Childhood Mental Illness

1. Childhood Mental Illness Schizophrenia and Dissociative Disorders

2. Stage 6: Adolescence • Recognition of behaviour and application of knowledge to life decisions • Child re-examines their social identity, making a more conscious choice rather than unconscious reactions to family dynamics • May correspond with interest in wider material – spirituality/religion, mythology, symbolism through music, poetry, lyrics, archetypal figures (celebrities), fashion.

3. Stage 6: Self-reflection • Archetypal identity – childhood history is mapped onto larger world-view • Traumas may be seen in history or mythology (e.g. poor mothering may influence fascination in women’s rights) • Personal life themes reflected in fairy tales, movies, mythology or news stories, etc

4. Stage 6: Comparative theories • Erikson: identity vs role confusion • Piaget: Formal operations • Hypothetical thinking and abstract concepts • Metaphors and analogies • Memories, comparison, time • Values

5. Stage 6: Characteristics • Intuition • Perception • Imagination • Memory • Dreams • Symbolic thought • Visualisation • Insensitivity • Denial of reality • Dogmatic (monopolarised) • Obsessive • Problems with concentration • Hallucinations etc

6. Archetypes of Development • Mother • Lover • Hero • Citizen/Healer • Artist • Manager/Seer • Sage/Master

7. What is mental illness? Psychopathology Disorder dysfunction Definitions The study of Nature, Development and treatment of psychological disorders Through the scientific method Syndrome or pattern of behaviour associated with distress or disability or with significantly increased risk of suffering, death, pain, disability or loss of freedom contain evidence from neurology, biology or medicine a level of cognitive or emotional wellbeing or an absenceof a mental disorder When an internal mechanism is unable to perform its natural /normal function Normal Health

8. The Scientific Method Science is a systematic pursuit of knowledge through observation • Forming a theory • Experimentation (& Data collection) • Forming a Hypothesis. • suggested explanation of a phenomenon

9. APA DSM-IV-TR American Psychiatric Association (2000) Diagnostic and Statistical Manual Revision IV, Text Revision

10. Origins of DSM Kraeplin(1907) suggested that mental disorder is caused by discrete identities as opposed to a continuum • Dementia praecox  schizophrenia • Manic Depression • Paranoia (delusional disorder)

11. 5 Axes of Classification • Axis I : All Diagnostic categories except personality disorders and Mental Retardation • Axis II : Mental Retardation and Personality Disorders • Axis II is harder to treat and may not be encouraged toward mental health clinicians (e.g. dependent personality disorder) • Axis I and II are the diagnoses of abnormal behaviour

12. 5 Axes of Classification • Axis III : General Medical conditions (e.g. Depression resulting from an endocrine gland dysfunction is an Axis I diagnosis listed as caused by a medical problem) • Axis IV : Psychosocial and Environmental Problems • Axis V : Global Assessment of Functioning (GAF) Scale • Current level of adaptive functioning • Social relationships, work and leisure time • Scale 0-100 from ‘persistent danger of severely hurting self or others’ to ‘superior functioning in a wide range of activities

13. DSM-IV-TR • Specific Diagnostic criteria • Listing symptoms including descriptions of symptoms • Many diagnostic categories, revised over time according with research • “Criteria Sets and Axes Provided for Further Study” (e.g. Premenstrual Dysphoric Disorder, more debilitating than Premenstrual Syndrome, Caffeine Withdrawl) • Characteristics of disorders • Essential features, syndromes • Summary of research literature (age of onset, course, prevalence, sex ratio, family patterns, differential diagnosis) • Associated features (lab findings, physical exams)

14. Ethical and Cultural Considerations Mental Illness is Universal. Symptoms of schizophrenia (e.g. delusions and hallucinations) and depression (e.g. loss of interest or pleasure in activities) are similar cross-culturally. However, cultures vary significantly in most mental disorder, for example - willingness to seek help - available treatments - types of symptoms - language Culture defines risk, symptom expression and outcomes

15. Ethical and Cultural Considerations Question: You feel a heavy heart, or a persistent knot in your stomach You would…

16. Ethical and Cultural Considerations • Mexicans who immigrate to U.S. are 50% less likely to meet criteria for mental illness than native born U.S. Citizens. • Over time, however, there is an increase to match U.S. citizens. DSM-IV counteracts this by • Providing a general framework for evaluating the role of culture and ethnicity • Describing cultural factors and ethnicity for each disorder • Listing culture-bound syndromes (diagnoses likely to be seen in specific regions) Koro – South and East Asia : Intense anxiety of the penis or nipples receding into the body possibly causing death TaijinKyofusho – intense anxiety about socially inappropriate behaviour, blushing, insult of heirarchy through eye contact or body odour, etc. - Overlaps with ‘Social Phobia’ and ‘Body Dysmorphic Disorder’

17. Diagnosing Schizophrenia “From the standpoint of social construction, we emphasize the extent to which diagnoses are products of their time and place. The relation of psychiatric diagnoses to culture-societal structure, and historical circumstance, is readily apparent if we look at the times and places other than our own.” Critical Psychology (Fox & Prilleltensky, 1997, p.108)

18. General Criticisms • Too many diagnoses (almost 300) • Broad categories (e.g. religious doubt, non-compliance with treatment, etc) • Comorbidity: 45% of people who meet criteria for at least one psychiatric diagnosis will meet criteria for at least one more • Categorical (yes-no) diagnosis, rather than continuum (e.g. Do you have high blood pressure (yes/no), where in the range of blood pressure do you fall?) • Reliability: Vague language (e.g. “Mood is abnormally elevated”) • Validity: Construct validity – inferred attribute (internal action, e.g. anxiety)

19. General Criticism • The use of standardised diagnostic criteria offers strength in classification, but it is solely for the benefit of labelling psychopathological phenomena, telling little about the patients • Bentall (1993): Psychiatry has been unable to reach a system of classification that is scientifically valid

20. General Criticism • Diagnoses are products of their time and place • Dreptomania – Slaves’ uncontrollable urge to escape from slavery • Kleptomania – emerged in parallel with large-scale department stores • Homosexuality – DSM diagnosis up to 1980

21. DSM and Schizophrenia • Two people may receive a diagnosis of schizophrenia while having little, if anything, in common • Panchreston– purports to explain everything but actually obscures the truth

22. Diagnosing Schizophrenia • History • Emil Kraepelin (1919) • Dementia Praecox was characterised by early onset followed by progressive deterioration • renamed schizophrenia by Eugen Bleuler in 1908 (Greek schizein phren, meaning “split mind”). • Between 0.5 % and 1.5% of all populations who have been adequately studied develop schizophrenia

23. Problems with Diagnosis: Absence of biological and neuropsychological abnormalities among the diagnostic material No essential symptom must be present for a diagnosis two people may receive the diagnosis while having little, if anything, in common

24. Problems with Diagnosis: Prior to 1972, at least 40% of people diagnosed with schizophrenia were actually suffering an affective disorder Within five years of the publication of DSM-III, the diagnoses of schizophrenia in one large university hospital decreased by 50 per cent. 25 per cent of patients diagnosed with manic depression show “first-rank” symptoms of schizophrenia, while 25 per cent of patients diagnosed with schizophrenia do not

25. Diagnosing Schizophrenia Schizotaxia: first suggested by Meehl (1962) characterised by predominance of negative symptoms, can be assessed using eye tracking and brain-structure abnormalities. Dysmetria: unified theory of schizophrenia based on neurodevelopmental disorder in the circuitry between the frontal lobes, thalamus and cerebellum

26. Diagnosing Schizophrenia Diagnostic classification is solely for the benefit of labelling psychopathological phenomena, telling little about the patients The term “mental illness” is a semantic strategy for medicalizing economic, moral, personal, political, and social problems.” (Szasz, 2001)

28. Dissociative Disorders • Dissociative Amnesia • Dissociative Fugue • Depersonalisation Disorder • Dissociative Identity Disorder Memory loss, typical of a stressful experience Memory loss, accompanied by leaving home and establishing a new identity Alteration in the experience of the self At least two distinct personalities that act independently of each other

29. Dissociative Identity Disorder (DID) Different modes of being, thinking, feeling and acting that exists independently and come forth at different times “Alters” – primary alter Diagnosis calls for inability of at least one alter to recall important information Usually at least one alter has no contact with the others Existence of alters must be chronic, cannot change with drug treatment, etc.

30. Dissociative Identity Disorder (DID) Usually begins in childhood but rarely diagnosed until adulthood Much more common in women People with DID do not show the thought disorder and behavioural disorganisation characteristic of schizophrenia

31. Etiology of D.I.D. • Post-traumatic model • Begins in childhood as a result of severe physical or sexual abuse • Diathesis may be present whereby the child is particularly likely to develop alters after trauma  Coping strategies to trauma • Sociocognitive model • DID may be resultant of therapy, where the patient is expressing the way they have learned to enact social roles

32. Schizophrenia • Disturbance in thought, emotion and behaviour • Disorganised thinking (not logically related) • Faulty perception and attention • Lack of emotional expressiveness/inappropriate expressions • Disturbances in movement and appearance

33. Schizophrenia • Frequently social withdrawal, delusions and hallucinations • Substance abuse rates are high (50% comorbidity) • Suicide rates high • Equal in men and women • Sometimes begins in childhood, usually late adolescence or early adulthood

34. Schizophrenia in DSM • Disorganised schizophrenia • Catatonic schizophrenia • Paranoid schizophrenia • Brief Disorders • Schizophreniform disorder • Brief psychotic disorder • Shizoaffective disorder • Delusional disorder

35. Symptoms Positive:Excesses. Delusions, Hallucinations Negative:Avolition (apathy), Alogia (poverty of speech or poverty of content of speech), Flat affect, Asociality, Anhedonia Disorganised: Speech or behaviour

36. Positive Symptoms Categorises acute episodes of schiz. Excesses and distortions Delusions: Beliefs held contrary to reality and firmly held in spite of disconfirming evidence Persecutory delusions (paranoia) in 65% cross-nationally

37. Delusions: Thoughts have been placed into the mind by an external source Thoughts are broadcast or transmitted Thoughts are being stolen from them by an external force very suddenly Feelings or behaviours are controlled by external force

38. Delusions May also be present in Bipolar disorder, depression with psychotic features and delusional disorder Delusions in schizophrenia are highly implausible. Criteria for diagnosis involves the necessity to have had at least two of the “A-symptoms”, other psychotic illnesses need only one

39. Positive Symptoms Hallucinations / Disturbances in Perception Sense of “unreality”, depersonalisation Hallucinations: Sensory experiences in the absence of environmental stimuli 74% report auditory hallucinations

40. Hallucinations • Hearing one’s own thoughts spoken by another voice • Voices arguing • Voice(s) commenting on one’s behaviour

41. Auditory Hallucinations Schizophrenia patients with hallucinations are more likely to misattribute recordings of their own speech to a different source than are patients without hallucinations or non-patient controls • Broca’s area • frontal lobes (production and organisation of speech) • temporal lobes (enable understanding of speech)

42. Negative symptoms Deficits • Avolition (apathy): • Lack of energy, absence of interest in routine activities, difficulty with work, school or household chores • Alogia: • Poverty of speech. Poverty of content of speech *** • Anhedonia: • Lessening of the experience of pleasure (e.g. good food, sex, recreation) • Can still derive pleasure from positive things (in-the-moment pleasure)

43. Negative symptoms • Flat Affect: • No emotional expression. 66% of patients • Does not refer to the inner experience • Asociality: • Few friends, poor social skills

44. Disorganised Symptoms • Speech: • May repeat central ideas or themes, disconnected. • Loose associations, derailment • Problems in executive functioning – problem solving, planning, associations • Behaviour: • Sexual behaviour, agitation, hoarding, non-conforming to community standards

45. Other symptoms • Catatonia: • Motor abnormalities, complex sequences of movement. • May maintain poses for very long periods • Inappropriate Affect: • Emotional responses out of context • Rare and specific to schizophrenia

46. http://www.youtube.com/watch?v=aBKSOxqu7CQ

47. Etiology • Genetics Family and Twin studies • The largest single body of controlled studies of the genetics of psychopathology • can sometimes lack validity in the determination of zygosity, sampling methods and concordance calculation • may skew results, including the pooling of data from earlier, possibly unreliable sources

48. Genetics • 44.3 % for monozygotic twins • 9.35% for children of patients • Risk of developing schizophrenia increases from one percent for the general population to approximately ten per cent for first degree relatives of those diagnosed • negative symptoms have the strongest evidence for hereditability • Evidence from molecular genetics is inconsistent and results are simply too varied to justify any firm conclusions

49. Genetics • Association with the DTNBP1 gene responsible for encoding the dysbindin protein • Also NRGI neuregulin 1 • Little is known about the actual purpose of either gene or protein

50. Neurobiology Abnormalities in both brain structure and function • enlarged ventricles (also in BP and often in non-patients) • under activity of the prefrontal lobes during abstract reasoning tasks, and abnormal functioning of the temporal lobes • no single brain abnormality is pathognomonic for schizophrenia, though abnormalities are probably present in a large percentage