Diagnosis treatment of dysfunctional behavior

 Serotonin Implicated with depression, anxiety, sleep problems, weight loss, pain modulation, OCD, PTSD, GAD, social phobia, attachment disorders, eating disorders, and aggression  R

Diagnosis & Treatment of dysfunctional Behavior

 Introductions

 Review of Syllabus, Assignments, & Course Outline

 Brief Review of Historical Influences of DSM-5

 Brain Neuroanatomy: Cognitive, Behavioral, & Emotional Functioning

 Neuropsychopharmacology: Review of Major Neurotransmitters

 Introduction to DSM-5

Overview of Today’s Class

Class #1

 How to Contact Me:

 EMAIL is preferred

 Do not use your personal email

 972-279-6511 ext 149

 Office Hours by Request (office G)

 Private Practice Phone:

 719-433-4388

 PLEASE DO NOT TEXT ME

 USE THIS FOR EMERGENCY’S ONLY

Review of Syllabus, Assignments, Course Outline

 Textbook for the Class:

 DSM-5 (yes you need this)

 Recommended Supplemental Texts:

 DSM-5 Made Easy

 DSM-5 Essentials

 Final-Exam (11/19/2014)

 50% of Final Grade

 100 multiple choice questions

 Will be composed of 50 questions from mid-term and 50 new questions

 Will be given 50 new MC Q’s: 2 weeks in advance

 Psychological Theories

 Freud, Adler, Jung, Skinner, Beck, Maslow, Yalom Etc.

 Four Major Schools of Thought:

 Psychoanalytic, cognitivist, behaviorist, humanistic-existential

 Many “sub”-movements are derivatives

 Explain the “mind” portion of why abnormal behavior exists

 Medical model of abnormal behavior

 Disruption in physical body/brain causes aberrant cognition, emotions,

or behavior

 American Psychiatric Association

 Behavioral Neurology

 Normal vs Abnormal Behavior

 Culturally Defined & Dynamic

 Philosophical, Theological, Scientific, and

 Ancient Greece – soul or “psyche”

 Brain was a radiator to cool blood

Historical Conceptions of Abnormal Behavior

 Four Lobes of the Brain

 Cortex = outside of brain/gray matter

 Sub-Cortex = inside of brain/white matter

 Neo-Cortex = prefrontal area

 Limbic Region or “lobe”

 Inside the brain

 Bottom-Up Processing

 Basic Life Support = Brain Stem

 Primitive Drives = Mid-Brain

 Emotions = Limbic Region

 Reasoning/Thinking = Cortex

 Top-Down Processing

 Cortex & Neocortex can inhibit / control primitive behaviors and

reactions

 Brain Stem + Frontal

 Attention/Alertness/Arousal

 Motor Cortex

 Controls Complex Motor Movements

 Prefrontal Area

 Judgment, Abstract Reasoning, Planning, Initiation, Self-Monitoring,

Social Judgment, Emotional Regulation, Impulse Control, “Outside

the box” thinking

 Orbito-Prefrontal Area

 Connects with amygdala and regulates fight or flight response

 Also implicated with reward/punishment response

 Temporal Lobe

 Auditory Processing of Sounds

 Left = Verbal Memory

 Right = Visual Memory

 Memory for Faces, Words, Language

 Left Temporal-Parietal Junction

 Limbic system is considered the “primitive” area of the brain dealing with

emotional drives, social attachment, and learned emotional responses to

triggers

 Develops early as an infant but neocortex develops later (i.e., the

regulation of emotions come later)

The Central Nervous System: Brain Anatomy & Psych Functions

 Temporal Lobes (especially left)

 Left Hemisphere damage = depression

 Right Hemisphere damage = mania

 Thalamus, Corpus Callosum

 Neurotransmitters

 Chemical messengers of neurons

 Can be excitatory, inhibitory, or modulatory

 In other words, neurotransmitters can progress a message,

stop a message, or modify a message

Neuropsychopharmacology: The Basics

 Serotonin

 Implicated with depression, anxiety, sleep problems, weight loss,

pain modulation, OCD, PTSD, GAD, social phobia, attachment disorders, eating disorders, and aggression

 Raphe nuclei

 projects to limbic regions, basal ganglia, prefrontal, hypothalamus, brain stem

 Agonist

 SSRIs (e.g., Prozac, Effexor, Celexa,)

 Tricyclics (e.g., amitriptyline)

 Implicated with schizophrenia (too much dopamine), ADHD (too

little), depression (too little), and Parkinson’s (too little)

 Substantia Nigra & Ventral Tegmental

 Basal ganglia projects to frontal/pre-frontal

 Dopamine Antagonist = Antipsychotic medication

 Risperdal, Geodon, Clozaril, Seroquel

 Agonist = ADHD, depression meds

 Adderall, Vyvanse, Wellbutrin, MAOI Inhibitors, Ritalin

 Norepinephrine

 Implicated with attention disorders, pain modulation, bipolar disorder, anxiety, OCD, and depression

 Locus coeruleus

 Projects to entire cerebral cortex

 Agonists = methylphenidate, Concerta, Strattera, Provigil

 Antagonists = cholinergic and serotonergic agonists

 Acetylcholine

 Implicated with memory, attention, and cognitive disorders

 Basal Forebrain

 Projects to thalamus, cortex, hippocampus

 Antagonists = antihistamines, first generation antipsychotics,

tricyclic antidepressants

 Agonists = acetylcholinesterase inhibitor (e.g., Aricept)

 Supposedly improves memory/cognition in dementia and TBI

 Not to be confused with ACE-Inhibitors

Neuropsychopharmacology: The Basics

 Glutamate

 Implicated with neurodegenerative diseases such as Alzheimer’s

 Widely distributed throughout brain

 Agonists = NMDA receptor antagonists such as Namenda

 Implicated with learning, memory, and neurogenesis/synaptic

plasticity

 Gamma-aminobutryic acid (GABA)

 Implicated with anxiety disorders (too little), panic disorders (too

little), seizures (too little), and memory disorders (too much)

 Found throughout the cerebral cortex and limbic system

 Agonists = Valium, Xanax, Ativan

 Can have a negative effect on memory

 Can cause “drunk-like” symptoms

 Highly addictive

 Classes of Psychotropic Medications:

 Pro’s:

 New research, better classifications

 Enhanced clinical utility with ICD-10

 Includes neurocognitive disorders

 Con’s:

 Same old personality stuff

 Criteria “too sensitive”

 Potentially causing over-medicating

 Questionable Validity of Diagnostic Criteria

 Where exactly is the research?

 Complicated criteria for PTSD and other diagnoses

Changes from DSM-IV-TR include:

 No more 5-axis diagnosis

 Improved attempt at non-overlapping criteria

 Integration of neuroscience research

 Consolidated autism spectrum disorders

 Improved classification of:

 Bipolar, Depression, Mood disorders

 Addition of Neurocognitive Disorders

 Elimination disorders

 Sleep-wake disorders

 Sexual dysfunctions

 Gender dysphoria

 Disruptive, impulse control, Conduct

 Substance-related and addiction

 Neurocognitive disorders

 Personality disorders

 Paraphilic disorders

 Etc., etc., etc.,

 Don’t you fret! We will review all of these in detail in this class!

 DSM-5 Divided Into Diagnostic Categories:

 Neurodevelopmental disorders

 Schizophrenia Spectrum and other Psychotic Disorders

 Bipolar and Related Disorders

 Somatic symptom and related disorders

 Feeding and eating disorders

DSM-5: Basic Overview

Overview for Tonight:

 Research Paper Review

 APA Formatting

 Basic Requirements

 Brief Review of Last Class

 Brain Functions, Neurotransmitters

Tips from the Trenches Continued:

 Brief Introduction (no heading)

 Should have the following headings (level 1):

 Historical Data (MANDATORY)

 Diagnostic Criteria (MANDATORY)

 Differential Diagnoses (MANDATORY)

 Include medical conditions that can mimic disorder

 Neuroanatomical Correlates of Disorder (OPTIONAL)

 Recommended Treatment (MANDATORY)

 Counseling Interventions

 Common medications used to treat disorder

 Ethical/Legal Concerns (MANDATORY)

 Critique of DSM-5 Diagnostic Criteria (MANDATORY)

 Future Research Recommendations (OPTIONAL)

Tips from the Trenches:

 Read the APA formatting manual

 Review OWL’s website for help

 https://owl.english.purdue.edu/owl/resource/560/0

1

/

 You are writing a “review” or “article critique”

 Write as though you are a reporter for a

newspaper (without bias)

 See example of paper on FTP site

Research Paper Review

 What is a diagnostic interview?

 Usually performed during initial meeting with client

 Sometimes takes a few sessions (2 or 3 at most)

 Reviews a wide range of the client’s history and symptoms

 See next slide

 Purpose is to establish a provisional diagnosis so as to delineate a specific plan for treatment

 Identifies other conditions in need of a referral to ancillary providers

 Should be therapeutic in nature and an effective means for “breaking the ice” during initial sessions with the client

 Often erroneously overlooked when practicing counseling

 Can be performed with individuals, couples, and families

Diagnostic Interviewing

Lecture 1 of 2

 Review of the Client’s Chief Complaint/Main Areas of Concern

 Chief Complaint

 Client’s spontaneous list of concerns

 WHY SEEK THERAPY NOW?

 When did the symptoms begin?

 How often do they occur?

 What is the severity of the symptoms?

 In what context do the symptoms occur? Triggers, etc.?

 What, if anything, helps decrease or manage the symptoms?

 QUICK TIP: Most, if not all this information, can be gathered with an intake questionnaire to be reviewed by you in the first session

Diagnostic Interviewing

Lecture 1 of 2

 Background Information You Should Gather

 Developmental History

 Born and raised where?

 Born on time? If not, how many weeks early/late?

 Any complications with mother’s pregnancy or delivery? Exposure to any drugs/alcohol/trauma in utero?

 Any health complications immediately after birth?

 Treatment history of this, if any

 Developmental Milestones

 Feeding abilities

 Motor milestones – sitting up, crawling, walking, running, fine motor dexterity

 Speech-Language milestones – early vocalizations, reciprocal vocalizations, first word, first sentences, any speech delays or abnormalities

 Early Social Development

 Attachment style with parents, siblings, peers

 Early Behaviors & Cognitive Abilities

 Any inattention/hyperactivity early on?

 Impulsivity, defiant behaviors, acting out, explosive anger episodes?

 Home Life Growing Up & current relationships with family

 Background Information You Should Gather

 Academic History

 Pre-K – College History

 When, Where attended

 Any grades repeated/failed?

 Behaviors during elementary through college

 Any special education services (e.g., speech therapy, 504, IEP, etc.)

 Any learning disabilities diagnosed? – any specific testing?

 Social development through academic history

 Any bullying?

 Academic strengths & weaknesses

 DIAGNOSTIC INTERVIEW REVIEW TO BE CONTINUED NEXT CLASS…

 DSM-IV-TR had 5 “axis” for diagnosis

 Axis I: Mental Disorders (not including personality or intellectual functioning)

 Axis II: Personality Disorders & IDD or Borderline Intellectual Functioning

 Axis III: Medical Conditions of Note

 Axis IV: Psychosocial Limitations

 Axis V: Global Assessment of Functioning (GAF)

 Scale of 1-100 (very, very, very, subjective)

 DSM-5 no longer uses Multiaxial system

 Most important/salient diagnosis at the top when recording

 Include notes for medical conditions, psychosocial limitations, and how these negatively affect functional status

 In other words, same info as DSM-IV-TR but just not “called” Multiaxial system

 Also of note: see definition of mental disorder, descriptors, subtypes, provisional diagnoses, other conditions that may be focus

of clinical attention, and coding/reporting procedures

DSM-IV-TR to DSM-5

A Single Axis for Diagnosis vs The Multiaxial System

 Topics We Will Cover in this Section:

 Intellectual Developmental Disorder

 Major Points to Know:

 More of a syndrome than a disorder

 i.e., IDD is not an etiology, but a classification

 Multiple etiologies can cause IDD

 e.g., genetic disorders, trauma at birth, exposure to neurotoxins, neo-natal/early childhood seizure disorders

 Must include BOTH cognitive/intellectual testing and assessment of adaptive functioning

 Intellectual = verbal, non-verbal reasoning, processing speed, working memory

 WAIS-IV, WISC-IV – Need FSIQ

 Intellectual Disabilities

 Formerly Mental Retardation

 Obsolete Terminology/NO LONGER PC

 Consists of the following diagnoses:

 Intellectual Disability (IDD)

 Mild

 Moderate

 Severe

 Profound

 Global Developmental Delay

 Unspecified Intellectual Disability

DSM-5:

Neurodevelopmental Disorders

 Neuroanatomical Correlates:

 Wide range of neurophysiological manifestations – some subtle, some not so subtle (depending on etiology)

 Treatment

 Typically no cure but intervention can improve functional status

 E.g., PT, OT, Speech, Special Education

 Co-Morbid Psychiatric Difficulties

 Depression, Anxiety, Psychosis, OCD, Substance Abuse, Behavioral problems

 Co-Morbid Physical/Medical Difficulties

 Global Developmental Delay

 Only diagnosed under the age of 5

 No reliable means of IQ/Adaptive testing

 Unspecified Intellectual Disability

 Only used during exceptional circumstances

 IDD Continued:

 Severity is based primarily on adaptive functioning

 E.g., patient can have IQ of 50 but have all ADL’s and adaptive behaviors

relatively intact In this case, it would likely be mild ID

 Three Domains of Functional Deficits:

 Conceptual

 Social

 Practical

 Diagnostic Criteria Must Be Met During Development and Not

Acquired after Entering Adulthood

 Previously before age 18 in DSM-IV-TR

 Current language does not specify a specific age cut-off

 More vague for legal reasons most likely

 Speech vs Language

 Speech is motor aspects of language

 Articulation, Prosody, Oral-Motor Programming,

 The “sounds” of language

 Language is “higher-order”

 Receptive language abilities

 Comprehension of spoken language

 Auditory Processing/Discrimination

 Expressive language abilities

 Translating thoughts into words

 Syntax, Pragmatics, Semantics, WF abilities

 Communication Disorders

 Language Disorder

 Speech Sound Disorder

 Childhood-Onset Fluency Disorder

 Social Pragmatic Comm Disorder

 Unspecified Comm Disorder

DSM-5:

Neurodevelopmental Disorders

 Neuroanatomical Correlates:

 Language Disorder

 DSM-5: encompasses both expressive & receptive language abilities

 Onset must be in early development

 Cannot be acutely caused by hearing imp

 Typically diagnosed by speech-language pathologists, psychologists, or

physicians

 Often a history of language delays

 Treatment involves speech-language therapy

 Co-Morbid: Social anxiety, autism, depression, dyslexia

 Childhood-Onset Fluency Disorder

 Stuttering

 Prevalence is high until age 6 or so

 Many false-positives

 Occasionally due to anxiety

 Treatment includes speech therapy

 Co-Morbid: anxiety, etc

 Speech Sound Disorder

 DSM-5 encompasses all aspects of oral motor programming and

execution

 Reduced intelligibility of production of speech sounds

 Typically phonemes

 Not caused by congenital or acquired conditions – e.g., CP, TBI

 Treatment Includes speech therapy

 Co-Morbid: anxiety, depression, social anxiety, decreased

IQ/academic achievement

DSM-5:

Neurodevelopmental Disorders

 Social Pragmatic Comm Disorder

 Non-verbal aspects of language affected

 Not to be confused with Autism

 Many “autism-ish” patients will qualify for this

 Treatment is speech-language therapy

 Unspecified Comm Disorder

 Catch-all for symptoms not meeting the aforementioned diagnostic

criteria

Brain Break!

 Functional deficits:

 Poor academic success

 Poor social skills/very few friends

 Difficulty obtaining employment

 Difficulty completing college (higher funct.)

 Difficulty sustaining employment

 Difficulty with “executive functioning”

 Planning, prioritizing, execution, organizing

 Prone to being taken advantage of socially

 Occasional/frequent poor judgment leads to various legal, functional, adaptive consequences

 Autism Spectrum Disorder

 Way too much info to cover…

 Main Issues at Hand:

 Encompasses autistic disorder, Asperger’s disorder, and PDD NOS

 Notable for:

 Impairment of Social skills

 Repetitive Behaviors

 Restricted Interests (fixations)

 VERY WIDE RANGING SPECTRUM

 IDD through Genius

 Fine/Gross Motor Skill Difficulties

 Typically diagnosed by practitioners specializing in ASD

 Neuropsychological Eval is Recommended

 Neuroanatomical Correlates:

 See next slide…

 What causes Autism?

 That is a good question…

 Environment + Genetics (simple answer)

 Co-Morbid With:

 IDD, ADHD, Tourette’s, Anxiety, OCD, Mood Disorders, etc., etc., etc…

 Autism Spectrum Disorder Cont’d:

 Severity is based on functional deficits – similar to IDD

 Treatment includes (depending on severity and age):

 ECI (PT, OT, Speech, Social Skills)

 Special Education Services

 Vocational Rehab Services

 Social Skills “Coaching”

 Individual Therapy/Counseling

 Practical approach is better

 Work on symptom management vs insight

 Psychotropic medications treat psych Sxs

 Applied Behavior Analysis (ABA Therapy)

DSM-5:

Neurodevelopmental Disorders

 In my opinion continued…

 Often misdiagnosed in childhood

 Pediatric bipolar disorder

 Autism spectrum disorder

 Dyslexia

 Oppositional defiant disorder

 Childhood anxiety, depression

 Symptoms begin in the womb most likely

 Cannot be reliably diagnosed until age 5+

 May not begin until adolescence

 Brain re-wires itself during this time

 Interviews are NOT ENOUGH to diagnose

 Otherwise, everyone would likely qualify

 Some form of objective testing is needed

DSM-5:

Neurodevelopmental Disorders