treatments (systematic desensitization with increasingly anxiety- producing objects or situations and in vivo exposure) are common interventions that are preferred prior to initiating medication on a long- term basis.
Systematic desensitization, also known as graduated exposure therapy, is a type of behavior therapy developed by South African psychiatrist, Joseph Wolpe. That gradually alleviate the fear and anxiety associated with an object or event. Using relaxation exercise and imagery relaxation technique the CT is exposed to stimuli from a gradation of anxiety provoking situation.
In- Vivo exposure- the subject gradually approaches a feared stimulus while in a relaxed mood. - Panic Attack Specifier
A panic attack is characterized by a circumscribed period of intense fear or discomfort that the peaks within 10 minutes. At least four of the following symptoms are present: Palpitations, sweating, trembling & shaking, shortness of breath or sense of smothering, sense that one is chocking, discomfort or pain in chest area, nausea or abdominal discomfort, dizziness, lightheadedness, feeling faint, numbness or tingling sensations, chills or hot flashes, derealization (sense of unreality), depersonalization (sense of being detached from self), fearfulness that one is going to lose control or go crazy, fear of dying. - Panic disorder
is characterized by a pattern of recurrent panic attacks accompanied by persistent worry of behavioral change. Anxiety symptoms and functional impairment are independent of the actual panic attack. Panic attacks are uncued/ spontaneous. At lease one of the attacks has been followed by 1 month (or more) of one (or more) of the following: persistent concern about having additional attacks; worry about the implementations of the attack or its consequences (e.g. losing control, having a heart attack, “going crazy”); a significant change in behavior related to the attacks.
The panic attacks are not due to the direct physiological effects a drug or a medical condition. The panic attacks are not better accounted for by another mental disorder.
What does Anxiety Disorder entail?
Neurodevelopment Disorders - DSM-5
- Agoraphobia- is characterized by fear and anxiety in two or more of the following five situations: using public transportation, being in open spaces, being in closed places, standing in a line or being in a crowd, being outside of the home alone. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available.
- Many individuals can be treated for Panic Disorder or Agoraphobia without the aid of meds. If meds is needed, benzodiazepines and SSRI antidepressants are the medication of choice.
- Individual psychotherapy is preferred. Education around the “fight or flight” response and the associated physiological sensation as well as developing more effective coping strategies are the primary foci of treatment. Relaxation and imagery techniques have proven to be effective. A cognitive or rational- emotive approach for irrational thoughts during a Panic Attack is helpful as is a behavioral approach emphasizing graduated exposure to panic- inducing situations.
- “Fight or Flight”- hyperarousal- acute stress response- physiological reaction that occur in response to a perceived harmful event, attack or threat to survival.
- Generalized Anxiety Disorder (GAD)
This disorder involves excessive anxiety and worry about a number of things that persists for a minimum of 6 months. The behavior is not due to a medical condition or substance. - Meds should be prescribed if the anxiety symptoms are serious and interfering with normal daily functioning. The most commonly prescribed anti-anxiety meds are benzodiazepines (Ativan, Xanax, Valium, Librium and Klonipin). Antidepressants and Buspirone are alternatives to benzodiazepines.
- Individual therapy is the recommended treatment approach as individuals with the disorder are uncomfortable discussing their anxiety in front of others. Therapies for individuals with Generalized Anxiety Disorder need to focus on the the low-level, ever present anxiety. Relaxation exercises are a good initial strategy. Reducing stress and increasing overall coping skills are beneficial.
What is Obsessive- Compulsive Disorder (OCD)?
Obsessive- Compulsive & Related Disorder - DSM-5
- is characterized by anxiety- producing obsessions (persistent thoughts, urges, or images) or compulsions (behaviors the individual feels compelled to do repeatedly according to rigid rules). The obsessions or compulsions are time- consuming or causing clinically significant distress or impairment in social, occupational or other important areas of functioning.
- Certain psychiatric meds can help control the obsessions and compulsions of OCD. Most commonly, antidepressants are prescribed first. Antidepressants have been helpful in individuals with OCD- help increase levels of serotonin. Antidepressants that have been specifically approved by the DFA to treat OCD include: Clomipramine (Anafranil), Fluvoaxmine (Luvox), Fluoxetine (Prozac), Paroxetine (Paxil), Sertaline (Zoloft).
- Cognitive- Behavioral Therapy (CBT) has shown to be the most effective form of therapy for OCD in both children and adults. It involves retraining thought patterns and routines so the compulsive behaviors are no longer necessary. One CBT approach in particular is called exposure and response prevention, which involves gradually exposing the individual to a feared object or obsession and teaching the individual appropriate coping skills to manage anxiety.
- Body Dysmorphic Disorder- is characterized by a preoccupation with a slight or perceived physical defect judged by the individual to negatively affect his or her appearance.
- SSRI have been the primary meds used.
- CBT or behavior modification therapies are highly recommended in addition to meds. Body dysmorphic disorder is considered a chronic condition and requires maintenance therapy and regulation of SSRIs.
- Hoarding Disorder- is characterized by a persistent difficulty discarding or parting with possessions. The accumulation of possessions interferes with living areas of the home. The hoarding creates clinically significant distress and impairment.
- SSRI are used to treat. With mixed results.
- Hoarding is difficult to treat. The goal is to get rid of a significant amount of possessions to make living space livable and provide the individual with skills to maintain a positive balance between possessions and livable space. The most effective treatment is CBT that includes training in decision-making and categorizing; exposure and habituation to discarding; and cognitive restructuring.
What does Obsessive- Compulsive Disorder (OCD) cover?
Obsessive- Compulsive & Related Disorder - DSM-5
- Trichotrillomania (tri-kuh-ti-luh-mei-nee-uh)- (hair pulling disorder)- involves compulsive hair pulling that leads to significant hair loss. There is increased tension before hair pulling and pleasure or relief when pulling the hair out. The individual makes repeated attempts to decrease or stop the hair pulling. This behavior is not the result of a medical condition or another mental condition. This condition is more common in women and the average age of onset is 13 years of age.
- Meds treatment includes joint approach between mental health prescribers and dermatologists (topical steroids, anxiolytic with histamine properties, antidepressants and antipsychotics). (histamine produces many varied effects within the body, including the contraction of smooth muscle tissues of the lungs, uterus, and stomach; the dilation of blood vessels, which increases permeability and lowers blood pressure; the stimulation of gastric acid secretion in the stomach)
- Insight- oriented psychotherapy, behavioral treatment and hypnotherapy are effective treatments.
- Excoriation (Skin- Picking) Disorder- is characterized by the recurrent, compulsive picking of skin, leading to skin lesions. There have been repeated attempts to decrease or stop skin picking. This disorder causes clinically significant distress or impairment. The most common sites are hands, fingers, torso, arms, and legs. There may be multiple sites and sue of multiple instruments (fingernails, knives, tweezers, pins). Picking may result in significant tissue damage or localized infections.
- There is little data on effective treatment. There is some support that SSRI’s have been helpful. Naltrexone (an opioid antagonist) reduces the urge to skin pick. Lamictal has shown some efficacy.
- Brief Cognitive Therapy and habit reversal have been used to treat the disorder.
What does Trauma and Stressor Related Disorder covers- DSM-5?
- Reactive Attachment Disorder- is characterized as a disruption in a child’s normal attachment behavior. It is a result of grossly negligent parenting and maltreatment. The child exhibits a pattern of inhibited, emotionally withdrawn behavior toward adult caregivers. There is minimal social and emotionally responsiveness to others, episodes of unexplained irritability, sadness or fearfulness with adult caregivers. The onset must be before age 5. Developmentally the child should be at least 9 mnths old.
- Disinhibited Social Engagement Disorder- This disorder is characterized as a disruption in a child’s normal attachment behavior. It is a result of grossly negligent parenting and maltreatment. The child engages in an inappropriate pattern of behavior where he/she actively approaches and interacts with unfamiliar adults, violating cultural boundaries. The child does not check by with adult caregiver after venturing away and exhibits a willingness to go off with an unfamiliar adult with minimal or no hesitation. The child has a developmental age of at least 9 months.
Medications are not indicated for Reactive Attachment Disorder and Disinhibited Social Engagement Disorder unless there are other disorders such as depression, anxiety, or Attention Deficit Hyperactivity Disorder.
Treatment often includes individual psychological counseling, education of parents and caregivers about the disorder, parenting skills (Attachment and Biobehavioral Catch-up), family therapy, special education services, and residential or inpatient treatment for children with more serious issues or who put themselves or others at risk of harm.
- Post-traumatic Stress Disorder (PTSD)- is defined as exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways; directly experiencing a traumatic event, witnessing the event that occurred to others, learning that the traumatic event occurred to a close family or friend experiencing repeated or extreme exposure to aversive details of the traumatic events. The symptoms have occurred for over a 1-month period. The individual has increased and avoids internal and external stimuli that are reminiscent of the trauma. There are specific criteria for children 6 years and younger.
What does Trauma and Stressor Related Disorder covers- DSM-5?
- Acute Stress Disorder (ASD)- consists of PTSD like symptoms that immediately follow exposure to a traumatic event and that last b/w 3 days to 1 month after the trauma exposure.
In both ASD and PTSD, there are not specific pharmacological interventions that prevent the development of either disorder after trauma exposure. For individuals who are currently experiencing symptoms, SSRIs and other antidepressants have provided relief in PTSD symptoms of re-experiencing, avoidance, numbing, and hyperarousal.
After trauma, CBT may speed recovery to prevent PTSD when therapy begins 2 to 3 weeks after trauma exposure. Early supportive interventions, psycho-education (relying on personal strengths, using existing support networks), and CM appear to be helpful in ASD. EMDR (Eye Movement Desensitization and Reprocessing) is also effective. Single session techniques or psychological debriefings are not recommended as they many increase symptoms.
- Adjustment Disorder- is characterized by the development of emotional or behavioral symptoms, w/in 3 months of a stressor or stressors, which results in distress and/or impaired functioning.
The following Adjustments Disorders are identified in DSM-5:
Adjustment Disorder with Depressed Mood.
Adjustment Disorder with Anxiety
Adjustment Disorder with Mixed Anxiety and Depressed Mood
Adjustment disorder with Disturbance of Conduct (violation of others’ right or of important societal norms and rules)
Adjustment Disorder with Mixed Disturbance of Emotions and Conduct
Adjustment Disorder Unspecified.
Meds are not usually used for Adjustment Disorder unless it is complicated by another disorder. Psychotherapy is the treatment of choice for any Adjustment Disorder because the disorder is precipitated by a specific event. Therapy is short- term, rarely going beyond 6 mnths. The form of psychotherapy may vary, but should occur within a supportive, non-judgmental atmosphere that promotes individual growth. Solution-focused approaches are preferred. The goal of therapy is to provide the individual with new coping skills, more effective ways of dealing with stress, and an enhanced understanding of personal issues.
