Abnormal Psychology

Defining Abnormality

Terms to Remember

• Presents

  • Presenting problem of the client

• Prevalence

  • How many people in the population have the disorder

• Incidence

  • How many new cases occur during a given period of time

• Onset

  • Beginning of the disorder (acute or insidious onset)

• Course

  • Disorders follow an individual pattern (chronic course, episodic course, time-limited course)

• Etiology

  • What contributes to the development of the disorder

• Treatment Development

  • How to alleviate psychological suffering including pharmacology, psychotherapy, or combined treatments

• Prognosis

  • Anticipated/future course of a disorder

Abnormal Psychology

• Branch of psychology that deals with psychopathology and abnormal behavior

• Covers a broad range of disorders

Criteria for Defining Abnormality (4D)

• Distress; emotional pain

• Dysfunction; impairment or reduction in functioning

• Danger; risk to or could harm self or others

• Deviance; socially and culturally unacceptable behavior

Biopsychosocial Formulation (What causes abnormality?

• Biological Causes

• Psychological Causes

• Sociocultural Causes

Mental Health

• The successful performance of mental function resulting in productive activities, fulfilling relationships, and adaptation to change and cope with adversity

Mental Disorder (DSM V-TR)

• Syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior

• Reflects dysfunction in the psychological, biological, or developmental process underlying mental functioning activities

• Usually associated with significant distress or disability in important activities

• Expectable or culturally approved response to to a common stressor or loss such as death of a loved one, is not a mental disorder

• Socially deviant behaviors only become mental disorders when the deviance or conflicts results from a dysfunction in the individual

Basis for Assessing Maladjustment

• Conformity to norms or deviant?

  • Cultural relativity: too much relativity vs too much conformity

• Inner world: subjective experience

• Social Contribution - contributing members of the society

HISTORY OF ABNORMAL BEHAVIOR

Prehistoric and Ancient Beliefs

• Abnormal behaviors

  • demonology

  • evil spirits, demonic possessions, sorcery, or behest of an offended ancestral spirit

• Trephining/Trepanning

  • Creating a hole in the skull

• Exorcism

  • One of the oldest surgical procedures documented to date

• Dorothea Dix

  • Led reforms for mental health care in the United States

  • Investigated how those who are mentally ill and poor were cared for, and discovered an underfunded and unregulated system that perpetuated abuse of the population

• Clifford Beers

  • Founder of the mental hygiene movement

  • Launched of the earliest client-advocate health reform movements in the US

• Philippe Pinel

  • Argued for the more humane treatment of the mentally ill

  • Kindness and patience along with recreation, walks, and pleasant conversations with patients

• Emil Kraeplin

  • Connection of pathogenesis and manifestation of psychiatric disorders

  • Known for the classification of mental disorders

  • Created a statistical manual of psychiatric diseases long before the DSM

Contemporary Theories On The Causes Of Abnormality

Terms to Remember

• Disease

  • Mostly organic

  • Structural changers

  • Lab test

• Disorder

  • Mostly functional

  • Functional changes

  • Depends, not confirmatory

• Signs

  • Objective (physician’s observation)

• Symptoms

  • Subjective (patient’s observation)

• Primary Gain

  • Positive internal motivations

• Secondary Gain

  • Positive external motivations

• Classification

  • Systematic delineation of major categories of psychological conditions as well as the boundaries between and relations among them

  • Goal: improved prediction and ultimate understanding of disordered behavior

  • Helps in the prediction of:

    • Course and outcome of an individual’s mental disorders

    • Their family history

    • Performance in laboratory system

    • Treatment response

    • May provide important clues to the causes of psychopathological disorders

• Diagnosis

  • Process of assigning individuals to the categories generated by a classification system

• Other Specified

  • Allows the clinician to communicate specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class

• Unspecified Disorders

  • Clinicians decided not to put any specifiers

• Comorbidity

  • Co-occurring

• Differential Diagnosis

  • The process of determining which of two or more diseases or disorders with overlapping symptoms a particular patient has

• Premorbid Personality

  • Personality traits that existed before a physical injury or other traumatic event or before the development of a disease or disorder

Biological Approaches

• Structural abnormalities, disordered biochemistry, faulty genes are the cause of psychological symptoms and disorders

• Structural abnormalities can be caused by injury or disease processes

  • Location of brain damage influences psychological symptoms

• This theory focuses on neurotransmitters

  • Neurotransmitters are biochemicals that facilitate transmission of impulses in the brain

• Some people may be genetically predisposed to psychological disorders

  • Not linked to a single faulty gene but rather an accumulation of faulty genes

• Three methods of determining heritability of a disorder

  • Family history studie

  • Twin studies

  • Adoption studies

Neurotransmitter Theories

Serotonin

• Regulate our experience of reinforcements

or rewards and it is affected by substances

• One natural body chemical that controls your mood

• Works with melatonin to help control when you sleep and wake up as well as:

  • How you feel pain

  • Wellbeing

  • Sexual desire

• Insufficient and excessive serotonin may

be associated with:

• Depression and mood problems

  • Anxiety

  • Sleep problems

  • Digestive problems

  • Suicidal behavior

  • Obsessive-compulsive disorder

  • Post-traumatic stress disorder

  • Panic disorders

Dopamine

• Regulate our experience of reinforcements

or rewards and it is affected by substances

• Important to the functioning of the muscle

systems

• Plays a role in disorders involving

muscle control (Parkinson’s disease)

• Abnormally low prefrontal dopamine

activity is associated with schizophrenia

• Having too much or too little dopamine

are linked to illnesses including:

• Depression

  • Schizophrenia

  • Psychosis

• Having too much dopamine is linked to

aggressiveness and having trouble

controlling impulses

• Dopamine imbalances are related to ADHD

and addiction

Norepinephrine (noradrenaline)

• Produced by neurons in the brain stem

• Cocaine and amphetamines prolong

norepinephrine by slowing its reuptake

• Because of the delay, receiving

neurons are activated for a longer

period of time causing stimulating

effects

• Too little norepinephrine causes

depression

Social Structural Model Of Mental Health

Models Of Psychopathology

• Inferiority Model

  • The upbringing, physical and mental limitations, or experiences of lower social status

• Deprivation/deficit model

  • Absence of inputs in the environment such as cognitive and

social stimulation that alters cognitive development

• Multicultural model

  • Different cultures have different psychological disorders

Models In The Study Of Psychopathology

• Has an eclectic approach

• No single “true” model of abnormal behavior

Biogenic model

• Human thoughts, emotions and behavior are associated with nerve cell activities of brain and spinal cord

  • Changes in any of these domains are associated with changes in activity or structure of the brain

• A mental disorder is highly correlated with

brain dysfunction

• Mental disorders can be treated by drugs or

somatic intervention

• Responses are learned

  • Even abnormality can be learned

• Symptoms have underlying stimulus

• Psychological problems is a result of

dysfunctional behavioral patterns that was

learned and placed into practice

Cognitive-behavioral

• Faulty schema causes psychopathology

• Abnormality stems from mental processing

• Irrational thoughts or beliefs

• Cognitive patterns and distortions

Cognitive-neuroscience

• Puts basis on cognitive perspective

• Brain scans, genetic studies, endocrine

system

Biopsychosocial

“Eclectic approach”

• Consideration of precipitating, predisposing,

and perpetuating factors

• Predisposing factors

  • Risk

• Precipitating factors

  • Trigger

• Perpetuating factors

  • Maintain

• Protective factors

  • Reduce

Review Of The Psychological Theories

• Psychodynamic Approach

  • Focus on the psychological drives

and forces within individuals that explain human behavior and personality.

• Behavioral Approach

Focuses on how people learn

through their interactions with the

environment.

• Cognitive Behavioral Approach

  • Suggests that our thoughts,

emotions, body sensations, and

behavior are all connected, and that

what we think and do affects the way

we feel.

• Humanistic /existential / phenomenological

  • Emphasizes looking at the whole

individual and stresses concepts such as free will, self-efficacy, and self-actualization

• Interpersonal theories

  • Reciprocal social and emotional

interactions between the patient and

other persons in the environment

• Family systems

  • Posits that the family is a single

emotional, interdependent unit. The

needs and abilities of one family

member will affect all family members

• Social structure theories

  • The complex of relationships and

systems that organize and regulate

interpersonal phenomena in a group

or society

Introduction to DSM 5-TR

Impact of Racism and Discrimination on Psychiatric Diagnosis

• Racialization

  • social process by which specific categories of identity are constructed on the basis of racial ideologies and practices

  • important because they are strongly associated with systems of discrimination, marginalization, and social exclusion

  • may also be the focus of bias or stereotyping that can affect the process of diagnostic assessment

• Racism

  • an important social determinant of health

    • including hypertension, suicidal behavior, and posttraumatic stress disorder and can predispose individuals to substance use, mood disorders, and psychosis

• Sex

  • factors attributable to an individual’s reproductive organs

  • XX = Female

  • XY = Male

• Gender

  • result of reproductive organs as well as an individual’s self-representation

  • includes the psychological, behavioral, and social consequences of the individual’s perceived gender

• Influence of Sex and Gender to Illness

  • Sex may exclusively determine whether an individual is at risk for a disorder

  • Sex or gender may moderate the overall risk for development of a disorder as shown by marked differences in the prevalence and incidence rates for selected mental disorders in men and women

    • may influence the likelihood that particular symptoms of a disorder are experienced by an individual

    • may also have other effects on the experience of a disorder that are indirectly relevant to psychiatric diagnosis

• Association With Suicidal Thoughts or Behavior

  • based on studies demonstrating associations of suicidal thoughts or behavior with a given diagnosis

  • clinicians should use clinical judgment informed by known risk factors and not rely solely on the presence of a diagnosis

• Clinical judgment

  • refers to the professional capacity to make sound, informed decisions based on a thorough understanding of psychological theories, research evidence, and the unique circumstances of each client

  • integrating subjective observations, objective assessments, and theoretical knowledge to formulate diagnosis, treatment plans, and interventions tailored to the individual's needs

  • encompasses the ability to recognize and navigate ethical dilemmas, cultural differences, and personal biases while maintaining a commitment to the client's well-being and autonomy

  • applying expertise and wisdom to promote positive outcomes in clients' lives

• Approach to Clinical Case Formulation

  • The purpose of DSM-5 is to assist trained clinicians in the diagnosis of mental disorders as part of a case formulation assessment that leads to an informed treatment plan for each individual

  • The case formulation should involve a careful clinical history and a concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder

    • A thorough evaluation of these criteria may assure more reliable assessment

    • the relative severity and salience of an individual’s signs and symptoms and their contribution to a diagnosis will ultimately require clinical judgment

    • use the available contextual and diagnostic information in developing a comprehensive treatment plan that is informed by the individual’s cultural and social context

  • Diagnosis requires clinical training to recognize when the combination of predisposing, precipitating, perpetuating, and protective factors has resulted in a psychopathological condition in which the signs and symptoms exceed normal ranges

• Substance/Medication-Induced Mental Disorder

  • symptomatic presentations that are due to the physiological effects of an exogenous substance on the central nervous system, including symptoms that develop during withdrawal from an exogenous substance that is capable of causing physiological dependence

    • alcohol, inhalants, hallucinogens, cocaine

    • psychotropic medications

    • other medications

    • environmental toxins

• Independent Mental Disorders

  • “the disturbance is not better accounted for by an anxiety disorder that is not substance-induced…”

  • Subtypes

    • define mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis and are indicated by the instruction

    • “Specify whether”

  • Specifiers

    • not intended to be mutually exclusive or jointly exhaustive, and as a consequence, more than one specifier may be applied to a given diagnosis

• Use of Other Specified and Unspecified Mental Disorders

  • Other Specified

    • provided to allow the clinician to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class

• Diagnostic Features

  • provides descriptive text illustrating the use of the criteria and includes key points on their interpretation

• Associated Features

  • includes clinical features that are not represented in the criteria but occur significantly more often in individuals with the disorder than those without the disorder

• Prevalence

  • describes rates of the disorder in the community, most often described as 12-month prevalence, although for some disorders point prevalence is noted

• Development and Course

  • describes the typical lifetime patterns of presentation and evolution of the disorder

• Risk and Prognostic Factors

  • includes a discussion of factors thought to contribute to the development of a disorder

  • Divided into subsections:

    • temperamental factors

    • environmental factors

    • genetic and physiological factors

• Functional Consequences

  • discusses notable functional consequences associated with a disorder that are likely to have an impact on the daily lives of affected individuals

• Differential Diagnosis

  • discusses how to differentiate the disorder from other disorders that have some similar presenting characteristics

• Comorbidity

  • includes descriptions of mental disorders and other medical conditions

Neurodevelopmental Disorders

• Group of conditions with onset in the

developmental period

• Manifest early in development (before

entering grade school)

• Developmental deficits that produce

impairment of personal, social, or academic

functioning

• The developmental deficits rangers from

very specific limitations to global

impairments of social skills or intelligence

• Neurodevelopmental disorders usually co-

occur

Intellectual Disability (Intellectual Developmental Disorder)

• Deficits in adaptive functioning: how well a

person meets community standards of

personal independence and social

responsibility compared to others of similar

age and sociocultural background

• Intellectual functions: reasoning, problem

solving, planning, abstract thinking

Criteria

• Criterion A: Deficits in general mental abilities

• Criterion B: Impairment in everyday adaptive functioning

• Criterion C: Onset is during the developmental period

• Severity: mild, moderate, severe, profound

• Conceptual (academic) - competence in memory, language, reading, writing, math reasoning, acquisition of practical knowledge, problem solving, and judgment in novel situations

• Social domain - awareness of others’ thoughts, feelings, and experiences; empathy, interpersonal communication skills, and social judgment

• Practical domain - learning and self- management across life settings (personal care, job responsibilities, money management, task organization)

Relevant Information

• Rosa’s Law (Public Law 111-256) mental

retardation to intellectual disability

• Features:

  • Lack of communication skills may

predispose to disruptive and aggressive

behaviors

• Lack of awareness of risk may result in

exploitation

• At risk of suicide

• Prevalence:

  • 1% of the general population

severe intellectual disability: 6 per 1000

• Risk:

  • Prenatal etiologies

    • Chromosomal disorders, brain malformations

    • Maternal disease

    • Environmental influences

  • Perinatal causes

    • Labor and delivery

  • Postnatal

    • Traumatic brain injury, seizure,

intoxication, infection, severe and

chronic social deprivation

Global Developmental Delay

• Individuals fails to meet expected

developmental milestones in several areas of

intellectual functioning

• Unable to undergo systematic assessments

of intellectual functioning including children

who are too young to participate in

standardized testing

• Requires reassessment after a period of

time

• Diagnosis is for individuals under 5 years of

age when the clinical severity cannot be

reliably assessed during early childhood

Communication Disorders

• Deficits in speech

  • Articulation

  • Fluency

  • Voice

  • Resonance

  • Quality

  • Sounds

• Deficits in language

  • Form function and use of a

conventional system of symbols

• Deficits in communication

  • Verbal

  • Non-verbal

Language Disorder

Criteria

• Criterion A: difficulties in the acquisition

and use of language across modalities

• Reduced vocabulary

  • Limited sentence structure

  • Impairments in discourse

(explaining a topic or having

conversation)

• Criterion B: Language abilities are

substantially below those expected for age

that limits functioning in effective

communication, social participation,

academic achievement, and work

performance

• Criterion C: Onset is in early

developmental period

• Criterion D: Not attributable to another

medical or neurological condition

Relevant Information

• Expressive ability - the production of vocal,

gestures, or verbal signals

• Receptive ability - the process of receiving

and comprehending language messages

Features

• Family history of language disorder

• Shy or reticent to talk

• Prefers communication to family members or other familiar individuals only

• Co-occurs with speech sound disorder

Development and Course

• Those diagnosed from 4 years of age is likely to be stable overtime and typically persist into adulthood

Risk and Prognostic Factor

• Receptive language impairments

• More resistant to treatment and difficulties with reading comprehension

Speech Sound Disorder

• Criterion A: Difficulty with speech sound

production interferes with speech

intelligibility or prevents verbal

communication of messages

• Criterion B: Causes limitations in effective

communication that interfere with social

participation, academic achievement, or

occupational performance (individually or

combined)

• Criterion C: Onset is in the early

developmental period

• Criterion D: Not attributable to congenital

or acquired conditions

Relevant Information

• Expressive ability - the production of vocal,

gestures, or verbal signals

• Receptive ability - the process of receiving

and comprehending language messages

Features

• Speech sound production requires articulation of the phonemes, phonological knowledge of speech sounds and the ability to coordinate the movements of the articulators with breathing and vocalizing for speech

• Verbal dyspraxia is a term also used for

speech production problems

• Frequently articulated sounds

• Most children with speech sound disorder respond well to treatment and speech difficulties improve over time and may not be lifelong

Childhood-onset Fluency Disorder

Criteria

• Criterion A: Disturbance in the normal fluency and time patterning of speech that are inappropriate for the individual’s age and language skills, persist overtime, and:

  • Sound and syllable repetitions

  • Sound prolongations

  • Broken words (pauses within a word)

  • Audible or silent blocking (filled or unfilled pauses)

  • Circumlocutions (word substitutions to avoid problematic words)

  • Words produced with an excess of physical tension

  • Monosyllabic whole-word repetitions (I-i-i-i see him)

• Criterion B: Causes anxiety about speaking or limitations in effective communication, social participation, and academic or work performance (individually or combined)

• Criterion C: Onset is in the early developmental period

• Criterion D: Not attributable to another medical condition; not better explained by another mental disorder

Social (Pragmatic) Communication Disorder

Criteria

• Criterion A: Difficulties in the social use of communication

  • Deficits in using communication for social purposes in an appropriate manner

  • Impairment of the ability in changing communication to match context or the needs of the listener

  • Difficulties following rules for conversation and storytelling

  • Difficulties understanding what is not explicitly stated

• Criterion B: Result in functional limitations

in effective communication, social

participation, social relationships, academic

achievement, or work performance

(individually or combined)

• Criterion C: Onset is in the early

developmental period

• Criterion D: Not attributable to another

medical or neurological condition

Relevant Information

• History of delay in reaching language

milestones and structural language problems

• May avoid social interaction

• ADHD, behavioral problems, and

• specific learning disorders are common

• Rare among children under 4 years old

• Family history of autism,

communication disorder, or learning

disorder

Autism Spectrum Disorder

• Came from the greek word “autos”

meaning self

• Autism can be defined as “locked

within one’s self”

• Lack of “theory of mind”

  • How we ascribe mental states to other persons and how we use it to explain and predict their actions

• Spectrum

  • Manifestations vary depending on the severity of the condition, developmental level, and chronological age

Criteria

• Criterion A: Persistent deficits in social communication and social interaction

  • Deficits in social-emotional reciprocity

  • Deficits in nonverbal communicative behavior

  • Deficits in developing, maintaining, and understanding relationships

• Criterion B: Patterns of behavior should be at least 2 or more

  • Highly restricted fixated interests that are abnormal in intensity or focus (strong attachment to unusual objects)

  • Hyper- or hypo- reactivity to sensory input or unusual interest in sensory aspects of the environment

• Criterion C: Symptoms must be present in

the early developmental period

• Criterion D: Symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning

• Criterion E: These disturbances are not better explained by intellectual development disorder or global developmental delay. Intellectual developmental disorder and autism spectrum frequently co-occur

Relevant Information

• Formerly called:

✓ Early infantile autism

✓ Childhood autism

✓ Kanner’s autism (Leo Kanner, 1943)

• Henry Maudsley (1867)

  • First psychiatrist to pay serious attention to very young children with severe mental disorders

Features

• Can be inherited genetically

• 70% of children with autism suffer from

intellectual disability

• 4-5 times more frequent in boys than

girls

• Girls with autism are likely to have severe

intellectual disability

• Doesn’t show any physical signs

• Have higher incidence of

dermatoglyphics (adermatoglyphia)

• Dermatoglyphics

Study of of naturally occurring epidermal

ridges

Adermatoglyphia

Absence of fingerprints

• As babies they lack social smile

• They have poor eye contact with people

• Impaired attachment behavior

• Show anxiety when usual routine is

disrupted

• Lacks social and emotional reciprocity

• Symptoms are recognized during the

second year of lids (12-24 months)

✓ May be seen earlier than 12 months if developmental delays are severe

✓ Can be noted later than 24 months if symptoms are more subtle

Attention-Deficit/Hyperactivity Disorder (ADHD)

• Described by a pattern of diminished sustained attention and higher levels of impulsivity

• Three subtypes

✓ Predominantly inattentive presentation

✓ Predominantly hyperactive/impulsive presentation

✓ Combined presentation

• Inattention manifests behaviorally:

✓ Wandering off task

✓ Failing to follow through on

instructions, finishing work or

chores

✓ Having difficulty sustaining focus

✓ Being disorganized and is not

attributable to defiance or lack of

comprehension

• Hyperactivity

→ Excessive motor activity when it is not appropriate

→ Excessive fidgeting, tapping, or

talkativeness

• Impulsivity

→ Behaviors that are inappropriate, premature, unduly thought out and risky that lead to untoward outcomes

• Compulsivity

→ Tendency toward repetitive actions and repeated despite adverse consequences

Criteria

• Criterion A: Hyperactivity-impulsivity that

• interferes with functioning or development as

• characterized by 1 and 2 (if six or more of the

• following symptoms have persisted for at

• least 6 months):

• Inattention

✓ Overlooks details

✓ Task inattention

✓ Appears not to listen

✓ Fails to finish tasks

✓ Difficulty in organizing tasks

and activities

✓ Avoids tasks requiring

sustained mental activity

✓ Often loses things necessary

for tasks

✓ Easily distracted

✓ Often forgetful

• Hyperactivity and Impulsivity

✓ Often fidgets with or taps hands or feet or squirms in seat

✓ Leaves seat

✓ Runs or climbs

✓ Unable to maintain quiet

✓ Hyperactivity

✓ Talks excessively

✓ Blurts answers

✓ Struggle to take turns

✓ Interrupts or intrudes

• Criterion B: Symptoms were present prior

to age 12

• Criterion C: Symptoms are present in two

or more settings

• Criterion D: Impairment in functioning

• Criterion D: Symptoms do not occur exclusively during the course of schizophrenia or another

• Criterion E: Psychotic disorder is not better

explained by another mental disorder

Relevant Information

• Several inattentive or hyperactive-impulsive symptoms were present prior to

age 12 and in two or more settings

• Affects 2-20% of grade school children

(USA)

• Symptoms of ADHD

• Infants

✓ Unduly sensitive to stimuli and easily upset by noise, light, temperature, and other

environmental changes

✓ The child is placid or limp, sleep most of the time and appear to develop slowly

✓ Commonly active in the crib, sleep little and a great deal

• School aged children

✓ May attack a test rapidly

✓ Unable to wait to be called on

✓ They cannot put off for even a minute

✓ Frequently emotionally labile

✓ Impulsive and unable to delay gratification

✓ Susceptible to accidents

• Most cited characteristics

✓ May attack a test rapidly

✓ Unable to wait to be called on

✓ They cannot put off for even a

minute

✓ Frequently emotionally labile

✓ Impulsive and unable to delay

gratification

✓ susceptible to accidents

Development and Course

• Symptoms are difficult to distinguish

from normative behaviors before age 4

• Most often identified during

elementary school years and inattention

becomes more prominent and impairing

• Is correlated with smoking during

pregnancy

• There may be a history of child abuse,

• neglect, multiple foster placements, neurotoxin exposures, infections, or alcohol

exposure in utero

• Very low birth weight (less than 1500

grams)

• two- or threefold risk for ADHD

• Is associated with reduced behavioral

inhibition, effortful control or constraint,

negative emotionality, and/or elevated

novelty seeking

• More frequent in males than females

with a ratio of 2:1

Specific Learning Disorder

Criteria

• Criterion A: 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

  • Inaccurate or slow and effortful word reading

  • Difficulty understanding the meaning of what is read

  • Difficulties with spelling

  • Difficulties with written expression

  • Difficulties mastering number sense, number facts, or calculations

  • Difficulties with mathematical reasoning

• Criterion B: The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age and cause significant interference with academic or occupational performance as confirmed by individually administered standardized achievement measures and comprehensive clinical assessments

  • For individuals age 17 years or older, a documented history of impairing learning difficulties may be substituted for the standardized assessment

• Criterion C: Learning difficulties begins during school-age years but may not fully manifest until the demands exceed the individual’s limited capacities

• Criterion D: Learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction

• Specify if:

  • 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

    • Memorization of arithmetic facts

    • Accurate or fluent calculation

    • Accurate math reasoning

Relevant Information

• The phrase “unexpected academic underachievement” is often cited as the defining characteristic of specific learning disorder

• May also occur in individuals identified as intellectually “gifted”

• The learning difficulty cannot be attributed to more general external factors such as: economic or environmental disadvantage, chronic absenteeism, or lack of education

• The learning difficulty may be restricted to one academic skill or domain

• Can only be diagnosed after formal education starts but can be diagnosed at any point afterwards (providing there is evidence of onset during years of formal schooling or the developmental period)

Developmental Coordination Disorder

Definition

• Other term for:

  • Childhood dyspraxia

    • A specific developmental disorder of motor function

  • Clumsy child syndrome

• Diagnosed only if the impairment in motor skills significantly interferes with the performance of, or participation in daily activities in family, school, or community life

• Movement execution may appear awkward, slow, or less precise even when the skills are achieved

• Examples of activities that are affected

  • Getting dressed

  • Eating meals with age-appropriate utensils and without mess

  • Engaging in physical games with others

  • Using specific tools in class and participating in team exercise activities at school

• Handwriting competency is affected which affected legibility and/or speed of written output and academic achievement

Features

• Ages 5-11 are affected 5%-6%

• In children age 7 years, 1.8% are diagnosed with severe developmental coordination and 3% with probable developmental coordination disorder

• Males are more prone than females (2:1 and 7:1)

Stereotypic Movement Disorder

Criteria

• Criterion A: Repetitive, seemingly driven, and apparently purposeless motor behavior

  • Hand shaking

  • Waving

  • Body rocking

  • Head banging

  • Self-biting

  • Hitting own body

• Criterion B: Repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury

• Criterion C: Onset is in the early developmental period

• Criterion D: Not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental or mental disorder

Risks

• Social isolation triggers self-stimulation that may progress to stereotypic movements with repetitive self-injury

• Environmental stress

• Fear may alter physiological state that results in increased frequency of stereotypic behaviors

• Lower cognitive functioning is linked to a greater risk for stereotypic behaviors and poorer response to interventions

• More frequency among individuals with moderate to severe/profound intellectual disability

Tic Disorders

Definition

• Four diagnostic categories

  • Tourette’s disorder

    • Defined as rapid and repetitive muscle contractions resulting in movements or vocalizations that are involuntary

    • Georges Gilles de la Tourette

      • Was the first to describe the disorder

      • He noted patients with multiple motor tics, coprolalia and echolalia

    • Occurs in 4-5 per 10,000 individuals

    • Prevalent in children than adults

    • Occurs before age 7 (vocal tics by age 11)

    • Occurs 3 times more often in boys than girls

    • Are multiple motor tics and one or more vocal tics

    • Tics occur many times a day for more than a year

    • Has an onset before 18 years

  • Persistent (chronic) motor or vocal tic disorder

  • Provisional tic disorder

  • Other specified and unspecified disorders

• Simple Tics

  • Are of short duration and can include eye blinking, shoulder shrugging, and extension of the extremities

• Complex Motor Tics

  • Are of longer duration and often include a combination of simple tics such as simultaneous head turning and shoulder shrugging

  • Can appear purposeful such as:

    • Copropraxia

      • As a tic-like sexual or obscene

    • Echopraxia

      • Tic-like imitation of someone else’s movements

    • Palilia

      • Repeating one’s own sounds or words

    • Echolalia

      • Repeating the last heard word or phrase

    • Coprolalia

      • Uttering socially unacceptable words

      • Is an abrupt, sharp bark or grunt utterance

Criteria

• Tourette’s disorder

  • Criterion A: Both multiple motor and one or more vocal tics have been present at some time during the illness, although not concurrently

  • Criterion B: The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset

  • Criterion C: Onset is before age 18

  • Criterion D: The disturbance is not attributable to the physiological effects of a substance or another medical condition

• Persistent (chronic) motor or vocal tic disorder

  • Criterion A: Single or multiple motor or vocal tics have been present but not both motor and vocal

  • Criterion B: Persisted for more than 1 year since first onset

  • Criterion C: Onset is before age 18

  • Criterion D: Not caused by a substance or another medical condition

  • Criterion E: Criteria have never been met for Tourette’s disorder

  • Specify if:

    • With motor tics only or with vocal tics only

• Provisional tic disorder

  • Criterion A: Single or multiple motor or vocal tics have been present but not both motor and vocal

  • Criterion B: The tics have been present for less than 1 year since first onset

  • Criterion C: Onset is before age 18

  • Criterion D: The disturbance is not attributable to the physiological effects of a substance or another medical condition

  • Criterion E: Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic

• Other specified and unspecified disorders

Prevalence, Development and Course

• Common in childhood but transient in most cases

• Estimated prevalence ranges from 3-8 per 1,000 in school-age children

• Males are more commonly affected than females with a ratio varying from 2:1 to 4:1

• Onset of tics is typically between ages 4 and 6

• Peak severity occurs between ages 10 and 12 with a decline in severity during adolescence

Risk and Prognostic Factors

• Tics are worsened by anxiety, excitement, and exhaustion and are better when calm and focused

• May have fewer tics when engaged in schoolwork or tasks at works than when relaxing at home after school or in the evening

• Stressful/exciting events often make tics worse

• Obstetrical complications, older paternal age, lower birth weight, and maternal smoking during pregnancy are associated with worse tic severity

• Males are more commonly affected than females but there are no gender differences in the kinds of tics, age at onset, or course

• Women with persistent tic disorders may be more likely to experience anxiety and depression

SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS

• Emil Kraeplin

  • In 1896 he originally called Schizophrenia as dementia praecox meaning “madness of the mind”

    • To differentiate it from manic-depressive psychosis

• Eugen Bleuler

  • In 1908 he coined the term Schizophrenia

    • From the Greek word Skizho = Split and Phren = Mind

    • Schizophrenia is a split of mind

  • Primary Symptoms

    • Affective disturbance

    • Autistic thinking

    • Ambivalence

    • Associative looseness

• John Haslam (England)

  • Wrote a description of the symptoms of schizophrenia

• Philippe Pinel (France)

  • Described cases of schizophrenia.

• Benedict Morel

  • Used the term démence (loss of mind) précose (early) to describe schizophrenia.

• Catatonia

  • Alternating immobility and agitation

• Hebephrenia

  • Silly and immature emotionality

• Paranoia

  • Delusions of grandeur or persecution

• Kurt Schneider (1959)

  • Thought echo

  • Auditory hallucination

  • Thought withdrawal

  • Thought insertion

  • Thought broadcasting

  • Delusional perception

  • Somatic passivity

  • Made volition

Schizophrenia

• Occurs twice as often in people who are unmarried and divorced people

• More likely to be members of lower socioeconomic groups

Etiology

• Factors involved:

  • Genetic Factors

  • Stress-Diathesis Model

  • Biochemical Factors

  • Psychological Factors

  • Social Factors

Genetic Factors

• More common among people born of consanguineous marriages

• Relatives of schizophrenics have a much higher probability of developing the disease

Stress-Diathesis Model

• A person may have a specific vulnerability (diathesis) that, when acted on by a stressful influence, allows the symptoms of schizophrenia to develop

Psychological Factors

• Mother-child relationship

  • Characterized the mothers of schizophrenics as cold, over-protective, and domineering, thus retarding the ego development of the child

• Dysfunctional family system

  • Hostility between parents can lead to a schizophrenic daughter

• Double-bind communication

  • Parents convey two or more conflicting and incompatible messages at the same time

Social Factors

• Social disadvantages found to be a risk factor include:

  • Poverty

  • Migration related to social adversity

  • Racial discrimination

  • Family dysfunction

  • Unemployment

  • Poor housing

Risk Factors

• Certain factors seem to increase the risk of developing or triggering schizophrenia including:

  • Having a family history of schizophrenia

  • Exposure to viruses, toxins or malnutrition while in the womb,

  • particularly in the first and second trimesters

  • Stressful life circumstances

  • Older paternal age

  • Taking psychoactive drugs during adolescence and young adulthood

Phases of Schizophrenia

• Phase 1 - Prodromal Phase

• Phase 2 - Active Phase

• Phase 3 - Residual Phase

Delusions

• Fixed and irrational belief that is seen by most people as misrepresentation of reality

• Non Bizarre Delusions

  • Persecutory Delusion

    • Belief that one is going to be harmed by others; most common delusion

  • Referential Delusion

    • Belief that every event (e.g., comments and gestures) are directed at oneself

  • Grandiose Delusion

    • Belief that one has exceptional abilities, wealth, fame, etc.

  • Erotomanic Delusion

    • Belief that another person is falsely in love with the individual

  • Nihilistic Delusion

    • Belief that major catastrophes will occur

  • Somatic Delusion

    • Belief about something is wrong about their health and organ functioning

  • Jealous Delusion

    • Belief that the partner is unfaithful

• Bizarre Delusions

  • Thought Withdrawal

    • Belief that some outside force “removed” one‘s thoughts

  • Thought Insertion

    • Belief that thoughts are being inserted by an outside force

  • Delusion of Control

    • Belief that one‘s body or action is being manipulated by an outside force

  • Capgras Syndrome

    • Belief that believes someone he or she knows has been replaced by a double.

  • Cotard’s Syndrome

    • Belief that one is already dead

Hallucinations

• Experience of sensory events without any input from the surrounding environment

• Auditory Hallucination

  • One has heard something that did not really exist; most common hallucination

• Visual Hallucination

  • Sense of sight

• Gustatory Hallucination

  • Sense of taste

• Olfactory Hallucination

  • Sense of smell

• Tactile Hallucination

  • Sense of touch

Brief Psychotic Disorder

• >1 day, <1 month, with eventual full return function

• Criterion A: Presence of 1 of the following symptoms, at least one must be bold

  • delusions

  • hallucinations

  • disorganized speech

  • grossly disorganized or catatonic behavior

• Specifiers:

  • with marked stressor

  • without marked stressor

  • with postpartum onset

  • with catatonia

Schizophreniform

• >1 month, <6 months

• Presence of at least 2 of the following symptoms (during a 1 month period), at least one must be bold

  • delusions

  • hallucinations

  • disorganized speech

  • grossly disorganized or catatonic behavior

• Specifiers:

  • with good prognostic features

  • 2 of the following features

    • onset of prominent psychotic symptoms within 4 weeks of behavior change

    • confusion or perplexity

    • good premorbid social and occupational functioning

    • absence of blunted or flat affect

  • without good prognostic features

  • with catatonia

Schizophrenia

• 1 month of Criteria A symptoms, continuous signs for at least 6 months.

• Criterion A: 2 of the following, at least one must be bold

  • delusions

  • hallucinations

  • disorganized speech

  • grossly disorganized or catatonic behavior

  • negative symptoms

• Specifiers:

  • first episode, acute episode / partial remission / full remission

  • multiple episodes, acute episode / partial remission / full

  • remission

  • continuous

  • unspecified

  • with catatonia

  • than negative judgement about self

• Not exclusively during course of psychotic disorder

• Note: if met prior to onset of schizophrenia, add "premorbid"

Schizoaffective

• Major mood episode concurrent with Criterion A of schizophrenia

• Delusions or hallucinations for ≥2 weeks in absence of major mood episode

• Symptoms of major mood episode for majority of active/residual illness

• Specifiers:

  • bipolar type OR depressive type

  • with catatonia

  • first episode OR multiple episodes

  • currently in acute episode OR partial remission OR full remission

  • Continuous

  • Unspecified

Psychotic Disorder Due to Another Medical Condition

• Delusions or hallucinations

  • developed due another medical condition

• Not exclusively during delirium

• Specifiers:

  • with delusions

  • with hallucinations

Substance/Medication Induced Psychotic Disorder

• Delusions or hallucinations

  • developed after substance intoxication or withdrawal or medication that can produce these symptoms

• Not exclusively during delirium

• Specifiers:

  • with onset during intoxication

  • with onset during withdrawal

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

• Symptoms of schizophrenia spectrum that causes distress/impairment, but doesn't meet full criteria

• use when physician wants to communicate the reason criteria isn't met

• Specifiers:

  • persistent auditory hallucinations

  • delusions with significant overlapping and mood episodes

  • attenuated psychosis syndrome

  • delusional symptoms n partner of individual with delusional disorder

Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

• Symptoms of schizophrenia spectrum that causes distress/impairment, but doesn't meet full criteria

• use when physician doesn't want to communicate the reason criteria isn't met

Delusional Disorder

• 1 month

• Delusions but person doesn't meet Criterion A for schizophrenia

  • hallucinations if present are not prominent and related delusional theme

• apart from impact of delusions, functioning is not markedly impaired and behavior isn't bizarre

• Specifiers

  • erotomaniac

  • grandiose

  • jealous

  • persecutory

  • somatic

  • mixed

  • unspecified

• More Specifiers:

  • with bizarre content

    • if implausible

  • first episode, in acute episode

  • first episode, partial remission

  • first episode, full remission

  • multiple episodes, in acute / partial remission/ full remission

• Note: if met prior to onset of schizophrenia, add "premorbid"

Schizotypal (Personality) Disorder

• A pervasive pattern of social and interpersonal deficits marked by acute discomfort with reduced capacity for close relationships and cognitive/perceptual distortions and eccentricities of behavior beginning early and in multiple contexts requiring at least 5:

  • ideas of reference (excluding delusions of reference)

  • odd beliefs or magical thinking inconsistent with subcultural norms

  • unusual perceptual experiences

  • odd thinking and speech

  • suspiciousness or paranoid ideation

  • inappropriate or constricted affected

  • behavior/appearance that is odd, eccentric, or peculiar

  • lack of close friends other than first degree relatives

  • excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fear rather than negative judgement about self

• Not exclusively during course of psychotic disorder

• Note: if met prior to onset of schizophrenia, add "premorbid"