Psychopathology Exam

Neurodevelopmental Disorders 

• Disorders that appear in early development 

• Characterized by development deficits of differences in brain processes that result in impairment 

• Categories in the DSM-5-TR 

  • Intellectual developmental disorders 

  • Communication disorders 

  • Autism spectrum disorders 

  • Attention deficit hyperactive disorder 

  • Specific learning disorder 

  • Motor disorder 

Intellectual Development Disorder 

During developmental period... 

• Deficits in intellectual functions, such as reasoning, problem solving, abstract thinking, judgement, academic learning, and learning from experience 

  • Deficits must be confirmed by both clinical assessment and individualized, standardized intelligence testing 

• 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 areas of daily life 

Intellectual Functioning 

• What do we mean by “deficits in intellectual functioning?” 

  • ~2 standard deviations below the mean of the comparison sample 

    • e.g., On the WISC/WPPSI, an IQ score of <70. 

• Usually measured via IQ, testing directly with youth 

  • WISC/WPPSI (provides information on specific skills, updated more frequently) 

  • Stanford-Binet 

• IQ is not used to identify severity because… 

  • Scores are less valid and helpful in the lower ranges 

  • IQ is not clearly associated with supports needed for daily functioning 

Adaptive Functioning 

• Severity levels of IDD are based on impairments in adaptive functioning 

  • Often assessed via the Adaptive Behaviour Assessment System (ABAS) 

  • Conducted with caregivers (and youths if possible) 

• Can be identified as “mild”, “moderate”, “severe”, or “profound” across each of the following domains: 

  Conceptual (academic): e.g., problem solving, language, math, memory, reading, writing 

  Social: e.g., awareness of other’s thoughts and feelings, communication skills 

  Practical: e.g., personal care, self-management, money management, job responsibilities 

• Adaptive functioning is influenced by intellectual capacity, but also other factors (e.g., education, socialization, co-existing medical conditions) 

Prevalence 

• 1% prevalence; somewhat higher in youths 

• More severe impairment may be noticeable before age 2 

  • Milder impairment may only become notable closer to school age 

• IDD is generally a lifelong disorder 

  • Symptoms may improve with early and intensive intervention 

  • Important to identify whether improvements in symptoms are skill- or support-based 

• Risk can be conferred across early development 

  • Prenatal: e.g., genetic disorders, environmental influences 

  • Perinatal: i.e., labour and delivery related events 

  • Postnatal: e.g., Traumatic brain injury, seizure disorders, infections 

IQ and Assessment Concerns 

• Practically… 

  • Children younger than 5 may be diagnosed with “Global Developmental Delay” if they are unable to complete assessments 

    • This is a temporary label; reassessment is expected! 

  • Consider how co-occurring language or sensory difficulties may impair assessments 

• About IQ… 

  • Assessments “must be relative to age, gender, and socioculturally matched peers”, but are based on Western European standards of “intelligence” 

  • Scores indicating difficulties in cognitive functioning are expected to be two SDs below population means 

  • Substantial differences across subscales can make overall IQ uninterpretable 

  • Scores can improve with practice through repeated assessments 

• The “Flynn Effect” 

  • Trend of population IQ scores increasing by ~0.3/year 

  • The norms for IQ data change over time as populations change! 

  • Unclear what factors contribute to changes 

    • Nutrition, education, socioenvironmental factors 

    • May reflect changes in specific abilities (e.g., performance-based tasks) 

• How does the Flynn Effect relate to developmental psychology? 

  • Assessments conducted for youths may overestimate their ability as they age into adulthood 

  • May account for some observed age-related change across development 

"By any other name..." 

“Intellectual Developmental Disorder”  

• Can be used in professional/medical settings 

• Chosen to line up with the ICD-11’s “Disorders of Intellectual Development” 

“Intellectual Disability” 

• Can be used in professional/medical settings 

• Also used by schools, advocacy groups, the general public 

“General Learning Disability” 

• Used in the United Kingdom 

• Describes characteristics relative to Specific Learning Disability 

Specific Learning Disorder 

• Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months despite the provision of interventions that target these difficulties 

  • Inaccurate or slow word reading 

  • Difficulty understanding the meaning of what is read 

  • Difficulties with spelling 

  • Difficulties with written expression 

  • Difficulties mastering number sense, number facts, or calculation 

  • Difficulties with mathematical reasoning 

Severity 

• Based on number of academic domains affected and level of functioning with supports 

• Mild 

  • Some difficulties in one or two domains 

  • May be able to compensate/function well with supports 

• Moderate 

  • Marked difficulties in one or more academic domains, but unlikely to become proficient without intervals of intensive support/specialized teaching 

  • Accommodations required for at least part of the day to complete activities accurately and efficiently 

• Severe 

  • Severe difficulties across several domains, and unlikely to learn skills without ongoing intensive individualized/specialized teaching 

  • May not be able to complete all activities efficiently even with appropriate accommodations 

Assessment 

• Difficulties are domain specific; may appear as “unexpected” 

  • As evidence of overall functioning, must have an IQ of ~70 or above 

• Can be assessed through… 

  • Psychoeducational assessment (e.g., WISC/WPPSI, WIAT, skill-specific measures) 

    • Scores in these domains must be “well below” age level expectation (Arbitrary!) 

  • School reports 

  • Portfolios of schoolwork 

• Academic skills are not learned intuitively! 

  • Compare with IDD, Speech Sound Disorder 

  • Must have adequate opportunity to learn and appropriate targeted support in that learning 

Risk and Prevalence 

• Prevalence of 5-15% in youths, with difficulties persisting into adulthood 

• Similar across geographic area and culture, but may manifest different depending on language characteristics (e.g., orthographic regularity) 

In English, “al” can be pronounced as… 

/a/, like “half”, /eil/, like halo, /æ/, like salmon 

• Highly heritable within first-degree relatives 

• Commonly comorbid with: 

  • Other specific learning disorders (e.g., reading and writing) 

  • Anxious and depressive disorders 

  • Other neurodevelopmental disorders 

Specifiers 

• With impairment in reading: 

  • Word reading accuracy 

  • Reading rate or fluency 

  • Reading comprehension 

• With impairment in written expression: 

  • Spelling accuracy 

  • Grammar and punctuation accuracy 

  • Clarity or organization of written expression 

• With impairment in mathematics: 

  • Number sense (e.g., understanding quantities, greater than/less than) 

  • Memorization of arithmetic facts 

  • Accurate or fluent calculation 

  • Accurate math reasoning 

But why haven't we mentioned dyslexia/dyscalculia? 

• “Dyslexia” is one of the most common manifestations of specific learning disorder, related to language ability 

  • Dyscalculia is similar, but related to mathematics 

  • These labels can describe a very wide range of functioning  

• These terms are mentioned in the DSM-5-TR, but as an “alternative term” (not a diagnostic criteria!) 

  • More helpful in diagnosis/treatment to identify specific areas of difficulty 

  • Terms can still be used alongside DSM-5-TR specifiers 

Feeding and Eating Disorder 

• Any disorder resulting in an altered consumption or absorption of food that significantly impairs physical health or social functioning 

• Overall, typical onset is in adolescence and early adulthood 

  • May also be associated with stressful life event 

• Commonly discussed: anorexia nervosa, bulimia nervosa, binge-eating disorder 

  • Mutually exclusive; only one diagnosis can be assigned for a single episode 

    • Common psychological and behavioral features, but disorders differ substantially in treatment, course, and outcome 

Anorexia Nervosa 

Symptoms  

• Restriction of energy intake relative to requirements, leading to a significantly low body weight 

  • What defines a concerning low body weight? The DSM-5-TR indicates... 

    • In adults, "less than minimally normal" 

    • In children and adolescents, "less than minimally expected" 

• Intense fear of gaining weight and becoming fat, or a persistent behavior that interferes with weight gain, even though at a significantly low weight 

  • Why might we see youth deny experiencing fear, but still display persistent interfering behavior 

    • May be more common in younger individuals 

• Disturbance in the way in which ones body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of low body weight 

  • Distinguish from body dysmorphia, which can be focused on any part of the body and isn't characterized by changes in eating 

  • Weight loss may be seen as "impressive achievement"; weight gain may be seen as a "failure of self-control" 

  • Youths most likely to be brought to health care provided by a caregiver on account of weight-related concerns 

Subtypes and Specifiers 

• Binge-eating/purging type: weight loss is accomplished through self-induced vomiting, misuse of laxatives, diuretics, or enemas 

• Restricting type: no binging/purging; weight loss is accomplished largely through dieting, fasting, or excessive exercise  

• In partial remission: 

  • Criteria for low body weight has not been met for sustained period 

  • Other criteria are still met 

• In full remission: 

  • While full criteria were met previously, none of the criteria are met 

Prevalence and Course 

• 0.9 to 1.4% lifetimes prevalence in women 

• 0.1 to 0.3% lifetimes prevalence in men 

• Most individuals experience remission within 5 years of presentation 

• Very high risk of medical and psychological complications from starvation 

  • Higher rates of obsessive-compulsive behaviors, depression 

  • Physiological disturbances 

  • 18x higher rates of suicide compared to age-and gender-matched peers 

Symptom: Binge Eating 

• Binge eating is characterized by both of: 

  • Eating within a discrete period of time, an amount of food definitely larger than what most individuals would eat in a similar period of time under similar circumstances 

  • A sense of lack of control over eating during the episodes 

• Episodes may be triggered by interpersonal stress, negative feelings about shape and weight, or boredom 

• Binge eating without associated distress in youths 

• Must be considered relative to context, development, and individual differences 

  • What behaviours might “look like” binge eating in kids/teens? 

Binge Eating Disorder 

Recurrent episodes of binge eating, with episodes having 3+ of: 

• Eating more rapidly, until uncomfortably full, eating when not hungry, eating alone out of embarrassment about volume, feeling disgusted/depressed/guilty afterwards. 

• Episodes caused marked distress 

• Occurs, on average, at least 1/week for 3 months 

  • Severity increases with number of binge eating episodes per week 

• Lifetime prevalence: 

  • 1.25 – 3.5% in women; 0.42 – 2% in men 

• Higher remission rates than anorexia, bulimia 

  • Unlikely to transform into a different kind of eating disorder 

Body Mass Index 

• For Adults 

  • The DSM-5TR used Body Mass Index (BMI) to define whether an individual meets diagnostic criteria for weight differences 

  • In anorexia nervosa for adults, low bodyweight is defined as "less than minimally normal" 

• For Youths 

  • Weight and height change across development, but not always in a proportional way 

    • Also consider "failure to meet expected weight" 

  • For youths, BMI percentage looks at statistical deviance from expected developmental trajectories 

  • For anorexia nervosa in youths, low bodyweight is defined as "less than minimally expected" 

    • No definitive standards for low weight 

    • Suggested guidelines of <5^th percentile of BMI relative to age and sex 

• Is it for Anyone? 

  • BMI is a proxy measure of body fat percentage 

    • Body fat percentage and distribution varies in different bodies 

    • Some studies relate BMI to negative health outcomes, but these are not causal 

  • BMI is commonly acknowledged to have significant shortcomings 

    • Differences in height/frame 

      • BMI is typically less accurate for taller individuals 

    • Developed based on measurements of European males 

      • Less accurate for women and racialized minorities 

    • Despite its shortcoming, BMI is still frequently used, notable in the DSM-5-TR 

      • BMI is used as a guideline for severity, which may also be adjusted for clinical symptoms, degree of functional disability, and need for a supervision 

Bulimia Nervosa 

• Recurrent episodes of binge eating 

• Recurrent inappropriate compensatory behaviors both occur on average, at least once a week for 3 months 

  • Severity increases with frequency of compensatory behaviors 

• Self-evaluation in unduly influenced by body shape and weight 

Prevalence and Course 

• Lifetimes prevalence of 1.3%/0.5% in adolescents girls/boys 

  • Prevalence generally higher in higher-income, industrialized countries 

• May begin after multiple stressful life events and/or after an episode of dieting for weight loss 

• Course may be chronic or intermittent, but disturbed eating generally persists over the course of several years 

• 10-15% of cases will "switch over" to anorexia nervosa, and may also switch back and forth 

  • Current diagnosis should be based on the past 3 months 

• Symptoms tend to diminish over long term follow up 

  • Treatment is associated with significantly better outcomes 

While there are some similarities between disorders, you can only meet criteria for one label at a given time 

Feeding and Eating Disorder 

Any disorder resulting in an altered consumption or absorption of food that significantly impairs physical health or social functioning 

• More commonly discussed:  

  • anorexia nervosa, bulimia, binge-eating disorder 

• Less commonly discussed: 

  • Avoidant/restrictive food intake disorder, rumination disorder, pica 

Avoidant/Restrictive Food Intake Disorder 

An eating or feeding disturbance, such as… 

• Apparent lack of interest in eating or food 

• Avoidance based on sensory characteristics of food 

• Concern about aversive consequences of eating (e.g., choking) 

…associated with one or more of the following: 

• Significant weight loss (or differences in weight gain/growth in children) 

• Significant nutritional deficiency 

• Dependence on enteral feeding or oral nutritional supplements 

• Marked interference with psychosocial functioning (e.g., relationships with others, foods “allowed” in the home) 

Course & Prevalence: 

Previously considered to be a disorder of early childhood, but later extended across the lifespan 

• Infants may be observed refusing food or gagging/vomiting 

• Young children may not engage with caregivers in response to hunger cues 

• Older children/adolescents may have anxious or emotional symptoms around mealtimes, may cause distress for family/friends 

• Rare disorder; Estimated ~0.3% prevalence in individuals 15+ 

Can be better explained by... 

• lack of available food 

• cultural practice 

• other condition or disorder 

Should not include difficulties related to disturbances in perceptions of shape/weight! 

• Also insufficient evidence to support relationship with later EDs 

Can occur within the context of ASD, OCD, Specific Phobia 

• Consider which disorder is “primary” or “secondary” 

Rumination Disorder 

Repeated regurgitation of food over a period of at least 1 month. 

• Without apparent nausea, involuntary retching, or disgust. 

• Regurgitated food may be re-chewed, re-swallowed, or spit out. 

• Not better accounted for by another biological/psychiatric disorder 

• Causes not well understood 

  • May be self-soothing/stimulating, or a conditioned response of muscle contraction to specific stimuli 

• Distress is not listed as a requirement in diagnostic criteria; impairment may stem from medical complications 

Course and Prevalence: 

• In infants: 

  • Characteristic arched posture while making sucking movements with tongue 

• In adolescents and adults: 

  • May attempt to disguise the socially undesirable behaviour 

  • May avoid meals prior to social situations 

• Across the lifespan: 

  • May have serious health consequences on account of regurgitation or malnutrition 

• More often observed in infants or individuals with IDD 

  • Prevalence not well understood; ~1% in school-age children? 

Pica 

• Persistent eating of nonnutritive, non-food substances over a period of at least 1 month 

• The eating of nonnutritive, non-food substances is inappropriate to the developmental level of the individual 

• The eating behaviour is not part of a culturally supported or socially normative practice 

• If the behaviour occurs in the context of another disorder, it is sufficiently severe to warrant additional clinical attention 

Course and Prevalence: 

Substances may include chalk, clay, or ice, but also things like soap, cloth, hair, pebbles, lead, sharp objects… 

• May result in illness, intestinal blockage 

Onset may be associated with… 

• nutrient deficiencies (i.e., iron, zinc) 

• medical complications related to digestion 

• food scarcity 

• ..but also occurs in individuals without these difficulties! 

Onset across the lifespan, but most common onset in childhood 

• Estimated ~5% prevalence in school-age children 

  • Often self-remits in children,  more likely to persist in adults with IDD 

  • Estimated that ~30% of pregnant women engage in pica! 

Is "Obesity" a DSM-5-TR Disorder? 

• We’ve discussed DSM disorders with concerns about low weight 

• Should the DSM also consider obesity as a diagnostic category? 

• No! 

• Obesity is contributed to a range of genetic, behavioural, physiological, and environmental factors 

  • Compare with anorexia nervosa, which is driven by psychological concerns (i.e., fear, difficulties with perception, lack of insight) 

  • Compare with binge-eating disorder, which is associated with weight gain but can occur in individuals of any size 

  • Some correlation between obesity and other mental health disorders (e.g., depression) 

Category: Motor DIsorders 

• A subset of “neurodevelopmental disorders” 

  • Reminder: Onset is expected to be early and (relatively) persistent! 

• Disorders related to effortful or involuntary body movements 

• As a psychological disorder, shouldn’t be better explained by sensory impairments or biological concerns (e.g., cerebral palsy) 

  • Includes:  

    • Developmental coordination disorder 

    • Stereotypic movement disorder 

    • Tic disorder 

Developmental Coordination Disorder 

• The acquisition and execution of coordinated motor skills is substantially below that expected given the individuals’ chronological age and opportunity for skill learning and use. 

• Difficulties are manifested as clumsiness as well as slowness and inaccuracy of performance of motor skills. 

• Deficient motor skills significantly and persistently interfere with activities of daily living appropriate to chronological age, and impacts academic/school productivity, prevocational/vocational activities, leisure and play.  

Diagnosis: 

• Skill deficits that are observed may vary across development 

  • Overall: Movements more likely to be slow and imprecise 

  • In young children, e.g., early motor milestones, navigating stairs, completing puzzles 

  • In older children, e.g., handwriting/typing, driving, self-care skills 

• Be able to differentiate developmental coordination disorder from… 

  • ADHD 

  • Specific learning difficulty in writing 

  • Intellectual developmental disorder 

Prevalence: 

• 7-8% prevalence in children 5-11 years old 

• Rarely diagnosed before age 5 

  • Normal variability in when children meet developmental milestones 

  • Difficulties may not persist throughout development (i.e., children may “catch-up” with peers) 

• Difficulties continue through adolescence in 50-70% of diagnosed cases 

Stereotypic Movement Disorder 

• Repetitive, seemingly driven, and apparently purposeless motor behaviour (i.e., “stereotypies”) 

  • e.g., hand shaking or waving, body rocking, head banging, self-biting 

• Repetitive motor behaviour interferes with social, academic, or other activities, and may result in self-injury 

• Onset is early in the developmental period 

Specifiers: 

• Severity: 

  • Mild:  Symptoms are easily suppressed by sensory stimulus or distraction. 

  • Moderate:  Symptoms require explicit protective measures and behavioural modification. 

  • Severe: Continuous monitoring and protective measures needed to prevent serious injury. 

• With/without self-injurious behaviour 

• Associated with a known genetic or other medical condition, neurodevelopmental disorder, or environmental factor 

Course and Prevalence: 

Behaviours can occur many times per day, or may have several weeks between episodes 

• May occur more when distracted, bored, stressed, fatigued 

• Children typically enjoy stereotyped behaviour (“ego-syntonic”) 

• Typical onset within first 3 years of life 

  • Stereotypic movements may be an early indicator of other neurodevelopmental problems  

    • Simple stereotypical movements (e.g., rocking) occur commonly in young, typically developing children (i.e., 5-19% prevalence) 

      • Complex movements are less common (3-4%) 

      • Occurs in 10-15% of individuals with IDD living in residential facilities 

Symptom: Tics 

Tics are sudden, rapid, nonrhythmic motor movements or vocalizations 

• Eye blinking and throat clearing among most common 

• Simple motor tics involve one muscle group, while complex motor tics involve multiple 

• Simple vocal tics may be sharp and short sounds, while complex vocal tics may involve words or phrases 

• “Premonitory sensation”: Self-reported urge/discomfort that may occurs before tic behaviours 

• Tic behaviours are involuntary, but some can be suppressed 

  • Complex tics involve multiple motor groups and may appear purposeful 

  • Discussion of tics may trigger tic-related behaviour 

Tic Disorders 

While “Tic Disorder” is a diagnostic label, it has five subcategories: 

• Tourette’s Disorder 

• Persistent (Chronic) Motor or Vocal Tic Disorder 

• Provisional Tic Disorder 

• Other Specified Tic Disorder 

• Unspecified Tic Disorder 

Course and Prevalence: 

• Typically begin pre-puberty, between ages 4 and 6 

  • Symptoms typically peak between 10 and 12 and decline during adolescence 

  • A minority of individuals will have symptoms that persist or worsen in adulthood 

• 0.3 - 0.9% prevalence of Tourette’s Disorder in school-age children 

  • 70-85% heritability  

• May not be associated with impairment in milder cases 

• Risk for comorbid conditions changes across development 

  • Prepuberty: ADHD, OCD, separation anxiety 

  • Teenagers/Adults: Mood and anxiety disorders, substance use disorders 

Category: Somatic Symptoms and Related Disorders 

• Somatic: Related to the body. 

• “Somatic Symptom Disorders” are related to the experience of (or worry about) physical symptoms which are associated with significant distress or impairment. 

• In the context of this course, we’ll discuss: 

  • Somatic Symptom Disorder 

  • Illness Anxiety 

• Within somatic symptom disorders, symptoms cannot be… 

  • Attributed to a physical condition 

  • Explained entirely by another psychological condition associated with physical symptoms (e.g., depression, anxiety)

Somatic Symptom Disorder: Prevalence and Course 

Severity specifiers: 

• Mild: One of the distress-related symptoms. 

• Moderate: Two or more of the distress-related symptoms 

• Severe: Two or more distress-related symptoms AND multiple somatic symptoms (or one severe symptom) 

  • 6.7 – 17.4% prevalence in adults and adolescents 

    • ~20% prevalence in children; causes unclear but likely to be multifactorial 

  • Trauma exposure and/or multiple aversive experiences in childhood increase risk for disorder 

Somatic Symptoms Disorder in Children 

• In children, most common symptoms are: 

  • Recurrent abdominal pain 

  • Headache 

  • General fatigue 

  • Nausea 

• Children more likely to report a single, prominent symptom 

• Parents’ reports are important in determining the degree of distress, impairment (e.g., time away from school, time spent with medical professionals) 

Chronic Pain in Somatic Symptom Disorder 

Pain is a subjective physiological experience that functions to protect us from causing harm to our bodies 

• Pain occurs prior to and during tissue damage to prompt us to change activities 

“Chronic pain” refers to pain that: 

• lasts significantly beyond the healing period after an injury (i.e., 6 months) 

• has no biological value (i.e., maladaptive) 

• is generally non-responsive to specific remedies 

• overprotects us and prevent recovery 

“With predominant pain” is the most common type of somatic symptom disorder in older individuals 

Chronic Pain and Controversy: 

• “Chronic pain” is not a diagnostic label in the DSM-5-TR 

  • Instead: “Somatic symptom disorder with predominant pain” 

• What risks might there be to labelling someone’s somatic symptoms as psychological? 

  • Does pain that defies medical explanation mean there is no medical cause? 

  • How might a person experiencing somatic symptoms react to being recommended to seek mental health care? 

• What benefits might there be to labelling someone’s somatic symptoms as psychological? 

  • All experiences of pain are influenced by psychological factors! 

    • People can experience notable pain without significant injury 

    • People can experience notable injury without significant pain 

Chronic Pain and Treatment: 

• Multidisciplinary teams: 

  • Psychiatry, for pain management 

  • Psychology, for distress management 

  • Physiotherapy, to diagnose injury 

  • Kinesiology, to guide appropriate exercise 

  • Occupational therapy, to support day-to-day functioning 

  • Dietician, to manage weight, inflammation 

  • Social work, to support reintegration 

  • Recreational therapy, because fun is important too! 

Illness Anxiety Disorder 

• Preoccupation with having or acquiring a serious illness 

• Somatic symptoms are not present, or if present, are only mild in intensity.   

  • If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate 

• There is a high level of anxiety about health, and the individual is easily alarmed about personal health status 

• The individual performs excessive health-related behaviours or exhibits maladaptive avoidance 

• Preoccupation has been present or at least 6 months, and is not better explained by another disorder 

• Different from Somatic Symptom Disorder because… 

  • Concern is derived from non-pathological physical signs/sensations 

    • Normal physiological sensations 

    • Benign/limited dysfunction 

    • Discomfort not usually related to disease 

  • Distress emanates from anxiety about sensations, rather than the impact of the sensation themselves 

• Care-seeking type:  Medical care, including physician visits, undergoing tests and procedures, is frequently used. 

• Care-avoidant type: Medical care is rarely used. 

Generally rare in children, but may be observed in adolescence 

• Individuals do not respond to appropriate medical reassurance or negative diagnostic tests 

• Risk may be increased for individuals with a history of childhood abuse, serious childhood illness, serious illness/death in a parent 

• One-third to one-half of individuals have a transient form associated with less psychiatric comorbidity and more medical comorbidity 

Somatic Symptom/Illness Anxiety: Physical and Mental Health 

• In the short term, physician responses may: 

  • Involve many medical tests 

  • Temporarily relieve anxiety  

    • But remember the learning model of fear! 

• In the long term, physician responses may… 

  • Result in heightened anxiety as common disorders are ruled out 

  • Be characterized by frustration or hostility 

  • Result in clients feeling that they aren’t being taken seriously 

Category: Elimination Disorders 

• Two diagnostic labels in this category: 

  • Enuresis 

  • Encopresis 

• Disorders that involve the passage of urine or feces into “inappropriate places” (i.e., not the toilet) 

• Symptomatic behaviours can be voluntary or involuntary 

• Minimum age requirements for diagnosis based on expected developmental milestones 

  • Age requirements are based on developmental age rather than chronological age 

• Can be identified as: 

  • Primary:  Continence was never developed 

  • Secondary: Continence was developed before elimination disorder was established 

• Impairment based on: 

  • limitations in children’s social activities 

  • social ostracism from peers 

  • impact on youth’s self-esteem 

  • potential anger, punishment, and rejection from caregivers 

Enuresis 

Repeated voiding of urine into bed or clothes, whether involuntary or intentional 

• Behaviour is clinically significant, as manifested by either: 

  • A frequency of twice a week for at least 3 consecutive months 

  • Clinically significant distress or impairment in social, academic/occupational, or other important areas of functioning 

• Chronological age is at least 5 years (or equivalent developmental level) 

• Not attributable to effects of a substance or another medical condition 

• Specify: 

  • Nocturnal only 

  • Diurnal only 

  • Both nocturnal and diurnal 

Nocturnal Enuresis 

• i.e., “wetting the bed” 

• Most common form of enuresis 

• Typically occurs within the first 1/3rd of the night during REM sleep 

  • Children may recall dreams about urinating 

• Nocturnal enuresis is more common in males than females (2:1) 

Diurnal Enuresis 

Diurnal enuresis can be divided into… 

• Urge Incontinence – Sudden urge to urinate and difficulty controlling bladder muscle responses results in incontinence 

  • Likely due to executive functioning difficulties or neurological problems 

• Voiding Postponement – Delaying urges to urinate until incontinence results 

  • Likely due to social anxiety or preoccupation with school/play activity 

More common in females than males. 

Enuresis: Course and Prevalence 

Most children with enuresis do not have a comorbid mental health disorder 

• Higher prevalence in individuals with ADHD or learning disorders 

Prevalence decreases substantially across development: 

• After age 5, spontaneous remission in 5-10% of cases per year 

• 1% of cases may have persistent enuresis into adulthood 

Treatment: 

• Parent coaching 

  • Share data about prevalence, remission; assess frustrations 

• For nocturnal enuresis: 

  • Regular bladder emptying before bed 

  • Reduction of fluid, dairy, protein within ~4 hours of bed 

  • Antidiuretic medication 

  • Bedwetting alarm systems 

    • Works by conditioning a response to nocturnal urges to urinate 

    • Continue for 2-3 months until 14 consecutive nights without enuresis 

• For diurnal enuresis:  

  • Biofeedback/”bladder training” 

  • Anticholinergic medication (reduces bladder contractions) 

Encopresis 

• Repeated passage of feces into inappropriate places (i.e., clothing, floor), whether involuntary or intentional 

• At least one such event occurs each month for at least 3 months 

• Chronological age is at least 4 years (or equivalent developmental level) 

• The behaviour is not attributable to the physiological effects of a substance or another medical condition except through a mechanism involving constipation 

Specifiers: 

• With constipation and overflow incontinence 

  • Constipation may develop from anxious or oppositional retentive behaviours 

  • On account of severe constipation, a bowel movement is only partially completed during toileting 

  • Leakage may continue throughout the day/evening 

• Without constipation and overflow incontinence 

  • Less common form of encopresis 

  • When accidental, may result from bowel stretching from stool retention 

    • Reduces child’s ability to  

  • When deliberate, may be associated with ODD/CD 

Prevalence and Curse 

• Prevalence: 1-4% of children 

  • Higher prevalence in younger children (i.e., ages 4-6) 

• Equal prevalence in younger children 

  • In older children, more common in boys than girls (between 2:1 and 6:1) 

• Initial development may be contributed to by: 

  • Inconsistent toileting practices 

  • Psychosocial stress 

  • Anxiety, depression, behavioural disorders 

• Painful defecation can lead to retentive behaviours, which further contribute to constipation and encopresis 

• Encopresis may be persistent for many years 

Treatments 

• No well-established treatments at this time 

  • When associated with constipation, may resolve with adequate treatment of constipation and/or associated causes of retention 

  • When accidental and related to difficulties with stretch receptors in the colon, may resolve with biofeedback treatment 

  • When intentional, may resolve through addressing symptoms of ODD/CD 

Sleep and Wake Disorders 

“Parasomnias” are abnormal behavioural or physiological events that occur during sleep 

• Diagnoses intended to facilitate a referral to a sleep specialist 

  • But psychology may assist with comorbid/underlying mental health conditions! 

• Must result in significant impairment in important areas of functioning 

• Not attributable to physiological effects of a substance 

• Can’t be adequately explained by a comorbid mental health disorder 

• Covering a subset of disorders in this course: 

  • Nightmare Disorder 

  • Non-Rapid Eye Movement Sleep Arousal Disorders 

  • Insomnia Disorders 

Normative Sleep in Children and Adolescents 

• Infants spend the majority of their time (16-18 hours/day) asleep, sleeping for 3-4 hours at a time 

• Young children begin to develop circadian rhythms, sleeping 14-15 hours/day across two long sleep periods (~6 hours) plus naps throughout the day 

• Daily sleep reduces by ~1 hour/night/year throughout early childhood 

• Adolescents tend to sleep later and sleep less than younger children 

  • Average decline in sleep by 14 minutes/night per year of adolescence! 

  • Trend persists after accounting for cultural factors, but significant differences still noted in cultures with differences in… 

    • Beliefs about mid-day naps 

    • School start times 

• Preference for “eveningness” peaks around age 20, with a trend towards “morningness” throughout the remainder of development 

Normative Sleep Disturbances in Children and Adolescents 

Isolated parasomnias are normative:  

• 12-14.5% of Canadian children experience at least one episode of sleepwalking 

• 34.4% - 36.9% prevalence of sleep terrors at 18 months of age 

• Acute insomnia is associated with stressful life events and often resolves with the associated situation 

• Sleep continuity and depth are expected to decrease across development into adulthood 

  • These expectations may increase risk that pathological changes go unreported! 

Nightmare disorder 

Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams  

• Usually involve efforts to avoid threats to survival, security, or physical integrity 

• Generally occur during the second half of the major sleep episode (REM) 

• On awakening from the dysphoric dreams, the individual rapidly becomes alert 

Prevalence and Course 

• Prevalence of nightmares in… 

  • Early childhood: 1-5%  

    • with 1-4% parents of preschool children reporting nightmares “often” or “always” 

  • Older children: ~5.2% 

• Differs from “bad dreams”, which do not result in awakening 

• Nightmares often begin between ages 3 and 6 

  • Often appear in children exposed to acute/chronic stress 

  • Peak in prevalence and severity in late adolescence/early adulthood 

• Comorbid insomnia seen in 20% of children with frequent nightmares 

• Impairment related to sleep disruption for child and caregiver, especially when occurring several times per week 

  • Adaptive parental bedside behaviours (i.e., soothing) associated with less chronic course 

Specifiers 

• Severity: 

  • Mild: <1 episode per week (on average) 

  • Moderate: 1+ episodes per week, but less than nightly 

  • Severe: Episodes nightly 

• Persistence: 

  • Acute: Duration of nightmares is <1 month 

  • Subacute: Between 1 months and 6 months 

  • Persistent: >6 months 

Non-Rapid Eye Movement Sleep Arousal Disorders 

• Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either of sleepwalking or sleep terrors. 

  • Typically last 1 to 10 minutes, but may last up to an hour 

• Little-to-no dream imagery is recalled 

• Amnesia is present for the episodes 

Sleepwalking: 

Sleepwalking:  Repeated episodes of rising from bed during sleep and walking about. 

• Individual usually has a blank, staring face 

• Relatively unresponsive to efforts of others to communicate with them 

• Usually engage in simple/routine behaviours 

• Uncommonly engage in complex and higher risk behaviours 

  • e.g., a child going outside in the night, preparing or eating food 

• Can be awakened with great difficulty, resulting in a period of brief confusion or reorientation 

Sleep Terrors: 

Sleep terrors:  Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream.   

• Intense fear and autonomic arousal 

  • Flailing or tantrum-like behaviour could result in injury of self or nearby individuals 

• Relative unresponsiveness to efforts of others to comfort the individual 

• Individuals will often return to sleep and report no recollection of the episode the following morning 

  • If fear-related content is recalled, it is usually brief and fragmented (e.g., still images) 

• Differs from “bad dreams” and “nightmares” on account of amnesia 

Prevalence and Course: 

• Limited data on prevalence of disordered sleep terrors/sleepwalking 

• Behaviours are typically outgrown following infancy and childhood 

  • Remission rates of 50-65% 

• Family history of NREM sleep arousal disorders in 80% of cases 

• Impairment may stem from frequency of behaviours, risk for injury, disruption/distress for individual or their household 

Insomnia Disorder 

• A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following: 

  • Sleep-Onset (“Initial”) Insomnia: Difficulty initiating sleep  

    • In children, difficulty initiating sleep without caregiver intervention 

  • Sleep Maintenance (“Middle”) Insomnia: Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings 

    • In children, difficulty returning to sleep without caregiver intervention 

  • Late Insomnia: Early-morning awakening with inability to return to sleep 

• Occurs at least 3 nights per week, persisting for at least 3 months 

• Disturbance causes clinically significant impairment  

• Not better explained by another sleep-wake disorder or the physiological effects of a substance 

• Coexisting mental disorders and medical conditions do not adequately explain predominant complaint of insomnia 

Presentation: 

• Arbitrary guidelines for sleep loss are suggested (and acknowledged as arbitrary!) 

  • Taking over 20-30 minutes to fall asleep 

  • Waking and being unable to fall asleep for 20-30 minutes 

  • Waking at least 1 hour before intended 

• Sleep maintenance insomnia is the most common single symptom 

  • Symptoms are normally experienced in combination, though! 

• May result in impairment related to: 

  • Sleepiness and difficulties with cognitive performance 

  • Irritability or mood lability, and  

  • Risk for depression, anxiety, substance use disorders 

  • Risk for cardiovascular diseases 

Prevalence and Course: 

40-50% of individuals with insomnia have a comorbid mental health disorder 

• Prevalence is unclear, as onset is more common in young adulthood 

• In children, insomnia can result from: 

  • Conditioning factors (e.g., “I can only fall asleep when…”) 

  • Absence of consistent sleep schedules/bedtime routines 

  • Psychological and medical factors 

• In adolescents, insomnia can result from… 

  • Irregular sleep schedules 

  • Psychological and medical factors 

Category: Substance Use Disorders 

• DSM-5-TR contains specific disorders for 10 classes of substances 

  • All substances described directly activate the reward centres of the brain, although the mechanisms differ 

• Divided into “substance use” and “substance-induced” disorders 

  • “Substance Use Disorder” is used rather than “drug addiction” due to: 

    • Colloquial use of “drug addiction” referring to more severe presentations 

    • Stigma associated with “drug addiction” 

  • “Behavioural addictions” (e.g., sex, shopping, video games) have limited supporting research and are not included in the main body of the DSM-5-TR 

General Overview: 

• Impaired control 

  • Used in larger amounts than are intended, or for a longer period of time 

  • Unsuccessful attempts to regulate or cease use 

  • Time spent using substances/recovering from use 

  • Urges or cravings for substance use  

• Social impairment 

  • Failure to fulfill role obligations 

  • Continued use despite social difficulties 

  • Withdrawal from important activities on account of substance use 

• Risky use 

  • Continued use in physically hazardous situations 

  • Continued use despite psychological or medical consequences 

• Pharmacological criteria 

  • Development of tolerance and/or withdrawal 

Relevance in Youth: 

• Most commonly used substances in North America are alcohol, tobacco, and cannabis 

• Substance use disorders likely begin between ages 15 and 17 

  • Can start as early as age 10 

  • Prevalence likely peaks between ages 18 and 25 

• Youths and young adults more likely to report problems associated with substance use 

  • Early use may be associated with long-term impairment 

  • May use substances to self-medicate psychological difficulties 

  • Children may experience greater intoxication at lower doses 

    • e.g., Average adult caffeine consumers use 280mg/day, but children can experience intoxication at 200 mg or lower 

Cannabis Legalization in Canada 

Patterns of substance use reflect social and geographic norms 

• Psychoactive substance use has occurred throughout human history 

• Changes in nicotine use related to changes in perception 

• Studies reporting increases in substance use during COVID 

With legalization, Canada took a “public health” approach to cannabis use, which aimed to… 

• Reduce criminalization of benign and low-risk behaviours 

• Regulate and better manage risks for individuals susceptible to harm 

Reducing risk of harm to vulnerable populations includes reducing cannabis use in youths 

• Meta-analytic findings suggest higher risk and earlier onset of psychosis in adolescent use 

• Meta-review of meta-analyses found use in adolescents and adults found acute small-to-moderate negative impacts on neurocognitive functioning that persist in heavy users 

After legalization in 2018, studies have found… 

• No change in reported cannabis use by children and adolescents 

• A substantial portion of cannabis purchases are through illegal/unregulated avenues 

• Increases in reports of dangerous accidental consumption by children and youths 

Data still emerging about the long-term impact of legalization! 

Terminology 

Gender Identity:  Internal sense of being male, female, neither, both, or another gender(s). 

Gender Expression:  Physical manifestation of gender identity (e.g., voice, body shape, clothing) 

Sex Assigned At Birth: Classification of people as male, female, intersex, or other based on anatomy, hormones, chromosomes. 

Why are sex and Gender important in Research? 

• Resilience and risk for psychopathology is contributed to by… 

  • Biological factors 

  • Cognitive factors 

  • Behavioural factors 

  • Environmental factors 

  • Social factors 

• Gender and sex are highly correlated, but not the same! 

• Interactions of assigned sex and gender may be especially helpful in predicting risk for psychopathology 

Historical Sex and Gender Differences in the DSM 

Then: 

• DSM-I (1952): Essentially no references to sex/gender. 

• DSM-II (1958): Infrequently referred to sex/gender. 

  • Included two disorders specific to women; “Psychosis with Childbirth” and “Involutional Melancholia” 

• DSM-III (1980): First edition to refer to sex ratios in disorders 

  • Described with minimal info (e.g., “more common in women”) 

  • Some disorders had different criteria or thresholds for men and women 

    • e.g., “Somatization Disorder”; 14 symptoms required for women, 12 for men 

    • 4 of the 36 possible symptoms were categorized as “female reproductive symptoms” 

• DSM-IV/TR (1994/2000): Included a specific section on “Specific Age, Culture, And Gender Features” for each disorder 

  • Actually referring to sex differences, not gender! 

  • Inconsistent reporting of sex-related information! 

Now: 

• DSM-5/TR (2013/2022) 

  • More consistent reporting of sex ratios and sex-specific risk for disorder 

  • DSM-5-TR revised with particular attention to issues of sex and gender 

  • Still strongly focuses on sex differences, with minimal reference to gender 

    • The field’s understanding/acceptance of gender as important and distinct from biological sex is still evolving 

    • Canada was the first country to collect census data on transgender and non-binary people – in 2021! 

In summary, our understanding of psychopathology was “gender neutral” (but largely based on the experiences of men) 

Are There True Sex/Gender Differences? 

• Experience different environmental risk factors 

  • Davies & Lindsay (2004); Girls show greater sensitivity to maternal depression, potentially through greater involvement in interpersonal family events 

• Exposed to different levels of the same environmental risk factors 

  • APA (2022); Girls exposed to higher rates of traumatic events and childhood abuse 

• Different sensitivity to environmental processes 

  • Zahn-Waxler et al. (2008); Summarized literature finding mothers’ low warmth and coercive behaviour predicted increases in boys’ aggressive behaviour but decreases in girls’ 

• Different biological processes 

  • Angold et al. (1999): Onset of depression in adolescent females more closely tied to hormonal differences than chronological age 

• Differently experience interactions between biology and environment 

  • Daoust et al. (2018); Higher cortisol (i.e., stress hormone) response to a social stressor predicts increases in young girls’ (but not boys’) internalizing symptoms 

What Might we be Missing in our Research? 

Sex and gender are incorrectly equated in a substantial portion of modern research reports 

• While they are highly correlated, they measure different things 

• e.g., Being ticketed for speeding based on how fast your car sounds 

Sampling Bias: Some studies look only at males or females. 

• Increases statistical power by limiting  your research question 

• Can result in confirmation bias, where we limit our research to known populations 

Data Analytic Bias: Studies that include males and females but don’t look at sex/gender effects. 

• Gender-neutral effects do not “average out”! 

• Failing to examine sex/gender could “wash out” important findings. 

Example of sex-based effects "washing out" 

How Might we Miss Psychopathology in Children? 

Referral Bias: Who is more likely to get referrals for support/assessment? 

• Individuals with more disruptive / observable symptoms! 

• More noticeable symptoms are more likely to show up in clinics for research, influencing prevalence estimations 

Reverse Halo Effect: One negative judgement leads to more. 

• Similar to our discussion of implicit racial biases in diagnosis! 

  • When ODD symptoms were present, boys were rated as having more ADHD symptoms than girls. 

  • When ADHD symptoms were present, girls were rated as having more ODD symptoms than boys. 

How Might we Miss Psychopathology in the DSM? 

Criterion Bias Hypothesis: Symptom criteria themselves are biased 

• How did we decide on what should be included in the DSM 

• Missing Symptom Hypothesis: An important symptom is missing that would increase the reliability of a diagnosis in boys/girls 

  • e.g., relational aggression in CD 

Measurement Variance Hypothesis: Certain measures might be less valid for boys/girls. 

Bringing it all Together 

Ascertainment Bias: Combination of multiple biases contributing to (potentially) false findings. 

• e.g., Sex differences in ASD 

  • More research in ASD is done with boys (Sampling bias) 

    • Boys more likely to have comorbid externalizing problems, which increases chances of referral (Referral bias) 

    • Girls may have fewer/more acceptable restricted interests, better imaginative play, better social functioning (Criterion bias) 

  • May have resulted in assessment tools less sensitive to girls (Measurement variance bias) 

Back to the Start: What is Psychopathology 

• “The Loudest Girl in the World” 

  • Podcast about a 40-year-old female reporter documenting her journey of being diagnosed with autism as an adult 

    • Talks at length about the substantial variation between individuals with ASD, including differences between boys and girls 

  • “If you know one person with autism, then you know one person with autism” 

Should we have different diagnostic criteria for boys and girls? 

Should we have different diagnostic criteria for everyone?