ABPSYCH 311 – MIDTERMS NEURODEVELOPMENTAL DISORDERS

CHAPTER 14 DISORDERS OF CHILDHOOD - Group of conditions characterized by early onset and

AND ADOLESCENCE persistent course that are believed to be result of
(NEURODEVELOPMENTAL DISORDERS) disruptions to normal brain development
Neurodevelopmental – Childhood
Neurocognitive – Later years ATTENTION-DEFICIT/HYPERACTIVITY
DISRODERS (ADHD)
- Important that we view child’s behavior in context of
normal development - Characterized by persistent pattern of difficulties
sustaining attention and/or impulsiveness and
- Cannot consider child’s behavior abnormal without
excessive or exaggerated motor activity
determining whether the behavior in question is
appropriate for the child’s age - Perhaps due to partially to behavioral problems,
children with ADHD often score approximately 7 to 15
DEVELOPMENTAL PSYCHOPATHOLOGY –
points lower on intelligence quotient (IQ) tests and
Determining what is abnormal at any point in
show deficits on neuropsychological testing that
developmental process by comparing and contrasting it
related to poor academic functioning
with normal and expected changes that occur.
- Often exhibit specific learning disabilities such as
- No sharp line of demarcation between the
difficulties in reading or learning other basic school
maladaptive behavior patterns of childhood and those
subjects
adolescence (i.e., no precise age at which temper
tantrums are now considered officially “abnormal”) or - Hyperactive children often have great difficulty
between those adolescence and adulthood getting along with their parents because they often fail
to obey rules, their behavior problems also can result
PSYCHOLOGICAL VULNERABILITIES OF
in their being viewed negatively by their peers
YOUNG CHILDREN
- ADHD is fairly prevalent, occurring in approximately
- Young children are vulnerable to psychological
9% of children and adolescents
problems
- The rate of ADHD is much higher in boys (13%) than
- Don’t have complex and realistic view of themselves
in girls (4%) and is commonly comorbid with other
and their world as they will have late and not yet
externalizing disorders such as ODD and CD
developed stable sense of identity or clear
understanding of what is expected them and resources - Most cases of adult ADHD are characterized by
they might have to deal with. Problems symptoms of inattention (95%), whereas a much
smaller percentage are characterized by hyperactivity
- Immediately perceived threats are tempered less by
(35%)
considerations of past or future tend to be seen as
disproportionately important - ADHD begins in childhood, requirement that several
symptoms has been present before age 12 years
- Children often have more difficulty tan adults in
conveys the importance of substantial clinical
coping with stressful events
presentation during childhood
- Children’s lack of experience in dealing with
- Earlier age ate onset is not specified because of
adversity can make manageable problems seem
difficulties in establishing precise childhood onset
insurmountable
retrospectively
- Children also are more dependent on other people
HYPERACTIVITY – Excessive motor activity (such
than are adults
as child running about) when it’s not appropriate, or
- In some ways this dependency serves as buffer excessive fidgeting, tapping, or talkativeness
against other dangers because the adults around might
- In adults, may manifests as extreme restlessness or
“protect” against stressors in environment, it also make
wearing others out with their activity
the child highly vulnerable to abuse or neglect by
others IMPULSIVITY – Hasty actions that occur in moment
without forethought, which may have potential for
harm to individual (darting into the streets without
looking)
- May reflect a desire for immediate rewards or
inability to delay gratification
- Impulsive behaviors may manifest as social
intrusiveness and/or making important decisions
without consideration of long-term consequences
DSM 5-TR (Diagnostic Criteria)
A. Persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with
functioning or development, as characterized by (1)
and/or (2):
1. INATTENTION: 6 (or more) of following
symptoms have persisted for at least 6 months to
degree that is inconsistent with developmental level
and negatively impacts directly on social and
academic/occupational activities:
NOTE: Symptoms are not solely a manifestation of
oppositional behavior, defiance, hostility, or failure to
understand tasks. For older adolescents and adults (age
17 and older), at least 5 symptoms are required.
a. Often fails to give close attention to details or make
careless mistakes in schoolwork, at work, or during
other activities
b. Often has difficulty sustaining attention in tasks or
play activities (e.g., has difficulty remaining focuses
during lecture, conversations, or lengthy reading)
c. Often does not seem to listen when spoken to
directly (mind seems elsewhere, even in absence of
any obvious distraction)
d. Often does not follow through on instructions and
fails to finish schoolwork, chores, or duties in
workplace (starts tasks but quickly loses focus and is
easily sidetracked)
e. Often has difficulty organizing tasks and activities
(difficulty managing sequential tasks; difficulty
keeping materials and belongings in order; messy,
disorganized work; has poor time management; fails to
meet deadlines)
f. Often avoids, dislikes, or is reluctant to engage in
tasks that require sustained mental effort (schoolwork
or homework; for older adolescents and adults,
preparing reports, completing forms, reviewing
lengthy papers)
g. Often loses things necessary for tasks or activities
(school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile phones)
h. Often easily distracted by extraneous stimuli (for
older adolescents and adults, may include unrelated
thoughts)
i. Often forgetful in daily activities (doing chores,
running errands,; for older adolescents and adults,
returning calls, paying bills, keeping appointments)
2. HYPERACTIVITY AND IMPULSIVITY: 6 (or
more) following symptoms have persisted for at least 6
months to degree that is inconsistent with
developmental level and that negatively impacts
directly on social and academic/occupational activities
a. Often fidgets with or taps hands or feet or squirms in
seat
b. Often leaves seat in situation when remaining seated
is expected.
c. Often runs about or climbs in situations where it is
inappropriate (Note. In adolescents or adults, may be
limited to feeling restless)
d. Often unable to play or engage in leisure activities
quietly
e. Often “on the go” acting as if “driven by a motor”
(unable to be or uncomfortable being still for extended
time, as in restaurants, meetings; may be experiences
by other as being restless or difficult to keep up with)
f. Often talks excessively
g. Often blurts out an answer before a question has
been completed (completes people’s sentences, cannot
wait for turn in conversation)
h. Often has difficulty waiting his or her turn (while
waiting in line)
i. Often interrupts or intrudes on other (burst into
conversations, games, or activities’ may start using
other people’s things without asking or receiving
permission; for adolescents and adults, may intrude
into or take over what others are doing)
B. Several inattentive or hyperactive-impulsive
symptoms were present prior to age 12 years
C. Several inattentive or hyperactive-impulsive
symptoms are present in two or more setting (home,
school. or work; with friend or relatives; on other
activities)
D. There is clear evidence that symptoms interfere
with, or reduce the quality of social, academic, or
occupational functioning)
E. Symptoms do not occur exclusively during the
course of schizophrenia or another psychotic disorder
and are not better explained by another mental disorder
Specify whether:
COMBINED PRESENTATION: If both Criterion A1
(inattention) and Criterion A2 (hyperactivity-
impulsivity) are met for the past 6 months
PREDOMINANTLY INATTENTIVE
PRESENTATION: If Criterion A1 is met but Criterion
A2 is not met for the past 6 months
PREDOMINANTLY HYPERACTIVE-IMPULSIVE
PRESENTATION: If Criterion A2 is met and Criterion
A1 is not met for the past 6 months
IN PARTIAL REMISSION – When full criteria were
previously met, fewer that the full criteria have been
met for the past 6 months, and symptoms still result in
impairment in social, academic, or occupational
functioning
SPECIFY CURRENT SEVERITY
MILD – Few, if any, symptoms in excess of those
required to make the diagnoses are present, and
symptoms result in no more than minor impairments in
social or occupational functioning
MODERATE – Symptoms or functional impairments
between “mild” and “severe” are present
SEVERE – Many symptoms in excess of those
required to make the diagnosis, or several symptoms
that are particularly severe, are present, or symptoms
result in marked impairment in social or occupational
functioning
ASSOCIATED FEATURES
- Delays in language, motor, or social development are
not specific to ADHD but often co-occur
- Emotional dysregulation or emotional impulsivity
commonly occurs in children and adults with ADHD
- Individuals with ADHD self-report and are described
by others as being quick to anger, easily frustrated, and
overreactive emotionally
CAUSAL FACTORS IN ADHD
- Specific causes of ADHD have been widely debated
- Children with ADHD have smaller total brain
volumes than those without ADHD
- Their brains appear to mature approximately 3 years
more slowly than those without ADHD
- These maturational delays are most prominent in
prefrontal brain regions involved in attention and
impulsiveness
TREATMENTS AND OUTCOMES
RITALIN (Methylphenidate) – Stimulant medication
have quieting effect on children – just the opposite of
what we would expect from their effects on adults
- Decreases overactivity and distractibility and at the
same time increase their alertness
- Lower the amount of aggressiveness in children with
ADHD
POSSIBLE SIDE EFFECTS OF RITALIN
- Decreased blood flow to the brain, can result in
impaired thinking ability and memory loss
- Disruption of growth hormone, leading to
suppression of growth in body and brain of the child
- Insomnia, psychotic symptoms, and others
PEMOLINE – Chemically very different from Ritalin,
it exerts beneficial effects on classroom behavior by
enhancing cognitive processing and has fewer adverse
side effects than Ritalin
STRATTERA (Atomoxetine) – Noncontrolled
treatment option that can be obtained readily, U.S.
Food and Drug Administration (FDA) approved
nonstimulant medication
SIDE EFFECTS OF STRATTERA
- Decreases appetite
- Nausea
- Vomiting
- Fatigue
- Possibility of liver damage
ADDERALL – Reduces symptoms of impulsivity and
hyperactivity in children with ADHD
- Medication is combination of amphetamine and
dextroamphetamine
- Research suggested that Adderall provides no
advantage or improvement in results over Ritalin and
Strattera
BEHAVIORAL INTERVENTION TECHNIQUES –
Include teaching organizational and planning skills,
techniques for decreasing distractibility and
procrastination
- As well as parenting techniques focused on providing
reinforcement for adaptive child behavior
AUTISM SPECTRUM DISORDER
- We refer to as “Autism” is neurodevelopmental
disorder that involves a wide range of problematic
behaviors including deficits in language, and
perceptual and motor development
- Defective reality testing; and impairments in social
communication
- Autism was first described in 1943 (Kanner)
- Usually identified before a child is 20 months of age,
and diagnostic stability over the childhood years is
quite high
- Children diagnosed with autism by age 2 tend to be
similarly diagnosed at age of 9
- Early signs od problems with social communication
can be detected in the first 6 months of infant’s life
- Children later diagnosed with autism show
significant decline in their focus on eyes of others from
2 to 6 months of age and this decline continues until 24
months, approximately half the level of focus as seen
in typically developing children
DSM 5-TR (Diagnostic Criteria)
A. Persistent deficits in social communication and
social interaction across multiple contexts, as
manifested by all of following, currently or by history
(examples are illustrative, not exhaustive)
1. Deficit in social-emotional reciprocity, ranging, for
example, from abnormal social approach and failure of
normal back-and-forth conversation; to reduced
sharing of interest, emotions, or affect; to failure to
initiate or respond to social interactions
2. Deficits in nonverbal communicative behaviors used
for social interaction, ranging, for example, from
poorly integrated verbal and nonverbal
communication; to abnormalities in eye contact and
body language or deficits in understanding and use of
gestures; to total lack of facial expression and
nonverbal communication
3. Deficits in developing, maintaining, and
understanding relationships, ranging, for example,
from difficulties adjusting behavior to suit various
social contexts; to difficulties in sharing imaginative
play or in making friends; to absence of interest in
peers
B. Restricted, repetitive patterns of behavior, interests,
or activities, as manifested by at least 2 of the
following, currently or by history
1. Stereotyped or repetitive motor movements, use of
objects, or speech (simple motor stereotypies, lining up
toys or flipping objects. Echolalia. Idiosyncratic
phrases)
2. Insistence on sameness, inflexible adherence to
routines, or ritualized patterns of verbal or nonverbal
behavior (extreme distress at small changes,
difficulties with transitions, rigid thinking patterns,
greeting rituals, need to take same route or eat same
food every day)
3. Highly restricted, fixated interests that are abnormal
in intensity or focus (strong attachment to or
preoccupation with unusual objects, excessively
circumscribed or perspective interests)
4. Hyper – or hyperactivity to sensory input or unusual
interest in sensory aspects of the environment
(apparent indifference to pain/temperature, adverse
response to specific sounds or textures, excessive
smelling or touching of objects, visual fascination with
lights or movement)
C. Symptoms must be present in the early
developmental period (but may not become fully
manifest until social demands exceed limited
capacities, or may be masked by learned strategies in
later life)
D. Symptoms cause clinically significant impairment
in social, occupational, or other important areas of
current functioning
E. These disturbances are not better explained by
intellectual developmental disorder (intellectual
disability) or global developmental delay. Intellectual
developmental disorder and autism spectrum disorder
frequently co-occur; to make comorbid diagnoses of
autism spectrum disorder frequently co-occur; to make
comorbid diagnoses of autism spectrum disorder and
intellectual developmental disorder, social
communication should be below that expected for
general developmental level
SEVERITY LEVELS FOR AUTISM SPECTRUM
DISORDER
LEVEL 3 (Requiring very substantial support)
SOCIAL COMMUNICATION: Severe deficits in
verbal and nonverbal social communication skills
cause severe impairments in functioning, very limited
initiation of social interactions, and minimal response
to social overtures from others
RESTRICTED, REPETITIVE BEHAVIORS:
Inflexibility of behavior, extreme difficulty coping
with change, or other restricted/repetitive behaviors
markedly interfere with functioning in all spheres.
Great distress/difficulty changing focus or action
LEVEL 2 (Requiring substantial support)
SOCIAL COMMUNICATION: Marked deficits in
verbal and nonverbal social communication skills;
social impairments apparent even with supports in
place; limited initiation of social interactions; and
reduced or abnormal responses to social overtures
from other
RESTRICTED, REPETITIVE BEHAVIORS:
Inflexibility of behavior, difficulty coping which
change, or other restricted/repetitive behaviors appear
frequently enough to be obvious to the casual observer
and interfere with functioning in variety of contexts.
Distress and/or difficulty changing focus or action
LEVEL 1 (Requiring support)
SOCIAL COMMUNICATION: Without supports in
place, deficits in social communication cause
noticeable impairments. Difficulty initiating social
interactions, and clear examples of atypical or
unsuccessful responses to social overtures of other.
May appear to have decreased interest in social
interactions
RESTRICTED, REPETITIVE BEHAVIORS:
Inflexibility of behaviors cause significant interference
with functioning in one or more context. Difficulty
switching between activities. Problems of organization
and planning hamper independence
DIAGNOSTIC FEATURES
- Essential features of autism spectrum disorder are
persistent impairment in reciprocal social
communication and social interaction
- Intervention, compensation, and current supports may
mask difficulties in at least some contexts
- Manifestations of disorder also vary greatly
depending on the severity of the autistic condition,
developmental level, chronological age, and possibly
gender
THE CLINICAL PICTURE OF AUTISTIC
SPECTRUM DISORDER
- Show varying degrees of impairments and
capabilities
- Cardinal and typical sign is that child seems apart or
aloof from others, even in the earliest stages of life
- Mothers often remember such babies as not being
cuddly, not reaching out when being picked up, not
smiling or looking at them while being fed, and not
appearing to notice the comings and goings of other
people
SOCIAL DEFICIT – Do not show any need for
affection or contact with others
- Children with autism do express emotions and should
not be considered as lacking emotional reactions
- Some have characterized the seeming inability of
children with autism to respond to others as lack of
social understanding – deficit in the ability to attend to
social cues from others
- Neuroimaging studies have revealed that children
with autism show decreased activity in medial
prefrontal cortex, region associated with understanding
the mental states of others, but increased activation in
the ventral occipitotemporal regions involved in object
perception
- Deficits in attention and in locating and orienting to
sounds in their environment
- Show aversion to auditory stimuli, crying even at the
sound of parent’s voice
ABSENCE OF SPEECH – Have absence or severely
limited use of speech
ECHOLALIA – Parrot-like repetition of few words
- Echoing of parent’s verbal behavior is found to small
degree in normal children as they experiment with
their ability to produce articulate speech
- Typically developing children show that among those
with autism, there is under-developed connectivity
within regions of the brain associated with imitating
others, but over-developed connectivity between
imitation regions and other parts of the brain
- Among those with autism, the greater the under-
connectivity within imitation regions, the greater the
symptoms of disorders
SELF-SIMULATION – Takes form of such repetitive
movements as head banging, spinning, and rocking,
which may continue by the hour
MAINTAINING SAMENESS – Become preoccupied
with form string attachments to unusual object such as
rock, light switches, or keys
- When preoccupation with objects is disrupted – for
example, by its removal or by attempts to substitute
something in its place – or when anything familiar in
the environment is altered even slightly, may have
violent temper tantrum or crying spell that continues
until the familiar situation is restored
- Often said to be “obsessed with the maintenance of
sameness”
CAUSAL FACTORS IN AUTISM
- Autism is complex disorder and precise causes are
unknown
- Twin and sibling studies shown that there is very
string heritable component in autism
- 2 to 4% of siblings of children diagnosed with autism
also have the disorder, and approximately 20% have
some symptoms of the disorder
- Hundreds of different genes are associated with
increased risk of autism, suggesting that there are
many different paths to developing this disorder
- Portion of the genetic risk is inherited (52%) and
what is portion due to de novo genetic mutations (3%)
DE NOVO MUTATION – Occur in egg or sperm and
are passed on to every cell in the child’s body, despite
not appearing in parent’s DNA
- Genetic mutations have been reported to occur at
higher rates in sperm of older men, and there is now
converging evidence that older father age at child’s
birth is associated with increased risk of autism
TREATMENTS AND OUTCOMES OF AUTISM
INTENSIVE BEHAVIORAL INTERVENTION –
Administered via one-on-one meetings with the child
for over 40 hours per week for 2 years resulted in
extremely positive results
- Based on both discrimination-training strategies
(reinforcement) and contingent aversive techniques
(punishment)
- Treatment plan typically enlists parents in the process
and emphasizes teaching children to learn from and
interact with “normal” peers in real-world situations
EARLY START DENVER MODEL (ESDM) –
Involves more than 20 hours per week of intensive
behavioral work with child and parents
- Focused on interpersonal exchanges, verbal and
nonverbal communication, and adult sensitivity to
children’s cues
MOTOR DISORDERS (Developmental Coordination
Disorder)
- Made by clinical synthesis of history (developmental
and medical), physical examination, school or
workplace repost, and individual assessment using
psychometrically sound and culturally appropriate
standardized tests
- Other terms used to describe developmental
coordination disorder include childhood dyspraxia,
specific developmental disorder of motor function, and
clumsy child syndrome
- Children with developmental coordination disorder
show additional motor activity, such as choreiform
movements of unsupported limbs or mirror movements
- “Overflow” movements are referred to as
neurodevelopmental immaturities or neurological soft
sign rather than neurological abnormalities
DSM 5-TR (Diagnostic Criteria)
A. Acquisition and execution of coordinated motor
skills is substantially below that expected given
individual’s chronological age and opportunity for skill
learning and use. Difficulties are manifested as
clumsiness
B. The motor skills deficit in Criterion A significantly
and persistently interferes with activities of daily living
appropriate to chronological age and impacts
academic/school productivity, prevocational and
vocational activities, leisure, and play
C. Onset symptoms is in early developmental period
D. Motor skills deficits are not better explained by
intellectual developmental disorder or visual
impairment and not attributable to neurological
condition affecting movement
STEREOTYPIC MOVEMENT DISORDER
- Typically begin within the first 3 years of life
- Children who develop complex motor stereotypies,
approximately 80% exhibit symptoms before age of 24
months, 12% between 24 and 35 months, and 8% at 36
months or older
- Typically developing children the severity and
frequency of stereotyped movements diminish over
time
DSM 5-TR (Diagnostic Criteria)
A. Repetitive, seemingly driven, and apparently
purposeless motor behavior
B. Repetitive behavior interferes with social,
academic, or other activities and may result in self-
injury
C. Onset is in early developmental period
D. Repetitive motor behavior is not attributable to
physiological effects of substance or neurological
condition and is not better explained by another
neurodevelopmental or mental disorder
SPECIFY CURRENT SEVERITY:
MILD – Symptoms are easily suppressed by sensory
stimulus or distraction
MODERATE – Symptoms require explicit protective
measures and behavioral modifications
SEVERE – Continuous monitoring and protective
measure are required to prevent serious injury
TIC DISORDER
- Persistent, intermittent muscle twitch or spasm,
usually limited to localized muscle group
- Broadly used to include blinking the eye, twitching
the mouth, licking the lips, shrugging the shoulders,
clearing the throat, and grimacing, among other actions
- Tics occur most frequently between the ages of 8 and
14
TOURETTE’S DISORDER
DSM 5-TR (Diagnostic Criteria)
A. Both multiple motor and one or more vocal tics
have been present at some time during the illness,
although not necessarily concurrently
B. The tics may wax and wane in frequency but have
persisted for more than 1 year since first tic onset
C. Onset is before age 18 years
D. The disturbance is not attributable to physiological
effects of substance (cocaine) or another medical
condition (Huntington’s disease, post viral
encephalitis)
PERSISTENT (CHRONIC) MOTOR OR VOCAL
TIC DISORDER
DSM 5-TR (Diagnostic Criteria)
A. Single or multiple motor or vocal tics have been
present during the illness, but not both motor and vocal
B. The tics may wax and wane in frequency but have
persisted for more than 1 year since first tic onset
C. Onset is before age 18 years
D. The disturbance is attributable to the physiological
effects of substance or another medical condition
E. Criteria have never been met for Tourette’s disorder
Specify if:
With motor tics only
With vocal tics only
PROVISIONAL TIC DISORDER
DSM 5-TR (Diagnostic Criteria)
A. Single or multiple motor and/or vocal tics
B. The tics have been present for less than 1 year since
first tic onset
C. Onset is before age 18 years
D. The disturbance is not attributable to physiological
effects of substance or another medical condition
E. Criteria have never been met for Tourette’s disorder
or persistent (chronic) motor or vocal tic disorder
SIMPLE MOTOR TICS – Characterized by limited
involvement of specific muscle groups, often are short
duration and can include eye blinks, facial grimaces,
shoulder shrugs, or extension of the extremities
SIMPLE VOCAL TICS – Include throat clearing,
sniffs, chirps, barks, or grunting often caused by
contraction of the diaphragm or muscles of oropharynx
COMPLEX MOTOR TICS – Longer duration and
often include combination of simple tics such as
simultaneous head turning and shoulder shrugging
- Can appear purposeful, such as head gestures or torso
movements
ECHOPRAXIA – Imitations of someone else’s
movements
COPROPRAXIA – Sexual or taboo gestures
PALILALIA – Have linguistic meaning (words or
partial words) and can include repeating one’s own
sounds or words
ECHOLALIA – Repeating the last-heard word or
phrase
CORPOLALIA – Uttering socially unacceptable
words, including obscenities, or ethnic, racial, or
religious slurs
- Abrupt, sharp bark or grunt utterance and lacks the
prosody of similar inappropriate speech observed in
human interactions
DEVELOPMENT AND COURSE
- First onset of tics is typically between ages of 4 and 6
years
- Eye blinking is highly characteristic of as initial
symptoms
- Peak severity occurs between 10 and 12 years, with
decline in severity during adolescence
- Tics associated with premonitory urge may be
experienced as not completely “involuntary” in that the
urge and the tic can be resisted
- Individual may also feel the need to perform a tic
repeatedly or in specific way until the individuals feels
that the tic has been done “just right”
- Often there is a feeling of relief and tension reduction
following the expression of the tic or series of tics
SPECIFIC LEARNING DISORDER
- Delays in cognitive development in the areas of
language, speech, mathematical, or motor skills that
are not necessarily due to any demonstrable physical or
neurological defect
- Significantly more boys than girls are diagnosed as
having a learning disorder, but estimates of the extent
of this gender discrepancy have varied widely from
study to study
- Estimates suggest that 2 out of 10% of children have
learning disorder, most often classified as dyslexia
(80%) with about 30% of children with learning
disorder such as ADHD, depression, or anxiety
- Do not have obvious, crippling emotional problems,
nor do they seem to be lacking in motivation,
cooperativeness, or eagerness to please their teachers
and parents – at least not the outset of their formal
education
- May also occur in individuals identified as
intellectually “gifted” may sustain apparently adequate
academic functioning by using compensatory
strategies, extraordinarily high effort, or support, until
learning or accomplishing required tasks
DSM 5-TR (Diagnostic Criteria)
A. Difficulties learning and using academic skills, as
indicated by presence of at least one of the following
symptoms that have persisted for at least 6 months,
despite the provision of interventions that target those
difficulties:
1. Inaccurate or slow and effortful word reading (reads
single words aloud incorrectly or slowly and hesitantly,
frequently guesses words, has difficulty sounding out
words)
2. Difficulty understanding the meaning of what is read
(may read text accurately but not understand the
sequence, relationships, inferences, or deeper
meanings of what is read)
3. Difficulties with spelling (may add, omit, or
substitute vowels or consonants)
4. Difficulties with written expression (makes multiple
grammatical or punctuation errors within sentences;
employ poor paragraph organization; written
expression of ideas lacks clarity)
5. Difficulties mastering number sense, number facts,
or calculation (has poor understanding of numbers,
magnitude, and relationships; counts on fingers to add
single-digit numbers instead of recalling the math fact
as peers do; gets lost in the midst of arithmetic
computation and may switch procedures)
6. Difficulties with mathematical reasoning (has severe
difficulty applying mathematical concepts, facts, or
procedures to solve quantitative problems)
B. The affected academic skills are substantially and
quantifiably below those expected for the individual’s
chronological age, and cause significant interference
with academic or occupational performance, or with
activities of daily living, as confirmed by individually
administered standardized achievement measures and
comprehensive clinical assessment. For individuals age
17 years and older, documented history of impairing
learning difficulties may be substituted for the
standardized assessment
C. Learning difficulties begin during school-age years
but may not become fully manifest until the demands
for those affected academic skills exceed the
individual’s limited capacities (as in timed tests,
reading or writing lengthy complex reports for tight
deadline, excessively heavy academic loads)
D. Learning difficulties are not better accounted for by
intellectual disabilities, uncorrected visual or auditory
acuity, other mental or neurological disorders,
psychosocial adversity, lack of proficiency in the
language of academic instruction, or inadequate
educational instruction
NOTE: The four diagnostic criteria are to be met based
on clinical synthesis of individual’s history
(developmental, medical, family, educational), school
reports, and psychoeducational assessment
DYSLEXIA
- Alternative term used to refer to pattern of learning
difficulties characterized by problems with accurate or
fluent word recognition, poor decoding, and poor
spelling abilities
- Used to specify this particular pattern of difficulties,
it is important also to specify any additional difficulties
that are present, such as difficulties with reading
comprehension or math reasoning
DYSCALCULIA
- Alternative term used to refer pattern of difficulties
characterized by problems processing numerical
information, learning arithmetic facts, and performing
accurate or fluent calculations
- Also important to specify any additional difficulties
that are present, such as difficulties with math
reasoning or word reasoning accuracy
CAUSAL FACTORS IN LEARNING DISORDERS
- Most widely held view of the causes of specific
learning disorders is that the products of subtle CNS
impairments
- Result from some sort of immaturity, deficiency, or
dysregulation limited to brain functions that
supposedly mediate
- Identification of gene region for dyslexia on
chromosome 6 has been reported
TREATMENTS AND OUTCOMES
PHONICS INSTRUCTIONS – Involves teaching
children letter-sound correspondence as well as how to
decode and create syllables, associated with significant
improvements in reading and spelling abilities
INTELLECTUAL DEVELOPMENTAL DISORDERS
(INTELLECTUAL DISABILITY)
- Characterized by deficits in general mental abilities,
such as reasoning, problem solving, planning, abstract
thinking, judgement, academic learning, and learning
from experience
- Defines in terms of both intelligence and level of
performance, and for diagnosis to apply, these
problems must begin before the age of 18
- Functional equivalent of intellectual disability that
has its onset after age 17 is considered to be
“dementia” rather intellectual disability
- Initial diagnoses of intellectual disability most
frequently occur at ages 5 to 6 (around the time that
schooling begins for most children), peak at age 15,
and drop off sharply after that
DSM 5-TR (Diagnostic Criteria)
A. Deficits in intellectual functions, such as reasoning,
problem solving, planning, abstract thinking,
judgement, academic learning, and learning from
experience, confirmed by both clinical assessment and
individualized, standardized intelligence testing
B. Deficits in adaptive functioning that result in failure
to meet developmental and sociocultural standards for
personal independence and social responsibility.
Without ongoing support, adaptive deficits limit
functioning in one or more activities of daily life, such
as communication, social participation, and
independent living, across multiple environments, such
as home, school, work, and community
C. Onset of intellectual and adaptive deficits during the
developmental period
SEVERITY LEVELS FOR INTELLECTUAL
DEVELOPMENTAL DISORDER (INTELLECTUAL
DISABILITY)
- Tests of human intelligence produce IQ scores that
have an average of 100 and a standard deviation of 15
- Means that most people (95%) receive score
somewhere 70 and 130
MILD INTELLECTUAL DISABILITY
- Considered educable, their intellectual level as adults
is comparable to those of average 8–11-year-old
children
- Adult with mild disability with mental age of (let say
10) may not in fact be comparable to average 10-year-
old in information-processing ability or speed. On the
other hand, he/she will normally have far more
experience in living, which would tend to raise the
measures intelligence scores
- Social adjustment of people with mild intellectual
disability often approximates that of adolescents,
although they tend to lack normal adolescents’
imagination, inventiveness, and judgement
- Require some measure of supervision because of
limited abilities to foresee consequences of their
actions
MODERATE INTELLECTUAL DISABILITY
- Moderate intellectual disability have IQ scores
ranging between 35-40 and 50-55, even in adulthood,
attain intellectual levels similar to average 4- to 7-year-
old children
- Some can taught to read and write a little and may
manage to achieve fair command of spoken language
- Rate of learning is slow, their level of
conceptualizing is extremely limited
- Usually appear clumsy and ungainly suffer from
bodily deformities and poor motor coordination
- Parental help and adequate opportunities for training,
most individuals with moderate intellectual disability
can achieve partial independence in daily self-care,
acceptable behavior, and economic sustenance in
family or sheltered environment
- Can master routine skills such as cooking or minor
janitorial work if provided specialized instruction
SEVERE INTELLECTUAL DISABILITY
- Have IQ scores ranging from 20-25 to 35-40
commonly suffer from impaired speech development,
sensory defects, and motor handicaps
- Develop limited levels of personal hygiene and self-
help skills, lessen their dependency but always
dependent on others for care
- Some extent from training and can perform simple
occupational tasks under supervision
PROFOUND INTELLECTUAL DISABILITY
- Have IQ scores below 20-25 and severely deficient in
adaptive behavior and unable to master any but
simplest tasks
- Useful speech if develops at all, is rudimentary
- Severe physical deformities, CNS pathology, and
retarded growth are typical; convulsive seizures,
mutism, deafness, and other physical anomalies are
also common
- Must remain in custodial care all their lives
- Tend to have poor health and low resistance to
disease and thus short life expectancy
- Severe and profound cases can usually be readily
diagnosed in infancy because of presence of obvious
physical malformations, grossly delayed development,
and other obvious symptoms of abnormality
CAUSAL FACTORS IN INTELLECTUAL
DISABILITY
- Some cases occur in association with known organic
brain pathology
GENETIC-CHROMOSAL FACTORS
- Play much clearer role in etiology of relatively
infrequent but more severe types of intellectual
disability such as Down Syndrome and heritable
condition known as fragile X
- Genetic aberrations are responsible for metabolic
alteration that adversely effect brain’s development
- Genetic defects leading to metabolic alteration may
also involve many other developmental anomalies
besides intellectual disability
- Intellectual disability associated with known genetic-
chromosomal defects tends to be moderate to severe
INFECTIONS AND TOXIC AGENTS
- Can result from wide range of conditions due to
infection, such as viral encephalitis or genital herpes
- If pregnant woman is infected with syphilis or HIV-1
or German measles, her child may suffer brain damage
as result
- Number of toxic agents such as carbon monoxide and
lead may cause brain damage during fetal development
or after birth
-if pregnant woman if take certain drugs, including
excess of alcohol may lead to congenital
malformations
TRAUMA (PHYSICAL INJURY)
- Physical injury at birth can result intellectual
disability
- Accidents that affect development can occur during
delivery and after birth
- Difficulties in labor due to malposition of fetus or
other complications may irreparably damage the
infants brain
HYPOXIA – Lack of sufficient oxygen to brain
stemming from delayed breathing or other causes is
another type of birth trauma that may damage brain
IONIZINF RADIATION
- Damaging effects of ionizing radiation on sex cells
and other bodily cells and tissues
- Radiation may act directly on fertilized ovum or
produce gene mutations in sex cells of either or both
parents
MALNUTRITION AND OTHER BIOLOCIAL
FACTORS
-Dietary deficiencies in protein and other essential
nutrients during early development of fetus could
irreversible physical and mental damage
- Association between maternal weight/nutrition and
cognitive functioning in their offspring, as well as
potential benefits of providing pregnant women with
nutritional supplements found no clear links between
maternal nutritional status and offspring cognitive
functioning
DOWN SYNDROME
- First described by Langdon Down in 1866, best
known of clinical conditions associated with moderate
and severe intellectual disability
- Creates irreversible limitations on intellectual
achievement, competence in managing life tasks, and
survivability
- Chromosomal abnormalities other than the trisomy of
chromosome 21 may occasionally be involved in
etiology of Down Syndrome
- Extra version of chromosome 21 is present in at least
94% of cases
TREATMENTS AND OUTCOMES
- Significant changes in adaptive capacity of children
with intellectual disability are possible through special
education and other rehabilitative measures
- One decision that the parents did was place the child
in an institution, most authorities agree that this should
be considered as last resort in light of the unfavorable
outcomes normally experienced – particularly in
regard to erosion of self-care skills
MAINSTREAMING – “Inclusion programming”
requires careful planning, high level of teacher skill,
and facilitative teacher attitudes
COMMUNICATION DISORDERS
- Deficits in language, speech, and communication
SPEECH
- Expressive production of sounds and includes
individual’s articulation, fluency, voice, and resonance
quality
LANGUAGE
- Forms, function, and use of conventional system of
symbols (spoken words, sign language, written words,
picture) in rule-governed manner for communication
COMMUNICATION
- Vernal or nonverbal behavior (intentional or
unintentional) has potential to influence the behavior,
ideas, or attitudes of another person
LANGUAGE DISORDER
DSM-5 TR (Diagnostic Criteria)
A. Persistent difficulties in acquisition and use of
language across modalities (spoken, written, sign
language, or another) due to deficits in comprehension
or production that include the following:
1. Reduced vocabulary (word knowledge and use)
2. Limited sentence structure (ability to put words and
word endings together to form sentences based on the
rules of grammar and morphology)
3. Impairments in discourse (ability to use vocabulary
and connect sentences to explain or describe topic of
events or have conversation)
B. Language abilities are substantially and quantifiably
below those expected for age, resulting in functional
limitations in effective communication, social
participation, academic achievement, or occupational
performance, individually or in any combination
C. Onset of symptoms is in the early developmental
period
D. The difficulties are not attributable to hearing or
other sensory impairment, motor dysfunction, or
another medical or neurological condition and are not
better explained by intellectual developmental disorder
(intellectual disability) or global developmental delay
DIAGNOSTIC FEATURES
- Language deficits are evident in spoken
communication, written communication, or sign
language
- Language learning and use is dependent on both
receptive and expressive skills
- Language disorder usually affects vocabulary and
grammar, and these effect then limit the capacity for
discourse
- Deficits in comprehension of language are frequently
underestimated, as children may be good at using
context to infer meaning
- Problems with remembering new words and
sentences are manifested by difficulties rehearsing
strings of verbal information, and difficulties
remembering novel sound sequences, skill that may be
important for learning new words
EXPRESSIVE ABILITY – Production of vocal,
gestural, or verbal signals
RECEPTIVE ABILITY – Process of receiving and
comprehending language messages
DEVELOPMENT AND COURSE
- Changes appear across the dimensions of language
(sounds, words, grammar, narratives/expository texts,
and conversational skills) in age-graded increments
and synchronies
- Language disorder emerges during early
developmental period
- Considerable variation in early vocabulary
acquisition and early word combinations
- Individual differences in early childhood are not, as
single indicators, highly predictive of later outcomes,
although late onset of language at age 24 months in
population based sample was the best predictor of
outcomes at age 7 years
- By age 4 years, individual differences in language
ability are more stable, with better measurement
accuracy, and are highly predictive of later outcomes
- Language disorder diagnosed in children age 4 years
and older is likely to be stable over time and typically
persists into adulthood
- Children with language disorders are at risk for peer
victimization
- For females with childhood language disorders, there
could be almost 3 times the risk
SPEECH SOUND DISORDER
DSM-5 TR (Diagnostic Criteria)
A. Persistent difficulty with speech sound production
that interferes with speech intelligibility or prevents
verbal communication of messages
B. The disturbances causes limitations in effective
communication that interfere with social participation,
academic achievement, or occupational performance,
individually or in any combination
C. Onset of symptoms is in early development period
D. Difficulties are not attributable to congenital or
acquired conditions, such as cerebral palsy, cleft
palate, deafness or hearing loss, traumatic brain injury,
or other medical or neurological conditions
DIAGNOSTIC FEATURES
- Speech sound production describes the clear
articulation of the phonemes (individual sound) that in
combination make up spoken words
- Requires both the phonological knowledge of speech
sounds and ability to coordinate the movements of the
articulators (jaw, tongue, and lips) with breathing and
vocalizing for speech
- Difficulties may experience difficulty with
phonological knowledge of speech sound or ability to
coordinate movements for speech in varying degrees
- Speech sound disorder is diagnosed when speech
sound production is not what would be expected based
on child’s age and developmental stage and when
deficits are not result of physical, structural, overall
speech should be intelligible
- Developing children at age 3 years, overall speech
should be intelligible, at age 2 years, only 50% may be
understandable
- Boys are more likely (range of 1.5 – 1.8 to 1.0) to
have speech sound disorder than girls
ASSOCIATED FEATURES
- Positive family history of speech or language
disorders is often present
- Childhood apraxia of speech and verbal dyspraxia
are used for speech production with motor components
DEVELOPMENT AND COURSE
- Articulation of speech sounds follows developmental
pattern
- Not unusual for typically developing children to use
developmental processes for shortening words and
syllables as they are learning to talk
- Children with speech sound disorder continue to use
immature phonological simplification processes past
the age when most children can produce words clearly
LISPING – (Misarticulation sibilants) particularly
common and may involve frontal or lateral patterns of
airstream direction
- May be associated with tongue-thrust swallowing
pattern
CHILDHOOD-ONSET FLUENCY DISORDER
(STUTTERING)
DSM-5 TR (Diagnostic Criteria)
A. Disturbances in the normal fluency and time
patterning of speech that inappropriately for the
individual’s age and language skills, persist over time,
and are characterized by frequent and marked
occurrences of one (or more) of the following:
1. Sound and syllable repetitions
2. Sound and prolongations of consonants as well as
vowels
3. Broken words (pauses within a word)
4. Audible or silent blocking (filled or unfilled pauses
in speech)
5. Circumlocutions (words substitutions to avoid
problematic words)
6. Words produced with excess of physical tension
7. Monosyllabic whole-word repetition (I-I-I-I see
him)
B. Disturbances causes anxiety about speaking or
limitation if effective communication, social
participation, or academic or occupational
performance, individually or any combination
C. Onset of symptoms is in early developmental period
(NOTE. Later-onset cases are diagnosed as adult-onset
fluency disorder)
D. Disturbances is not attributable to speech-motor or
sensory deficit, dysfluency associated with
neurological insult (stroke, tumor, trauma), or another
medical condition and is not better explained by
another mental disorder
DIAGNOSTIC FEATURES
- Essential feature of this is disturbance in the normal
fluency and time patterning of speech that is
inappropriate for individual’s age
- Characterized by frequent repetition or prolongations
of sounds or syllables and other types of speech
dysfluencies, including broken words, audible or silent
blocking, circumlocutions (word substitutions to avoid
problematic words), words produced with excess of
physical tension, and monosyllabic whole-word
repetitions
- Disturbance in fluency may interfere with academic
or occupational achievement and with social
communication
- Dysfluency is often absent during oral reading,
singing, or talking to inanimate objects or to pets
DEVELOPMENT AND COURSE
- Childhood-onset fluency disorder, or developmental
stuttering occurs by age of 6 for 80%-90% of affected
individuals, with age at onset ranging from 2-7 years
- Dysfluencies start gradually, with repetition of initial
consonants, first words of phrase, or long words
SOCIAL (PRAGMATIC) COMMUNICATION
DISORDER
DSM-5 TR (Diagnostic Criteria)
A. Persistent difficulties in social use of verbal and
nonverbal communication as manifested by all of the
following:
1. Deficits in using communication for social purposes,
such as greeting and sharing information, in manner
that is appropriate for the social context
2. Impairment of ability to change communication to
match context of needs of listener, such as speaking
differently in classroom than on playground, talking
differently to child than to an adult, and avoiding use
of overly formal language
3. Difficulties following rules for conversation and
storytelling, such as taking turns in conversation,
rephrasing when misunderstood, and knowing how to
use verbal and nonverbal signals to regulate interaction
4. Difficulties understanding what is not explicitly
stated (making inferences) and nonliteral or ambiguous
meanings of language (idioms, humor, metaphors,
multiple meanings that depend on context for
interpretation)
B. Deficits result in functional limitations in effective
communication, social participation, social
relationships, academic achievement, or occupational
performance, individually or in combination
C. Onset of the symptoms is in early developmental
period (but deficits may not become fully manifest
until social communication demands exceed limited
capacities)
D. Symptoms are not attributable to another medical or
neurological condition or to low abilities in domains of
word structure and grammar, and not better explained
by autism spectrum disorder, intellectual
developmental disorder, global developmental delay,
or another mental disorder
DIAGNOSTIC FEATURES
- Characterized by primary difficulty with pragmatic
(social use of language and communication)
- Deficits in understanding and following social rules
of both verbal and nonverbal communication in
naturalistic contexts, changing language according to
need of the listener or situation, and following rules for
conversation and storytelling
- Limitations in effective communication, social
participation, development of social relationships,
academic achievement, or occupational performance
ASSOCIATED FEATURES
- Associated features of social (pragmatic)
communication disorder is language impairment
- History of delay in reaching language milestones, and
historical, if not current, structural language problems
- Individuals with social communication deficits may
avoid social interaction
DEVELOPMENT AND COURSE
- Diagnosis of social (pragmatic) communication
disorder is rare among children younger than 4 years
- By age 4 or 5 years, most children should possess
adequate speech and language abilities to permit
identification of specific deficits in social
communication
- Midler forms of disorder may not become apparent
until early adolescence, when language and social
interactions become more complex
CHAPTER 13: SCHIZOPHRENIA AND OTHER
PSYCHOTIC DISORDERS
BENEDICT MOREL – Belgian psychiatrist describe
the case of 13-year-old boy, he used the term démence
précoce (mental deterioration at early age)
- Describe the condition and to distinguish it from the
dementing disorders associated with old age
EMIL KRAEPELIN (1856-1926) – Known for his
careful description of now regard as schizophrenia
- Used Latin version of Morel’s term (Dementia
Praecox) refer to group of conditions that all seemed to
feature mental deterioration beginning early in life
EUGEN BLEULER (1857-1939) – Swiss psychiatrist
gave the diagnostic term still use today
- In 1911, Bleuler used Schizophrenia (from Greek
roots of Schizo, meaning “to split or crack”, and Phren,
meaning “mind”)
- Characterized primarily by disorganization of thought
processes, lack of coherence between thought and
emotion, and inward orientation away “split off” from
reality
- Schizophrenia spectrum and other psychotic
disorders include Schizophrenia, other psychotic
disorder, and Schizotyplal (personality) disorder
- Disorder characterized by array of diverse symptoms,
including extreme oddities in perception, thinking,
action, sense of self, and manner of relating to others
PSYCHOSIS – Hallmark of schizophrenia is
significant loss of contact with reality
- Defined by abnormalities in one or more following 5
domains:
DELUSIONS
- Latin verb Ludere, which means “to play”
- Fixed beliefs that are not amendable to change in
light of conflicting evidence
- Delusions that express a loss of control over mind or
body are generally considered to be bizzare
- May include variety of themes:
PERSECUTORY DELUSIONS – Belief that one is
going to be harmed, harassed, and so forth by
individual, organization, or other group, most common
REFERENTIAL DELUSIONS – Belief that certain
gestures, comments, environmental cues, and so forth
are directed at oneself, also common
GRANDIOSE DELUSIONS – Individual believes that
he or she has exceptional abilities, wealth, or fame
EROTOMANIC DELUSIONS – When individual
believes falsely that another person is in love with him
or her
NIHILISTIC DELUSIONS – involve the conviction
that major catastrophe will occur
SOMATIC DELUSIONS – Preoccupations regarding
health and organ function
HALLUCINATIONS
- From Latin verb Hallucinere or Allucinere, meaning
to “wander in mind”or “idle talk”
- Perception-like experiences that occur without
external stimulus
- Vivid and clear, with full force and impact of normal
perceptions, and not voluntary control
- Auditory hallucination are the most common in
schizophrenia and related disorder
- Usually experienced as voices, whether familiar or
unfamiliar, perceived as distinct from individual’s own
thoughts
- Must occur in context of clear sensorium those occur
while falling asleep (hypnagogic) and waking up
(hypnopompic)
DISORGANIZED THINGKING (SPEECH)
- (Formal thought disorder) typically inferred from
individual’s speech
- May switch from one topic to another (derailment or
loose association)
- Speech may be severely disorganized that is nearly
incomprehensible and resembles receptive aphasia in
its linguistic disorganization (incoherence or “word
salad”)
- Less severe disorganized thinking or speech may
occur during the prodromal and residual periods of
schizophrenia
GROSSLY DISORGANIZED OR ABNORMAL
MOTOR BEHAVIOR (INCLUDINF CATATONIA)
- Manifest itself in variety of ways, ranging from
childlike “silliness” to unpredictable agitation
- Problem may not be noted in any form of goal-
oriented behavior, leading to difficulties in performing
activities of daily living
CATATONIC BEHAVIOR – Marked decrease in
reactivity to environment, ranges from resistance to
instructions (negativism); to maintaining rigid,
inappropriate or bizarre posture; to a complete lack of
verbal and motor responses (mutism and stupor)
- Other features are repeated stereotyped movement,
staring, grimacing, and the echoing speech
NEGATIVE SYMPTOMS
- Substantial portion of morbidity associated with
schizophrenia but less prominent in other psychotic
disorder
- 2 negative symptoms are prominent in schizophrenia:
diminished emotional expression and avolition
4 A’s
AVOLITION – Decrease in motivated self-initiated
purposeful in work or social activities
ALOGIA – Manifested by diminished speech output
ANHEDONIA – Decreased ability to experience
pleasure. Individuals with schizophrenia can still enjoy
pleasurable activity in the moment and recall it, but
show reduction in frequency of engaging in
pleasurable activity
ASOCIALITY/AFFECT – Apparent lack of interest in
social interaction and may associated with avolition,
but can also manifestation of limited opportunities for OTHER PSYCHOTIC DISORDERS
social interaction
SCHIZOAFFECTIVE DISORDER
PHASES
- Conceptually something of hybrid, in that used to
PRODROMAL – Start of symptoms describe people who have features of schizophrenia
ACTIVE – Full blast and severe mood disorder

RESIDUAL – Slowly/mild symptoms or reoccurring - Person not only has psychotic symptoms that meet
criteria for schizophrenia but also has marked changes
in mood for substantial amount of time
- Prognosis for patients diagnosed with schizoaffective
disorder is somewhere between those patients with
schizophrenia and patients with mood disorder
SCHIZOPHRENIFORM DISORDER
- Category reserved for schizophrenia-like psychoses
that last at least a month but do not last for at least 6
months and so do not warrant a diagnosis of
schizophrenia
- Possibility of early and lasting remission after first
psychotic breakdown, the prognosis for schizophrenia
disorder is better than that for established forms of
schizophrenia
DELUSIONAL DISORDER
- Hold beliefs that are considered false and absurd by
those around them
- People given the diagnoses of delusional disorder
may otherwise behave quite normally
- Behavior does not show gross disorganization and
performance deficiencies characteristics of
schizophrenia, and general behavioral deterioration is
rarely observed in disorder
EROTOMANIA – Theme of the delusion involves
great love for a person, usually of higher status
- Significant proportion of female stalkers are
diagnosed with erotomania
SPECIFY WHETHER:
EROTOMANIC TYPE – Another person is in love
with the individual
GRANDIOSE TYPE – Conviction of having some
great (but unrecognized) talent or insights or having
important discovery
JEALOUS TYPE – His or her spouse or lover is
unfaithful
PROSECUTORY TYPE – He or she is being
conspired against, cheated, or spied on, followed,
poisoned or drugged, maliciously maligned, harassed,
or obstructed in pursuit of long-term goals
SOMATIC TYPE – Involves bodily functions or
sensation
MIXED TYPE – Applies when no one delusional
theme predominates
UNSPECIFIED TYPE – Dominant delusional belief
cannot clearly determined or not described in specific
types
BRIEF PSYCHOTIC DISORDER
- Exactly what its name suggest
- Sudden onset of psychotic symptoms or disorganized
speech or catatonic behavior
- Often great emotional turmoil, episode usually lasts
only a matter of days (too short to warrant a diagnosis
of schizophreniform disorder)
- Person returns to his/her former level of functioning
and may never have another episode again
- Brief psychotic disorder is often triggered by stress
GENETIC AND BIOLOGICAL FACTORS
- The old dichotomy of nature of nature vs nurture is as
misleading as it is simplistic
- Complex interplay between genetic and
environmental factors is responsible
GENETIC FACTORS
- Schizophrenia type are “familial” and tend to “run in
families”
- Diagnosed group of people who provide the starting
point for inquiry (also called probands)
- There is strong association between the closeness of
the blood relationship and risk for developing the
disorder
- Prevalence of schizophrenia in the 1st degree relative
(parents, siblings, and offspring) of proband is about
10%
- 2nd degree relatives who share only 25% of their
genes with proband (half-siblings, aunt, uncle, nieces,
nephews, and grandchildren) the lifetime prevalence of
schizophrenia is closer to 3%
- The term familial and genetic are not synonymous
and disorder can run in family for nongenetic reason
TWIN STUDIES
- Shown a higher concordance for schizophrenia
among identical (monozygotic) twins than among
people related in any other way including fraternal
(dizygotic) twins
- Pairwise concordance rate is 28% in MZ and 6% in
DZ
- Reduction in shared genes from 100% to 50%
reduces risk of schizophrenia by nearly 80%
- Sharing 50% of one’s genes with co-twin with
schizophrenia is associated with lifetime risk for
schizophrenia of 6%
STRUCTURAL AND FUNCTIONAL BRAIN
ABNORMALITIES
- Abnormalities in the structure and function of brain
as well as neurotransmitter activity in people with
schizophrenia
NEUROCOGNITION
- Cognitive impairments is core feature of
schizophrenia
- People with schizophrenia perform much worse than
healthy controls on board range of neuropsychological
tests
- Almost all aspects of cognition (involving attention,
language, and memory) are impaired
- Cognitive impairments appear early
- Having lower IQ may itself be an independent risk
factor for developing schizophrenia at later point and
having higher IQ may be protective in some way
- Sharp decline in cognitive ability (and IQ) occurs
during the period of transition from the premorbid into
full-blown illness
SOCIAL COGNITION
- Concerned with how we recognize, think about, and
respond to social information including the emotions
and intentions of other
- People with schizophrenia show significant
impairments in social cognition
- Fail to spot the kinds of subtle (or not so subtle)
social hints that most of us can detect without
difficulty
- Difficulties recognizing emotion in faces and emotion
being conveyed in speech
LOSS OF BRAIN VOLUME
- Brain abnormalities associated with illness, both in
terms of brain structure and brain function
- Most-well replicated findings concerns the brain
ventricles
- Fluid-filled spaces that lie deep within the brain
- Patients with schizophrenia have enlarges brain
ventricles, with males possibly being more affected
than females
- Enlarged brain ventricles are not seen in all patients
and are not specific to schizophrenia
- Enlarged brain ventricles are important because they
are indicator of reduction in amount of brain tissues
-Imply that the brain areas that border the ventricles
have somehow shrunk or decreased in volume,
ventricular space becoming larger as result
- Patients with schizophrenia show about 3% reduction
in whole brain volume relative to that in control
- Decrease in brain volume is present very early in the
illness
- Adolescents who became psychotic showed steep
declines in the gray matter in prefrontal cortes
- Loss of gray matter (which is made up of nerve cells)
also seemed to be occurring exactly as psychosis was
developing
- Not due to any influences of medications
- If neurons cannot connect well with each other, many
problems are likely to result
WHITE MATTER PROBLEMS
- Also involved problems with white matter
- Nerve fibers are covered in myelin sheath (which
looks white in color in chemically preserved brain)
- Myelin acts as insulator and increases the speed and
efficiency of conduction between nerve cells
- White mater crucially important for the connectivity
of the brain
- If there are disruptions in the integrity of white
matter, there will be problems in how well the cells of
the nervous system can function
- Patients with schizophrenia show that they have
reductions in white matter volume as well as structural
abnormalities in white matter itself
- This could make internally generated speech (self-
talk) seem as if it’s being “heard”
- In people at high risk of developing schizophrenia,
white matter changes in temporal areas of the brain
also predict later social function
- Even though they are not psychotic themselves, have
reduction in volume of the corpus callosum – massive
tract of white matter fibers that connects the two
hemisphere of the brain
- Neuroimaging research showing just how disrupted
brain functioning is in patients with this disorder
- Hyperactivation in frontal brain areas is found,
suggesting that they are having to work harder to be
successful on task
- Frontal lobe dysfunction is believed to account for
some of negative symptoms of schizophrenia and
perhaps to be involves in some attention-cognitive
deficits

- Adolescents who showed the steepest declines in - Dysfunction of the temporal lobe is also found
brain gray matter (more cortical thinning) also had
highest levels of inflammatory markers in their blood
- Psychosis and cortical thinning go hand in hand
- Brain changes that occur during the transition to
psychosis
AFFECTED BRAIN AREAS
- There is loss of gray matter in the prefrontal cortex
- Any loss of gray matter will have consequences for
neural connectivity
NEUROCHEMISTRY
- Serious mental disorders are due to “chemical
imbalances” in brain is commonplace
DOPAMINE
- Most well-studies neurotransmitter implicated in
schizophrenia
- Dopamine hypothesis dates to 1960s and was derive
from 3 important observations
- First was pharmacological action of drug
Chlorpromazine (Thorazine), first used in treatment of
schizophrenia in 1952
- Rapidly became clear that this drug was helpful to
patients, was learned that therapeutic benefits of
chlorpromazine were linked to ability to block
dopamine receptors
- Second implicating dopamine in schizophrenia came
from entirely different direction
- Amphetamines are drugs that produce functional
excess of dopamine
- Drug that gave rise to functional excess of dopamine
also gave rise to psychotic state that looked a lot like
schizophrenia
- Third was from clinical studies that actually treated
patients by giving them drugs that increase the
availability of dopamine in the brain
- Activity in dopamine system may play role in
determining how much salience we give to internal and
external stimuli
- Dysregulated dopamine transmission may actually
make pay more attention to give more significance to
stimuli that are not relevant or important (this is called
“aberrant salience”)
- Might develop delusions or experience hallucinations
and why psychotic experiences might be shaped by
patient’s culture and history
GLUTAMATE
- Excitatory neurotransmitter that is widespread in
brain
- First, PCP (angel dust) is known to block glutamate
receptors
- PCP also induces symptoms (both negative and
positive) that are very similar to schizophrenia, when
they take PCP it exacerbates their symptoms
- Second physician had to stop ketamine which sis
anesthetic, because when it is given intravenously to
healthy volunteers it produces schizophrenia-like
positive and negative symptoms
- When given to patient whose schizophrenia is stable
and well controlled
- Ketamine exacerbates hallucinations, delusions, and
thought disorder
- One action of dopamine receptors is to modulate the
excitability of glutamate neurons and inhibit the
release of glutamate (pressing the brake pedal on
glutamate neurotransmission, as it were)
- Overactive dopaminergic system could result in
excessive suppression (too much heavy braking) of
NMDA receptors
PSYCHOSOCIAL AND CULTURAL FACTORS
- Schizophrenia was caused by destructive parental
interactions
- Disturbances and conflict in families that include an
individual with schizophrenia may well be caused by
having a person with psychosis in family
- Adverse family environments and communication
deviance probably have little pathological consequence
if child who is exposed has no genetic risk for
schizophrenia
TREATEMENTS AND OUTCOMES
- Before the 1950s treatment options were very
limited
- Agitated patients might be put in straitjackets or
treated with electroconvulsive “shock” therapy
- In 1950s when class of drugs known as
antipsychotics was introduce
- Pharmacotherapy (treatment by drugs) with these
medications rapidly transformed the environment of
mental hospitals by calming patients and virtually
eliminating their wild, dangerous, and out-of-control
behaviors
PHARMACOLOGICAL APPROACHES
FIRST-DEGREE ANTIPSYCHOTICS
- Like chlorpromazine (Thorazine) and haloperidol
(Haldol), were among the first generation to be used to
treat psychotic disorder
- Sometimes referred to neuroleptics (literally “seizing
the neurons”) these medications revolutionized the
treatment of schizophrenia
- They are called first generation antipsychotics (or
typical antipsychotics) to distinguish to second
generation (or atypical) antipsychotics
- Work best for the positive symptoms of schizophrenia
- Quieting the voices and diminishing delusional
beliefs, these medications provide patients with
significant clinical improvement
- Common side effects of these include drowsiness, dry
mouth, and weight gain
- Also experience what are known as extrapyramidal
side effects (EPS), these are involuntary movement
abnormalities (muscle spasms, rigidity, shaking) that
resemble Parkinson’s disease
- For long period may also develop tardive dyskinesia,
involves marked involuntary movements of lips and
tongue (sometimes the hands and neck)
- Very rare cases there is toxic reaction that is
neuroleptic malignant syndrome, characterized by high
fever and extreme muscle rigidity and left untreated it
can be fatal
SECOND-GENERATION ANTIPSYCHOTICS
- 1980s new class of antipsychotics medication began
to appear
- First to be used was clozapine (Clozaril), initially
reserved for use with treatment refractory patients
(those who were not helped by other medication,
clozapine is now used widely
- Other second-generation are risperidone (Risperdal),
olanzapine (Zyprexa), quetiapine (Seroquel), and
ziprasidone (Geodon)
- Recent additions include aripiprazole
(Abilify) and lurasidone (Latuda)
- They cause fewer extrapyramidal symptoms than the
earlier medications
- Drowsiness and considerable weight gain are very
common, Diabetes is also very serious concern
- In rare cases Clozapine also causes life-threatening
drop in white blood cells knows agranulocytosis
PSYCHOSOCIAL APPROACHES
Cases Management
Family Therapy
Psychoeducation
Social-Skills Training
Cognitive Remediation
Exercise
CHAPTER 7: MOOD DISORDER AND
DEPRESSION
DEPRESSION
- Can refer either to a mood or to clinical syndrome,
combination of emotional, cognitive, and behavioral
symptoms
MANIA
- Flip side of depression, involves a disturbance in
mood accompanied by additional symptoms
- Distinct period of abnormally and persistently
elevated, expansive, irritable mood and persistently
energy for activities
- Exaggerated elation, joy, euphoria
TYPES OF MOOD DISORDERS
UNIPOLAR DEPRESSIVE DISORDERS
- Those in which the person experiences only episodes
of depression
- Depression or mania alone
- Typically depression alone
BIPOLAR DISORDER
- Person experiences episodes of mania as well as
depression
- Mixed manic episode
- Also known as Manic Depressive Disorder
DEPRESSIVE EPISODE – Markedly depressed or
lose interest in formerly pleasurable activities (or both)
for at least 2 weeks
- Other symptoms such as changes in sleep or appetite,
or feelings of worthlessness
MANIC EPISODE – Markedly elevated, euphoric, or
expansive mood, often interrupted by occasional
outbursts of intense irritability or even violence –
particularly when others refuse to go along with manic
person’s wishes and schemes
- Extreme moods must persist for at least a week for
these diagnoses to be made
HYPOMANIC EPISODES – Experiences abnormal
elevated, expansive, or irritable mood for at least 4
days
- Person must have at least 3 symptoms similar to - Return of symptoms is one of two types:
those involves in mania but to lesser degree (inflated
RELAPSE – Return of symptoms within fairly short
self-esteem, decreased need for sleep, flights of ideas,
period of time, situation that probably reflects the fact
pressured speech, etc.)
that the underlying episode of depression has not yet
run its course
RECURRENCE – Onset of new episode of depression,
occurs in approximately 40-50% of people who
experience depressive episodes
- Single episode – No mania – Rare
- Recurrent – 4-7 episodes – 4-5 months

PREVALENCE OF MOOD DISORDERS

- Major mood disorders occur with alarming frequency
– at least 15 to 20 times more frequently than
schizophrenia
UNIPOLAR DEPRESSIVE DISORDERS
- Sadness, discouragement, pessimism, and
hopelessness about matters improving are familiar
feelings to most people
- Feelings of depression are unpleasant when we are
experiencing them , but usually do not last long,
dissipating on own after a period of days or weeks or
after reached certain intensity level
- By slowing us down, mild depression sometimes
saves from wasting a lot of energy in futile pursuit PERSISTENT DEPRESSIVE DISORDER
unobtainable goals (DYSTHYMIA)

- Normal depression would be expected to occur in
people undergoing painful but common life events
such as significant personal, interpersonal, or
economic losses
MAJOR DEPRESSIVE DISORDER
- Must be in major depressive episode and never had
manic, hypomanic, or mixed episodes
- Differs from major depression in terms of both
severity and duration
- Dysthymia represents chronic mild depressive
condition that has been present for many years
- Distinction between Major Depressive Disorder and
Dysthymia is somewhat artificial as it can have same
frequent symptoms that could seen in same person

- When diagnosis of MDD is made, usually also
specified whether this is first , and therefore single
(initial), episode or recurrent episode (preceded by one
or more previous episodes)
- Depressive episodes typically last about 6-9 months
if untreated
- Periods of normal mood may occur briefly, but
usually last for only a few weeks (maximum of 2
months)
- Persistently depressed mood most of the day, for
more days than not, for at least 2 years (1 year for
children and adolescents)

- Approximately 10-20% of people with MDD, the

symptoms do not remit for over 2 years, in which
case persistent depressive disorders is diagnosed

DOUBLE DEPRESSION
- Someone with persistent depressive disorder
develops major depression
- Major Depressive Episodes and Dysthymic Disorder
- Dysthymia first
- Severe Psychopathology
ADDITIONAL DEFINING CRITERIA FOR
DEPRESSIVE DISORDERS
SYMPTOMS SPECIFIERS:
PSYCHOTIC FEATURES – Hallucinations or
delusions – during the most recent episode of
depression or mania
- Psychotic features can be either consistent with the
patient’s mood
ANXIOUS DISTRESS – Presence of typical
symptoms of anxiety, such as feeling tense or worried,
difficulty concentrating, or sense of loss of control
- Comorbid Disorders or Anxiety symptoms
MELANCHOLIC – Term used to describe particularly
severe type of depression
- Presence of melancholic feature may also indicate
that the persons is likely to have good response to
biological forms of treatment, such as antidepressant
medications and electroconvulsive therapy
OTHER FORMS OF DEPRESSION
- Depression is always precipitated by stressful life
events
- Most stressful events possible are those involving the
loss of life, as well as the creation of new life
LOSS AND THE GRIEVING PROCESS
- Grief has certain characteristics that there are usually
4 phases of normal response to loss of spouse or close
family members:
1. Numbing and disbelief
2. Yearning and searching for the dead person
3. Disorganization and despair that sets in when the
person accepts the loss as permanent
4. Some reorganization as the person gradually begins
to rebuild his or her life
POSTPARTUM “BLUES”
- Sometimes occurs in new mothers (and occasionally
fathers) and it known to have adverse effects on child
outcomes
- Typically include changeable mood, crying easily,
sadness, and irritability, often liberally intermixed with
happy feeling
- Occur in as many as 50-70% of women within 10
days of the birth of their child
- May likely to occur if the new mother has lack of
social support or has difficulty, or if the woman has
personal or family history of depression that leads to
heightened sensitivity to stress of childbirth
PREMENSTRUAL DYSPHORIC DISORDER
- PMDD condition similar to PMS that also happens in
the week or two before your period starts as hormone
levels begin to fall after ovulation
- PMDD causes more severe symptoms than PMS,
including severe depression, irritability, and tension
- PMDD affects up to 5% of women of childbearing
age, many women with PMDD may also have anxiety
or depression
DSM-5 TR (Diagnostic Criteria)
A. In majority of menstrual cycles, at least 5 symptoms
must be present in final week before the onset of
menses, start to improve within a few days after the
onset of menses, and becoming minimal or absent in
the week post menses
B. One (or more) of the following symptoms must be
present
1. Marked affective lability (mood swings, feeling
suddenly sad or tearful, or increased sensitivity to
rejection)
2. Marked irritability or anger or increased
interpersonal conflicts
3. Marked anxiety, tension, and/pr feelings of being
keyed up or on edge
C. One (or more) of the following symptoms must
additionally to be present, to reach a total five
symptoms when combined with symptoms from
Criterion B above
1. Decreased interest in usual activities (work, school,
friends, hobbies)
2. Subjective difficulty in concentration
3. Lethargy, easy fatigability, or marked lack of energy
4. Marked change in appetite; overeating; or specific
food cravings
5. Hypersomnia or insomnia
6. Sense of being overwhelmed or out of control
7. Physical symptoms such as breast tenderness or
swelling, joint or muscle pain, sensation of “bloating”
or weight gain
NOTE. Symptoms in Criteria A-C must have been met
for most menstrual cycles that occurred in preceding
year
D. Symptoms cause clinically significant distress or
interfere with work, school, usual social activities, or
relationships with other
E. Disturbance is not merely an exacerbation of the
symptoms of another disorder, such as major
depressive disorder, panic disorder, persistent
depressive disorder, or personality disorder
F. Criterion A should be confirmed by prospective
daily ratings during at least two symptomatic cycles
G. Symptoms are not attributable to physiological
effects of substance or another medical condition
BIPOLAR DISORDER
BIPOLAR I
- Modern understanding of the classic manic-
depressive disorder or affective psychosis describe in
nineteenth century
- Mixed episode is characterized by symptoms of both
full-blown manic and major depressive episodes for at
least 1 week, either intermixed or alternating rapidly
every few days
BIPOLAR II
- Requiring the lifetime experience of at least one
major depressive episode at least one hypomanic
episode (but no history of mania), no longer thought to
be less severe condition than bipolar I disorder
- Bipolar II disorder is equally or somewhat more
common than bipolar I
- Subthreshold form of bipolar II disorder also have
been recognized as many as 40% of individuals
diagnosed with MDD have similar number of
hypomanic symptoms
CYCLOTHYMIC DISORDER
- Experience cyclical mood changes that are more
severe than normal, but less severe that the mood
swings seen in bipolar disorder
- Adults who experience at least 2 years (for children,
full year) of both hypomanic and depressive periods
without ever fulfilling the criteria for an episode of
mania, hypomania, or major depression
- In this phase of the disorder, the person may become
especially creative and productive because of increased
physical and mental energy
- The person may show other symptoms such as low
energy, feelings of inadequacy, social withdrawal, and
pessimistic, brooding attitude
CAUSES OF MOOD DISORDER
NEUROTRANSMITTER SYSTEMS
- Neurotransmitter is chemical messenger of body
- Each neurotransmitter works in broad set of pathways
connecting fairly specific brain locations
- Current thinking is that the balance of the various
neurotransmitters and their interaction with systems of
self-regulation are more important than the absolute
level of any one neurotransmitters
THE ENDOCRINE SYSTEM
- Endocrine system plays an important role in in
regulating person’s response to stress
- Hypothalamic-Pituitary-Adrenal (HPA) axis is one of
the important pathway in endocrine system
- Also activated in response to stress
- Hypothalamus > Pituitary Gland > - Women tend to ruminate more than men about their
Adrenocorticotrophic hormone > Adrenal glands > situation and blame themselves for being depressed
Cortisol
- Response style predicted the later development of
- Association between HPA axis and depression is depression when under stress
indicated by evidence regarding dexamethasone
- Men tend to ignore their feelings, perhaps engaging
suppression test (DST), which has been used
in activity to take their minds off them
extensively to study endocrine dysfunction in patients
with mood disorders SOCIAL SUPPORT
SLEEP AND CIRCADIAN RHYTHMS - Early landmark study, first suggested the important
role of social support in the onset of depression
- Sleep disturbances are even more severe among
depressed older adults - Large number of women who had experience serious
life stress, they discovered that only 10% of women
- Insomnia, frequently experienced by older adults, is
who had friend in whom they could confide became
risk factor for both the onset and persistence of
depressed
depression
- Compared with 37% of women who did not have
- Also occur in bipolar patients, where they are
close supportive relationship. Later prospective studies
particularly severe and characterized not only by
have also confirmed the importance of social support
decrease REM latency but also by severe insomnia and
(or lack of it) in predicting the onset of depressive
hypersomnia (excessive sleep)
symptoms at later time
LEARNED HELPLESSNESS
TREATMENT AND MEDICATIONS
- People become anxious and depressed when they
TREATMENT OF MOOD DISORDERS
decide that they have no control over the stress in their
lives - Changing of the chemistry of the brain
- Depressive Attributional Style: - Medications
1. INTERNAL – Individual attributes negative events - ECT
to personal failings “it is all my fault”
- Psychological Treatment
2. STABLE – Even after particular negative event
passes, the attribution that “additional bad things will ANTIDEPRESSANT MEDICATIONS
always be my fault” remains - Selective Serotonin Reuptake Inhibitors (SSRI’s)
3. GLOBAL – Attributions extend across variety of - Fluoxetine (Prozac)
issues
- First treatment choice
MARITAL RELATIONS
- Block Presynaptic Reuptake
- Depression and bipolar are strongly influenced by
interpersonal stress and especially marital - Many side effects
dissatisfaction, as suggested earlier when it was noted
- Mixed Reuptake Inhibitor
that disruptions in relationships often lead to
depression - Blocking reuptake of norepinephrine as well as
serotonin
MOOD DISORDERS IN WOMEN
- Other medications
- Data on prevalence of mood disorders indicated
dramatic gender imbalances - Venlafaxine
- Although bipolar disorder is evenly divided between - Similar to tricyclics
men and women, almost 70% of the individuals with
major depressive disorder and dysthymia are women - St. John’s Wort

- Suggest that if the disruption in marital relationship - Questionable efficacy

reaches the stage of divorce, men who had previously
been functioning well are at greater risk for depression
 BEHAVIORAL THERAPY
- Increased positive events
- Exercise
INTERPERSONAL PSYCHOTHERAPY (IPT)
- Address interpersonal issues in relationships
- Roled disputes
- New relationships

LITHIUM - Social skills deficits

- Mood-stabilizing drug STAGE OF DISPUTE

- Common salt - Negotiation stage

- Primary treatment for bipolar disorders - Impasse stage

- Unsure of mechanism of action - Resolution stage

- Narrow therapeutic window COMBINED TREATMENTS FOR DEPRESSION

- Too little – ineffective - Possible benefits above individual treatment

- Too much – toxic, lethal - 48% benefits from meds or CBT

ELECTROCONVULSIVE THERAPY AND - 73% benefit from combined

TRANSCRANIAL MAGNETIC STIMULATION SUICIDE
ELECTROCONVULSIVE THERAPY (ECT) INDICES
- Temporary seizures - Attempts
- 6-10 treatments - Ideations
- Severe depression RISK FACTORS
- Few side effects - Family history
- Relapse is common - Neurobiology
TRANCRANIAL MAGNETIC STIMULATION - Stressful life event
(TMS)
- Shameful/humiliating stressor
- Localized electromagnetic pulse
TREATMENT
- Fewer side effects
- Importance of assessment
- Efficacy is likely good
- More studies needed
PSYCHOLOGICAL TREATMENT FOR
DEPRESSION
COGNITIVE THERAPY
- Identify errors in thinking
- Correct cognitive errors
- Substitute more adaptive thoughts
- Correct negative cognitive schemas
ANXIETY, OBSESSIONS, TRAUMA, SOMATIC,
AND THEIR DISORDERS
FEAR AND ANXIETY RESPONSE PATTERS
ANXIETY DISORDERS
SEPARATION ANXIETY DISORDER
- Developmentally inappropriate and excessive fear of
anxiety concerning separation from those to whom the
individual is attached
- Fear, anxiety, or avoidance is persistent, lasing at
least 4 weeks in children and adolescents and typically
6 months or more in adults
- Disturbance causes clinically significant distress or
impairment in social, academic, occupational, or other
important areas of functioning
- Disturbance is not better explained by another mental
disorder
SELECTIVE MUTISM
- Consistent failure to speak in social situation in
which there is expectation to speak even though the
individual speaks in other situations
- Interfere with normal social communication
- Failure to speak is not attributable to lack of
knowledge of, or comfort with, the spoken language
required in the social situation
- Disturbances is not better explained by
communication disorder (childhood onset fluency
disorder) and does not occur exclusively during the
course of autism spectrum disorder, schizophrenia, or
another psychotic disorder
SPECIFIC PHOBIA
- Marked and disproportionate fear consistently
triggered by specific objects or situations
- Object or situation is avoided or else endured with
intense anxiety
- Symptoms persists for at least 6 months
- Fear, anxiety, or avoidance causes clinically
significant distress or impairment in social,
occupational, or other important areas of functioning
- Not better explained by the symptoms of another
mental disorder
SUBTYPES IDENTIFIED IN DSM-5
- Animal
- Natural environment
- Blood-injection-injury
- Situational (airplanes, elevators, enclosed places)
- Other (situations that may lead to choking or
vomiting; in children, loud sound or costumed
characters)
SOCIAL ANXIETY DISORDER
- Marked and disproportionate fear consistently
triggered by exposure to potential social scrutiny
- Exposure to trigger leads to intense anxiety about
being evaluated negatively
- Trigger situations are avoided or else endured with
intense anxiety
- Symptoms persist for at least 6 months
- Fear, anxiety, or avoidance causes clinically
significant distress or impairment in social,
occupational, or other important areas of functioning
- Not better explained by the symptoms of another
mental disorder
- If another medical condition is present, the fear,
anxiety, or avoidance is clearly unrelated or is
excessive
PANIC DISORDER
- Recurrent unexpected panic attacks
- At least 1 month of concern about the possibility of
more attacks, worry about the consequences of an
attack, or maladaptive behavioral changes because of
attacks
AGORAPHOBIA
- Disproportionate and marked fear or anxiety about at
least 2 situations where it would be difficult to escape
or receive help in the event of incapacitation,
embarrassing symptoms, or panic-like symptoms
- Such as being outside of the home alone; traveling on
public transportation; being in open spaces such as
parking lots and marketplaces; being in enclosed
spaced such as, theaters, or cinemas; or standing in line CAUSAL FACTORS
or being in a crowd
- Situations consistently provoke fear or anxiety
- Situations are avoided, require the presence of
companion, or endured with intense fear or anxiety
- Symptoms last at least 6 months
GENERALIZED ANXIETY DISORDER (GAD)
- Excessive anxiety and worry at least 50% of days
about number of events or activities
- Person finds it hard to control the worry
- Worry sustained for at least 6 months TREATMENTS

- Anxiety and worry associated with at least 3 (or one - Exposure therapy
in children) of the following: restlessness or feeling
- Participant modeling
keyed up on edge; easily fatigued; difficulty
concentrating or mind going blank; irritability; muscle - Virtual reality components
tension; sleep disturbance
- Cognitive techniques combination
SUBSTANCE/MEDICATION-INDUCED ANXIETY
- Medications
DISORDER
TRAUMA AND STRESSOR RELATED DISORDER
- Symptoms precede the onset of substance/medication
use; symptoms persist for substantial period of time TRAUMA
(e.g., about 1 month) after the cessation of acute
withdrawal or severe intoxication - Event that involves actual or threatened death or
serious injury or sexual violation in which the
- There is other evidence suggesting the existence of individual:
independent non-substance/medication-induced
anxiety disorder (history of recurrent - Directly experiences the event
nonsubstance/medication-related episodes) - Witnesses the event in person
- Disturbances does not occur exclusively during the - Learns that the event occurred to close friend or
course of delirium relative
- Disturbances causes clinically significant distress or - Experiences first-hand repeated or extreme exposure
impairment in social, occupational, or other important to aversive details of traumatic event
areas of functioning
BRUCE PERRY’S NEUROSEQUENTIAL MODEL
WITH ONSET DURING INTOXICATION – Criteria
are met for intoxication with the substance and the
symptoms develop during intoxication
WITH ONSET DURING INTOXICATION – Criteria
are met for withdrawal from the substance and
symptoms develop during or shortly after withdrawal
WITH ONSET AFTER MEDICATION USE –
Symptoms developed at initiation of medication, with
a change in use of medication, or during withdrawal of
medication
POSTTRAUMATIC STRESS DISORDER (PTSD) - Child has experienced patter of extremes of
insufficient care
- Exposure to actual or threatened death, serious injury,
or sexual violence - Disturbance is evident before age 5 years
- Presence of intrusion symptoms - Child has developmental age of at least 9 months
- Persistent avoidance of stimuli associated with
traumatic event
- Negative alteration in cognitions and mood
associated with the traumatic events
DISINHIBITED SOCIAL ENGAGEMENT
- Marked alterations arousal and reactivity associated
DISORDER
with traumatic event
- Pattern of behavior in which child actively
- Duration is more than 1 month
approaches and interacts with unfamiliar adults
- Functional impairment
- Behaviors are not limited to impulsivity
- Not attributable to physiological effects of substance
- Child has experienced a pattern of extremes of
or any medical condition
insufficient care
ACUTE STRESS DISORDER
CAUSAL FACTORS IN PTSD
- Fairly similar to those of PTSD, but the duration is
shorter
- Symptoms occur between 3 days and 1 month a
trauma
ADJUSTMENT DISORDER
- Development of emotional or behavioral symptoms
in response to identifiable stressor occurring within 3
months of the onset of stressor
- These symptoms or behavior are clinically
significant, as evidenced by one or both of the
following
MARKED DISTRESS – Out of proportion to severity
or intensity of stressor PREVENTION AND TREATMENT OF STRESS
SIGNIFICANT IMPAIRMENT – Social, occupational, DISORDERS
or other important areas of functioning
- The stress-related disturbance does not meet the
criteria for another mental disorder and is not merely
exacerbation of preexisting mental disorder
- Symptoms do not represent normal bereavement
- Once the stressor or consequences have terminated,
symptoms do not persist for more than additional 6
months
REACTIVE ATTACHMENT DISORDER
- Absence or grossly underdeveloped attachment
between the child and putative caregiving adults
- Persistent social and emotional disturbance
characterized
PERRY’S 3 RS
REGULATE
- Brainstem and midbrain – the sensory motor brain
- Help the child to regulate and calm their stress
responses – fight, flight, freeze. Offer soothing comfort
and reassurance
RELATE
- Limbic brain – the emotional relational brain
- Connect with child through attuned, sensitive
relationship
- Empathized and validate the child’s feelings so that
they feel seen, heard and understood
REASON
- Cortical brain – the great human thinking brain
- Now that the child is calm and connected they are
able to fully engage in learning
- Heading straight for reasoning part of the brain
cannot work if the child is dysregulated and
disconnected from others
OBSESSIVE-COMPULSIVE DISORDER AND
RELATED DISORDER
OCD
- Characterized by obsessions or compulsions
OBSESSION – Intrusive and recurring thoughts,
images, or impulses that are persistent and
uncontrollable
COMPULSION – Repetitive, clearly excessive
behaviors or mental acts that the person feels driven to
perform to reduce the anxiety caused by obsessive
thoughts or prevent some calamity from occurring
- Pursuing cleanliness and orderliness, sometimes
through elaborate rituals
- Performing repetitive, magically protective acts, such
as counting or touching body part
- Repetitive checking to ensure that certain acts are
carried out
- The obsession and compulsions are time consuming
and cause significant distress and impairment
- Not attributable to direct physiological effects of
substances or any medical condition
- Not better explained by other mental disorders
OBSESSIONS
- Contamination fears
- Fears of harming oneself or others
- Lack of symmetry
- Pathological doubt
COMPULSION
- Cleaning
- Checking
- Repeating
- Ordering/Arranging
- Counting
BODY DYSMORPHIC DISORDER
- Preoccupation with one or more perceived defects in
appearance
- Person gas performed repetitive behaviors or mental
acts (mirror checking, seeking reassurance, or
excessive grooming) in response
- Preoccupation is not restricted to concerns about
weight or body fat
HOARDING DISORDER
- Persistent difficulty discarding or parting with
possessions, regardless of actual value
- Perceived need to save items and Distress associated
with discarding
- Symptoms result in accumulation of large number of
possessions that clutter active living spaces to the
extent that their intended use is compromised unless
others intervene
- Not attributable to any medical condition
- Not better explained by another mental disorder
TRICHOTILLOMANIA (HAIR-PULLING
DISORDER)
- Recurrent pulling out of one’s hair, resulting in hair
loss
- Repeated attempts to decrease or stop hair pulling
- Functional impairment and significant distress
- Not attributable to any medical condition
- Not better explained by symptoms of another mental
disorder
EXCORIATION (SKIN-PICKING) DISORDER
- Recurrent skin picking resulting in skin lesions
- Repeated attempts to decrease or stop skin picking
- Functional impairment and significant distress
- The symptoms are incompatible with recognized
medical disorder
- When patients reports neurological symptom, it is
important to assess whether that symptoms has true
neurological basis

- Not attributable to any medical condition - No better explained by another medical condition

- Not better explained by the symptoms of another - Functional impairment and significant distress
mental disorder
TREATMENTS
- Antidepressants/Medication
- Cognitive-behavioral therapy
- Exposure and response prevention
SOMATIC SYMPTOM AND RELATED DISORDER
SOMATIC SYMPTOM DISORDER
- One or more somatic symptoms that distressing or
result in significant disruption in daily life
- Excessive thoughts, feelings, or behaviors related to
seriousness of somatic symptoms as manifested in at
least 1 of the following:
- Persistent thoughts about the seriousness of one’s
symptoms
- Persistently high level of anxiety about health or
symptoms
- Excessive time or energy devoted to these symptoms
- Duration of at least 6 months
ILLNESS ANXIETY DISORDER
- Preoccupation with fears of having serious disease
FACTITIOUS DISORDER
- No significant somatic symptoms present
- People with this disorder fake or manufacture
- High level of anxiety about health physical or physiological symptoms, but without any
apparent motive
- These fears must lead to excessive care seeking or
maladaptive avoidance behaviors - Person presents himself to others as ill or injured

- Duration of at least 6 months - Deceptive behavior is evident

- Not better explained by another mental disorder - Not better explained by another mental disorder

CONVERSION DISORDER FACTITIOUS DISORDER SUBTYPES

- One or more symptoms affecting voluntary motor or
sensory function
- People may experience partial or complete paralysis
of arms or legs; seizures and coordination
disturbances; sensation of prickling, tingling, or
creeping on skin; insensitivity to pain; or anesthesia
- Factitious disorder on self (Münchausen Syndrome)
the person presents himself or herself to others as ill,
impaired, or injured
- Factitious disorder imposed on another person
fabricates symptoms in another person and then
presents that person to others as ill, impaired, or
injured
NOTE. Factitious disorder is not the same as - Not better explained by another dissociative disorder,
malingering. Because malingering is motivated by another psychological disorder, or by medical
external rewards or incentives. It is not considered condition
mental disorder within the DSM framework
DISSOCIATIVE IDENTITY DISORDER
TREATMENTS
- Disruption of identity characterized by two or more
- Behavioral therapy distinct personality states (alters) or experience of
possession
- Cognitive-behavioral therapy
- Disruption may be observed by others reported by the
- Hypnosis
patient
DISSOCIATIVE DISORDERS
- Recurrent gaps in recalling events or important
- Conditions involving disruptions in normally personal information that are beyond ordinary
integrated functions forgetting

- Consciousness - Functional impairment

- Memory - Symptoms are not part of broadly accepted cultural

or religious practice, and are not due to drugs or
- Identity medical condition (children, symptoms are not better
- Perception explained by imaginary playmate or by fantasy play)

DISSOCIATIVE AMNESIA - Not attributable to physiological effects of substance

or another medical condition
- Inability to remember important information, usually
of traumatic or stressful nature, that is too extensive to
be ordinary forgetfulness
- Functional impairment and significant distress
- Amnesia is not explained by substances or medical
condition
- Not better explained another psychological
conditions
Specify dissociative figure subtype if:
- Amnesia is associated with bewildered or apparently
purposeful wandering
DEPERSONALIZATION/DEREALIZATION
DISORDER
- Presence or persistent and recurrent experiences of
depersonalization and derealization
DEPERSONALIZATION – Experience of detachment
from one’s mental processes or body, as though one is
in a dream
DEREALIZATION – Experiences of unreality of
surroundings
- Reality testing remains intact
- Significant distress and functional impairment
- Symptoms are not explained by substances, or by
medical condition
TREATMENT AND OUTCOMES IN
DISSOCIATIVE DISORDERS
- Hypnosis
- Integration of separate alters
- Medications