Psychopathology and DSM 5: Neurodevelopmental and Psychotic Disorders

Psychopathology and DSM 5 Overview

• An acceptable or culturally approved response to a stressor or loss is not a mental disorder.
• Socially deviant behavior is not a mental health disorder (ex: gang affiliation)
• Allow multiple diagnosis for presentations that meet the criteria for multiple disorders (Autism & ADHD) - this is new

Changes from DSM 4 to 5

*COME BACK TO CHANGES IN PREP JET - AUDIO - 3

Neurodevelopmental Disorders

• Usually manifest early in development
• Usually before kid enters school
• Some very specific and some very global/broad and many co-occur

Intellectual Disability/Intellectual Developmental Disorder

• (1) Deficits in general learning abilities/intellectual functioning
• (2) As well as deficits in one or more adaptive functioning (communication, social participation, independent living) across multiple environments
• (3) an onset of deficits during developmental period
• IQ scores Typically two or more standard deviations below mean

Etiology of Intellectual Disability

• Cause is known in 25-50% of all cases
• can be prenatal (80-85%), perinatal (5-10%) or postnatal (5-10%)
• Genetic factors have small influence - 5% like down syndrome (most common), enviro factors play much more significant role (particularly in embryonic stage), fetal alcohol syndrome most common preventable cause
• Prevalence Rate: 1% - 85% is mild
• 3-4 times more comorbid
• Male to female ration is: 1.5 to 1
• Level of severity based on adaptive functioning - specifiers: mild, moderate, severe, profound

Adaptive Functioning Areas

1. conceptual/academic: memory, language, reading, writing, problem solving, etc.
2. social: empathy, friendship, social judgement, interpersonal communication
3. Practical: self-care, recreation, money management, school/task organization

Intellectual Disability, Mild

• Some delays, some supports

Intellectual Disability, Moderate

In adults, intelligence at elementary child's level

• Capacity for self-care/very specific vocation with intense training

Intellectual Disability, Severe

• Comprehension is limited to simple speech/gestures
• support/supervision always needed

Intellectual Disability, Profound

• Adaptive functioning can be assessed with Vineland Adaptive Behaviours Scale as well as clinical assessment

Global Developmental Delay

• Child under the age of 5 and too difficult to assess but fails to meet developmental milestones

Unspecified Intellectual Disability

• Over the age of 5
• Difficult to assess due to other impairments (blindness, severe behaviour issues)

Communication Disorders

• Deficit in language (form, function, and use of words), speech (expression of words/sounds) , and communication (verbal/non-verbal behaviour)

Language Disorder

• Difficulty acquiring and using language due to deficits in comprehension or production (limited vocab, sentence structure, and impairments in discourse)
• If diagnosed from age 4, likely to be stable with time

Speech/Sound Disorder

• Difficulty with phonology, articulation interferes with intelligibility and prevents verbal communication (Ex: substituting one sound for another, or omitting sounds)
• Children respond well to treatment and usually isn't life long

Childhood Onset/Fluency Disorder (Stuttering)

• Disturbance in natural fluency and time patterning of speech
• Sound/syllable repetition, broken words, blocking, etc.
• Stuttering is considered to be normal until age 2, age of onset usually 2-7
• 65-85% recover
• Severity of symptoms at the age of 8 a good indicator of prognosis
• Treatment: habit reversal training (regulated breathing)

Social (Pragmatic) Fluency Disorder*NEW

• Deficit in verbal/non-verbal communication for social purposes, difficulty following rules of conversation (interrupting), problems changing speech in context (home vs. school), difficulty understanding literal or unambiguous speech

Unspecified Communication Disorder

Autism Spectrum Disorder

(a) Persistent deficits in social communication/interaction across multiple contexts (b) Restricted, repetitive patterns of behaviour, interests, of activities as manifested by at least two of the following: stereotyped or repetitive motor movements, use of objects, or speech; inflexible adherence to routine; restricted fixated interests; or hyper or hypo reactivity to sensory input

• Symptoms must be present in early developmental period
• Symptoms must cause significant impairment in functioning
• Severity is coded in terms of level of support needed in BOTH social communication and restricted/repetitive patterns of behaviour:

1. Level 1: Requiring support
2. Level 2: Requiring substantial support
3. Level 3: Requiring very substantial support

*Usually record also: with or without substantial intellectual impairment and/or language impairment - this is very common comordbidity - Prognosis is best without one of these labels before 5

• Prevalence Rate: 1-2% of population
• Male/Female Ratio: 4:1
• Heritability high (35-95%) -> identical twins (69-95%), fraternal (0-24%)
• 15% of all cases known genetic mutation
• ASD typically evident in 12-24 month olds, but may be seen earlier
• Savant: An individual with striking abilities (complex math in head, or play music after one time of hearing it) and can sometimes be found in individuals with ASD
• Shared features with Rett Syndrome: found in females, between 5-48 month delay in head growth, loss of social engagement, repetitive movements, poor coordination. However, after this period improvement in social skills and autistic features no longer present
• Non-genetic risks -> male gender, birth before 26 weeks of gestation, advanced parental age, and enviro toxins
• Studies have found accelerated brain growth in children with ASD beginning at 6 months that plateaus by preschool, larger than normal head circumference, brain volume, and weight
• Abnormalities also found in cerebellum, corpus callosum, and amygdala
• Neurotransmitters: Lower levels of serotonin in brain but higher in blood. Also, ASD might be influenced by dopamine, GABA, Glutamate, acetycholine
• Best prognosis: IQ over 70, functional language by 5, and absence of mental health problems
• Treatment: Research evaluating the outcomes of EIBI have found that it has the greatest positive impact on intelligence and languageacquisition and a smaller and less consistent impact on adaptive skills, social functioning, and severity of core ASD symptoms (Weitlauf et al., 2014).

Interventions for ASD

Attention-Deficit/Hyperactivity (ADHD)

Requirements for ADHD Diagnosis

• A persistent pattern (at least 6 months) of in attention and/or hyperactivity/impulsivity
• Must have been present before 12 years of age, hard to diagnose before 4
• Impairment in 2 or more settings
• Co-morbid diagnosis with ASD now allowed
• Disorder is relatively stable throughout childhood, adolescence, and adulthood - with motoric hyperactivity decreasing

Criteria for Inattention (ADHD)

Criteria - 6 of the following (five for adults) for Inattention:

• Failure to pay attention to details resulting in careless effort
• Difficulty sustaining attention for tasks
• Does not seem to listen when spoken to directly
• Does not follow through or fails to finish assignments
• Difficulty organizing tasks
• Avoids tasks requiring sustained attention
• Frequently losing things
• Easily distracted
• Forgetful in daily activities

Criteria for Hyperactivity (ADHD)

Criteria - 6 of the following (five for adults) for Hyperactivity:

• Frequently fidgets or squirms
• Stands up when seating is expected
• Runs or climbs excessively in inappropriate situations
• Difficulty playing quietly
• Constantly "on the go"
• Talks excessively
• Blurts out answers before question completed
• Difficulty waiting turn
• Interrupts or intrudes on others

Etiology of ADHD

• Studies have found reduced total brain volume in prefrontal cortex, striatum, corpus callosum, cerebellum and reduced activity
• Neurotransmitters: low levels ot dopamine and noreepinephrine
• Genetic contribution- Has also been linked to low birth weight, pre-mature birth, maternal smoking/alochol use

Disorders Coding for ADHD

Disorder coded as "combined presentation", "predominantly inattentive" or "predominantly hyperactivity/impulsivity"

• Coded as mild, moderate, severe
• Clinician can also specify 'partial remission' -> when only some of the criteria is now met, not full 6

ADHD Prevalence and Demographics

Prevalence Rate: 5% of children, 2.5% of adults Male to Female Ratio: 2:1 (gender difference decreases in adulthood)

• *Most prevalent diagnosed disorder for those age 3-17
• One of those most heritable psychiatric disorders (twins -76%) 41% for fraternal twins

ADHD Treatment

• Children & adolescence: parent training behavioural management (PTBM), parent child interaction therapy (PCIT) included
• Medication only when behavioural interventions do not produce improvement
• For adolescents - prescribe meds (and combine with behavioural interventions when possible)
• Evidence adolescents may benefits from behavioural therapy, motivational interviewing, mindfulness-based training, and classroom training
• For adults, first line is med but CBT have strong support
• is stimulant and non-stimulant (Strattera - atomoxetine) medicine, behaviour therapy, social skills training, parenting education, and neurofeedback (EFG). For adults: CBT

ADHD Comorbidities

• Other features associated with ADHD: low frustration tolerance, irritability, mood lability, as well as social rejection and interpersonal conflict. Academic achievement/work can be impaired.
• *When diagnosis is ADHD combined, 50% of the time ODD comorbid or conduct disorder 25% of time
• *Most children with disruptive mood disorder have ADHD but not all children with ADHD have disruptive mood disorder
• *Specific learning disorders can also co-occur
• *Higher rates of anxiety disorders, major depressive disorder, substance abuse, antisocial and other personality disorders, obsessive compulsive, tic disorder, and ASD
• *By adulthood ADHD associated with increased suicide risk, especially when comorbid with a mood, conduct, or substance use disorder
• *ADHD symptoms shift in adulthood -> for example excessive motor activity turns into impatience, restlessness, etc.

Requirements for Diagnosis: