Mental Health

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Mental Health Diagnosis Training
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Anxiety

• Panic Disorder
• Agoraphobia
• Obsessive Compulsive Disorder
• Specific Phobias
• Separation Anxiety Disorder
• Posttraumatic Stress Disorder
• Generalized Anxiety Disorder
• Anxiety Disorder NOS

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What Type of Anxiety?

• Marcus has come for a follow-up appointment at
  the SBHC. He reported several anxiety symptoms
  during his comprehensive risk assessment, and
  screened positively for panic attacks during the
  Diagnostic Predictive Scales. Marcus indicates
  that the panic attacks are triggered by a fear of
  being called on in class. He experiences symptoms
  of panic (heart palpitations, nervousness,
  sweating, etc) on the way to school, while
  sitting in class, and even just thinking about
  being in class.

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Panic Disorder Diagnostic Criteria

• I. Recurrent, Unexpected Panic Attacks
• Criteria for Panic Attack A discrete period of
  intense fear or discomfort, in which four (or
  more) of the following symptoms developed
  abruptly and reached a peak within 10 minutes
• Palpitations, pounding heart, or accelerated
  heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Derealization (feelings of unreality) or
  depersonalization (being detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Paresthesias (numbness or tingling sensations)
• Chills or hot flushes

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Panic Disorder Diagnostic Criteria

• II. At least one of the attacks has been followed
  by 1 month (or more) of one (or more) of the
  following
• Persistent concern about having additional
  attacks
• Worry about the implications 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

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What Type of Anxiety?

• Philip was referred to the SBHC by his mother,
  because she has become increasingly concerned by
  his fears of going outside. Upon interview,
  Philip reveals that after being attacked by a
  neighborhood dog a few years ago, he has
  developed a fear of dogs. His fear is getting
  worse, and he is beginning to limit his outdoor
  activities. He reports getting nervous even when
  seeing dogs on television, even though he knows
  they cannot hurt him.

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Specific Phobias

• Marked and persistent fear of a specific object
  or situation with exposure causing an immediate
  anxiety response that is excessive or
  unreasonable
• In children, anxiety may be expressed as crying,
  tantrums, freezing, or clinging.
• Adults recognize that their fear is excessive.
  Children may not.
• Causes significant interference in life, or
  significant distress.
• Under 18 years of age symptoms must be gt 6
  months

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Specific Phobias

• Animal phobias most common childhood phobia.
• Also frequently afraid of the dark and imaginary
  creatures
• In older children, fears are more focused on
  health, social and school problems

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What Type of Anxiety?

• Sally is brought to the SBHC by her parents, who
  are worried about her poor attendance in school.
  Sally has had some difficulty leaving her parents
  for the past several years, but her concerns have
  grown increasingly more intense. She reports
  having fears that if she goes to school, her
  parents will abandon her or something very bad
  might happen to them. She sometimes has dreams
  that they have died, and she wakes up in a panic.
  Sally has come to the SBHC several times in the
  past few months complaining of headaches and
  stomachaches, requesting that she be sent home.

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Separation Anxiety Disorder

• Developmentally inappropriate and excessive
  anxiety concerning separation from home or from
  those to whom the individual is attached, as
  evidenced by three (or more) of the following
• Recurrent excessive distress when separation from
  home or major attachment figures occurs or is
  anticipated
• Persistent and excessive worry about losing, or
  about possible harm befalling, major attachment
  figures
• Persistent and excessive worry that an untoward
  event will lead to separation from a major
  attachment figure (e.g., getting lost or being
  kidnapped)
• Persistent reluctance or refusal to go to school
  or elsewhere because of fear of separation

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Separation Anxiety Disorder

1. Persistently and excessively fearful or reluctant
   to be alone or without major attachment figures
   at home or without significant adults in other
   settings
2. Persistent reluctance or refusal to go to sleep
   without being near a major attachment figure or
   to sleep away from home
3. Repeated nightmares involving the theme of
   separation
4. Repeated complaints of physical symptoms (such as
   headaches, stomachaches, nausea, or vomiting)
   when separation from major attachment figures
   occurs or is anticipated

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Separation Anxiety Disorder

• Duration of at least 4 weeks
• Causes clinically significant distress or
  impairment in social, academic (occupational), or
  other important areas of functioning

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What Type of Anxiety?

• James walks into the SBHC for an appointment. He
  reports having great difficulty concentrating in
  his classes because of his increased worrying. He
  cannot pinpoint his worries Rather, he reports
  being nervous about many things in his life,
  including his relationships with peers, his
  grades, and even his performance in basketball.
  His worries are beginning to impact his sleep,
  and he is finding himself becoming more irritable
  than usual.

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Generalized Anxiety Disorder

• Excessive anxiety worry for at least 6 months,
  more days than not
• Worry about performance at school, sports, etc.
• DSM IV criteria less stringent for children (Need
  only one criteria instead of three of six)
• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance (difficulty falling or staying
  asleep, or restless unsatisfying sleep)

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What Type of Anxiety?

• Shelleys teacher brings her down to the SBHC
  because he is concerned that her grades have been
  declining, and he has noticed that she has not
  been completing her homework. Shelley reports
  that she is being plagued by distressing thoughts
  of doing bad things, including hurting herself
  and others. In order to get rid of the thoughts,
  Shelley often has to engage in intricate
  routines, including counting to 1000 and
  backwards, and touching her desk at home in
  specific patterns. Although these routines
  decrease her anxiety, they are causing her to
  skip homework assignments and even lose sleep.

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Obsessive Compulsive Disorder

• Presence of Obsessions (thoughts) and/or
  Compulsions (behaviors)
• Although adults may have insight, kids may not
• Interferes with life or causes distress
• One third to one half of all adult patients
  report onset in childhood or adolescence

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What Type of Anxiety?

• Ginny comes to the SBHC for a sports physical.
  During her risk assessment, she reveals that her
  parents have a history of domestic violence, and
  that she witnessed her father attack her mother
  on several occasions. In the past few months,
  Ginny has been having nightmares about the abuse,
  and finds herself having flashbacks even during
  class. Ginny has been avoiding certain rooms in
  her house that remind her of the incidents. She
  also reports having difficult sleeping and
  concentrating in class.

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Post-Traumatic Stress Disorder (PTSD)

• The person has been exposed to a traumatic event
  in which both of the following were present
• The person experienced, witnessed, or was
  confronted with an event or events that involved
  actual or threatened death or serious injury, or
  a threat to the physical integrity of self or
  others
• The person's response involved intense fear,
  helplessness, or horror. (Note In children, this
  may be expressed instead by disorganized or
  agitated behavior.)

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Persistent Re-Experiencing of Event (1)

1. Recurrent and intrusive distressing recollections
   of the event, including images, thoughts, or
   perceptions. (Note In young children, repetitive
   play may occur in which themes or aspects of the
   trauma are expressed.)
2. Recurrent distressing dreams of the event. (Note
   In children, there may be frightening dreams
   without recognizable content.)
3. Acting or feeling as if the traumatic event were
   recurring (includes a sense of reliving the
   experience, illusions, hallucinations, and
   dissociative flashback episodes, including those
   that occur on awakening or when intoxicated).
   (Note In young children, trauma-specific
   reenactment may occur.)
4. Intense psychological distress at exposure to
   internal or external cues that symbolize or
   resemble an aspect of the traumatic event
   physiological reactivity on exposure to internal
   or external cues that symbolize or resemble an
   aspect of the traumatic event

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Avoidance and Numbing (3)

1. Efforts to avoid thoughts, feelings, or
   conversations associated with the trauma
2. Efforts to avoid activities, places, or people
   that arouse recollections of the trauma
3. Inability to recall an important aspect of the
   trauma
4. Markedly diminished interest or participation in
   significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have
   loving feelings)
7. Sense of a foreshortened future (e.g., does not
   expect to have a career, marriage, children, or a
   normal life span)

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Increased Arousal (2)

1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response

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Post-Traumatic Stress Disorder (PTSD)

• At least one month duration.
• Causes clinically significant distress or
  impairment in social, occupational, or other
  important areas of functioning
• Note Many students with PTSD meet criteria for
  another Axis I Disorder (e.g., major depression,
  Panic Disorder) both should be diagnosed

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Anxiety Disorder NOS

• Disorders with anxiety symptoms BUT do not meet
  criteria for any specific Anxiety Disorder,
  Adjustment Disorder with Anxiety, or Adjustment
  Disorder with Mixed Anxiety and Depressed Mood
• Example mixed anxiety-depressive disorder
• Also used in situations in which clinician has
  concluded that an anxiety disorder is present,
  but is unable to determine whether it is primary,
  due to medical condition, or substance induced

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Depressive Disorders

• Major Depressive Disorder
• Dysthymic Disorder

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Depression

• Epidemiology
• 2.5 of children, up to 5 of adolescents
• Prepubertal-11/MF adolescence-41/FM
• Average length of untreated MDD-7.2 months
• Recurrence rates-40 within 2 years

• Genetics
• Most important risk factor for the development of
  depressive illness is having at least one
  affectively ill parent

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What Type of Depression?

• Tonya has come for an initial appointment to the
  SBHC. During the risk assessment, Tonya reports a
  number of depressive symptoms, including suicidal
  ideation. Tonya seems to display a lot of
  negative thinking and cognitive distortions. For
  example, she believes that nobody likes her and
  that s/he will never be successful in school.
  Her math teacher often compliments her work, but
  Tonya dismisses the teachers comments as him
  just trying to be nice. Tonya has good grades
  in all classes except for one, yet she only
  acknowledges her below average Chemistry grade.
  Tonya has felt extremely sad for about three
  weeks, which is a contrast from her usually happy
  disposition.

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Major Depressive Disorder

• Major Depressive Episode
• Five (or more) of the following symptoms have
  been present during the same two-week period and
  represent a change from previous functioning.
  At least one symptom is either (1) depressed mood
  or (2) loss of interest or pleasure.
• Depressed mood most of the day, nearly every day,
  as indicated by subjective report or based on the
  observations of others. In children and
  adolescents, this is often presented as
  irritability.
• Markedly diminished interest or pleasure in all,
  or almost all, activities most of the day, nearly
  every day
• Significant weight loss when not dieting or
  weight gain (change of more than 5 of body
  weight in a month), or decrease or increase in
  appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every
  day (observable by others)
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or inappropriate guilt
  nearly every day
• Diminished ability to think, concentrate, make a
  decision nearly every day
• Recurrent thoughts of death, recurrent suicidal
  ideation with or without a specific plan, or an
  actual suicide attempt

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Major Depressive Disorder

• Symptoms cause clinically significant distress or
  impairment in social or academic functioning
• Symptoms are not due to the direct physiological
  effects of a substance (drugs or medication) or a
  general medical condition
• Although there is a different diagnostic category
  for individuals who suffer from Bereavement, many
  of the symptoms are the same and counseling
  techniques may overlap.

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Depression

• Modifications in DSM- IV for children
• irritable mood (vs. depressive mood)
• observed apathy and pervasive boredom (vs.
  anhedonia)
• failure to make expected weight gains (rather
  than significant weight loss)
• somatic complaints
• social withdrawal
• declining school performance

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Adolescent Development
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Adolescent Development

• Periods of transient milder problems with low
  self-esteem, anxiety, depressive feelings are
  quite common.
• Needs to be differentiated from clinical
  depression!

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Suicide

• Attempts- 31/FM, Completions- 41/MF
• Most common means of completed suicide FIREARMS
• Most often associated with depressive disorder.
• Risk factors Age, sex, presence of psychiatric
  illness, family history, isolation from friends,
  substance abuse

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Adolescents and Suicide

• In 1998, 4,153 young people, ages
• 15-24, committed suicide in the United States an
  average of 11.3 per day.1
• Suicide is the third leading cause of death in
  this age group following unintentional injury and
  homicide2
• Suicide accounts for 13.5 of all deaths in this
  age-group1

1 Murphy, SL, 1998 2 The Surgeon Generals Call
to Action to Prevent Suicide, 1999
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Mortality in Children Ages 1-19 years
Source CDC Wonder Mortality Statistics Center
for Disease Control and Prevention, 2001
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What Type of Depression?

• Maria comes for a follow-up appointment to the
  SBHC. Her risk assessment showed that she has
  felt sad or blue for at least two weeks. Upon
  further inquiry, Maria reports that she generally
  feels sad, and finds little enjoyment in
  activities. She reports having felt this way for
  several years. In fact, she cant recall a time
  when she didnt feel mostly down. She denies
  suicidal ideation, and is doing pretty well in
  school. She is not very social, but does have a
  few friends.

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Dysthymic Disorder

• Major difference between a diagnosis of Major
  Depressive Disorder and Dysthymia is the
  intensity of the feelings of depression and the
  duration of symptoms.
• Dysthymia is an overarching feeling of depression
  most of the day, more days than not, that does
  not meet criteria for a Major Depressive Episode.
• Impairs functioning and lasts for at least one
  year in children and adolescents, two in adults.

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Depressive Disorder NOS

• Disorders with depressive symptoms BUT do not
  meet criteria for Major Depressive Disorder,
  Dysthymic Disorder, Adjustment Disorder with
  Depressed Mood, or Adjustment Disorder with Mixed
  Anxiety and Depressed Mood
• Examples premenstrual dysphoric disorder, minor
  depressive disorder (at least 2 weeks, but lt 5
  symptoms)
• Also used in situations in which clinician has
  concluded that a depressive disorder is present,
  but is unable to determine whether it is primary,
  due to medical condition, or substance induced

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Disruptive Disorders In Children

• Attention Deficit Hyperactivity Disorder
• Oppositional Defiant Disorder
• Conduct Disorder
• Disruptive Behavior Disorder NOS

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What Type of Disruptive Behavior Disorder?

• Joseph was referred to the main office by his
  teacher for disrupting her class. Josephs
  teacher reported that she cannot manage him in
  class because he is constantly out of his seat
  and will not concentrate on work. He has a hard
  time completing tasks, and is very disorganized.
  He talks back to her occasionally when
  frustrated, but is not frequently defiant. His
  peers are getting tired of him constantly
  interrupting them, and he is losing friends
  quickly.

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Attention Deficit Hyperactivity Disorder

• Symptoms for at least six months to a degree that
  it is maladaptive and INCONSISTENT with
  developmental level
• Some symptoms present prior to age 7 years
• Two or more settings

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Attention Deficit Hyperactivity Disorder

• Inattention
• Poor organization
• Does not seem to listen when spoken to
• Loses objects
• Easily distracted
• Forgetful in daily activities

• Hyperactivity/Impulsivity
• Fidget
• Leaves seat often
• Runs or climbs excessively
• Always on the go
• Talks excessively
• Blurts out answers
• Cant wait turn, interrupts others

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Attention Deficit Hyperactivity Disorder

• Attention deficit disorder can occur WITH and
  WITHOUT hyperactivity
• Hyperactivity is more common in boys than girls

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Attention Deficit Hyperactivity Disorder

• ADHD can be a lifetime disorder with 30-50
  having symptoms as adults
• Learning Disabilities are frequently seen in
  children with ADHD
• Behavior in a providers office does NOT always
  reflect the situation at home or in school

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What Type of Disruptive Behavior Disorder?

• The principal of your school has called you to a
  meeting with Jonathons parents and his teachers,
  all of whom complain that Jonathon has been
  acting out for over a year, and refuses to
  listen to their direction. He is constantly
  arguing with all authority figures, and will not
  take responsibility for his actions. Jonathons
  teacher and mother say that he is always angry,
  and that he lashes out at everyone around him. He
  has been breaking more rules at home and in
  school. He has not been drinking alcohol or using
  drugs, not has he broken the law up until this
  point, but his parents are worried that his
  behaviors are going to grow steadily worse.

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Oppositional Defiant Disorder

• A pattern of negativistic, hostile and defiant
  behavior lasting greater than 6 months of which
  you have 4 or more of the following
• Loses temper
• Argues with adults
• Actively defies or refuses to comply with rules
• Often deliberately annoys people
• Blames others for his/her mistakes
• Often touchy or easily annoyed with others
• Often angry and resentful
• Often spiteful or vindictive

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Oppositional Defiant Disorder(ODD)

• Prevalence-3-10
• Male to female -2-31
• Outcome-in one study, 44 of 7-12 year old boys
  with ODD developed into CD
• Evaluation-Look for comorbid ADHD, depression,
  anxiety LD/MR

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What Type of Disruptive Behavior Disorder?

• Matthew was referred to the social worker at the
  SBHC because he has been going down the wrong
  path for several years, according to his mother.
  Matthews negative behaviors began before
  puberty, when he started hanging out with
  negative peers. Matthews mother has caught him
  hurting their family pet as well as other
  animals, and he was recently arrested for
  vandalizing school property. He has been getting
  into frequent fights at school without apparent
  instigation. Matthews mother also realized that
  he had stolen from her when she noticed 50
  missing from her purse and found it in his pocket.

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Conduct Disorder (CD)

• Aggression toward people or animals

• Deceitfulness or Theft

• Serious violation of rules

• Destruction of property

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Conduct Disorder (CD)

• Prevalence-1.5-3.4
• Boys greatly outnumber girls (3-51)
• Comorbid ADHD in 50, common to have LD
• Course-remits by adulthood in 2/3. Others become
  Antisocial Personality Disorder

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Conduct Disorder (CD)
You left your D__M car in the driveway again!
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Disruptive Behavior Disorder NOS

• Disorders characterized by conduct or
  oppositional defiant behaviors that do not meet
  criteria for ODD or CD
• Still must have impairment in functioning

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Substance Abuse
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• Experimentation with substances is common,
  particularly during adolescence.
• Teenagers use alcohol and drugs for a variety of
  reasons
• curiosity
• to reduce stress
• to fit in with a peer group
• it feels good
• Difficult to determine which
• youths will experiment and stop and
• which will develop more serious problems
• with substances.

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Adolescent Brain Changes

• Earlier drinking more likely to result in alcohol
  dependence independent of family hx (Grant 1998)
• Exposure of alcohol may indeed cause alterations
  in brain chemistry. There are studies indicating
  heaving drinking during adolescence causes memory
  and neuropsychological changes (Brown, et al)
• Animal studies show that early exposure to
  alcohol results in longer term problems such as
  cognitive and behavioral problems

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Dependence vs. Abuse

• Dependence A maladaptive pattern of substance
  use, leading to clinically significant impairment
  or distress, as manifested by three (or more) of
  the following, occurring at any time in the same
  12-month period
• Tolerance, as defined by either of the following
• A need for markedly increased amounts of the
  substance to achieve intoxication or desired
  effect or
• Markedly diminished effect with continued use of
  the same amount of the substance
• Withdrawal, as manifested by either of the
  following
• The characteristic withdrawal syndrome for the
  substance or
• The same (or a closely related) substance is
  taken to relieve or avoid withdrawal symptoms
• The substance is often taken in larger amounts or
  over a longer period than was intended.

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Dependence vs. Abuse

1. There is a persistent desire or unsuccessful
   efforts to cut down or control substance use.
2. A great deal of time is spent n activities
   necessary to obtain the substance (e.g., visiting
   multiple doctors or driving long distances), use
   the substance (e.g., chain-smoking), or recover
   from its effects
3. Important social, occupational, or recreational
   activities are given up or reduced because of
   substance use.
4. The substance use is continued despite knowledge
   of having a persistent physical or psychological
   problem that is likely to have been caused or
   exacerbated by the substance (e.g., current
   cocaine use despite recognition of
   cocaine-induced depression, or continued drinking
   despite recognition that an ulcer was made worse
   by alcohol consumption).

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Dependence vs. Abuse

• Abuse A maladaptive pattern of substance use,
  leading to clinically significant impairment or
  distress, as manifested by one (or more) of the
  following, occurring at any time in the same
  12-month period
• Recurrent substance use resulting in a failure to
  fulfill major role obligations at wok, school, or
  home (e.g., repeated absences or poor work
  performance related to substance use
  substance-related absences, suspensions, or
  expulsions from school neglect of children or
  household
• Recurrent substance use in situations in which it
  is physically hazardous (e.g. driving an
  automobile or operating a machine when impaired
  by substance use)
• Recurrent substance-related legal problems (e.g.,
  arrests for substance-related disorderly conduct)
  
• Continued substance use despite having persistent
  or recurrent social or interpersonal problems
  caused or exacerbated by the effects of the
  substance (e.g., arguments with spouse about
  consequence of intoxication, physical fights)
• The symptoms have never been met the criteria for
  Substance Dependence for this class of substance.

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Dependence vs. Abuse?

• Martina was referred to the substance abuse
  counselor because her teacher thinks she has been
  high during class. Martina reported to the
  counselor that she has been drinking alcohol and
  smoking marijuana for the past couple of years,
  and that she is having to drink and smoke more to
  feel the same effects that she used to. She
  notices that when she does not drink, she has
  trouble sleeping at night. Martina reports trying
  to stop drinking and smoking in the past, but she
  never succeeded. She has recently been cutting
  classes to purchase alcohol and drugs.

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DEPENDENCE
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Dependence vs. Abuse?

• During his sports physical at the SBHC, Samuel
  reported that he has drank alcohol in the past
  several months. He indicated that he only drinks
  on the weekend, and that he usually drinks the
  same amount (a few beers) each weekend. His
  family and his girlfriend have complained to him
  that his drinking is causing problems in their
  relationships, and have asked him to stop. Over
  the past summer, Samuel was arrested for drinking
  while driving. He also said that he has been late
  to work a few mornings because he had stayed out
  late drinking.

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ABUSE