Week 4

Question 1

What is neurodevelopmental disorders?

Answer 1

a class of disorders that are commence
during childhood or prenatal development.
Include:

• Intellectual disability
• Communication Disorders (eg stuttering) • Autism Spectrum Disorder
• Learning Disorders (eg dyslexia)
• Attention-Deficit/Hyperactivity Disorder
Today we will just look at ASD and ADHD
Includes:

Question 2

What is autism spectrum disorder?

Answer 2

Previously separated into several disorders including autistic disorder and Asperger’s disorder.

• Whilst there may be a range of severity, symptoms must be present in early development, and cause significant impairment in social and/or occupational functioning

Question 3

Autism spectrum disorder is Persistent deficits in social communication and interaction,
including:

Answer 3

• Inability to engage in social emotional reciprocity
• Difficulty expressing and interpreting non-verbal behaviour
• Difficulty understanding and forming relationships

Question 4

Autism spectrum disorder have Restricted, repetitive behaviours, interests or activities, demonstrated by at least two of the following:

Answer 4

• Stereotypes/repetitive motor movements, use of objects, or speech.
• Insistence of sameness, inflexibility, ritualized behaviour
• Narrow, fixated interests that are excessively intense
• Extreme sensitivity or limited sensitivity to environmental stimuli (eg indifference to pain, excessive touching of objects)

Question 5

Autism spectrum disorder prevalence rate:

Answer 5

Prevalence: .6% -2% of children
4 x more common in males

• Appears to have a strong genetic component – Twin concordance rates range from 37% to 90%
• Pruning hypothesis - Lack of neuronal pruning during developmental periods?

Question 6

Attention deficit hyperactivity disorder (ADHD):

Answer 6

A disorder that first appears in childhood and is characterised by the presence of inattention, impulsivity and hyperactivity that impacts on daily functioning and/or development. Symptoms must:

• Be age inappropriate
• Occur across multiple settings
• Of a level that impacts on social, academic and/or
occupational functioning

Question 7

One half of diagnosing ADHD includes diagnosing inattention. Inattention diagnosis requires 6+ of the following for at least 6 months:

Answer 7

• Unable to pay close attention
• Has problems sustaining attention
• Doesn’t listen
• Frequently fails to complete tasks
• Inability to organise tasks/activities
• Reluctant to engage in effortful
mental tasks
• Loses materials needed for tasks
• Easily distracted
• Forgetful in daily activities

Question 8

One half of diagnosing ADHD includes diagnosing hyperactivity/impulsivity . Hyperactivity/impulsivity diagnosis requires 6+ of the following for at least 6 months:

Answer 8

• Restless – frequently fidgets/squirms
• Leaves seat in situations where expected to stay seated
• Runs/climbs in situations that are inappropriate
• Unable to play in a quiet manner
• Often ‘on the go’
• Talks excessively
• Blurts answers/interrupts before the other person has stopped
talking
• Difficulty waiting turn
• Interrupts or intrudes on others

Question 9

Prevalence rate of ADHD

Answer 9

• Prevalence in Australia estimated at 2.3-6% of school-aged children.
• ADHD 5-9 times more common in males than females.
• Persists into adulthood – but hyperactivity symptoms decline, inattention remains.
• Appears to be a genetic link – ADHD does run in families through generations.
• Evidence that low birth weight or maternal smoking (during pregnancy) increases risk of ADHD

Question 10

Neurocognitive disorders:

Answer 10

class of disorders in which the predominant symptom is cognitive impairment (deficits in memory, learning, thought).

Some common causes are:

• Advanced Age (eg Alzheimer’s Disease)
• Illness (eg HIV related dementia)
• Injury (eg Traumatic Brain Injury)
• Genetics (eg Huntington’s Disease)

Question 11

What is the difference between dementia and Alzheimer’s disease?

Answer 11

Dementia – an umbrella term that covers a range of disorders in which there is a steady, usually irreversible, pattern of cognitive decline. Can affect memory, language, thought, behaviour.

• Whilst some forms are treatable (eg those due to infection), most are irreversible (eg Alzheimer’s Disease)
• Onset is typically insidious (proceeding gradually)

So, Alzheimer’s disease is one of a number of types of dementia.

Question 12

Alzheimer’s disease:

Answer 12

Degenerative brain disorder that involves progressive cognitive decline. Culminates in widespread cognitive failure and death.

Neurofibrillary Tangles: Threads of protein that occur within a neuron.

Senile Plaques (aka Amyloid Plaques): Deposits caused by debris from degenerating neurons and build-up of protein

AD is the most commonly diagnosed form of dementia, but technically can only be confirmed post mortem, so classified as either:

• Probable Alzheimer’s Disease if there is a family history and/or there is significant cognitive decline.
• Possible Alzheimer’s Disease if there is no family history, but there is steady cognitive decline which cannot be explained by other medical history

Question 13

Prevalence rate of Alzheimer’s disease:

Answer 13

Prevalence: 13% in 65 + 42% in 85 +

• Average lifespan following diagnosis = 10 years
• Tends to be more frequent in females (even after longevity differences between sexes is accounted for)
• AD is characterised by the presence of neurofibrillary tangles, senile (aka amyloid) plaques and neuron loss, typically concentrated in specific regions of the brain.

Question 14

Alzheimer’s disease progression - neuroanatomical

Answer 14

• The damage associated with AD usually commences in specific brain regions, then spreads in a predicable pattern.
• We can therefore predict in many cases what functions will become impaired during the progression of the disease

Question 15

Alzheimer’s disease progression : cognitive

Answer 15

• Often starts with general confusion and irritability, speech deficits.
• As the condition progresses the memory impairments become increasingly noticeable.
• Memory loss follows pattern of structural deterioration.
• Occurs in all types of memory –
- Episodic (memory of events that have happened)
- Semantic (general knowledge)
- Procedural (how to make a cup of tea)

• Recent memories are first to be lost, and there is a chronological progression backwards:
Eg – forget grandchildren’s names, then children’s, then partners, then siblings etc.

Question 16

As well as memory decline, there is a number of other changes which come with the progression of Alzheimer’s disease:

Answer 16

• Mood – depression often see in early stages
• Mood – can become combative/argumentative
• Language impairment
• Restlessness/Motor agitation
• Motor impairment – eg difficulty walking
• Psychosis
• Lose social inhibitions

Question 17

Alzheimer’s disease - causes

Answer 17

Genetic Factors:

• There is strong evidence that a number of genes influence likelihood of developing AD

Medical History:

• Previous experience of a traumatic brain injury increases risk of developing AD
• Certain other conditions (eg Downs Syndrome) are associated with greater risk of AD

Question 18

Eating disorders - introduction

Answer 18

• Eating disorders first appeared in DSM in 1980

• Historical accounts of self starvation have exited from the 17th century (“wasting disease”)
- But it is unclear if this is true anorexia nervosa in the modern sense – was there a fear of weight gain?

• In DSM-5 eating disorders are in a category called “feeding and eating disorders”

Question 19

What is BMI in eating disorders?

Answer 19

• BMI = Body Mass Index
• In Anorexia Nervosa: BMI = severely underweight
• In Bulimia Nervosa: BMI = normal – overweight

BMI=weight over/height^2

Question 20

Outline the BMI Chart

Answer 20

BMI less than 18.50 is underweight

BMI 18.50-24.99 is healthy weight

BMI 25:00-29.99 is overweight

BMI 30 or more is obese

Question 21

What is anorexia nervosa characterised by?

Answer 21

1.Severely underweight

• Client is severely underweight (as opposed to the other eating disorders)
• BMI less than < 18.5

2. Intense fear of gaining weight and becoming fat
   - Preoccupied with this fear
3. Distorted body image of sense of body shape
   - Believe they are overweight when they are not
   - Inaccurate when reporting their own body shape/size

Question 22

Bulimia Nervosa Diagnostic Criteria

Answer 22

a. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
b. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
c. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Question 23

Bulimia Nervosa diagnostic criteria in specifying what type they have:

Answer 23

• Restricting type:

During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.

• Binge-eating/purging type:

During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enema

Question 24

Anorexia Nervosa Severity

Answer 24

Specify current severity:
• The minimum level of severity is based, for adults, on current body mass index (BMI) or, for children and adolescents, on BMI percentile.

• Mild: BMI ≥ 17
• Moderate: BMI 16–16.99 • Severe: BMI 15–15.99
• Extreme: BMI < 15

The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.

Question 25

Clinical features of anorexia nervosa

Answer 25

Prevalence:

• Lifetime <1% in general population
• Higher in certain groups (e.g. elite athletes)

Onset:

• Early to middle adolescence,rarely before puberty or after the age of 50
• Onset highly associated with history of dieting

Gender differences:
- 10x more prevalent in women then men

Comorbidities:
- Highly comorbid with anxiety, mood and personality disorders

Question 26

Other features of anorexia nervosa

Answer 26

• High levels of suicidality
• Death rates are twice as high as other psychological disorders (physiological complications or suicide)
• High levels of perfectionism
• Found across all cultural and ethnic groups

Question 27

What are the physical consequences of anorexia nervosa?

Answer 27

• Low blood pressure
• Heart problems
• Kidney problems
• Gastrointestinal problems
• Bone mass density declines
• Skin dies out
• Brittle nails
• Anaemia
• Hormone changes
• Hair loss and hair growth
• Electrolyte changes
• Amenorrhea

Question 28

Bulimia Nervosa diagnostic criteria 2:

Answer 28

a. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

• Eating, in a discrete period of time (e.g., within any 2- hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
• A sense of lack of control over eating during the episode

b. Recurrent inappropriate compensatory behaviours in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
c. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months.
d. Self-evaluation is unduly influenced by body shape and weight.
e. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Question 29

Bulimia Nervosa severity:

Answer 29

Specify current severity:

• Mild: An average of 1–3 episodes of inappropriate
compensatory behaviours per week.
• Moderate: An average of 4–7 episodes of inappropriate compensatory behaviours per week.
• Severe: An average of 8–13 episodes of inappropriate compensatory behaviours per week.
• Extreme: An average of 14 or more episodes of inappropriate compensatory behaviours per week.

The level of severity may be increased to reflect other symptoms and the degree of functional disability.

Question 30

Clinical features of bulimia Nervosa?

Answer 30

Lifetime prevalence
• 1.5% in women and 0.5% in men

Onset
• Typically late adolescence to early adulthood
• Some evidence to suggest that a stressful life event(s) often occurs before onset of BN

Gender differences:
• 10x more common in women (cf prevalence)

Highly comorbid with other disorders
Less frequent in non-westernised societies

Question 31

What is the mortality rate of bulimia Nervosa?

Answer 31

4%

Question 32

What might binges be triggered by in bulimia?

Answer 32

Binges may be triggered by stress and/or negative emotions

• Usually highly secretive
• Wide variation on calories consumed amongst people with bulimia

Question 33

Suicide with bulimia?

Answer 33

Suicide rate in bulimia nervosa is higher than the general population, but lower than in anorexia nervosa

Question 34

Physical consequences of bulimia Nervosa

Answer 34

• Amenorrhea
• Electrolyte imbalances (leads to heart irregularities)
• Dental problems (from recurrent vomiting)
• Swollen salivary glands

Question 35

Most research originates from Western cultures. This can restrict our understanding of the ways disorders might present, and the way we treat disorders.
Differences in the way symptoms are described:
Eg Depression

Answer 35

• Nigeria - more physiological (eg heaviness or heat in the head, feeling bloated)
• US – sense of worthlessness, loss of motivation

Question 36

Most research originates from Western cultures. This can restrict our understanding of the ways disorders might present, and the way we treat disorders.

Anxiety – social, environmental and religious beliefs can be associated with specific types of anxiety:

Answer 36

• JAPAN - Taijin kyofusho (concerns about offending others with inappropriate social behaviour).
• GREENLAND - Kayak-angst (paralysing anxiety and disorientation in kayak hunters).
• LATIN AMERICA - Susto (anxiety about the soul leaving the body as a result of a severe fright)

Question 37

Differences in depression rates in regards to gender:

Answer 37

Females in Brazil 2.6 times more likely to be diagnosed than males, but only slightly more females than males are diagnosed in China.

Women are all more likely to be diagnosed.

Question 38

Cultural differences and (mis)diagnosis

Answer 38

People from minority groups are more likely to be diagnosed with schizophrenia.

This could be due to increased experiencing more environmental stressors (exposure to racism, potentially reduced educational and occupational opportunities). But….

Goater et al (1999) treatment provided to white and black people with a diagnosis of schizophrenia in the UK. They reported that black people more likely to:

• Be involuntarily detained
• Taken to a hospital by police
• Be given emergency injections of antipsychotic medication

Despite similarities in presentation and severity of schizophrenia.

Question 39

Cultural and religious differences and treatment: two sides

Answer 39

• Islamic perspective – medicine and religion are combined
• Christian perspective – interpretation of symptoms/demonic model

Elder (2013) – explored paediatric head injury in a Māori population, and found that recovery is improved by considering the Te Whare Tapa Whā (the four walled house) model of wellbeing;

• Whānau(extendedfamily)
• Tinana(physical)
• Hinengaro(mind)
• Wairua(connectedness with the universe)

Question 40

Cultural differences and the DSM-5

Answer 40

Culture: The values, knowledge and practices that individuals derive from membership of ethnic, religious, or other social group.

This may also impact on how an individual interprets their own/family member’s experience with mental health disorders

The DSM 5 recommends that clinicians consider using a ‘Cultural Formulation Interview’

Question 41

What does context refer to in the cultural formulation interview?

Answer 41

• The values, orientations, knowledge, and practices that individuals derive from membership in diverse social groups (e.g., ethnic groups, faith communities, occupational groups, veterans groups).
• Aspects of an individual’s background, developmental experiences, and current social contexts that may affect his or her perspective, such as geographical origin, migration, language, religion, sexual orientation, or race/ethnicity.
• The influence of family, friends, and other community members (the individual’s social network) on the individual’s illness experience.

Question 42

Cultural differences and the DSM-5 - the cultural formulation interview

Answer 42

16 questions that cover four domains of assessment:

1. Cultural Definition of the Problem:
   Eg Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?
2. Cultural Perceptions of Cause, Context, and Support:
   Eg What do others in your family, your friends, or others in your community think is causing your [PROBLEM]?
3. Cultural Factors Affecting Self-Coping and Past Help Seeking:
   Often, people look for help from many different sources, including different kinds of doctors, helpers, or healers. In the past, what kinds of treatment, help, advice, or healing have you sought for your [PROBLEM]?
4. Cultural Factors Affecting Current Help Seeking.
   Eg Sometimes doctors and patients misunderstand each other because they come from different backgrounds or have different expectations. Have you been concerned about this and is there anything that we can do to provide you with the care you need?

Baarnhielm, Wistedt, & Rosso (2015) – use of CFI in refugees and immigrants to Sweden. 56.5% of diagnoses were revised following application of the CFI