ABPSYCH 311 – MIDTERMS NEURODEVELOPMENTAL DISORDERS

CHAPTER 14 DISORDERS OF CHILDHOOD - Group of conditions characterized by early onset and

AND ADOLESCENCE persistent course that are believed to be result of
(NEURODEVELOPMENTAL DISORDERS) disruptions to normal brain development
Neurodevelopmental – Childhood
Neurocognitive – Later years ATTENTION-DEFICIT/HYPERACTIVITY
DISRODERS (ADHD)
- Important that we view child’s behavior in context of
normal development - Characterized by persistent pattern of difficulties
sustaining attention and/or impulsiveness and
- Cannot consider child’s behavior abnormal without
excessive or exaggerated motor activity
determining whether the behavior in question is
appropriate for the child’s age - Perhaps due to partially to behavioral problems,
children with ADHD often score approximately 7 to 15
DEVELOPMENTAL PSYCHOPATHOLOGY –
points lower on intelligence quotient (IQ) tests and
Determining what is abnormal at any point in
show deficits on neuropsychological testing that
developmental process by comparing and contrasting it
related to poor academic functioning
with normal and expected changes that occur.
- Often exhibit specific learning disabilities such as
- No sharp line of demarcation between the
difficulties in reading or learning other basic school
maladaptive behavior patterns of childhood and those
subjects
adolescence (i.e., no precise age at which temper
tantrums are now considered officially “abnormal”) or - Hyperactive children often have great difficulty
between those adolescence and adulthood getting along with their parents because they often fail
to obey rules, their behavior problems also can result
PSYCHOLOGICAL VULNERABILITIES OF
in their being viewed negatively by their peers
YOUNG CHILDREN
- ADHD is fairly prevalent, occurring in approximately
- Young children are vulnerable to psychological
9% of children and adolescents
problems
- The rate of ADHD is much higher in boys (13%) than
- Don’t have complex and realistic view of themselves
in girls (4%) and is commonly comorbid with other
and their world as they will have late and not yet
externalizing disorders such as ODD and CD
developed stable sense of identity or clear
understanding of what is expected them and resources - Most cases of adult ADHD are characterized by
they might have to deal with. Problems symptoms of inattention (95%), whereas a much
smaller percentage are characterized by hyperactivity
- Immediately perceived threats are tempered less by
(35%)
considerations of past or future tend to be seen as
disproportionately important - ADHD begins in childhood, requirement that several
symptoms has been present before age 12 years
- Children often have more difficulty tan adults in
conveys the importance of substantial clinical
coping with stressful events
presentation during childhood
- Children’s lack of experience in dealing with
- Earlier age ate onset is not specified because of
adversity can make manageable problems seem
difficulties in establishing precise childhood onset
insurmountable
retrospectively
- Children also are more dependent on other people
HYPERACTIVITY – Excessive motor activity (such
than are adults
as child running about) when it’s not appropriate, or
- In some ways this dependency serves as buffer excessive fidgeting, tapping, or talkativeness
against other dangers because the adults around might
- In adults, may manifests as extreme restlessness or
“protect” against stressors in environment, it also make
wearing others out with their activity
the child highly vulnerable to abuse or neglect by
others IMPULSIVITY – Hasty actions that occur in moment
without forethought, which may have potential for
harm to individual (darting into the streets without
looking)
- May reflect a desire for immediate rewards or i. Often forgetful in daily activities (doing chores,
inability to delay gratification running errands,; for older adolescents and adults,
returning calls, paying bills, keeping appointments)
- Impulsive behaviors may manifest as social
intrusiveness and/or making important decisions 2. HYPERACTIVITY AND IMPULSIVITY: 6 (or
without consideration of long-term consequences more) following symptoms have persisted for at least 6
months to degree that is inconsistent with
DSM 5-TR (Diagnostic Criteria)
developmental level and that negatively impacts
A. Persistent pattern of inattention and/or directly on social and academic/occupational activities
hyperactivity-impulsivity that interferes with
a. Often fidgets with or taps hands or feet or squirms in
functioning or development, as characterized by (1)
seat
and/or (2):
b. Often leaves seat in situation when remaining seated
1. INATTENTION: 6 (or more) of following
is expected.
symptoms have persisted for at least 6 months to
degree that is inconsistent with developmental level c. Often runs about or climbs in situations where it is
and negatively impacts directly on social and inappropriate (Note. In adolescents or adults, may be
academic/occupational activities: limited to feeling restless)
NOTE: Symptoms are not solely a manifestation of d. Often unable to play or engage in leisure activities
oppositional behavior, defiance, hostility, or failure to quietly
understand tasks. For older adolescents and adults (age
e. Often “on the go” acting as if “driven by a motor”
17 and older), at least 5 symptoms are required.
(unable to be or uncomfortable being still for extended
a. Often fails to give close attention to details or make time, as in restaurants, meetings; may be experiences
careless mistakes in schoolwork, at work, or during by other as being restless or difficult to keep up with)
other activities
f. Often talks excessively
b. Often has difficulty sustaining attention in tasks or
g. Often blurts out an answer before a question has
play activities (e.g., has difficulty remaining focuses
been completed (completes people’s sentences, cannot
during lecture, conversations, or lengthy reading)
wait for turn in conversation)
c. Often does not seem to listen when spoken to
h. Often has difficulty waiting his or her turn (while
directly (mind seems elsewhere, even in absence of
waiting in line)
any obvious distraction)
i. Often interrupts or intrudes on other (burst into
d. Often does not follow through on instructions and
conversations, games, or activities’ may start using
fails to finish schoolwork, chores, or duties in
other people’s things without asking or receiving
workplace (starts tasks but quickly loses focus and is
permission; for adolescents and adults, may intrude
easily sidetracked)
into or take over what others are doing)
e. Often has difficulty organizing tasks and activities
B. Several inattentive or hyperactive-impulsive
(difficulty managing sequential tasks; difficulty
symptoms were present prior to age 12 years
keeping materials and belongings in order; messy,
disorganized work; has poor time management; fails to C. Several inattentive or hyperactive-impulsive
meet deadlines) symptoms are present in two or more setting (home,
school. or work; with friend or relatives; on other
f. Often avoids, dislikes, or is reluctant to engage in
activities)
tasks that require sustained mental effort (schoolwork
or homework; for older adolescents and adults, D. There is clear evidence that symptoms interfere
preparing reports, completing forms, reviewing with, or reduce the quality of social, academic, or
lengthy papers) occupational functioning)
g. Often loses things necessary for tasks or activities E. Symptoms do not occur exclusively during the
(school materials, pencils, books, tools, wallets, keys, course of schizophrenia or another psychotic disorder
paperwork, eyeglasses, mobile phones) and are not better explained by another mental disorder
h. Often easily distracted by extraneous stimuli (for Specify whether:
older adolescents and adults, may include unrelated
thoughts)
COMBINED PRESENTATION: If both Criterion A1 RITALIN (Methylphenidate) – Stimulant medication
(inattention) and Criterion A2 (hyperactivity- have quieting effect on children – just the opposite of
impulsivity) are met for the past 6 months what we would expect from their effects on adults
PREDOMINANTLY INATTENTIVE - Decreases overactivity and distractibility and at the
PRESENTATION: If Criterion A1 is met but Criterion same time increase their alertness
A2 is not met for the past 6 months
- Lower the amount of aggressiveness in children with
PREDOMINANTLY HYPERACTIVE-IMPULSIVE ADHD
PRESENTATION: If Criterion A2 is met and Criterion
POSSIBLE SIDE EFFECTS OF RITALIN
A1 is not met for the past 6 months
- Decreased blood flow to the brain, can result in
IN PARTIAL REMISSION – When full criteria were
impaired thinking ability and memory loss
previously met, fewer that the full criteria have been
met for the past 6 months, and symptoms still result in - Disruption of growth hormone, leading to
impairment in social, academic, or occupational suppression of growth in body and brain of the child
functioning
- Insomnia, psychotic symptoms, and others
SPECIFY CURRENT SEVERITY
PEMOLINE – Chemically very different from Ritalin,
MILD – Few, if any, symptoms in excess of those it exerts beneficial effects on classroom behavior by
required to make the diagnoses are present, and enhancing cognitive processing and has fewer adverse
symptoms result in no more than minor impairments in side effects than Ritalin
social or occupational functioning
STRATTERA (Atomoxetine) – Noncontrolled
MODERATE – Symptoms or functional impairments treatment option that can be obtained readily, U.S.
between “mild” and “severe” are present Food and Drug Administration (FDA) approved
nonstimulant medication
SEVERE – Many symptoms in excess of those
required to make the diagnosis, or several symptoms SIDE EFFECTS OF STRATTERA
that are particularly severe, are present, or symptoms
result in marked impairment in social or occupational - Decreases appetite
functioning - Nausea
ASSOCIATED FEATURES - Vomiting
- Delays in language, motor, or social development are - Fatigue
not specific to ADHD but often co-occur
- Possibility of liver damage
- Emotional dysregulation or emotional impulsivity
commonly occurs in children and adults with ADHD ADDERALL – Reduces symptoms of impulsivity and
hyperactivity in children with ADHD
- Individuals with ADHD self-report and are described
by others as being quick to anger, easily frustrated, and - Medication is combination of amphetamine and
overreactive emotionally dextroamphetamine

CAUSAL FACTORS IN ADHD - Research suggested that Adderall provides no

advantage or improvement in results over Ritalin and
- Specific causes of ADHD have been widely debated Strattera
- Children with ADHD have smaller total brain BEHAVIORAL INTERVENTION TECHNIQUES –
volumes than those without ADHD Include teaching organizational and planning skills,
- Their brains appear to mature approximately 3 years techniques for decreasing distractibility and
more slowly than those without ADHD procrastination

- These maturational delays are most prominent in - As well as parenting techniques focused on providing
prefrontal brain regions involved in attention and reinforcement for adaptive child behavior
impulsiveness
TREATMENTS AND OUTCOMES
AUTISM SPECTRUM DISORDER 1. Stereotyped or repetitive motor movements, use of
objects, or speech (simple motor stereotypies, lining up
- We refer to as “Autism” is neurodevelopmental
toys or flipping objects. Echolalia. Idiosyncratic
disorder that involves a wide range of problematic
phrases)
behaviors including deficits in language, and
perceptual and motor development 2. Insistence on sameness, inflexible adherence to
routines, or ritualized patterns of verbal or nonverbal
- Defective reality testing; and impairments in social
behavior (extreme distress at small changes,
communication
difficulties with transitions, rigid thinking patterns,
- Autism was first described in 1943 (Kanner) greeting rituals, need to take same route or eat same
food every day)
- Usually identified before a child is 20 months of age,
and diagnostic stability over the childhood years is 3. Highly restricted, fixated interests that are abnormal
quite high in intensity or focus (strong attachment to or
preoccupation with unusual objects, excessively
- Children diagnosed with autism by age 2 tend to be circumscribed or perspective interests)
similarly diagnosed at age of 9
4. Hyper – or hyperactivity to sensory input or unusual
- Early signs od problems with social communication interest in sensory aspects of the environment
can be detected in the first 6 months of infant’s life (apparent indifference to pain/temperature, adverse
- Children later diagnosed with autism show response to specific sounds or textures, excessive
significant decline in their focus on eyes of others from smelling or touching of objects, visual fascination with
2 to 6 months of age and this decline continues until 24 lights or movement)
months, approximately half the level of focus as seen C. Symptoms must be present in the early
in typically developing children developmental period (but may not become fully
manifest until social demands exceed limited
capacities, or may be masked by learned strategies in
DSM 5-TR (Diagnostic Criteria) later life)
A. Persistent deficits in social communication and D. Symptoms cause clinically significant impairment
social interaction across multiple contexts, as in social, occupational, or other important areas of
manifested by all of following, currently or by history current functioning
(examples are illustrative, not exhaustive)
E. These disturbances are not better explained by
1. Deficit in social-emotional reciprocity, ranging, for intellectual developmental disorder (intellectual
example, from abnormal social approach and failure of disability) or global developmental delay. Intellectual
normal back-and-forth conversation; to reduced developmental disorder and autism spectrum disorder
sharing of interest, emotions, or affect; to failure to frequently co-occur; to make comorbid diagnoses of
initiate or respond to social interactions autism spectrum disorder frequently co-occur; to make
comorbid diagnoses of autism spectrum disorder and
2. Deficits in nonverbal communicative behaviors used
intellectual developmental disorder, social
for social interaction, ranging, for example, from
communication should be below that expected for
poorly integrated verbal and nonverbal
general developmental level
communication; to abnormalities in eye contact and
body language or deficits in understanding and use of SEVERITY LEVELS FOR AUTISM SPECTRUM
gestures; to total lack of facial expression and DISORDER
nonverbal communication
LEVEL 3 (Requiring very substantial support)
3. Deficits in developing, maintaining, and
understanding relationships, ranging, for example, SOCIAL COMMUNICATION: Severe deficits in
from difficulties adjusting behavior to suit various verbal and nonverbal social communication skills
social contexts; to difficulties in sharing imaginative cause severe impairments in functioning, very limited
play or in making friends; to absence of interest in initiation of social interactions, and minimal response
peers to social overtures from others

B. Restricted, repetitive patterns of behavior, interests, RESTRICTED, REPETITIVE BEHAVIORS:

or activities, as manifested by at least 2 of the Inflexibility of behavior, extreme difficulty coping
following, currently or by history with change, or other restricted/repetitive behaviors
markedly interfere with functioning in all spheres. appearing to notice the comings and goings of other
Great distress/difficulty changing focus or action people
LEVEL 2 (Requiring substantial support) SOCIAL DEFICIT – Do not show any need for
affection or contact with others
SOCIAL COMMUNICATION: Marked deficits in
verbal and nonverbal social communication skills; - Children with autism do express emotions and should
social impairments apparent even with supports in not be considered as lacking emotional reactions
place; limited initiation of social interactions; and
- Some have characterized the seeming inability of
reduced or abnormal responses to social overtures
children with autism to respond to others as lack of
from other
social understanding – deficit in the ability to attend to
RESTRICTED, REPETITIVE BEHAVIORS: social cues from others
Inflexibility of behavior, difficulty coping which
- Neuroimaging studies have revealed that children
change, or other restricted/repetitive behaviors appear
with autism show decreased activity in medial
frequently enough to be obvious to the casual observer
prefrontal cortex, region associated with understanding
and interfere with functioning in variety of contexts.
the mental states of others, but increased activation in
Distress and/or difficulty changing focus or action
the ventral occipitotemporal regions involved in object
LEVEL 1 (Requiring support) perception
SOCIAL COMMUNICATION: Without supports in - Deficits in attention and in locating and orienting to
place, deficits in social communication cause sounds in their environment
noticeable impairments. Difficulty initiating social
- Show aversion to auditory stimuli, crying even at the
interactions, and clear examples of atypical or
sound of parent’s voice
unsuccessful responses to social overtures of other.
May appear to have decreased interest in social ABSENCE OF SPEECH – Have absence or severely
interactions limited use of speech
RESTRICTED, REPETITIVE BEHAVIORS: ECHOLALIA – Parrot-like repetition of few words
Inflexibility of behaviors cause significant interference
with functioning in one or more context. Difficulty - Echoing of parent’s verbal behavior is found to small
switching between activities. Problems of organization degree in normal children as they experiment with
and planning hamper independence their ability to produce articulate speech

DIAGNOSTIC FEATURES - Typically developing children show that among those

with autism, there is under-developed connectivity
- Essential features of autism spectrum disorder are within regions of the brain associated with imitating
persistent impairment in reciprocal social others, but over-developed connectivity between
communication and social interaction imitation regions and other parts of the brain
- Intervention, compensation, and current supports may - Among those with autism, the greater the under-
mask difficulties in at least some contexts connectivity within imitation regions, the greater the
symptoms of disorders
- Manifestations of disorder also vary greatly
depending on the severity of the autistic condition, SELF-SIMULATION – Takes form of such repetitive
developmental level, chronological age, and possibly movements as head banging, spinning, and rocking,
gender which may continue by the hour
THE CLINICAL PICTURE OF AUTISTIC MAINTAINING SAMENESS – Become preoccupied
SPECTRUM DISORDER with form string attachments to unusual object such as
rock, light switches, or keys
- Show varying degrees of impairments and
capabilities - When preoccupation with objects is disrupted – for
example, by its removal or by attempts to substitute
- Cardinal and typical sign is that child seems apart or
something in its place – or when anything familiar in
aloof from others, even in the earliest stages of life
the environment is altered even slightly, may have
- Mothers often remember such babies as not being violent temper tantrum or crying spell that continues
cuddly, not reaching out when being picked up, not until the familiar situation is restored
smiling or looking at them while being fed, and not
- Often said to be “obsessed with the maintenance of psychometrically sound and culturally appropriate
sameness” standardized tests
CAUSAL FACTORS IN AUTISM - Other terms used to describe developmental
coordination disorder include childhood dyspraxia,
- Autism is complex disorder and precise causes are
specific developmental disorder of motor function, and
unknown
clumsy child syndrome
- Twin and sibling studies shown that there is very
- Children with developmental coordination disorder
string heritable component in autism
show additional motor activity, such as choreiform
- 2 to 4% of siblings of children diagnosed with autism movements of unsupported limbs or mirror movements
also have the disorder, and approximately 20% have
- “Overflow” movements are referred to as
some symptoms of the disorder
neurodevelopmental immaturities or neurological soft
- Hundreds of different genes are associated with sign rather than neurological abnormalities
increased risk of autism, suggesting that there are
DSM 5-TR (Diagnostic Criteria)
many different paths to developing this disorder
A. Acquisition and execution of coordinated motor
- Portion of the genetic risk is inherited (52%) and
skills is substantially below that expected given
what is portion due to de novo genetic mutations (3%)
individual’s chronological age and opportunity for skill
DE NOVO MUTATION – Occur in egg or sperm and learning and use. Difficulties are manifested as
are passed on to every cell in the child’s body, despite clumsiness
not appearing in parent’s DNA
B. The motor skills deficit in Criterion A significantly
- Genetic mutations have been reported to occur at and persistently interferes with activities of daily living
higher rates in sperm of older men, and there is now appropriate to chronological age and impacts
converging evidence that older father age at child’s academic/school productivity, prevocational and
birth is associated with increased risk of autism vocational activities, leisure, and play

TREATMENTS AND OUTCOMES OF AUTISM C. Onset symptoms is in early developmental period

INTENSIVE BEHAVIORAL INTERVENTION – D. Motor skills deficits are not better explained by
Administered via one-on-one meetings with the child intellectual developmental disorder or visual
for over 40 hours per week for 2 years resulted in impairment and not attributable to neurological
extremely positive results condition affecting movement

- Based on both discrimination-training strategies STEREOTYPIC MOVEMENT DISORDER

(reinforcement) and contingent aversive techniques
- Typically begin within the first 3 years of life
(punishment)
- Children who develop complex motor stereotypies,
- Treatment plan typically enlists parents in the process
approximately 80% exhibit symptoms before age of 24
and emphasizes teaching children to learn from and
months, 12% between 24 and 35 months, and 8% at 36
interact with “normal” peers in real-world situations
months or older
EARLY START DENVER MODEL (ESDM) –
- Typically developing children the severity and
Involves more than 20 hours per week of intensive
frequency of stereotyped movements diminish over
behavioral work with child and parents
time
- Focused on interpersonal exchanges, verbal and
DSM 5-TR (Diagnostic Criteria)
nonverbal communication, and adult sensitivity to
children’s cues A. Repetitive, seemingly driven, and apparently
purposeless motor behavior
B. Repetitive behavior interferes with social,
MOTOR DISORDERS (Developmental Coordination
academic, or other activities and may result in self-
Disorder)
injury
- Made by clinical synthesis of history (developmental
C. Onset is in early developmental period
and medical), physical examination, school or
workplace repost, and individual assessment using D. Repetitive motor behavior is not attributable to
physiological effects of substance or neurological
condition and is not better explained by another With motor tics only
neurodevelopmental or mental disorder
With vocal tics only
SPECIFY CURRENT SEVERITY:
PROVISIONAL TIC DISORDER
MILD – Symptoms are easily suppressed by sensory
DSM 5-TR (Diagnostic Criteria)
stimulus or distraction
A. Single or multiple motor and/or vocal tics
MODERATE – Symptoms require explicit protective
measures and behavioral modifications B. The tics have been present for less than 1 year since
first tic onset
SEVERE – Continuous monitoring and protective
measure are required to prevent serious injury C. Onset is before age 18 years
D. The disturbance is not attributable to physiological
effects of substance or another medical condition
TIC DISORDER
E. Criteria have never been met for Tourette’s disorder
- Persistent, intermittent muscle twitch or spasm,
or persistent (chronic) motor or vocal tic disorder
usually limited to localized muscle group
SIMPLE MOTOR TICS – Characterized by limited
- Broadly used to include blinking the eye, twitching
involvement of specific muscle groups, often are short
the mouth, licking the lips, shrugging the shoulders,
duration and can include eye blinks, facial grimaces,
clearing the throat, and grimacing, among other actions
shoulder shrugs, or extension of the extremities
- Tics occur most frequently between the ages of 8 and
SIMPLE VOCAL TICS – Include throat clearing,
14
sniffs, chirps, barks, or grunting often caused by
TOURETTE’S DISORDER contraction of the diaphragm or muscles of oropharynx
DSM 5-TR (Diagnostic Criteria) COMPLEX MOTOR TICS – Longer duration and
often include combination of simple tics such as
A. Both multiple motor and one or more vocal tics
simultaneous head turning and shoulder shrugging
have been present at some time during the illness,
although not necessarily concurrently - Can appear purposeful, such as head gestures or torso
movements
B. The tics may wax and wane in frequency but have
persisted for more than 1 year since first tic onset ECHOPRAXIA – Imitations of someone else’s
movements
C. Onset is before age 18 years
COPROPRAXIA – Sexual or taboo gestures
D. The disturbance is not attributable to physiological
effects of substance (cocaine) or another medical PALILALIA – Have linguistic meaning (words or
condition (Huntington’s disease, post viral partial words) and can include repeating one’s own
encephalitis) sounds or words
PERSISTENT (CHRONIC) MOTOR OR VOCAL ECHOLALIA – Repeating the last-heard word or
TIC DISORDER phrase
DSM 5-TR (Diagnostic Criteria) CORPOLALIA – Uttering socially unacceptable
words, including obscenities, or ethnic, racial, or
A. Single or multiple motor or vocal tics have been
religious slurs
present during the illness, but not both motor and vocal
- Abrupt, sharp bark or grunt utterance and lacks the
B. The tics may wax and wane in frequency but have
prosody of similar inappropriate speech observed in
persisted for more than 1 year since first tic onset
human interactions
C. Onset is before age 18 years
DEVELOPMENT AND COURSE
D. The disturbance is attributable to the physiological
- First onset of tics is typically between ages of 4 and 6
effects of substance or another medical condition
years
E. Criteria have never been met for Tourette’s disorder
- Eye blinking is highly characteristic of as initial
Specify if: symptoms
- Peak severity occurs between 10 and 12 years, with 3. Difficulties with spelling (may add, omit, or
decline in severity during adolescence substitute vowels or consonants)
- Tics associated with premonitory urge may be 4. Difficulties with written expression (makes multiple
experienced as not completely “involuntary” in that the grammatical or punctuation errors within sentences;
urge and the tic can be resisted employ poor paragraph organization; written
expression of ideas lacks clarity)
- Individual may also feel the need to perform a tic
repeatedly or in specific way until the individuals feels 5. Difficulties mastering number sense, number facts,
that the tic has been done “just right” or calculation (has poor understanding of numbers,
magnitude, and relationships; counts on fingers to add
- Often there is a feeling of relief and tension reduction
single-digit numbers instead of recalling the math fact
following the expression of the tic or series of tics
as peers do; gets lost in the midst of arithmetic
SPECIFIC LEARNING DISORDER computation and may switch procedures)

- Delays in cognitive development in the areas of 6. Difficulties with mathematical reasoning (has severe
language, speech, mathematical, or motor skills that difficulty applying mathematical concepts, facts, or
are not necessarily due to any demonstrable physical or procedures to solve quantitative problems)
neurological defect
B. The affected academic skills are substantially and
- Significantly more boys than girls are diagnosed as quantifiably below those expected for the individual’s
having a learning disorder, but estimates of the extent chronological age, and cause significant interference
of this gender discrepancy have varied widely from with academic or occupational performance, or with
study to study activities of daily living, as confirmed by individually
administered standardized achievement measures and
- Estimates suggest that 2 out of 10% of children have comprehensive clinical assessment. For individuals age
learning disorder, most often classified as dyslexia 17 years and older, documented history of impairing
(80%) with about 30% of children with learning learning difficulties may be substituted for the
disorder such as ADHD, depression, or anxiety standardized assessment
- Do not have obvious, crippling emotional problems, C. Learning difficulties begin during school-age years
nor do they seem to be lacking in motivation, but may not become fully manifest until the demands
cooperativeness, or eagerness to please their teachers for those affected academic skills exceed the
and parents – at least not the outset of their formal individual’s limited capacities (as in timed tests,
education reading or writing lengthy complex reports for tight
- May also occur in individuals identified as deadline, excessively heavy academic loads)
intellectually “gifted” may sustain apparently adequate D. Learning difficulties are not better accounted for by
academic functioning by using compensatory intellectual disabilities, uncorrected visual or auditory
strategies, extraordinarily high effort, or support, until acuity, other mental or neurological disorders,
learning or accomplishing required tasks psychosocial adversity, lack of proficiency in the
DSM 5-TR (Diagnostic Criteria) language of academic instruction, or inadequate
educational instruction
A. Difficulties learning and using academic skills, as
indicated by presence of at least one of the following NOTE: The four diagnostic criteria are to be met based
symptoms that have persisted for at least 6 months, on clinical synthesis of individual’s history
despite the provision of interventions that target those (developmental, medical, family, educational), school
difficulties: reports, and psychoeducational assessment

1. Inaccurate or slow and effortful word reading (reads DYSLEXIA

single words aloud incorrectly or slowly and hesitantly, - Alternative term used to refer to pattern of learning
frequently guesses words, has difficulty sounding out difficulties characterized by problems with accurate or
words) fluent word recognition, poor decoding, and poor
2. Difficulty understanding the meaning of what is read spelling abilities
(may read text accurately but not understand the - Used to specify this particular pattern of difficulties,
sequence, relationships, inferences, or deeper it is important also to specify any additional difficulties
meanings of what is read) that are present, such as difficulties with reading
comprehension or math reasoning
DYSCALCULIA B. Deficits in adaptive functioning that result in failure
to meet developmental and sociocultural standards for
- Alternative term used to refer pattern of difficulties
personal independence and social responsibility.
characterized by problems processing numerical
Without ongoing support, adaptive deficits limit
information, learning arithmetic facts, and performing
functioning in one or more activities of daily life, such
accurate or fluent calculations
as communication, social participation, and
- Also important to specify any additional difficulties independent living, across multiple environments, such
that are present, such as difficulties with math as home, school, work, and community
reasoning or word reasoning accuracy
C. Onset of intellectual and adaptive deficits during the
CAUSAL FACTORS IN LEARNING DISORDERS developmental period

- Most widely held view of the causes of specific

learning disorders is that the products of subtle CNS
SEVERITY LEVELS FOR INTELLECTUAL
impairments
DEVELOPMENTAL DISORDER (INTELLECTUAL
- Result from some sort of immaturity, deficiency, or DISABILITY)
dysregulation limited to brain functions that
supposedly mediate
- Identification of gene region for dyslexia on
chromosome 6 has been reported
TREATMENTS AND OUTCOMES
PHONICS INSTRUCTIONS – Involves teaching - Tests of human intelligence produce IQ scores that
children letter-sound correspondence as well as how to have an average of 100 and a standard deviation of 15
decode and create syllables, associated with significant
improvements in reading and spelling abilities - Means that most people (95%) receive score
somewhere 70 and 130
MILD INTELLECTUAL DISABILITY
INTELLECTUAL DEVELOPMENTAL DISORDERS
(INTELLECTUAL DISABILITY) - Considered educable, their intellectual level as adults
is comparable to those of average 8–11-year-old
- Characterized by deficits in general mental abilities, children
such as reasoning, problem solving, planning, abstract
thinking, judgement, academic learning, and learning - Adult with mild disability with mental age of (let say
from experience 10) may not in fact be comparable to average 10-year-
old in information-processing ability or speed. On the
- Defines in terms of both intelligence and level of other hand, he/she will normally have far more
performance, and for diagnosis to apply, these experience in living, which would tend to raise the
problems must begin before the age of 18 measures intelligence scores
- Functional equivalent of intellectual disability that - Social adjustment of people with mild intellectual
has its onset after age 17 is considered to be disability often approximates that of adolescents,
“dementia” rather intellectual disability although they tend to lack normal adolescents’
- Initial diagnoses of intellectual disability most imagination, inventiveness, and judgement
frequently occur at ages 5 to 6 (around the time that - Require some measure of supervision because of
schooling begins for most children), peak at age 15, limited abilities to foresee consequences of their
and drop off sharply after that actions
DSM 5-TR (Diagnostic Criteria) MODERATE INTELLECTUAL DISABILITY
A. Deficits in intellectual functions, such as reasoning, - Moderate intellectual disability have IQ scores
problem solving, planning, abstract thinking, ranging between 35-40 and 50-55, even in adulthood,
judgement, academic learning, and learning from attain intellectual levels similar to average 4- to 7-year-
experience, confirmed by both clinical assessment and old children
individualized, standardized intelligence testing
- Some can taught to read and write a little and may
manage to achieve fair command of spoken language
- Rate of learning is slow, their level of - Genetic aberrations are responsible for metabolic
conceptualizing is extremely limited alteration that adversely effect brain’s development
- Usually appear clumsy and ungainly suffer from - Genetic defects leading to metabolic alteration may
bodily deformities and poor motor coordination also involve many other developmental anomalies
besides intellectual disability
- Parental help and adequate opportunities for training,
most individuals with moderate intellectual disability - Intellectual disability associated with known genetic-
can achieve partial independence in daily self-care, chromosomal defects tends to be moderate to severe
acceptable behavior, and economic sustenance in
INFECTIONS AND TOXIC AGENTS
family or sheltered environment
- Can result from wide range of conditions due to
- Can master routine skills such as cooking or minor
infection, such as viral encephalitis or genital herpes
janitorial work if provided specialized instruction
- If pregnant woman is infected with syphilis or HIV-1
SEVERE INTELLECTUAL DISABILITY
or German measles, her child may suffer brain damage
- Have IQ scores ranging from 20-25 to 35-40 as result
commonly suffer from impaired speech development,
- Number of toxic agents such as carbon monoxide and
sensory defects, and motor handicaps
lead may cause brain damage during fetal development
- Develop limited levels of personal hygiene and self- or after birth
help skills, lessen their dependency but always
-if pregnant woman if take certain drugs, including
dependent on others for care
excess of alcohol may lead to congenital
- Some extent from training and can perform simple malformations
occupational tasks under supervision
TRAUMA (PHYSICAL INJURY)
PROFOUND INTELLECTUAL DISABILITY
- Physical injury at birth can result intellectual
- Have IQ scores below 20-25 and severely deficient in disability
adaptive behavior and unable to master any but
- Accidents that affect development can occur during
simplest tasks
delivery and after birth
- Useful speech if develops at all, is rudimentary
- Difficulties in labor due to malposition of fetus or
- Severe physical deformities, CNS pathology, and other complications may irreparably damage the
retarded growth are typical; convulsive seizures, infants brain
mutism, deafness, and other physical anomalies are
HYPOXIA – Lack of sufficient oxygen to brain
also common
stemming from delayed breathing or other causes is
- Must remain in custodial care all their lives another type of birth trauma that may damage brain
- Tend to have poor health and low resistance to IONIZINF RADIATION
disease and thus short life expectancy
- Damaging effects of ionizing radiation on sex cells
- Severe and profound cases can usually be readily and other bodily cells and tissues
diagnosed in infancy because of presence of obvious
- Radiation may act directly on fertilized ovum or
physical malformations, grossly delayed development,
produce gene mutations in sex cells of either or both
and other obvious symptoms of abnormality
parents
CAUSAL FACTORS IN INTELLECTUAL
MALNUTRITION AND OTHER BIOLOCIAL
DISABILITY
FACTORS
- Some cases occur in association with known organic
-Dietary deficiencies in protein and other essential
brain pathology
nutrients during early development of fetus could
GENETIC-CHROMOSAL FACTORS irreversible physical and mental damage
- Play much clearer role in etiology of relatively - Association between maternal weight/nutrition and
infrequent but more severe types of intellectual cognitive functioning in their offspring, as well as
disability such as Down Syndrome and heritable potential benefits of providing pregnant women with
condition known as fragile X nutritional supplements found no clear links between
maternal nutritional status and offspring cognitive A. Persistent difficulties in acquisition and use of
functioning language across modalities (spoken, written, sign
language, or another) due to deficits in comprehension
DOWN SYNDROME
or production that include the following:
- First described by Langdon Down in 1866, best
1. Reduced vocabulary (word knowledge and use)
known of clinical conditions associated with moderate
and severe intellectual disability 2. Limited sentence structure (ability to put words and
word endings together to form sentences based on the
- Creates irreversible limitations on intellectual
rules of grammar and morphology)
achievement, competence in managing life tasks, and
survivability 3. Impairments in discourse (ability to use vocabulary
and connect sentences to explain or describe topic of
- Chromosomal abnormalities other than the trisomy of
events or have conversation)
chromosome 21 may occasionally be involved in
etiology of Down Syndrome B. Language abilities are substantially and quantifiably
below those expected for age, resulting in functional
- Extra version of chromosome 21 is present in at least
limitations in effective communication, social
94% of cases
participation, academic achievement, or occupational
TREATMENTS AND OUTCOMES performance, individually or in any combination

- Significant changes in adaptive capacity of children C. Onset of symptoms is in the early developmental
with intellectual disability are possible through special period
education and other rehabilitative measures
D. The difficulties are not attributable to hearing or
- One decision that the parents did was place the child other sensory impairment, motor dysfunction, or
in an institution, most authorities agree that this should another medical or neurological condition and are not
be considered as last resort in light of the unfavorable better explained by intellectual developmental disorder
outcomes normally experienced – particularly in (intellectual disability) or global developmental delay
regard to erosion of self-care skills
DIAGNOSTIC FEATURES
MAINSTREAMING – “Inclusion programming”
- Language deficits are evident in spoken
requires careful planning, high level of teacher skill,
communication, written communication, or sign
and facilitative teacher attitudes
language
- Language learning and use is dependent on both
COMMUNICATION DISORDERS receptive and expressive skills

- Deficits in language, speech, and communication - Language disorder usually affects vocabulary and
grammar, and these effect then limit the capacity for
SPEECH discourse
- Expressive production of sounds and includes - Deficits in comprehension of language are frequently
individual’s articulation, fluency, voice, and resonance underestimated, as children may be good at using
quality context to infer meaning
LANGUAGE - Problems with remembering new words and
- Forms, function, and use of conventional system of sentences are manifested by difficulties rehearsing
symbols (spoken words, sign language, written words, strings of verbal information, and difficulties
picture) in rule-governed manner for communication remembering novel sound sequences, skill that may be
important for learning new words
COMMUNICATION
EXPRESSIVE ABILITY – Production of vocal,
- Vernal or nonverbal behavior (intentional or gestural, or verbal signals
unintentional) has potential to influence the behavior,
ideas, or attitudes of another person RECEPTIVE ABILITY – Process of receiving and
comprehending language messages
LANGUAGE DISORDER
DEVELOPMENT AND COURSE
DSM-5 TR (Diagnostic Criteria)
- Changes appear across the dimensions of language
(sounds, words, grammar, narratives/expository texts,
and conversational skills) in age-graded increments - Speech sound disorder is diagnosed when speech
and synchronies sound production is not what would be expected based
on child’s age and developmental stage and when
- Language disorder emerges during early
deficits are not result of physical, structural, overall
developmental period
speech should be intelligible
- Considerable variation in early vocabulary
- Developing children at age 3 years, overall speech
acquisition and early word combinations
should be intelligible, at age 2 years, only 50% may be
- Individual differences in early childhood are not, as understandable
single indicators, highly predictive of later outcomes,
- Boys are more likely (range of 1.5 – 1.8 to 1.0) to
although late onset of language at age 24 months in
have speech sound disorder than girls
population based sample was the best predictor of
outcomes at age 7 years ASSOCIATED FEATURES
- By age 4 years, individual differences in language - Positive family history of speech or language
ability are more stable, with better measurement disorders is often present
accuracy, and are highly predictive of later outcomes
- Childhood apraxia of speech and verbal dyspraxia
- Language disorder diagnosed in children age 4 years are used for speech production with motor components
and older is likely to be stable over time and typically
DEVELOPMENT AND COURSE
persists into adulthood
- Articulation of speech sounds follows developmental
- Children with language disorders are at risk for peer
pattern
victimization
- Not unusual for typically developing children to use
- For females with childhood language disorders, there
developmental processes for shortening words and
could be almost 3 times the risk
syllables as they are learning to talk
SPEECH SOUND DISORDER
- Children with speech sound disorder continue to use
DSM-5 TR (Diagnostic Criteria) immature phonological simplification processes past
the age when most children can produce words clearly
A. Persistent difficulty with speech sound production
that interferes with speech intelligibility or prevents LISPING – (Misarticulation sibilants) particularly
verbal communication of messages common and may involve frontal or lateral patterns of
airstream direction
B. The disturbances causes limitations in effective
communication that interfere with social participation, - May be associated with tongue-thrust swallowing
academic achievement, or occupational performance, pattern
individually or in any combination
C. Onset of symptoms is in early development period
CHILDHOOD-ONSET FLUENCY DISORDER
D. Difficulties are not attributable to congenital or (STUTTERING)
acquired conditions, such as cerebral palsy, cleft
DSM-5 TR (Diagnostic Criteria)
palate, deafness or hearing loss, traumatic brain injury,
or other medical or neurological conditions A. Disturbances in the normal fluency and time
patterning of speech that inappropriately for the
DIAGNOSTIC FEATURES
individual’s age and language skills, persist over time,
- Speech sound production describes the clear and are characterized by frequent and marked
articulation of the phonemes (individual sound) that in occurrences of one (or more) of the following:
combination make up spoken words
1. Sound and syllable repetitions
- Requires both the phonological knowledge of speech
2. Sound and prolongations of consonants as well as
sounds and ability to coordinate the movements of the
vowels
articulators (jaw, tongue, and lips) with breathing and
vocalizing for speech 3. Broken words (pauses within a word)
- Difficulties may experience difficulty with 4. Audible or silent blocking (filled or unfilled pauses
phonological knowledge of speech sound or ability to in speech)
coordinate movements for speech in varying degrees
5. Circumlocutions (words substitutions to avoid 1. Deficits in using communication for social purposes,
problematic words) such as greeting and sharing information, in manner
that is appropriate for the social context
6. Words produced with excess of physical tension
2. Impairment of ability to change communication to
7. Monosyllabic whole-word repetition (I-I-I-I see
match context of needs of listener, such as speaking
him)
differently in classroom than on playground, talking
B. Disturbances causes anxiety about speaking or differently to child than to an adult, and avoiding use
limitation if effective communication, social of overly formal language
participation, or academic or occupational
3. Difficulties following rules for conversation and
performance, individually or any combination
storytelling, such as taking turns in conversation,
C. Onset of symptoms is in early developmental period rephrasing when misunderstood, and knowing how to
(NOTE. Later-onset cases are diagnosed as adult-onset use verbal and nonverbal signals to regulate interaction
fluency disorder)
4. Difficulties understanding what is not explicitly
D. Disturbances is not attributable to speech-motor or stated (making inferences) and nonliteral or ambiguous
sensory deficit, dysfluency associated with meanings of language (idioms, humor, metaphors,
neurological insult (stroke, tumor, trauma), or another multiple meanings that depend on context for
medical condition and is not better explained by interpretation)
another mental disorder
B. Deficits result in functional limitations in effective
DIAGNOSTIC FEATURES communication, social participation, social
relationships, academic achievement, or occupational
- Essential feature of this is disturbance in the normal performance, individually or in combination
fluency and time patterning of speech that is
inappropriate for individual’s age C. Onset of the symptoms is in early developmental
period (but deficits may not become fully manifest
- Characterized by frequent repetition or prolongations until social communication demands exceed limited
of sounds or syllables and other types of speech capacities)
dysfluencies, including broken words, audible or silent
blocking, circumlocutions (word substitutions to avoid D. Symptoms are not attributable to another medical or
problematic words), words produced with excess of neurological condition or to low abilities in domains of
physical tension, and monosyllabic whole-word word structure and grammar, and not better explained
repetitions by autism spectrum disorder, intellectual
developmental disorder, global developmental delay,
- Disturbance in fluency may interfere with academic or another mental disorder
or occupational achievement and with social
communication DIAGNOSTIC FEATURES

- Dysfluency is often absent during oral reading, - Characterized by primary difficulty with pragmatic
singing, or talking to inanimate objects or to pets (social use of language and communication)

DEVELOPMENT AND COURSE - Deficits in understanding and following social rules

of both verbal and nonverbal communication in
- Childhood-onset fluency disorder, or developmental naturalistic contexts, changing language according to
stuttering occurs by age of 6 for 80%-90% of affected need of the listener or situation, and following rules for
individuals, with age at onset ranging from 2-7 years conversation and storytelling
- Dysfluencies start gradually, with repetition of initial - Limitations in effective communication, social
consonants, first words of phrase, or long words participation, development of social relationships,
academic achievement, or occupational performance

SOCIAL (PRAGMATIC) COMMUNICATION ASSOCIATED FEATURES

DISORDER - Associated features of social (pragmatic)
DSM-5 TR (Diagnostic Criteria) communication disorder is language impairment

A. Persistent difficulties in social use of verbal and - History of delay in reaching language milestones, and
nonverbal communication as manifested by all of the historical, if not current, structural language problems
following:
- Individuals with social communication deficits may DELUSIONS
avoid social interaction
- Latin verb Ludere, which means “to play”
DEVELOPMENT AND COURSE
- Fixed beliefs that are not amendable to change in
- Diagnosis of social (pragmatic) communication light of conflicting evidence
disorder is rare among children younger than 4 years
- Delusions that express a loss of control over mind or
- By age 4 or 5 years, most children should possess body are generally considered to be bizzare
adequate speech and language abilities to permit
- May include variety of themes:
identification of specific deficits in social
communication PERSECUTORY DELUSIONS – Belief that one is
going to be harmed, harassed, and so forth by
- Midler forms of disorder may not become apparent
individual, organization, or other group, most common
until early adolescence, when language and social
interactions become more complex REFERENTIAL DELUSIONS – Belief that certain
gestures, comments, environmental cues, and so forth
are directed at oneself, also common
GRANDIOSE DELUSIONS – Individual believes that
CHAPTER 13: SCHIZOPHRENIA AND OTHER he or she has exceptional abilities, wealth, or fame
PSYCHOTIC DISORDERS
EROTOMANIC DELUSIONS – When individual
BENEDICT MOREL – Belgian psychiatrist describe believes falsely that another person is in love with him
the case of 13-year-old boy, he used the term démence or her
précoce (mental deterioration at early age)
NIHILISTIC DELUSIONS – involve the conviction
- Describe the condition and to distinguish it from the that major catastrophe will occur
dementing disorders associated with old age
SOMATIC DELUSIONS – Preoccupations regarding
EMIL KRAEPELIN (1856-1926) – Known for his health and organ function
careful description of now regard as schizophrenia
HALLUCINATIONS
- Used Latin version of Morel’s term (Dementia
- From Latin verb Hallucinere or Allucinere, meaning
Praecox) refer to group of conditions that all seemed to
to “wander in mind”or “idle talk”
feature mental deterioration beginning early in life
- Perception-like experiences that occur without
EUGEN BLEULER (1857-1939) – Swiss psychiatrist
external stimulus
gave the diagnostic term still use today
- Vivid and clear, with full force and impact of normal
- In 1911, Bleuler used Schizophrenia (from Greek
perceptions, and not voluntary control
roots of Schizo, meaning “to split or crack”, and Phren,
meaning “mind”) - Auditory hallucination are the most common in
schizophrenia and related disorder
- Characterized primarily by disorganization of thought
processes, lack of coherence between thought and - Usually experienced as voices, whether familiar or
emotion, and inward orientation away “split off” from unfamiliar, perceived as distinct from individual’s own
reality thoughts
- Schizophrenia spectrum and other psychotic - Must occur in context of clear sensorium those occur
disorders include Schizophrenia, other psychotic while falling asleep (hypnagogic) and waking up
disorder, and Schizotyplal (personality) disorder (hypnopompic)
- Disorder characterized by array of diverse symptoms, DISORGANIZED THINGKING (SPEECH)
including extreme oddities in perception, thinking,
action, sense of self, and manner of relating to others - (Formal thought disorder) typically inferred from
individual’s speech
PSYCHOSIS – Hallmark of schizophrenia is
significant loss of contact with reality - May switch from one topic to another (derailment or
loose association)
- Defined by abnormalities in one or more following 5
domains: - Speech may be severely disorganized that is nearly
incomprehensible and resembles receptive aphasia in
its linguistic disorganization (incoherence or “word
salad”)
- Less severe disorganized thinking or speech may
occur during the prodromal and residual periods of
schizophrenia
GROSSLY DISORGANIZED OR ABNORMAL
MOTOR BEHAVIOR (INCLUDINF CATATONIA)
- Manifest itself in variety of ways, ranging from
childlike “silliness” to unpredictable agitation
- Problem may not be noted in any form of goal-
oriented behavior, leading to difficulties in performing
activities of daily living
CATATONIC BEHAVIOR – Marked decrease in
reactivity to environment, ranges from resistance to
instructions (negativism); to maintaining rigid,
inappropriate or bizarre posture; to a complete lack of
verbal and motor responses (mutism and stupor)
- Other features are repeated stereotyped movement,
staring, grimacing, and the echoing speech
NEGATIVE SYMPTOMS
- Substantial portion of morbidity associated with
schizophrenia but less prominent in other psychotic
disorder
- 2 negative symptoms are prominent in schizophrenia:
diminished emotional expression and avolition
4 A’s
AVOLITION – Decrease in motivated self-initiated
purposeful in work or social activities
ALOGIA – Manifested by diminished speech output
ANHEDONIA – Decreased ability to experience
pleasure. Individuals with schizophrenia can still enjoy
pleasurable activity in the moment and recall it, but
show reduction in frequency of engaging in
pleasurable activity
ASOCIALITY/AFFECT – Apparent lack of interest in
social interaction and may associated with avolition,
but can also manifestation of limited opportunities for OTHER PSYCHOTIC DISORDERS
social interaction
SCHIZOAFFECTIVE DISORDER
PHASES
- Conceptually something of hybrid, in that used to
PRODROMAL – Start of symptoms describe people who have features of schizophrenia
ACTIVE – Full blast and severe mood disorder

RESIDUAL – Slowly/mild symptoms or reoccurring - Person not only has psychotic symptoms that meet
criteria for schizophrenia but also has marked changes
in mood for substantial amount of time
- Prognosis for patients diagnosed with schizoaffective DELUSIONAL DISORDER
disorder is somewhere between those patients with
- Hold beliefs that are considered false and absurd by
schizophrenia and patients with mood disorder
those around them
- People given the diagnoses of delusional disorder
may otherwise behave quite normally
- Behavior does not show gross disorganization and
performance deficiencies characteristics of
schizophrenia, and general behavioral deterioration is
rarely observed in disorder
EROTOMANIA – Theme of the delusion involves
great love for a person, usually of higher status
- Significant proportion of female stalkers are
diagnosed with erotomania
SPECIFY WHETHER:
EROTOMANIC TYPE – Another person is in love
with the individual
GRANDIOSE TYPE – Conviction of having some
great (but unrecognized) talent or insights or having
important discovery
SCHIZOPHRENIFORM DISORDER JEALOUS TYPE – His or her spouse or lover is
unfaithful
- Category reserved for schizophrenia-like psychoses
that last at least a month but do not last for at least 6 PROSECUTORY TYPE – He or she is being
months and so do not warrant a diagnosis of conspired against, cheated, or spied on, followed,
schizophrenia poisoned or drugged, maliciously maligned, harassed,
or obstructed in pursuit of long-term goals
- Possibility of early and lasting remission after first
psychotic breakdown, the prognosis for schizophrenia SOMATIC TYPE – Involves bodily functions or
disorder is better than that for established forms of sensation
schizophrenia
MIXED TYPE – Applies when no one delusional
theme predominates
UNSPECIFIED TYPE – Dominant delusional belief
cannot clearly determined or not described in specific
types
BRIEF PSYCHOTIC DISORDER - Prevalence of schizophrenia in the 1st degree relative
(parents, siblings, and offspring) of proband is about
- Exactly what its name suggest
10%
- Sudden onset of psychotic symptoms or disorganized
- 2nd degree relatives who share only 25% of their
speech or catatonic behavior
genes with proband (half-siblings, aunt, uncle, nieces,
- Often great emotional turmoil, episode usually lasts nephews, and grandchildren) the lifetime prevalence of
only a matter of days (too short to warrant a diagnosis schizophrenia is closer to 3%
of schizophreniform disorder)
- The term familial and genetic are not synonymous
- Person returns to his/her former level of functioning and disorder can run in family for nongenetic reason
and may never have another episode again
TWIN STUDIES
- Brief psychotic disorder is often triggered by stress
- Shown a higher concordance for schizophrenia
among identical (monozygotic) twins than among
people related in any other way including fraternal
(dizygotic) twins
- Pairwise concordance rate is 28% in MZ and 6% in
DZ
- Reduction in shared genes from 100% to 50%
reduces risk of schizophrenia by nearly 80%
- Sharing 50% of one’s genes with co-twin with
schizophrenia is associated with lifetime risk for
schizophrenia of 6%
STRUCTURAL AND FUNCTIONAL BRAIN
ABNORMALITIES
- Abnormalities in the structure and function of brain
as well as neurotransmitter activity in people with
schizophrenia
NEUROCOGNITION
- Cognitive impairments is core feature of
schizophrenia
- People with schizophrenia perform much worse than
healthy controls on board range of neuropsychological
tests
GENETIC AND BIOLOGICAL FACTORS
- Almost all aspects of cognition (involving attention,
- The old dichotomy of nature of nature vs nurture is as
language, and memory) are impaired
misleading as it is simplistic
- Cognitive impairments appear early
- Complex interplay between genetic and
environmental factors is responsible - Having lower IQ may itself be an independent risk
factor for developing schizophrenia at later point and
GENETIC FACTORS
having higher IQ may be protective in some way
- Schizophrenia type are “familial” and tend to “run in
- Sharp decline in cognitive ability (and IQ) occurs
families”
during the period of transition from the premorbid into
- Diagnosed group of people who provide the starting full-blown illness
point for inquiry (also called probands)
SOCIAL COGNITION
- There is strong association between the closeness of
- Concerned with how we recognize, think about, and
the blood relationship and risk for developing the
respond to social information including the emotions
disorder
and intentions of other
- People with schizophrenia show significant - If neurons cannot connect well with each other, many
impairments in social cognition problems are likely to result
- Fail to spot the kinds of subtle (or not so subtle) WHITE MATTER PROBLEMS
social hints that most of us can detect without
- Also involved problems with white matter
difficulty
- Nerve fibers are covered in myelin sheath (which
- Difficulties recognizing emotion in faces and emotion
looks white in color in chemically preserved brain)
being conveyed in speech
- Myelin acts as insulator and increases the speed and
LOSS OF BRAIN VOLUME
efficiency of conduction between nerve cells
- Brain abnormalities associated with illness, both in
- White mater crucially important for the connectivity
terms of brain structure and brain function
of the brain
- Most-well replicated findings concerns the brain
- If there are disruptions in the integrity of white
ventricles
matter, there will be problems in how well the cells of
- Fluid-filled spaces that lie deep within the brain the nervous system can function
- Patients with schizophrenia have enlarges brain - Patients with schizophrenia show that they have
ventricles, with males possibly being more affected reductions in white matter volume as well as structural
than females abnormalities in white matter itself
- Enlarged brain ventricles are not seen in all patients - This could make internally generated speech (self-
and are not specific to schizophrenia talk) seem as if it’s being “heard”
- Enlarged brain ventricles are important because they - In people at high risk of developing schizophrenia,
are indicator of reduction in amount of brain tissues white matter changes in temporal areas of the brain
also predict later social function
-Imply that the brain areas that border the ventricles
have somehow shrunk or decreased in volume, - Even though they are not psychotic themselves, have
ventricular space becoming larger as result reduction in volume of the corpus callosum – massive
tract of white matter fibers that connects the two
- Patients with schizophrenia show about 3% reduction
hemisphere of the brain
in whole brain volume relative to that in control
- Neuroimaging research showing just how disrupted
- Decrease in brain volume is present very early in the
brain functioning is in patients with this disorder
illness
- Hyperactivation in frontal brain areas is found,
- Adolescents who became psychotic showed steep
suggesting that they are having to work harder to be
declines in the gray matter in prefrontal cortes
successful on task
- Loss of gray matter (which is made up of nerve cells)
- Frontal lobe dysfunction is believed to account for
also seemed to be occurring exactly as psychosis was
some of negative symptoms of schizophrenia and
developing
perhaps to be involves in some attention-cognitive
- Not due to any influences of medications deficits

- Adolescents who showed the steepest declines in - Dysfunction of the temporal lobe is also found
brain gray matter (more cortical thinning) also had
highest levels of inflammatory markers in their blood
- Psychosis and cortical thinning go hand in hand
- Brain changes that occur during the transition to
psychosis
AFFECTED BRAIN AREAS
- There is loss of gray matter in the prefrontal cortex
- Any loss of gray matter will have consequences for
neural connectivity
NEUROCHEMISTRY healthy volunteers it produces schizophrenia-like
positive and negative symptoms
- Serious mental disorders are due to “chemical
imbalances” in brain is commonplace - When given to patient whose schizophrenia is stable
and well controlled
DOPAMINE
- Ketamine exacerbates hallucinations, delusions, and
- Most well-studies neurotransmitter implicated in
thought disorder
schizophrenia
- One action of dopamine receptors is to modulate the
- Dopamine hypothesis dates to 1960s and was derive
excitability of glutamate neurons and inhibit the
from 3 important observations
release of glutamate (pressing the brake pedal on
- First was pharmacological action of drug glutamate neurotransmission, as it were)
Chlorpromazine (Thorazine), first used in treatment of
- Overactive dopaminergic system could result in
schizophrenia in 1952
excessive suppression (too much heavy braking) of
- Rapidly became clear that this drug was helpful to NMDA receptors
patients, was learned that therapeutic benefits of
PSYCHOSOCIAL AND CULTURAL FACTORS
chlorpromazine were linked to ability to block
dopamine receptors - Schizophrenia was caused by destructive parental
interactions
- Second implicating dopamine in schizophrenia came
from entirely different direction - Disturbances and conflict in families that include an
individual with schizophrenia may well be caused by
- Amphetamines are drugs that produce functional
having a person with psychosis in family
excess of dopamine
- Adverse family environments and communication
- Drug that gave rise to functional excess of dopamine
deviance probably have little pathological consequence
also gave rise to psychotic state that looked a lot like
if child who is exposed has no genetic risk for
schizophrenia
schizophrenia
- Third was from clinical studies that actually treated
TREATEMENTS AND OUTCOMES
patients by giving them drugs that increase the
availability of dopamine in the brain - Before the 1950s treatment options were very
limited
- Activity in dopamine system may play role in
determining how much salience we give to internal and - Agitated patients might be put in straitjackets or
external stimuli treated with electroconvulsive “shock” therapy
- Dysregulated dopamine transmission may actually - In 1950s when class of drugs known as
make pay more attention to give more significance to antipsychotics was introduce
stimuli that are not relevant or important (this is called
- Pharmacotherapy (treatment by drugs) with these
“aberrant salience”)
medications rapidly transformed the environment of
- Might develop delusions or experience hallucinations mental hospitals by calming patients and virtually
and why psychotic experiences might be shaped by eliminating their wild, dangerous, and out-of-control
patient’s culture and history behaviors
GLUTAMATE PHARMACOLOGICAL APPROACHES
- Excitatory neurotransmitter that is widespread in FIRST-DEGREE ANTIPSYCHOTICS
brain
- Like chlorpromazine (Thorazine) and haloperidol
- First, PCP (angel dust) is known to block glutamate (Haldol), were among the first generation to be used to
receptors treat psychotic disorder
- PCP also induces symptoms (both negative and - Sometimes referred to neuroleptics (literally “seizing
positive) that are very similar to schizophrenia, when the neurons”) these medications revolutionized the
they take PCP it exacerbates their symptoms treatment of schizophrenia
- Second physician had to stop ketamine which sis
anesthetic, because when it is given intravenously to
- They are called first generation antipsychotics (or Exercise
typical antipsychotics) to distinguish to second
generation (or atypical) antipsychotics
CHAPTER 7: MOOD DISORDER AND
- Work best for the positive symptoms of schizophrenia
DEPRESSION
- Quieting the voices and diminishing delusional
DEPRESSION
beliefs, these medications provide patients with
significant clinical improvement - Can refer either to a mood or to clinical syndrome,
combination of emotional, cognitive, and behavioral
- Common side effects of these include drowsiness, dry
symptoms
mouth, and weight gain
MANIA
- Also experience what are known as extrapyramidal
side effects (EPS), these are involuntary movement - Flip side of depression, involves a disturbance in
abnormalities (muscle spasms, rigidity, shaking) that mood accompanied by additional symptoms
resemble Parkinson’s disease
- Distinct period of abnormally and persistently
- For long period may also develop tardive dyskinesia, elevated, expansive, irritable mood and persistently
involves marked involuntary movements of lips and energy for activities
tongue (sometimes the hands and neck)
- Exaggerated elation, joy, euphoria
- Very rare cases there is toxic reaction that is
neuroleptic malignant syndrome, characterized by high TYPES OF MOOD DISORDERS
fever and extreme muscle rigidity and left untreated it UNIPOLAR DEPRESSIVE DISORDERS
can be fatal
- Those in which the person experiences only episodes
SECOND-GENERATION ANTIPSYCHOTICS of depression
- 1980s new class of antipsychotics medication began - Depression or mania alone
to appear
- Typically depression alone
- First to be used was clozapine (Clozaril), initially
reserved for use with treatment refractory patients BIPOLAR DISORDER
(those who were not helped by other medication,
- Person experiences episodes of mania as well as
clozapine is now used widely
depression
- Other second-generation are risperidone (Risperdal),
- Mixed manic episode
olanzapine (Zyprexa), quetiapine (Seroquel), and
ziprasidone (Geodon) - Also known as Manic Depressive Disorder
- Recent additions include aripiprazole DEPRESSIVE EPISODE – Markedly depressed or
lose interest in formerly pleasurable activities (or both)
(Abilify) and lurasidone (Latuda)
for at least 2 weeks
- They cause fewer extrapyramidal symptoms than the
- Other symptoms such as changes in sleep or appetite,
earlier medications
or feelings of worthlessness
- Drowsiness and considerable weight gain are very
MANIC EPISODE – Markedly elevated, euphoric, or
common, Diabetes is also very serious concern
expansive mood, often interrupted by occasional
- In rare cases Clozapine also causes life-threatening outbursts of intense irritability or even violence –
drop in white blood cells knows agranulocytosis particularly when others refuse to go along with manic
person’s wishes and schemes
PSYCHOSOCIAL APPROACHES
- Extreme moods must persist for at least a week for
Cases Management these diagnoses to be made
Family Therapy HYPOMANIC EPISODES – Experiences abnormal
Psychoeducation elevated, expansive, or irritable mood for at least 4
days
Social-Skills Training
Cognitive Remediation
- Person must have at least 3 symptoms similar to - Return of symptoms is one of two types:
those involves in mania but to lesser degree (inflated
RELAPSE – Return of symptoms within fairly short
self-esteem, decreased need for sleep, flights of ideas,
period of time, situation that probably reflects the fact
pressured speech, etc.)
that the underlying episode of depression has not yet
run its course
RECURRENCE – Onset of new episode of depression,
occurs in approximately 40-50% of people who
experience depressive episodes
- Single episode – No mania – Rare
- Recurrent – 4-7 episodes – 4-5 months

PREVALENCE OF MOOD DISORDERS

- Major mood disorders occur with alarming frequency
– at least 15 to 20 times more frequently than
schizophrenia
UNIPOLAR DEPRESSIVE DISORDERS
- Sadness, discouragement, pessimism, and
hopelessness about matters improving are familiar
feelings to most people
- Feelings of depression are unpleasant when we are
experiencing them , but usually do not last long,
dissipating on own after a period of days or weeks or
after reached certain intensity level
- By slowing us down, mild depression sometimes
saves from wasting a lot of energy in futile pursuit PERSISTENT DEPRESSIVE DISORDER
unobtainable goals (DYSTHYMIA)

- Normal depression would be expected to occur in - Differs from major depression in terms of both
people undergoing painful but common life events severity and duration
such as significant personal, interpersonal, or - Dysthymia represents chronic mild depressive
economic losses condition that has been present for many years
MAJOR DEPRESSIVE DISORDER - Distinction between Major Depressive Disorder and
- Must be in major depressive episode and never had Dysthymia is somewhat artificial as it can have same
manic, hypomanic, or mixed episodes frequent symptoms that could seen in same person

- When diagnosis of MDD is made, usually also - Periods of normal mood may occur briefly, but
specified whether this is first , and therefore single usually last for only a few weeks (maximum of 2
(initial), episode or recurrent episode (preceded by one months)
or more previous episodes) - Persistently depressed mood most of the day, for
- Depressive episodes typically last about 6-9 months more days than not, for at least 2 years (1 year for
if untreated children and adolescents)

- Approximately 10-20% of people with MDD, the

symptoms do not remit for over 2 years, in which
case persistent depressive disorders is diagnosed
 1. Numbing and disbelief
2. Yearning and searching for the dead person
3. Disorganization and despair that sets in when the
person accepts the loss as permanent
4. Some reorganization as the person gradually begins
to rebuild his or her life
POSTPARTUM “BLUES”
- Sometimes occurs in new mothers (and occasionally
fathers) and it known to have adverse effects on child
outcomes
DOUBLE DEPRESSION
- Typically include changeable mood, crying easily,
- Someone with persistent depressive disorder sadness, and irritability, often liberally intermixed with
develops major depression happy feeling

- Major Depressive Episodes and Dysthymic Disorder - Occur in as many as 50-70% of women within 10
days of the birth of their child
- Dysthymia first
- May likely to occur if the new mother has lack of
- Severe Psychopathology social support or has difficulty, or if the woman has
ADDITIONAL DEFINING CRITERIA FOR personal or family history of depression that leads to
DEPRESSIVE DISORDERS heightened sensitivity to stress of childbirth

SYMPTOMS SPECIFIERS: PREMENSTRUAL DYSPHORIC DISORDER

PSYCHOTIC FEATURES – Hallucinations or - PMDD condition similar to PMS that also happens in
delusions – during the most recent episode of the week or two before your period starts as hormone
depression or mania levels begin to fall after ovulation

- Psychotic features can be either consistent with the - PMDD causes more severe symptoms than PMS,
patient’s mood including severe depression, irritability, and tension

ANXIOUS DISTRESS – Presence of typical - PMDD affects up to 5% of women of childbearing

symptoms of anxiety, such as feeling tense or worried, age, many women with PMDD may also have anxiety
difficulty concentrating, or sense of loss of control or depression

- Comorbid Disorders or Anxiety symptoms DSM-5 TR (Diagnostic Criteria)

MELANCHOLIC – Term used to describe particularly A. In majority of menstrual cycles, at least 5 symptoms
severe type of depression must be present in final week before the onset of
menses, start to improve within a few days after the
- Presence of melancholic feature may also indicate onset of menses, and becoming minimal or absent in
that the persons is likely to have good response to the week post menses
biological forms of treatment, such as antidepressant
medications and electroconvulsive therapy B. One (or more) of the following symptoms must be
present
OTHER FORMS OF DEPRESSION
1. Marked affective lability (mood swings, feeling
- Depression is always precipitated by stressful life suddenly sad or tearful, or increased sensitivity to
events rejection)
- Most stressful events possible are those involving the 2. Marked irritability or anger or increased
loss of life, as well as the creation of new life interpersonal conflicts
LOSS AND THE GRIEVING PROCESS 3. Marked anxiety, tension, and/pr feelings of being
keyed up or on edge
- Grief has certain characteristics that there are usually
4 phases of normal response to loss of spouse or close C. One (or more) of the following symptoms must
family members: additionally to be present, to reach a total five
symptoms when combined with symptoms from - Subthreshold form of bipolar II disorder also have
Criterion B above been recognized as many as 40% of individuals
diagnosed with MDD have similar number of
1. Decreased interest in usual activities (work, school,
hypomanic symptoms
friends, hobbies)
2. Subjective difficulty in concentration
3. Lethargy, easy fatigability, or marked lack of energy
4. Marked change in appetite; overeating; or specific
food cravings
5. Hypersomnia or insomnia
6. Sense of being overwhelmed or out of control
7. Physical symptoms such as breast tenderness or
swelling, joint or muscle pain, sensation of “bloating”
or weight gain
NOTE. Symptoms in Criteria A-C must have been met CYCLOTHYMIC DISORDER
for most menstrual cycles that occurred in preceding
year - Experience cyclical mood changes that are more
severe than normal, but less severe that the mood
D. Symptoms cause clinically significant distress or swings seen in bipolar disorder
interfere with work, school, usual social activities, or
relationships with other - Adults who experience at least 2 years (for children,
full year) of both hypomanic and depressive periods
E. Disturbance is not merely an exacerbation of the without ever fulfilling the criteria for an episode of
symptoms of another disorder, such as major mania, hypomania, or major depression
depressive disorder, panic disorder, persistent
depressive disorder, or personality disorder - In this phase of the disorder, the person may become
especially creative and productive because of increased
F. Criterion A should be confirmed by prospective physical and mental energy
daily ratings during at least two symptomatic cycles
- The person may show other symptoms such as low
G. Symptoms are not attributable to physiological energy, feelings of inadequacy, social withdrawal, and
effects of substance or another medical condition pessimistic, brooding attitude
BIPOLAR DISORDER CAUSES OF MOOD DISORDER
BIPOLAR I NEUROTRANSMITTER SYSTEMS
- Modern understanding of the classic manic- - Neurotransmitter is chemical messenger of body
depressive disorder or affective psychosis describe in
nineteenth century - Each neurotransmitter works in broad set of pathways
connecting fairly specific brain locations
- Mixed episode is characterized by symptoms of both
full-blown manic and major depressive episodes for at - Current thinking is that the balance of the various
least 1 week, either intermixed or alternating rapidly neurotransmitters and their interaction with systems of
every few days self-regulation are more important than the absolute
level of any one neurotransmitters
BIPOLAR II
THE ENDOCRINE SYSTEM
- Requiring the lifetime experience of at least one
major depressive episode at least one hypomanic - Endocrine system plays an important role in in
episode (but no history of mania), no longer thought to regulating person’s response to stress
be less severe condition than bipolar I disorder
- Hypothalamic-Pituitary-Adrenal (HPA) axis is one of
- Bipolar II disorder is equally or somewhat more the important pathway in endocrine system
common than bipolar I
- Also activated in response to stress
- Hypothalamus > Pituitary Gland > - Women tend to ruminate more than men about their
Adrenocorticotrophic hormone > Adrenal glands > situation and blame themselves for being depressed
Cortisol
- Response style predicted the later development of
- Association between HPA axis and depression is depression when under stress
indicated by evidence regarding dexamethasone
- Men tend to ignore their feelings, perhaps engaging
suppression test (DST), which has been used
in activity to take their minds off them
extensively to study endocrine dysfunction in patients
with mood disorders SOCIAL SUPPORT
SLEEP AND CIRCADIAN RHYTHMS - Early landmark study, first suggested the important
role of social support in the onset of depression
- Sleep disturbances are even more severe among
depressed older adults - Large number of women who had experience serious
life stress, they discovered that only 10% of women
- Insomnia, frequently experienced by older adults, is
who had friend in whom they could confide became
risk factor for both the onset and persistence of
depressed
depression
- Compared with 37% of women who did not have
- Also occur in bipolar patients, where they are
close supportive relationship. Later prospective studies
particularly severe and characterized not only by
have also confirmed the importance of social support
decrease REM latency but also by severe insomnia and
(or lack of it) in predicting the onset of depressive
hypersomnia (excessive sleep)
symptoms at later time
LEARNED HELPLESSNESS
TREATMENT AND MEDICATIONS
- People become anxious and depressed when they
TREATMENT OF MOOD DISORDERS
decide that they have no control over the stress in their
lives - Changing of the chemistry of the brain
- Depressive Attributional Style: - Medications
1. INTERNAL – Individual attributes negative events - ECT
to personal failings “it is all my fault”
- Psychological Treatment
2. STABLE – Even after particular negative event
passes, the attribution that “additional bad things will ANTIDEPRESSANT MEDICATIONS
always be my fault” remains - Selective Serotonin Reuptake Inhibitors (SSRI’s)
3. GLOBAL – Attributions extend across variety of - Fluoxetine (Prozac)
issues
- First treatment choice
MARITAL RELATIONS
- Block Presynaptic Reuptake
- Depression and bipolar are strongly influenced by
interpersonal stress and especially marital - Many side effects
dissatisfaction, as suggested earlier when it was noted
- Mixed Reuptake Inhibitor
that disruptions in relationships often lead to
depression - Blocking reuptake of norepinephrine as well as
serotonin
MOOD DISORDERS IN WOMEN
- Other medications
- Data on prevalence of mood disorders indicated
dramatic gender imbalances - Venlafaxine
- Although bipolar disorder is evenly divided between - Similar to tricyclics
men and women, almost 70% of the individuals with
major depressive disorder and dysthymia are women - St. John’s Wort

- Suggest that if the disruption in marital relationship - Questionable efficacy

reaches the stage of divorce, men who had previously
been functioning well are at greater risk for depression
 BEHAVIORAL THERAPY
- Increased positive events
- Exercise
INTERPERSONAL PSYCHOTHERAPY (IPT)
- Address interpersonal issues in relationships
- Roled disputes
- New relationships

LITHIUM - Social skills deficits

- Mood-stabilizing drug STAGE OF DISPUTE

- Common salt - Negotiation stage

- Primary treatment for bipolar disorders - Impasse stage

- Unsure of mechanism of action - Resolution stage

- Narrow therapeutic window COMBINED TREATMENTS FOR DEPRESSION

- Too little – ineffective - Possible benefits above individual treatment

- Too much – toxic, lethal - 48% benefits from meds or CBT

ELECTROCONVULSIVE THERAPY AND - 73% benefit from combined

TRANSCRANIAL MAGNETIC STIMULATION SUICIDE
ELECTROCONVULSIVE THERAPY (ECT) INDICES
- Temporary seizures - Attempts
- 6-10 treatments - Ideations
- Severe depression RISK FACTORS
- Few side effects - Family history
- Relapse is common - Neurobiology
TRANCRANIAL MAGNETIC STIMULATION - Stressful life event
(TMS)
- Shameful/humiliating stressor
- Localized electromagnetic pulse
TREATMENT
- Fewer side effects
- Importance of assessment
- Efficacy is likely good
- More studies needed
PSYCHOLOGICAL TREATMENT FOR
DEPRESSION
COGNITIVE THERAPY
- Identify errors in thinking
- Correct cognitive errors
- Substitute more adaptive thoughts
- Correct negative cognitive schemas
ANXIETY, OBSESSIONS, TRAUMA, SOMATIC, - Fear, anxiety, or avoidance causes clinically
AND THEIR DISORDERS significant distress or impairment in social,
occupational, or other important areas of functioning
FEAR AND ANXIETY RESPONSE PATTERS
- Not better explained by the symptoms of another
mental disorder
SUBTYPES IDENTIFIED IN DSM-5
- Animal
- Natural environment
- Blood-injection-injury
- Situational (airplanes, elevators, enclosed places)
ANXIETY DISORDERS - Other (situations that may lead to choking or
SEPARATION ANXIETY DISORDER vomiting; in children, loud sound or costumed
characters)
- Developmentally inappropriate and excessive fear of
anxiety concerning separation from those to whom the SOCIAL ANXIETY DISORDER
individual is attached - Marked and disproportionate fear consistently
- Fear, anxiety, or avoidance is persistent, lasing at triggered by exposure to potential social scrutiny
least 4 weeks in children and adolescents and typically - Exposure to trigger leads to intense anxiety about
6 months or more in adults being evaluated negatively
- Disturbance causes clinically significant distress or - Trigger situations are avoided or else endured with
impairment in social, academic, occupational, or other intense anxiety
important areas of functioning
- Symptoms persist for at least 6 months
- Disturbance is not better explained by another mental
disorder - Fear, anxiety, or avoidance causes clinically
significant distress or impairment in social,
SELECTIVE MUTISM occupational, or other important areas of functioning
- Consistent failure to speak in social situation in - Not better explained by the symptoms of another
which there is expectation to speak even though the mental disorder
individual speaks in other situations
- If another medical condition is present, the fear,
- Interfere with normal social communication anxiety, or avoidance is clearly unrelated or is
- Failure to speak is not attributable to lack of excessive
knowledge of, or comfort with, the spoken language PANIC DISORDER
required in the social situation
- Recurrent unexpected panic attacks
- Disturbances is not better explained by
communication disorder (childhood onset fluency - At least 1 month of concern about the possibility of
disorder) and does not occur exclusively during the more attacks, worry about the consequences of an
course of autism spectrum disorder, schizophrenia, or attack, or maladaptive behavioral changes because of
another psychotic disorder attacks

SPECIFIC PHOBIA AGORAPHOBIA

- Marked and disproportionate fear consistently - Disproportionate and marked fear or anxiety about at
triggered by specific objects or situations least 2 situations where it would be difficult to escape
or receive help in the event of incapacitation,
- Object or situation is avoided or else endured with embarrassing symptoms, or panic-like symptoms
intense anxiety
- Such as being outside of the home alone; traveling on
- Symptoms persists for at least 6 months public transportation; being in open spaces such as
parking lots and marketplaces; being in enclosed
spaced such as, theaters, or cinemas; or standing in line CAUSAL FACTORS
or being in a crowd
- Situations consistently provoke fear or anxiety
- Situations are avoided, require the presence of
companion, or endured with intense fear or anxiety
- Symptoms last at least 6 months
GENERALIZED ANXIETY DISORDER (GAD)
- Excessive anxiety and worry at least 50% of days
about number of events or activities
- Person finds it hard to control the worry
- Worry sustained for at least 6 months TREATMENTS

- Anxiety and worry associated with at least 3 (or one - Exposure therapy
in children) of the following: restlessness or feeling
- Participant modeling
keyed up on edge; easily fatigued; difficulty
concentrating or mind going blank; irritability; muscle - Virtual reality components
tension; sleep disturbance
- Cognitive techniques combination
SUBSTANCE/MEDICATION-INDUCED ANXIETY
- Medications
DISORDER
TRAUMA AND STRESSOR RELATED DISORDER
- Symptoms precede the onset of substance/medication
use; symptoms persist for substantial period of time TRAUMA
(e.g., about 1 month) after the cessation of acute
withdrawal or severe intoxication - Event that involves actual or threatened death or
serious injury or sexual violation in which the
- There is other evidence suggesting the existence of individual:
independent non-substance/medication-induced
anxiety disorder (history of recurrent - Directly experiences the event
nonsubstance/medication-related episodes) - Witnesses the event in person
- Disturbances does not occur exclusively during the - Learns that the event occurred to close friend or
course of delirium relative
- Disturbances causes clinically significant distress or - Experiences first-hand repeated or extreme exposure
impairment in social, occupational, or other important to aversive details of traumatic event
areas of functioning
BRUCE PERRY’S NEUROSEQUENTIAL MODEL
WITH ONSET DURING INTOXICATION – Criteria
are met for intoxication with the substance and the
symptoms develop during intoxication
WITH ONSET DURING INTOXICATION – Criteria
are met for withdrawal from the substance and
symptoms develop during or shortly after withdrawal
WITH ONSET AFTER MEDICATION USE –
Symptoms developed at initiation of medication, with
a change in use of medication, or during withdrawal of
medication
POSTTRAUMATIC STRESS DISORDER (PTSD) - Child has experienced patter of extremes of
insufficient care
- Exposure to actual or threatened death, serious injury,
or sexual violence - Disturbance is evident before age 5 years
- Presence of intrusion symptoms - Child has developmental age of at least 9 months
- Persistent avoidance of stimuli associated with
traumatic event
- Negative alteration in cognitions and mood
associated with the traumatic events
DISINHIBITED SOCIAL ENGAGEMENT
- Marked alterations arousal and reactivity associated
DISORDER
with traumatic event
- Pattern of behavior in which child actively
- Duration is more than 1 month
approaches and interacts with unfamiliar adults
- Functional impairment
- Behaviors are not limited to impulsivity
- Not attributable to physiological effects of substance
- Child has experienced a pattern of extremes of
or any medical condition
insufficient care
ACUTE STRESS DISORDER
CAUSAL FACTORS IN PTSD
- Fairly similar to those of PTSD, but the duration is
shorter
- Symptoms occur between 3 days and 1 month a
trauma
ADJUSTMENT DISORDER
- Development of emotional or behavioral symptoms
in response to identifiable stressor occurring within 3
months of the onset of stressor
- These symptoms or behavior are clinically
significant, as evidenced by one or both of the
following
MARKED DISTRESS – Out of proportion to severity
or intensity of stressor PREVENTION AND TREATMENT OF STRESS
SIGNIFICANT IMPAIRMENT – Social, occupational, DISORDERS
or other important areas of functioning
- The stress-related disturbance does not meet the
criteria for another mental disorder and is not merely
exacerbation of preexisting mental disorder
- Symptoms do not represent normal bereavement
- Once the stressor or consequences have terminated,
symptoms do not persist for more than additional 6
months
REACTIVE ATTACHMENT DISORDER
- Absence or grossly underdeveloped attachment
between the child and putative caregiving adults
- Persistent social and emotional disturbance
characterized
PERRY’S 3 RS OBSESSIONS
REGULATE - Contamination fears
- Brainstem and midbrain – the sensory motor brain - Fears of harming oneself or others
- Help the child to regulate and calm their stress - Lack of symmetry
responses – fight, flight, freeze. Offer soothing comfort
- Pathological doubt
and reassurance
COMPULSION
RELATE
- Cleaning
- Limbic brain – the emotional relational brain
- Checking
- Connect with child through attuned, sensitive
relationship - Repeating
- Empathized and validate the child’s feelings so that - Ordering/Arranging
they feel seen, heard and understood
- Counting
REASON
BODY DYSMORPHIC DISORDER
- Cortical brain – the great human thinking brain
- Preoccupation with one or more perceived defects in
- Now that the child is calm and connected they are appearance
able to fully engage in learning
- Person gas performed repetitive behaviors or mental
- Heading straight for reasoning part of the brain acts (mirror checking, seeking reassurance, or
cannot work if the child is dysregulated and excessive grooming) in response
disconnected from others
- Preoccupation is not restricted to concerns about
OBSESSIVE-COMPULSIVE DISORDER AND weight or body fat
RELATED DISORDER
HOARDING DISORDER
OCD
- Persistent difficulty discarding or parting with
- Characterized by obsessions or compulsions possessions, regardless of actual value
OBSESSION – Intrusive and recurring thoughts, - Perceived need to save items and Distress associated
images, or impulses that are persistent and with discarding
uncontrollable
- Symptoms result in accumulation of large number of
COMPULSION – Repetitive, clearly excessive possessions that clutter active living spaces to the
behaviors or mental acts that the person feels driven to extent that their intended use is compromised unless
perform to reduce the anxiety caused by obsessive others intervene
thoughts or prevent some calamity from occurring
- Not attributable to any medical condition
- Pursuing cleanliness and orderliness, sometimes
through elaborate rituals - Not better explained by another mental disorder

- Performing repetitive, magically protective acts, such TRICHOTILLOMANIA (HAIR-PULLING

as counting or touching body part DISORDER)

- Repetitive checking to ensure that certain acts are - Recurrent pulling out of one’s hair, resulting in hair
carried out loss

- The obsession and compulsions are time consuming - Repeated attempts to decrease or stop hair pulling
and cause significant distress and impairment - Functional impairment and significant distress
- Not attributable to direct physiological effects of - Not attributable to any medical condition
substances or any medical condition
- Not better explained by symptoms of another mental
- Not better explained by other mental disorders disorder
EXCORIATION (SKIN-PICKING) DISORDER - The symptoms are incompatible with recognized
medical disorder
- Recurrent skin picking resulting in skin lesions
- When patients reports neurological symptom, it is
- Repeated attempts to decrease or stop skin picking
important to assess whether that symptoms has true
- Functional impairment and significant distress neurological basis

- Not attributable to any medical condition - No better explained by another medical condition

- Not better explained by the symptoms of another - Functional impairment and significant distress
mental disorder
TREATMENTS
- Antidepressants/Medication
- Cognitive-behavioral therapy
- Exposure and response prevention
SOMATIC SYMPTOM AND RELATED DISORDER
SOMATIC SYMPTOM DISORDER
- One or more somatic symptoms that distressing or
result in significant disruption in daily life
- Excessive thoughts, feelings, or behaviors related to
seriousness of somatic symptoms as manifested in at
least 1 of the following:
- Persistent thoughts about the seriousness of one’s
symptoms
- Persistently high level of anxiety about health or
symptoms
- Excessive time or energy devoted to these symptoms
- Duration of at least 6 months
ILLNESS ANXIETY DISORDER
- Preoccupation with fears of having serious disease
FACTITIOUS DISORDER
- No significant somatic symptoms present
- People with this disorder fake or manufacture
- High level of anxiety about health physical or physiological symptoms, but without any
apparent motive
- These fears must lead to excessive care seeking or
maladaptive avoidance behaviors - Person presents himself to others as ill or injured

- Duration of at least 6 months - Deceptive behavior is evident

- Not better explained by another mental disorder - Not better explained by another mental disorder

CONVERSION DISORDER FACTITIOUS DISORDER SUBTYPES

- One or more symptoms affecting voluntary motor or - Factitious disorder on self (Münchausen Syndrome)
sensory function the person presents himself or herself to others as ill,
impaired, or injured
- People may experience partial or complete paralysis
of arms or legs; seizures and coordination - Factitious disorder imposed on another person
disturbances; sensation of prickling, tingling, or fabricates symptoms in another person and then
creeping on skin; insensitivity to pain; or anesthesia presents that person to others as ill, impaired, or
injured
NOTE. Factitious disorder is not the same as - Not better explained by another dissociative disorder,
malingering. Because malingering is motivated by another psychological disorder, or by medical
external rewards or incentives. It is not considered condition
mental disorder within the DSM framework
DISSOCIATIVE IDENTITY DISORDER
TREATMENTS
- Disruption of identity characterized by two or more
- Behavioral therapy distinct personality states (alters) or experience of
possession
- Cognitive-behavioral therapy
- Disruption may be observed by others reported by the
- Hypnosis
patient
DISSOCIATIVE DISORDERS
- Recurrent gaps in recalling events or important
- Conditions involving disruptions in normally personal information that are beyond ordinary
integrated functions forgetting

- Consciousness - Functional impairment

- Memory - Symptoms are not part of broadly accepted cultural

or religious practice, and are not due to drugs or
- Identity medical condition (children, symptoms are not better
- Perception explained by imaginary playmate or by fantasy play)

DISSOCIATIVE AMNESIA - Not attributable to physiological effects of substance

or another medical condition
- Inability to remember important information, usually
of traumatic or stressful nature, that is too extensive to
be ordinary forgetfulness
- Functional impairment and significant distress
- Amnesia is not explained by substances or medical
condition
- Not better explained another psychological
conditions
Specify dissociative figure subtype if:
- Amnesia is associated with bewildered or apparently
purposeful wandering
DEPERSONALIZATION/DEREALIZATION
DISORDER
- Presence or persistent and recurrent experiences of
depersonalization and derealization
DEPERSONALIZATION – Experience of detachment
from one’s mental processes or body, as though one is
in a dream
DEREALIZATION – Experiences of unreality of
surroundings
- Reality testing remains intact
- Significant distress and functional impairment
- Symptoms are not explained by substances, or by
medical condition
TREATMENT AND OUTCOMES IN
DISSOCIATIVE DISORDERS
- Hypnosis
- Integration of separate alters
- Medications