Psycopathology Unit 2

Psychopathology class material for second test

Autism Spectrum Disorder

From early childhood the client has impaired social interactions and communications, and shows sterotyped behaviors and interests.

• Deficits in social communication and social interaction across multiple contexts

  • Back and forth reciprocity, not sharing interrsts, initiation

  • Poor verbal and nonverbal communication, facial expressions

  • Developing, maintaining, and understanding relationships

• Restricted, repetitive patterns of behaviors, interests, or activities; at least 2 of the following:

  • Motor movements, echolalia, speech

  • Sameness, inflexible routines, ritualized patterns

  • Highly fixated interests, abnormal in intensity

  • Sensory issues

• 3 levels of severity: can be high functioning/masking BUT persistent impairment

• Typically recognized around 12 months old if severe, but can be later if symptoms are less severe

ADHD

Clients are hyperactive, impulsive, or inattention, and often all three.

• Persistent pattern of inattention and/or hyperactivity-impulsivity

  • A: Inattention: 6 or more symptoms

  • B: hyperactivity + Impulsivity: 6 or more symptoms

• Combined presentation: both Criterion A and B met for the past 6 months

• Predominantly Inattentive: Criterion A met, not B

• Predominantly Hyperactive/Impulsive: Criterion B met, not A

• Duration: Symptoms present before age 12

• Distress/Disability: Varying presentations! In TWO settings!

  • Can be very high functioning

• Can co-occur with learning disorders, sensory issues, developmental delays

• Remember risk: Impulsivity!

Intellectual Disability

Usually begins in infancy, low intelligence that cuases them to need special help in coping with life.

• Borderline intellectual functioning: intellectual disability but without coping problems associated with it.

• Intellectual and adaptive functioning deficits in conceptual, social, and practical domains. Must meet 3 criteria:

  • Deficits in intellectual functions (reasoning, problem solving, planning, abstract thinking, academic learning, etc.)

  • Deficitys in adaptive functioning (not meeting developmental and sociocultural standards without ongoing support)

  • Onset during developmental period

• Specify severity: IQ

  • Mild: 50-70

  • Moderate: 35-49

  • Severe: 20-34

  • Profound: Below 20

• Also Global Developmental Delay: Reserved for individuals under the age of 5 when severity cannot be reliably assessed.

Communication and Language Disorders

Affecting language, vocabulary, sentences, understanding, or talking.

• Deficits in language, speech, and communication

• Duration: ALL begin in early childhood

• Note: You will likely not solely be responsible for diagnosing these on your own. You will likely work with an SLP, OT, PCP, or special education for assistance in diagnosis.

Motor Disorders

Think coordination, movements, tics, motor delays.

• Deficits in motor behavior OR strange mood behaviors

• Duration: ALL begin in early childhood

• Note: You will likely not solely be responsible for diagnosing these on your own. You will likely work with an SLP, OT, PCP, or special education for assistance in diagnosis.

Learning Disorders

Ability to learn or use certain skills, like reading, writing, or math.

• Difficulties learning and using academic skills

  • Reading (slow or understanding issues)

  • Spelling

  • Written expression

  • Numbers/math

• “Each impaired academic domain and subskill of specific learning disorder should be recorded. Because of ICD coding requirements, impairments in reading, impairments in written expression, and impairments in mathematics, with their corresponding impairments in subskills, must be coded separately.”

Etiology for Neurodevelopmental Disorders

• No clear biomarkers identified

• Genetic mutations

• Heavy metals/toxins

• Chemical pollutants

• Maternal exposures in utero

• Infections/Immune Disorders/Inflammation

• Trauma/neglect

• Attachment

Differential Diagnoses for Neurodevelopmental Disorders

• Other medical diagnoses

• Other ND disorders

• Selective Mutism

• Schizophrenia

• ODD or Intermittent Explosive Dx

• OCD

• Neurological issues

• Anxiety Dx

• Depressive Dx

• Bipolar Dx

• Substance Use Dx

• Personality Dx

• Medication induced Dx

Internalized Behaviors

Social withdrawal, loneliness, depression, anxiety, concentration

Externalized Behaviors

Internal thoughts and feelings directed externally

Oppositional Defiant Disorder

Multiple examples of negativistic behaviors

• A pattern of behavior with at least 4 symptoms from the following categories for at least the last 6 months, at least every week:

  • Angry/Irritable mood: losing temper, touchy or easily annoyed, angry and resentful

  • Argumentative/defiant behavior: arguing with authority, refuses to comply, deliberately annoys others, blames others for their misbehavior

  • Vindictiveness: spiteful or vindictive

• Duration: At least once per week for at least 6 months in children 5 and older. For children younger, should occur on most days for a period of at least 6 months.

• Usually beginning in the preschool years!

Intermittent Explosive Disorder

Episodes of acting out aggressively

• Short summary:

  • Recurrent behavioral outbursts with aggressive impulses

    • Could be verbal or physical aggressive towards property, animals, or people

    • 3 outbursts involving damage occur within a 12 month period

• Must be at least 6 years old!

• Can co-occur with ADHD, ASD, Conduct Dx, or ODD when outbursts are in excess of the usual.

• This is rarely developing after the age of 40.

Conduct Disorder

Persistently violates rules or rights of others

• Short Summary:

• Repetitive and persistent pattern of behavior of violating others rights, societal norms, or rules. At least 3 of the following 15 criteria have been met in the last 12 months, with at least 1 criterion present in the last 6 months:

  • Aggression to people and animals: bullying, fighting, used a weapon, cruel to people or animals, stolen while confronting a victim, forced sexual activity

  • Destruction of property: fire setting or deliberate destruction

  • Deceitfulness or theft: broken into home/car, lies to obtain goods/favors, stolen items of nontrivial value

  • Serious Violation of Rules: stays out past curfew, run away from home, truant from school

• Use a specifier for onset and prosocial emotions!

Kleptomania

Stealing repeatedly “tension and release”

Pyromania

Fire setters “tension and release”

Antisocial Personality Disorder

Listed in this chapter, but no criteria listed. In the Personality Disorders chapter. Irresponsible, often criminal behavior and showing no remorse.

Etiology for Disruptive, Impulse-Control, and Conduct Disorders

• Low serotonin levels (related to aggression more broadly)

• Brain Structure difference (May be less responsive to fear conditioning)

• Genetics

• Impulsive traits would have been helpful in ancestral times

• Extreme Male Brain Theory

• Inflammation (May be PANS/PANDAS)

• Attachment and Parenting

• Psychodynamic: CBT, ABA, Executive Skills Training, CCPT, PCIT

• Diet (food dyes, sugar intake, gluten)

• TRAUMA

Differential Diagnoses for Disruptive, Impulse-Control, and Conduct Disorders

• Trichotillomania

• Paraphillic disorders

• OCD

• Substance use disorders

• Bipolar I

• Schizophrenia

• Disruptive mood dysregulation disorder

• ADHD

• Intellectual Disability

• Social anxiety

• Delirium

• Adjustment Disorders

Treatment for Neurodevelopmental Disorders

• Early Intervention/Birth to 3 services

• Behavioral Therapies

• Educational modifications

• Medication

• Occupational and/or Speech Therapies

• Parenting/Caretaker therapy

• Life and social skills training

• Psychotherapy

Treatment for Disruptive/Impulse/Control Disorders

• Psychotherapy (individual, family, or group)

  • CBT, DBT, IPT, Trauma Informed

  • Behavior

• Parent training

• Skill training

• Medications

• Case management

PDA: Pathological Demand Avoidance OR Persistent Drive for Autonomy

• NOT a diagnosis in the DSM - a neurodivergent profile

• Intense need for autonomy, leading to an overwhelming resistance to everyday demands and requests

• It is NOT defiance. It is a desire for control and choice. There is a fear/anxiety about losing control or not having a say in what happens.

• It may look like: refusing requests, making excuses, withdrawing, having outbursts to avoid tasks, stubborn

• When Working with PDA:

  • TRUST and RAPPORT! Empathy! Patience!

  • Lots of choice giving

  • Gentle, indirect language

    • Direct language: You need to finish this

    • Indirect language: How would you prefer we complete your homework today?

  • Flexible routines

  • Disguise tasks as games

  • Depersonalizing requests

Other Neurodivergent Profiles

• Verbal comprehansion very high, but processing speed very slow

• Deep Special Interest but no short term memory

• Asynchronous Development

• Super Pattern Recognition

• Hyper Empath

• Justice Sensitivity

• Rejection Sensitivity

Schizophrenia Spectrum & Other Psychotic Disorders

• Defined by abnormalities in one or more of the following five domains

  • Delusions

  • Hallucinations

  • Disorganized Thinking (speech)

  • Grossly disorganized or abnormal motor behavior

  • Negative symptoms

Delusions

A false belief that cannot be explained by the patient’s culture or education; patient cannot be persuaded that their belief is false, despite evidence to the contrary.

• Types of Delusions:

  • Erotomanic: someone is in love with the patient

  • Grandeur: the patient is of exalted station, such as God or famous

  • Jealousy: partner has been unfaithful

  • Persecution: being followed or interfered with

  • Somatic: patients’ body functions have altered

Hallucination

A false sensory perception that occurs in the absence of a related sensory stimulus.

• Nearly always abnormal and can affect any of the five senses, though autdiory and visual are most common

• MUST occur whole the patient is awake and fully alert

  • NOT during delirium or falling/waking from sleep

• MUST lack insight into its unreality

• Illusions are different: misinterpretations of actual sensory stimuli

Disorganized Speech

Mental associations are governed not by logic, but rhymes, puns, and other rules not apparent to the observer, or by no evident rule at all.

Abnormal Behavior

Physical actions that do not appear to be goal-directed. (Catatonia: decreased responsiveness to surroundings; page 120)

Negative Symptoms

Reduced range of expression of emotions, markedly reduced speech, and loss of will to do things. “Something taken away”

Schizophrenia

For at least 6 months, patients have had two or more of the 5 types of psychotic symptoms. All other conditions ruled out.

A. Two or more of the 5 domains, each present for a significant portion of time during a 1 month period. At least one of these must be delusions, hallucinations, or disorganized speech.

B. Functioning has been effected.

C. At least 6 months with at least 1 month that includes Criterion A.

D. Other disorders have been ruled out.

• Development: Typically emerging late teens and the mid 30s, adolescence is rare. Typically gradual and slow development. Earlier onset typically seen as predictor of worse prognosis.

Shizophreniform Disorder

Patients who have the basic symptoms of schizophrenia but have been ill for only 1-6 months.

A. Two or more of the 5 domains, each present for a significant portion of time in a 1 month period. At least one must be delusions, hallucinations, or disorganized speech.

B. At least 1 month, but less than 6 months.

C. Others ruled out.

• This is identical to schizophrenia, but duration is shorter.

• Distress/Disability: there isn’t a specific criterion requiring impaired functioning. They may be present, but not necessary.

Shizoaffective Disorder

For at least 1 month, these patients have basic schizophrenia symptoms, but also have prominent symptoms of mania or depression.

A. Criterion A of schizophrenia + Major Mood Episode (depressive or manic).

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness.

C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness

• Specify type: Bipolar or Depressive

• Typically not diagnosed first - after pattern of mood episodes has become more apparent.

• Distress/Disability may be present, but not a diagnostic criterion

Brief Psychotic Disorder

Have at least 1 of the basic psychotic symptoms for less than 1 month

A. Presence of 1 or more of the domains. At least one must be delusions, hallucinations, or disorganized speech.

B. Duration: at least 1 day but less than 1 month.

C. Not better explained by something else.

• Specifiers

  • With marked stressors

  • Without marked stressors

  • Peripartum onset

  • With catatonia

Delusional Disorder

Have delusions, but not the other symptoms of schizophrenia.

A. Presence of 1 or more delusions with a duration of 1 month or longer

B. Never had schizophrenia

C. Functioning is not markedly impaired

D. if manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.

• Pay attention to the specifiers!

• More prevalent in older individuals, and connected to both schizophrenia and schizotypal personality disorder.

Etiology for Shizophrenia/Psychotic Disorders

• Dopamine hypothesis: too much dopamine

• Overactive dopamine pathways

• Neurotransmitter issues

• Brain structure abnormalities

• Genetics

• Evolutionary purpose

• Inflammation

• Biopsychosocial approach

• Terror or trauma

• inequality/adversity

• Maybe even cannabis use

Differential Diagnosis for Shizophrenia/Psychotic Disorders

• OCD

• Delirium, neurocognitive disorder

• Other psychotic disorders

• Depressive and bipolar disorders

• Substance use Disorders

• Other medical conditions

• Malingering and factitious disorders

• Personality disorders

• PTSD

Treatment of Schizophrenia/Psychotic Disorders

• Antipsychotic medications/medication management

• Psychotherapy

• Skills training

• Support groups/social supports

• Residential/support homes

• Case management

Obsessions

• Recurring thoughts, urges, or images that dominate a person’s mental content.

• They persist even when the person knows they are unrealistic.

• Attempts made to ignore, suppress, or neutralize the thoughts.

• Usually cause anxiety and dread.

Compulsions

• Repetitive behaviors OR mental acts that an individual feels driven to perform in response to an obsession or rules that must be applied rigidly.

• Aimed to prevent or reduce anxiety, prevent some event; but not connected in a realistic way; excessive.

• Can be simple or complex.

Common Themes of Obsessions

• Contamination

  • Fear of germs, first, or bodily fluids

• Doubts

  • Did I turn my stove top off?

• Symmetry

  • Need things to be in order

• Forbidden Thoughts

  • Religious, sexual

• Harm

  • To oneself or others

Ego-Syntonic

• Thoughts and behaviors are consistent with the person’s self-image and values

• See the obsessions and compulsions as rational or helpful

• Example: germs and hand washing

Ego-Dystonic

• Thoughts and behaviors are distressing and inconsistent with the person’s self-image and values

• Knows their obsessions and compulsions are irrational and intrusive, but can’t stop

• Example: taboo sexual acts

Obsessive-Compulsive Disorder

Patients are bothered by repeated thoughts or behaviors that appear senseless, even to them.

A. Presence of obsessions, compulsions, or both

B. Obsessions or compulsions are time consuming or cause distress/impairment

C. Not due to a substance

D. Not better explained by something else

• Insight specifier! (good/fair, poor, absent insight/delusional beliefs)

• Typically beginning in adolescence, not usually start after 35 years old

• Symptoms can wax/wane; but chronic and debilitating

• MANY times comorbid with another disorder, especially depression (as many as two-thirds!)

• Suicidality!

Body Dysmorphic Disorder

Physically normal patients believe that parts of their bodies are misshapen or ugly.

A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

B. Performed repetitive behaviors or mental acts in response to appearance concerns (mirror checking, excessive grooming, reassurance seeking)

C. Distress/impairment in functioning

E. Not better explained by something else

• Insight specifier! (good/fair, poor, absent insight/delusional beliefs)

• May frequent medical procedures, though this is contraindicated

Hoarding Disorder

An individual accumulates so many objects that they interfere with life and living.

A. Persistent difficulty discarding or parting with possessions, regardless of their actual value

B. Perceived need to save the items and to distress associated with discarding the items

C. Accumulation of possessions that congests and clutters active living

D. Distress/Impairment

E. Not better explained by medical condition

F. Not better explained by another disorder

• Insight specifier! (good/fair, poor, absent insight/delusional beliefs)

• Excessive acquisition specifier

• Often don’t consider the symptoms intrusive, distressing, or unpleasant

• Beings young, and gets worse with time. More often in older adults

• Strongly hereditary! HUGE trauma component!

Trichotillomania Disorder

Pulling hair from various parts of the body is often accompanied by feelings of “tension and release.”

“Hair pulling disorder”

A. Recurrent pulling out of one’s hair, resulting in hair loss

B. Repeated attempts to decrease or stop hair pulling

C. Distress/impairment

D. Not due to medical condition

E. Not better explained by something else

• May feel a mounting tension until they succumb to the urge, then feel release

• Hair, beards, eyebrows, eye lashes

• May put hair in the mouth, 30% swallow it

• Typically beginning in childhood/adolescence

• Patients try to hide - feel embarrassed by the behavior

• More common in women; more common in intellectual disability

Excoriation Disorder

Patients so persistently pick at their skin that they traumatize it.

“Skin-picking disorder”

A. Recurrent skin picking resulting in skin lesions

B. Repeated attempts to decrease or stop skin picking

C. Causes distress/impairment in functioning

D. Not due to substance or medical condition (scabies)

E. Not better explained by something else

• Usually begins in adolescence

• Spend a lot of time (maybe even hours!) digging at their skin

• Infections are common

• Comorbid with many other conditions: body dysmorphia, OCD, trichotillomania

OCD Differential Diagnosis

• Anxiety Disorders

• Major Depressive Disorder

• Other OCD disorders

• Eating Disorders

• Tics and stereotyped movements

• Psychotic Disorders/Schizophrenia

• OCPD

• Illness Anxiety Disorder

• ASD

• Somatic symptom and related disorders

• Adjustment Disorders

• Life