Tuesday, August 30, 2011

Schizoaffective Disorder (295.70)

Schizoaffective disorder is characterized by mood disturbance along with psychosis.  The criteria are:
  • An uninterrupted period of illness during which there is either a major depressive, manic or mixed episode and symptoms that meet the characteristic symptoms of schizophrenia. 
  • Two or more of the following characteristic symptoms, present for a significant portion of the time over a one-month period
    • Delusions
    • Hallucinations
    • Disorganized speech (such as frequent derailment or incoherence)
    • Grossly disorganized or catatonic behavior
    • Negative symptoms (flatness of affect, avolition)
  • Symptoms of the mood episode are present for a substantial portion of the total duration of the illness.
  • This disturbance is not caused by the effects of a substance or a medical condition.

Schizophreniform Disorder (295.40)

Schizophreniform disorder is essentially the same as schizophrenia except that the total duration of the illness is at least one month, but less than 6 months and social/occupational impairment is not required (although it is not exclusionary).  Some people who are initially diagnosed with schizophreniform disorder will go on to later be diagnosed with schizophrenia or schizoaffective disorder (about two-thirds).


Schizophrenia is characterized by positive & negative symptoms.  Positive symptoms are the presence of something that should not be there (such as psychosis) and negative symptoms are the absence of something that should be there (such as flatness of affect, avolition).  I could talk for a long time about various types of delusions & hallucinations and other symptoms of thought disorder; however, for simplicity sake, I will cover the basic criteria of schizophrenia.

·        Two or more of the following characteristic symptoms, present for a significant portion of the time over a one-month period
·        Delusions
·        Hallucinations
·        Disorganized speech (such as frequent derailment or incoherence)
·        Grossly disorganized or catatonic behavior
·        Negative symptoms (flatness of affect, avolition)
·        Social or occupational dysfunction – achievement in work or social life that is below the level of functioning previously experienced
·        Duration – symptoms must be present for a minimum of 6 months, with at least one month of characteristic symptoms.
·        Can't also have Schizoaffective or mood disorder; rule this out by ensuring no major depressive, manic or mixed episodes that have occurred concurrently with active-phase symptoms.
·        Disturbance cannot be caused by a medical condition or be the effects of a substance.
·        If there is autism or other PDD, the diagnosis of schizophrenia can only be made if prominent delusions or hallucinations are present for at least a month.

Specifiers for subtype are paranoid type (295.30), characterized by prominent delusions and hallucinations; disorganized type (295.10), characterized by disorganized speech or behavior & flat or inappropriate affect; catatonic type (295.20), characterized by marked immobility, excessive motor activity, mutism, echolalia (repeating what you say), echopraxia (imitating your physical movements), or peculiar voluntary movements; undifferentiated type (295.60), characterized by not meeting the criteria for another subtype; and lastly, residual type (295.60), characterized by having one schizophrenic episode, but the current clinical picture lacks prominent positive symptoms, but there are ongoing negative symptoms & the presence of milder forms of psychosis (odd behavior, strange beliefs, or mildly disorganized behavior).  Other specifiers describe the course and current symptomology, and you can refer to the DSM to learn more about those specifiers.

Substance Use Disorders

Substance use disorders differ from substance-induced disorders.  I find the names self-explanatory – substance use disorders are related to disordered use of substances and substance-induced disorders are disorders brought on by use of substances.  Rather than covering each individual substance related disorder, I am simply going to review the difference between abuse & dependence & you can apply these general criteria to most substances.

Criteria for Substance Dependence

Substance dependence is a maladaptive pattern of substance use that leads to either impairment or distress.  Person must have 3 or more of the following symptoms within 12 months. 
  • Tolerance – either needing to use more & more to get the same effect or less of an effect using the same amount
  • Withdrawal – either the person experiences withdrawal symptoms when they stop use or substitute a similar substance to avoid withdrawal
  • Use of more or over a longer time period than intended (I go out for one drink & stay out all night; I'm only going to do two lines… ten lines later.)
  • The person often wants to cut down or control use or makes unsuccessful attempts at the same.
  • Much time is spent in obtaining, using & recovering from use of the substance.
  • Other activities are reduced or given up because of use.
  • Use is continued despite being aware that the use is exacerbating physical or psychological problems (like smoking cigs despite having cancer)
Criteria for Substance Abuse

Substance abuse is also a maladaptive pattern of use of a substance that causes impairment or distress.  The person must not have ever met the criteria for substance dependence for the class of substance in question.  The person must have one or more of the following symptoms within a 12-month period.
  •  Recurrent use that results in the person being unable to fulfill role obligations (missing work, neglecting children).
  • Recurrent use in hazardous situations (driving while intoxicated, etc.)
  • Recurrent substance-related legal problems.
  • Continued use despite social/interpersonal problems that are either caused by or exacerbated by the substance use (arguing with significant others about use, fighting due to intoxication).

Thursday, August 25, 2011

Attention-Deficit/Hyperactivity Disorder (ADHD) (314.xx)

ADHD is characterized by a pattern of inattentive and/or hyperactive behavior that is more severe than what would normally be observed in a person of a similar developmental level.  Some of the symptoms have to be present before the age of 7.  Look for people who aren’t able to pay close attention to details; work may look messy and disorganized.  The person may jump from task to task without actually completing any.  They may seem like they are not paying attention in conversation & look like they aren’t listening.  You want to be certain, however, that the person is unable to complete tasks due to having difficulties with attention & not due to being oppositional.  Symptoms are more often observed in group settings than in individual settings, so even if a person doesn’t display any symptoms in your office, if you suspect ADHD, it may be worthwhile to observe in other settings. 

It is difficult to diagnose in children younger than age 4 – 5 & it would be exceedingly rare to be able to diagnose in a 2 or 3 year old, as it is normal for 2 – 3 year olds to flit from one thing to the next.  Generally, the symptoms become less noticeable as the person ages; adolescents might just look a little fidgety, or may just feel restless but be able to sit still.  Adults may look pretty normal, but may avoid desk jobs, or activities that require a lot of sitting still.  ADHD is more common in males than females.  Use caution in making an ADHD diagnosis, as it is easy to mistake the symptoms of something else for ADHD.  Some common misdiagnoses include mistaking a smart child who is bored in an under stimulating environment for being inattentive.  Oppositional behavior may look like ADHD at times.  Sometimes mood or anxiety disorders can cause children to have difficulty focusing or completing tasks.

On to the criteria!

  • Symptoms have to occur for more than six months, have to cause impairment & have to be inconsistent with what is considered normal for the stage of development.
  • Symptoms have to be present before the age of 7.
  • Impairment has to be observed in multiple settings (such as at home as well as at school).
Six or more of the following symptoms of inattention AND/OR
Six or more of the following symptoms of hyperactivity-impulsivity
-fails to give close attention or makes careless mistakes in work
-often has difficulty sustaining attention on play, work, or other activities
-seems not to listen, even when spoken to directly
-doesn’t follow through on instructions & doesn’t finish work (and is not due to being oppositional)
-has difficulty organizing tasks
-avoids/dislikes tasks that require sustained mental effort (like schoolwork or homework)
-loses things that are necessary to complete tasks or activities
-is easily distracted by extraneous stimuli (Hey, look, a chicken!)
-is forgetful
-often fidgets or squirms in seat
-leaves seat during class or elsewhere where remaining seated is expected
-runs around or climbs at inappropriate times (adolescents & adults may feel restless, and are less likely to be observed climbing on their desks during math class)
-has difficulty playing quietly
-is usually “on the go” or described as like the infamous Energizer bunny (Okay, so the DSM doesn’t use copyrighted terminology, but that’s what they mean.)
-talks too much
-blurts out answers before the question is finished being asked
-has difficulty waiting for his/her turn
-interrupts/intrudes on others, like interrupting conversations or games

  • ADHD combined type has 6 from both columns above
  • ADHD predominantly inattentive type has 6 from the 1st column & less than 6 from the 2nd
  • ADHD predominantly hyperactive-impulsive type has 6 from the 2nd column & less than 6 from the 1st
  • You can specify “In Partial Remission” for people, particularly adults & older adolescents, who no longer meet the full criteria.

Autistic Disorder 299.00

Autistic disorder is characterized by abnormal or impaired development, especially in social interaction & communication, along with restricted activities & interests.  There is a lot of variability in impairment levels among people with autism based on age and individual differences.  Autism onsets before the age of three & though it may be very subtle in infancy, it can sometimes be identified very early on.  Autism occurs in males more than females, but females are more likely to have more severe mental retardation w/ autism.  In most cases, there is a co-occurring diagnosis of mental retardation.

I will endeavor to summarize the diagnostic criteria.  For further clarification, look in the DSM.  To make it easy, the criteria for autistic disorder can be found on page 75.  Aren’t I great?  I’m trying to put these criteria into my own words, but at times it is difficult.  Please don’t call me out for plagiarizing the DSM!

The person has to have a minimum of six total of the criteria below.

At least two criteria from here
At least one criterion from here
At least one criterion from here
-impairment in use of multiple nonverbal behaviors (eye contact, facial expression, gestures & postures) to regulate social interaction
-failure to develop appropriate peer relationships
-does not seek to share interests, enjoyment or achievements with other people (doesn’t point things out to others or bring things to show or share)
-lack of social or emotional reciprocity
-delay or complete lack of spoken language & with no attempts to compensate by gesturing/miming
-impaired ability to start/sustain conversations
-repetitive use of language or stereotyped language
-lack of make-believe play or imitative play that is congruent with developmental level
-preoccupation with stereotyped/restricted interests that is abnormal in focus or intensity
-inflexible adherence to specific, nonfunctional routines/rituals (think gotta see Wapner in Rain Man)
-stereotyped or repetitive physical movements, like hand or finger flapping/twisting
-persistent preoccupation with parts of objects

Delays must onset before the age of 3 & can’t be better accounted for by Rett’s disorder or childhood disintegrative disorder.

General Notes Regarding Multiaxial Diagnosis

  • Using the 5 axes for recording:
    • Axis I: clinical disorders & other conditions that may be a focus of clinical attention – Here you record most clinical disorders (depressive disorders, schizophrenia/psychotic disorders, substance-related disorders, v-codes that are the main reason for a visit).  You should put them in order by which is the main reason for a visit or the principal diagnosis.  You can note parenthetically if there is any confusion about which is the principal diagnosis vs which is the main reason for the visit.
    • Axis II: personality disorders & mental retardation – Hopefully self explanatory
    • Axis III: general medical conditions – If you want to get fancy here you can use ICD-9 codes.  Otherwise, just write any medical problems.
    • Axis IV: psychosocial and environmental problems – The DSM offers a few general categories of psychosocial/environmental stressors & you can write either the specific stressor (recent death of mother, marital discord, recent expulsion from school) or the general category (problems with primary support group, educational problems) or both.  If one of these problems is going to be the primary focus of treatment, you can also include it as a v-code on Axis I.
    • Axis V: the dreaded GAF score – a scale of 0 – 100 that gives you a way to score the person’s overall level of functioning at a point in time.
  • The following are the general categories of disorders included in the DSM:
    • Disorders usually first diagnosed in infancy, childhood or adolescence
    • Delirium, dementia and amnestic and other cognitive disorders
    • Mental disorders due to a general medical condition
    • Substance-related disorders
    • Schizophrenia and other psychotic disorders
    • Mood disorders
    • Anxiety disorders
    • Somatoform disorders
    • Factitious disorders
    • Dissociative disorders
    • Sexual & gender identity disorders
    • Eating disorders
    • Sleep disorders
    • Impulse-control disorders not elsewhere classified
    • Adjustment disorders
    • Personality disorders
    • Other conditions that may be a focus of clinical attention
  • Now that I have essentially typed up the Table of Contents from the DSM, I will obviously not be able to summarize each & every disorder in the DSM, and I may not even cover each category.  I will attempt to hit the high points.  I may focus a bit more on personality disorders, simply because I am a bit weak in that area.  If you want more information on any of these general categories of disorders, I strongly recommend you read your DSM.  I know it may not be the most exciting reading you’ve ever done, but it really is the best place to learn about the DSM.
  • Lastly a few critiques: As social workers, we’re trained in the business of empowerment & finding strengths.  As you can see if the 5 axes above, there isn’t anywhere to focus on strengths.  Some social workers like to make a little note underneath their 5 axes listing client strengths.  Additionally, I find that for some clients, the diagnosis itself can sometimes be an empowering thing.  I’m thinking of people who find out that they have depression or bipolar disorder and say, “That’s what’s wrong with me?  All this time, I just thought I was lazy/stupid/crazy/whatever.  That explains it all!”  Alternatively, some clients will hide behind their diagnoses, as in, “Oh, I can’t do that, I have [insert diagnosis here].”  However you look at it, this is the system we have to work within, and this is surely going to be on our exam.

Blowing it up this Weekend!

It has been a relatively quiet week at work, so in my available time, I've written a bunch on the DSM.  As I revise & edit, you can look forward to a lot of posting over the weekend.  I'm trying to hit the high points in the DSM & my own personal weakest spots.  If there are diagnoses or segments you're interested in, feel free to let me know & I will attempt to post additional information.

Sunday, August 21, 2011

Wednesday, August 17, 2011

Bowlby, Ainsworth, the incomparable Harlow & Attachment Theory

Attachment theory is one of my favorites, so I will try not to get too carried away here.  Much of the theory is easy to take for granted if you don’t consider the era in which it was born.  After my son was born, he really liked to be held, as most newborns do.  I recall talking to a much older mother who told me how after her children (now in their 50s) were born, her doctor told her not to hold them too much so as to avoid spoiling them & turning the boys into sissies.  Kind of shows you how attachment theory has changed our thinking in the last 50 or so years.  Anyway, on to the theory!

Attachment theory was developed in part by John Bowlby, Mary Ainsworth & contributed to by Harry Harlow’s research with rhesus monkeys.  The basic idea is that early relationships with caregivers play a major role in child development & continue to impact functioning & relationships throughout adulthood.  Again, this may inspire a “duh” reaction now, but 50 – 60 years ago, this was revolutionary stuff.  Attachment is a “lasting psychological connectedness between human beings” (Bowlby, 1969, p. 194, qtd in Cherry n.d.).  According to attachment theory, infants who have mothers who are available and responsive will establish a sense of security & know that their caregivers can be relied upon.  Securely attached children will become distressed when they are separated from a caregiver & will be happy when the caregiver returns.  This is understood to be a normal reaction & indicative of a healthy or secure attachment.

Attachment theory got its start from the work of Bowlby & James Robertson, a social worker by trade.  Robertson created a film called “A Two Year Old Goes to the Hospital.”  You’ll never guess what it’s about!  All right, so that was kind of corny, but they film a young girl who goes in for an 8-day stay in an era when visits from parents were severely restricted by hospital policy.  What ensues (although I have not seen it) sounds totally heart-wrenching, as I’m sure you can imagine.  Bowlby argues that this young girl’s distress is not merely an unavoidable inconvenience, but rather a potentially serious psychiatric disturbance worth further investigation.  Check out more about it here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1918555/?page=1, including Robertson’s summary of the film & Bowlby’s commentary on it.

Bowlby also worked with Mary Ainsworth, who conducted the “Strange Situation” study in Baltimore, MD.  Wikipedia describes the set-up of the “Situation” here: http://en.wikipedia.org/wiki/Mary_Ainsworth, but in essence, tot comes in with mom, mom leaves tot with stranger briefly, mom comes back, stranger leaves, stranger returns & mom leaves again.  Each interval is about 3 minutes, so mom never leaves the tot for long.  Based on the infant’s behavior during the “Situation,” Ainsworth & company came up with a classification system that described their reactions.  A securely attached infant will engage with the stranger when mom is around, but not when mom leaves, will be upset when mom leaves & will calm when mom returns.  An anxious resistant infant will be very upset when mom leaves, not particularly interested in the stranger even when mom is around & will be ambivalent when mom returns.  An anxious avoidant infant will avoid or ignore the mom altogether & won’t show much change regardless of who is in the room with him or her.  Lastly, they observed a disorganized style, that was for infants whose behavior defied classification due to being unpredictable, or displaying stereotyped behavior, like rocking or hitting themselves.

Finally, there is the work of Harry Harlow.  I think you would be remiss to talk about attachment theory & not talk about Harlow.  Harlow’s best known research was conducted from 1957 – 1963 & would likely not be approved by any contemporary IRB.  Nevertheless, inspired in part by Bowlby’s theorizing, Harlow separated infant rhesus monkeys from their mothers & offered them a choice between a soft terry mother or a hard wire mother.  There were two groups, and in one group, the terry mother had the bottle & in the other group, the wire mother had the bottle.  Conventional thinking of the era would dictate that the babies were governed by their need to eat & would go where the dinner was.  Harlow’s monkeys, however, wanted the terry mother, whether she had food or not & would jump to the wire mother to eat, then go right back to the terry mother.  If the monkeys were afraid, they would go to the terry mother, even if the wire mother was there with food.  Harlow also did some research on isolating the monkeys at birth.  Suffice it to say that monkeys who were raised in isolation, even if only for a few months, had a difficult time integrating in with the rest of the monkeys.

As I’ve said about a lot of these theories, this stuff might seem kind of obvious now, but at the time, it flew in the face of what the general understanding was about what made babies tick & what the love between a mother & her child is all about.  I promised not to get carried away, and I’m not altogether sure I kept the promise.  I hope you found this helpful & interesting.