Neurodevelopmental, Intellectual, Substance Use Disorders, and Obsessive Compulsive Disorder

Neurodevelopmental Disorders

• Onset in developmental periods

• Symptoms often manifest early (before school)

• Developmental deficits or brain processes 

• Deficits vary greatly

• Impairs functioning to different degrees 

• LPCs and LMFTs usually do not diagnose these in isolation

Intellectual Development Disorders

• Onset during formative years 

• 5% genetic causes 

• 30% early pregnancy factors (infections, substance use)

• 10% later pregnancy (birth trauma, fetal malnutrition)

• 5% acquired childhood physical conditions

  • Difficulty with intellectual tasks 

    • Reasoning, making plans, thinking abstract, problem-solving, judgement, learning from formal study 

    • Difficulty modifying behaviors to become independent, socially adaptable

Intellectual Development Disorders: Severity Domains

• Conceptual (academic) Domain: memory, language, reading/writing, mathematical reasoning, problem solving

• Social Domain: awareness of how others think/feel, communication, empathy, making friends

• Practical Domain: self-care, ADL’s, managing money, grocery shopping, etc.

Intellectual Development Disorders: Severity Degrees

• F70 Mild:

  • Learn slowly, extra help managing everyday situations, can usually work independently in jobs 

  • IQ: 50-70, 85% of all diagnosed

• F71 Moderate 

  • Language slow to develop, increased support needed at home/school

  • IQ: 30-50, 10% of all diagnosed 

• F72 Severe 

  • May learn commands, communication skills very base, need much supervision and support 

  • IQ: low 20s-high 30s

  • 3-4% of all diagnoses

• F73 Profound

  • Limited speech, difficulty with most social interactions, communicate with gestures, completely reliant on others for needs 

  • IQ low 20’s, 1-2% of all diagnosed

Autism Spectrum Disorder

• Persistent deficits in social communication & interaction across multiple contexts 

• Deficits in social-emotional reciprocity (back-and-forth conversation)

• Deficits in nonverbal communication:

  • Abnormalities in eye contact, difficulty understanding body language/gestures, facial expression

• Deficits in developing, maintaining, understanding relationships 

  • Restricted, repetitive behavioral patterns, interests, or activities

  • Repetitive motor movements, use of objects or speech 

  • Inflexible adherence to routines, ritualized patterns of behavior 

  • Highly restricted, fixated interest with abnormal intensity 

    • Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of their environment

      • Indifference to pain/temperature

      • Adverse responses to specific sounds/sensations

      • Excessive smelling/touching objects 

      • Visual fascination with lights/movement

    • Symptoms present in early developmental period 

    • Clinically significant impairment in social, occupational functioning

ASD Specifiers

• Level 3: Requiring very substantial support

• Level 2: Requiring substantial support

• Level 1: Requiring support

Attention-Deficit/Hyperactivity Disorder (ADHD):

• Persistent pattern of inattention and/or hyperactivity

• Inattention:

  • Difficulty maintaining focus, paying attention when spoken to directly, readily distracted

  • May dislike or avoid sustained mental effort such as studying

  • Poor organization habits - messy work, lost assignments, careless errors

• Hyperactivity:

  • Constant motion, restlessness, excessive talking, difficult to play quietly or take turns, interrupting

Specific Learning Disorder

• Despite targeted interventions, ct has issues with reading, writing, or arithmetic

• Reading is slow or requires inordinate effort, difficulty grasping meaning

• Trouble with writing content, not meaning 

• F81.0: With impaired reading (Dyslexia)

• F81.2: With impairment in mathematics (Dyscalculia)

• F81.81: With impairment in written expression (Dysgraphia)

  • Severity based on level of support needed

Tic Disorders (Tourette’s Disorders)

• Tics appear around age 6; began as eye blinks

• Later joined by vocal tics; may initially be grunts or throat clearings

• Eventually multiple motor tics & at least 1 vocal tic

• Coprolalia - involuntary & repetitive use of obscene language

• Echolalia - involuntary repetition of words/phrases from someone else

• Symptoms present longer than 1 year

Neurocognitive Disorders

• Disorders of cognition 

• Most common in advanced age 

• Won’t be diagnosed without medical evidence

  • LPCs and LMFTs do not provide

Substance Use Disorders

• Alcohol, Caffeine & Cannabis Disorders 

  • X Use Disorder 

  • X Intoxication 

  • X Withdrawal

  • X-Induced Mental Disorder

Gambling Disorder

• Persistent and recurrent problematic gambling behavior

• Need to gamble with increased amounts of money

• Restless/irritable 

• Repeated unsuccessful efforts to control

• Preoccupation

• Gambling when feeling distressed 

• Lies

• Jeopardized or lost a significant relationship

• Relying on others to provide money to relieve desperate financial situation

Z-Codes: Other Conditions that may be a focus of clinical attention

• Suicidal behavior 

• Non-suicidal self-injury

• Abuse and neglect

• Emotional problems

• Educational, occupational problems, housing or economic problems

• Problems related to social environment 

• Problems related to interaction with the legal system

• Problems related to other psychosocial, personal, or environmental circumstances

Obsessive Compulsive Disorder

Disorder marked by uncontrollable and recurring thoughts (obsessions), repetitive and excessive behaviors (compulsions), or both

Obsessions

Recurrent/persistent thoughts, urges, or images that are experienced as disturbing, intrusive, unwanted, and cause marked anxiety or distress

Compulsions

Repetitive behaviors or mental acts that the person feels driven in response to obsession

Common Obsessions

• Contamination

• Harm (self/others)

• Illness related

• Sexual intrusive thoughts 

• Scrupolosity 

• “Just right”, if I don’t do this until it feels right something bad will happen 

• Moral responsibility 

• Identity (what if I’m not who I think I am, gender or sexual identity)

• Relationship (family, friends, or partners)

Common Compulsions

• Checking 

• Reassurance seeking 

• Avoidance 

• Mental rituals 

  • Neutralizing thoughts

  • Mental review

  • Rumination 

  • Self reassurance 

• Just right

What OCD is NOT

• Not perfectionism 

• Not just worry/anxiety

• Not intentional thoughts 

• Not psychosis

Assessment Tools

• Yale-Brown Obsessive Compulsive Scale (YBOCS)

  • CYBOCS (children/adolescents)

  • OCI-R

  • Emphasize identifying mental compulsions

Medications

• SSRI’s: Zoloft, Prozac

• Antipsychotics

  • May be extra anxious about taking meds

ERP

• Exposure: intentionally facing feared thoughts/situations

• Response Prevention: resisting compulsions

• Goal: learn anxiety decreases without rituals 

How does ERP work?

• Anxiety tolerance vs. reduction

• Disconfirming feared outcomes

• Distress tolerance

Types of Exposures

• In vivo (real life)

• Imaginal 

• Interoceptive 

• Rumination exposure

Building the Exposure Hierarchy

• Identify triggers and core fear 

• Rate distress  (0-10 or 0-100)

• Gradual vs. Intensive approach 

• Collaboration with client

Response Prevention Strategies

• Reducing reassurance seeking 

• Accepting uncertainty 

• Dropping safety behaviors 

• Delaying

ACT for OCD

• Cognitive Defusion: reduces the grip of the thought without trying to disprove it

• Acceptance and Willingness 

• Mindfulness

• Values work

Common challenges in ERP

• Hidden mental rituals

• Family accomodation

• Poor insight 

• Comorbid conditions

• Trauma

• Fear of “making it worse”

What helps ERP succeed

• Psychoeducation

• Consistency 

• Structure 

• Family environment