Psychobabble 101: Mental Health Professions, Diagnoses, Terminology, and Methods April 17, 2007 Michael Jenuwine Notre Dame Law School Common Feature? Moron Idiot Maniac Retard Lunatic Imbecile Mental Health: A Report of the Surgeon General We have allowed stigma and a now unwarranted sense of hopelessness about the opportunities for recovery from mental illness to erect these barriers. It is time to take them down. Dr. David Satcher Surgeon General How Common is MI? Mental illnesses account for approximately 15% of all cases of disease in the United States. How Common is MI? About 1 in 5 Americans (approximately 44 million people) experiences a mental disorder in the course of a year. This figure is roughly the same for children and adolescents (21%) as for adults. Understanding Mental Health Professions Who are the MH Professionals in Your Neighborhood? Counselor Social Worker Psychiatrist Psychologist Psychoanalyst People receiving services may not understand the differences, so they often use these titles interchangeably. Mental Health Credential Scramble IV EdD ACSW HSPP MSW HTTP PsyD CADC KFC PsyF MD LSW LMHC DSW EIEIO AARP LMNO MPh LMFT QMHP BSA TGIF OPP ABPP BSW OSW LCSW Mental Health Credential Scramble IV EdD ACSW HSPP MSW HTTP PsyD CADC KFC PsyF MD LSW LMHC DSW EIEIO AARP LMNO MPh LMFT QMHP BSA TGIF OPP ABPP BSW OSW LCSW Psychiatrists: MD or DO Physicians Training focused on psychopathology and treatment Prescription Privileges Expertise Distinguishing physical disorders with emotional manifestations from psychiatric disorders Organic/Neurological impairment Psychologists: PhD or PsyD Doctoral level psychologists Training focused on assessment and treatment of psychopathology Expertise: Psychological testing and standardized assessment of psychopathology, intellectual functioning, behavioral functioning, and academic achievement Verbal and behavioral interventions Social Workers: MSW or MA Master’s level social work training Training focused on assessment and treatment of psychopathology using a systems perspective Expertise Social and family systems as they affect the individual Social services and programs available for persons with emotional/behavioral problems Educational Degree Board Certification HSPP ABPP BSW Social Work MSW DSW & PhD Psychiatry MD LSW LCSW ACSW Other QMHP CADC LMHC LMFT Psychology PhD EdD PsyD State License BA BS MA Understanding Diagnosis of Mental Disorders Name that book? Classification of Mental Disorders DSM is a Categorical Classification System Communication Tool Only Uses Polythetic Classification First published in 1952 Current version? Defines a class in terms of characteristic features Individual presents with a subset of items from a larger list (overall similarity) Two people with completely different symptoms can have the same diagnosis Multiaxial Classification System How many DSM axes? DSM-IV Disclaimers There is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from all other metal disorders or from no mental disorder There is also no assumption that all individuals described as having the same mental disorder are alike in all important ways Structure of the DSM Uses Polythetic Classification Defines a class in terms of characteristic features Individual presents with a subset of items from a larger list (overall similarity) Two people with completely different symptoms can have the same diagnosis Multiaxial Classification System How many DSM axes? Multiaxial Classification Axis I: All clinical disorders or other conditions that may be a focus of clinical attention Axis II: Personality Disorders & Mental Retardation Axis III: General Medical Condition Axis IV: Psychosocial & Environmental Problems Axis V: Global Assessment of Functioning DSM Diagnosis Example 1 Axis Axis Axis Axis I II III IV Axis V Major Depression, Recurrent Paranoid Personality Disorder Hearing Loss Unemployment, Inadequate Finances GAF= 30 (current); 65 (highest level past year) Diagnostic Uncertainty Diagnosis Deferred Used when there is insufficient information to make a definite diagnosis v. 799.9 Specific Diagnosis – Provisional Used when there is sufficient information for a tentative, but not firm diagnosis “working” diagnosis is given but indicates significant uncertainty Diagnostic Uncertainty (cont’d.) Not Otherwise Specified (NOS) Used when there’s enough information to know a disorder belongs to a particular category, but insufficient to make a more specific diagnosis Either not enough info or symptoms don’t match any specific categories Rule Out (R/O) Enough information is available to indicate that a certain diagnosis needs further consideration in the future, but further specification is not possible DSM Diagnosis Example 2 Axis I 315.00 Axis II V71.09 Axis III 382.9 Axis IV Axis V Depressive Disorder, NOS Reading Disorder R/O Alcohol Abuse No diagnosis, histrionic personality features Otitis Media, recurrent Threat of Job Loss GAF=83 (highest level past year) Disorders First Diagnosed in Infancy, Childhood, or Adolescence Mental Retardation Learning Disorders Motor Skills Disorder Communication Disorders Pervasive Developmental Disorders Attention Deficit and Disruptive Behavior Disorders Mental Retardation Three diagnostic criteria must be met Significantly subaverage intellectual functioning (below 70 on IQ test: 2 S.D. below mean) Concurrent deficits in adaptive functioning in at least two areas: Communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety. Onset prior to age 18 Severity of Mental Retardation Mild Mental Retardation IQ score between 50 and 69 Roughly comparable to 6th to 8th grade functioning level Persons with Mild MR can live independently as adults and work in the community Severity of Mental Retardation Moderate Mental Retardation IQ Score between 35 and 49 Roughly comparable to 2nd grade functioning level Persons with moderate MR may perform unskiled or semi-skilled tasks with supervision as adults Severity of Mental Retardation Severe Mental Retardation IQ Score between 20 and 34 Can acquire elementary self-care skills Can learn to count and read simple “survival” words Can perform simple tasks under close supervision Severity of Mental Retardation Profound Mental Retardation IQ Score below 20 May show improvement in self care and communication with training Require highly structured environments Require constant supervision and care Residential Facilities Pervasive Developmental Disorders: Autism (onset <3 y/o) Impaired Social Interactions (impaired nonverbal behavior) Impaired Communication No eye contact, babies stiffen when picked-up Lack social or emotional reciprocity No language, echolalia (without meaning), pronoun reversal (“you” for “me”), metaphorical language (can only be understood by caregiver) Restricted/Repetitive Behavior, Interests, & Activities Stereotyped movements & Preoccupation with parts of objects Trends in Adult Diagnoses The majority of disorders seen by therapists are Axis I disorders Person feels distress (i.e. depressed) and seeks help for it Many can be medicated In general, medication PLUS therapy is most beneficial Major Mental Illnesses are on Axis I Trends in Adult Diagnoses Axis II Personality Disorders cannot be cured Often do not seek treatment on their own Cannot be medicated Difficult people with whom to interact Long-term, ongoing issues Often co-morbid with Axis I Axis II Diagnoses ARE NOT considered major mental illnesses Axis I Disorders Overview of Axis I disorders Mood Disorders Anxiety Disorders Psychotic Disorders Substance Related Disorders Mood Disorders Predominant symptom is a disturbance of mood (self-reported feeling state) Mood = what person reports feeling Affect = what is observable i.e. Patient reports mood as sad and exhibits flat affect. i.e. Patient reports mood as euthymic. Patient’s affect is labile. Depressive Disorders Major Depressive Disorder: Marked by one or more depressive episode Can be mistaken as dementia in older adults General Features: Negative beliefs about oneself Negative beliefs about the future Negative beliefs about the world & environment Before puberty equally common in both sexes After puberty women are twice as likely to suffer from depression Occurs in 16 million Americans Depression and Psychosis Depression can specified as “with psychotic features” Delusions or hallucinations (usually auditory) Mood Congruent psychotic features: delusions of guilt: being responsible for the illness of a loved one Delusions of deserved punishment: being punished because of some personal inadequacy Nihilistic delusions: beliefs of world or personal destruction Somatic delusions: false beliefs of body rotting away Delusions of poverty: false beliefs of being bankrupt Mood incongruent psychosis is less common Dysthymic Disorder Fairly constant symptoms Chronically depressed mood for 2 or more years in adults Chronically depressed mood for 1 or more years in children and adolescents Cannot be a period of two months or more during which the person is symptom-free Symptoms cannot be severe enough to rise to the level of MDD Bipolar Disorders Bipolar I - Essential feature is a clinical course characterized by one or more Manic episodes or Mixed episodes Individuals typically also have one or more Major Depressive Episodes Bipolar II – Essential feature is a clinical course characterized by one or more Major Depressive Episodes with at least one Hypomanic episode Major Affective Disorders & Suicide 50% to 80% of people who attempt or commit suicide have a history of depression Suicide rate increases with increasing age 80 year olds are twice as likely to commit suicide as 20 year olds Gender Differences in Suicidal Behavior Males (especially white males aged 70 and older) are at highest risk for COMPLETED suicide Females aged 24 to 44 are at highest risk for ATTEMPTED suicide Anxiety Disorders: Panic Panic Attacks Discrete period with sudden onset of apprehension, fearfulness, and terror Often associated with feelings of impending doom Shortness of breath, heart palpitations, chest pain, choking, smothering sensations Fear of “going crazy” or losing control may be present Anxiety Disorders: Agoraphobia Anxiety about or avoidance of places and situations from which escape might be difficult or embarrassing in which help may not be available in the event of having a panic attack or panic-like symptoms Agoraphobia can be with or without panic attacks Anxiety Disorders: Phobias Specific Phobia - Characterized by a clinically significant anxiety provoked by exposure to a feared object or situation, often leading to avoidance behavior Social Phobia - Characterized by a clinically significant anxiety provoked by certain types of social or performance situations, often leading to avoidance behavior May manifest as fear of how others will judge you Anxiety Disorders: OCD Obsessive-Compulsive Disorder: troubled by obsessions or compulsions, and these thoughts and/or behaviors take up a significant amount of time, cause considerable distress to the individual, and frequently interfere with occupational or social adjustment Obsessions = recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause marked anxiety and stress Compulsions = repetitive behaviors that serve to reduce anxiety Anxiety Disorders: PTSD Post Traumatic Stress Disorder- Personally witnessed or experienced some event that involved Actual or threatened death or Serious injury, and Responded with intense fear, helplessness, or horror Persistently re-experience the event Persistently avoid stimuli associated with the event Persistent symptoms of increased arousal Psychotic Disorders Substance induced psychotic disorder Prominent hallucinations or delusions Due to direct physiological effects of a drug of abuse, medication, or toxin exposure Hallucinations the individual realizes are substance-induced don’t count Substance intoxication or Substance withdrawal with perceptual disturbances Schizophrenia At least six months with one month of activephase symptoms Positive Symptoms Delusions (fixed false beliefs) Hallucinations (see/hear/feel something not there) Disorganized Speech (loosening of associations, rhyming) Disorganized or Catatonic Behavior (also frenetic activity) Negative Symptoms Avolition (can’t start things, no goal-directed behavior) Flat Affect (decreased range and intensity of emotions) Alogia (poverty of thought and speech) Anosognosia (lack of insight about being sick) Schizophrenia Subtypes Paranoid- Delusions and Hallucinations organized around a theme Disorganized- Disorganized speech, disorganized behavior, and flat or inappropriate affect Most favorable prognosis & strongest familial link Delusions and hallucinations are fragmentary and not organized into coherent theme Catatonic- Motoric immobility OR excessive motor activity, extreme mutism, peculiarities in voluntary movement, echolalia OR echopraxia Substance Related Disorders Substance Induced Disorders Dependence - three or more symptoms in a 12 month period i.e. tolerance, withdrawal, persistent efforts to cut down, give up or reduce normal activities Abuse - one or more symptom in a 12 month period i.e. substance related legal problems, use substance when physically hazardous Axis II Characterological/Personality Disorders Personality Disorders: Overview Characterized by a stable, enduring pattern of behavior that deviates from the expectations of a person’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, and causes distress or impairment Personality Disorders Cluster A: Odd/Eccentric Behaviors Cluster B: Dramatic, Irrational or Erratic Behaviors Paranoid Personality d/o, Schizoid Personality d/o, Schizotypal Personality d/o Antisocial Personality d/o, Borderline Personality d/o, Histrionic Personality d/o, Narcissistic Personality d/o Cluster C: Anxiety or Fearfulness Avoidant Personality d/o, Dependent Personality d/o, Obsessive-Compulsive Personality d/o, Paranoid Personality Disorder Suspiciousness about the motives of others Pervasive distrust Believes others are exploiting, harming or deceiving him or her (unjustified) Michael Douglas in Falling Down Schizoid Personality Disorder Detachment from social relationships Restricted range of emotional expression No desire for intimacy with others James Spader as “Graham” in Sex, Lies, and Videotape Schizotypal Personality Disorder Acute discomfort in close relationships Distorted cognitions or perceptions Behavioral eccentricities Peter O’Toole as the Christ figure in The Ruling Class Antisocial Personality Disorder Disregard for others’ feelings Violation of the rights of others Lack of empathy Michael Rooker as the killer in Henry: Portrait of a Serial Killer Borderline Personality Disorder Instability in interpersonal relationships Labile affect Impulsivity and poor self-image Suicidality & Violence Glenn Close in Fatal Attraction Histrionic Personality Disorder Excessive Emotionality Constantly Seeking Attention from Others Overly dramatic Take over the room Blanche du Bois in A Streetcar Named Desire Narcissistic Personality Disorder Grandiose & too self-centered to be empathic to others Need for validation & admiration Lack of empathy for the problems and needs of others Gloria Swanson in Sunset Boulevard Avoidant Personality Disorder Socially Inhibited Feelings of inadequacy Hypersensitivity to criticism and negative evaluation “Laura” in The Glass Menagerie Dependent Personality Disorder Submissive Constant clingy behavior Needs other to be responsible for him or her Bill Murray in What About Bob? Obsessive-Compulsive D/O Preoccupation with Orderliness, Perfectionism, and Control Lacks flexibility, efficiency & openness Painstaking attention to trivial details Jack Lemmon as “Felix Unger” in The Odd Couple Child vs Adult Mental Health Mental Illness often evidences itself as behavioral problems in children It is extremely uncommon for children to be diagnosed with a personality disorder (any AXIS II diagnosis) More specific criteria required for rare cases Antisocial PD requires age 18 or older If you see this, it should raise a red flag Psychological Testing Personality Testing Projective Testing TAT, CAT, Rorschach, KFD, HFD, HTP Intellectual Testing MMPI, MCMI, PAI WAIS, WISC, Stanford-Binet, KBIT, SIT Achievement Testing Woodcock-Johnson, WIAT, WRAT Psychological Testing Terms Standardized Normed Given the same to everyone Individual scores can be compared to a normative sample Battery More than one test must be given and conclusions are drawn based on overlapping data from different measures