Mental Disorders
After studying Chapter 14, you should be able to:
1. Name some contributing factors to mental disorders.
2. List some of the many causes of mental retardation.
3. Describe the characteristic manifestations of pervasive development disorders including autism.
4. List criteria for diagnosis of attention-deficit hyperactivity disorder.
5. List some examples of tic disorders.
6. Describe the progressive degenerative changes in an individual with Alzheimer’s disease.
7. Explain important factors in the treatment of Alzheimer’s disease.
8. Explain the cause of vascular dementia.
9. Relate treatment options for alcohol abuse.
10. Name the classic signs and symptoms of schizophrenia. Explain what is included in the multidimensional treatment plan.
11. Explain why bipolar disorder is considered a major affective disorder. Describe the treatment approach.
12. Explain the difference between reactive depression and major depressive disorder.
13. Name the distinguishing characteristics of personality disorders.
14. Discuss how each type of anxiety disorder prevents a person from leading a normal life.
15. Explain how posttraumatic stress disorder differs from other anxiety disorders.
16. Explain how a somatization disorder is diagnosed.
17. Discuss the relationship between anxiety and conversion disorder.
18. Describe Münchausen’s syndrome.
19. Contrast insomnia to narcolepsy.
Mental Wellness and Mental Illness
At some time in life, almost everyone is affected by mental disorders, either personally or by the involvement of a family member or friend. Stress is considered a contributing factor causing exacerbation of mental disorders. Other factors are hereditary or congenital, accidental, traumatic, psychosocial, socioeconomic, or ones related to drug toxicity. Chemical imbalances in the brain and its neurotransmitters also are postulated to be causative factors. The specific causes of mental illness remain unclear in many cases.
Mental illness has been linked to the patient’s inability to cope with stress imposed by modern society. Pressures imposed by life circumstances can be a source of personal pain and distress. The definition of mental wellness, or being in a good state of mental health, varies and is a relative state of mind. When healthy people have the capacity to cope and adjust in a reasonable manner to the ongoing stresses of everyday life, they are considered to be in a state of equilibrium known as mental wellness. E14-1
Psychological pain is real and intense and can affect physical health. Subsequently, impaired or pathologic coping skills emerge in people’s behavior. Some coping behaviors are conscious, and some are not easily controlled because they are unconscious. Certain disorders in thinking, perceiving, and behaving can be organized into clusters of signs and symptoms. These clusters become diagnostic criteria and a part of a total physical and psychological evaluation. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (Figure 14-1) E14-2, is the accepted reference that offers guidelines for criteria to be used in the clinical setting when diagnosing a mental disorder. In addition to diagnostic criteria, the DSM-IV gives the practitioner a standardized diagnostic code, similar to the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM and ICD-10-CM) coding systems. E14-3
Mental disorders include those of congenital and hereditary origins. Other categories such as maladaptive disorders, phobias, anxiety, depression, addiction, and psychotic disorders have uncertain or unknown causes and possibly more than one contributing factor. Psychosis is a severe mental disorder where the individual loses touch with reality. The individual may experience verbal or visual hallucinations, irrational thoughts, delusions, regressive behavior, and degeneration of personality.
Mental disorders cause mild to severe disruption in a person’s ability to function in interpersonal relationships, self-care, and occupational settings. In some disorders, the person may experience incapacitating psychotic symptoms. The DSM-IV also includes substance-related, eating, and sleep disorders. In some mental disorders, oxygen and nutrient deprivation with necrosis result in the death of brain cells; these are known as organic disorders and are permanent and cannot be reversed. Supportive therapy and custodial care often are the only available interventions.
Modern therapeutic approaches include control of symptoms with psychotropic drugs, including antipsychotic drugs, antidepressants, anxiolytics (antianxiety agents), central nervous system (CNS) stimulants, and antimanic agents; hospitalization during acute episodes; psychotherapy; electroconvulsive therapy; and group therapy. Outpatient treatment is available and preferred in many cases (Figure 14-2). Play therapy is included in counseling sessions for some children. (See the Enrichment box on play therapy.) Patients with mental illnesses and conditions need established routines and consistency in treatment and daily living activities.
Mental illnesses are categorized by axis. The process of diagnosing a mental illness in DSM-IV format uses a five-axis system. Each axis represents a different part of the diagnosis, as follows:
Axis I: Mood and thought disorders, which often respond to medication and psychotherapy.
Axis II: Mental retardation and personality disorders. Many third-party providers currently do not reimburse for Axis-II disorders.
Axis III: Medical conditions that contribute to the psychological condition.
Axis IV: Stressors that contribute to the psychological condition.
Axis V: GAF (Global Assessment of Functioning). This is a number, 0 to 100, that indicates level of functioning with 0 representing the lowest level of functioning and 100 representing the highest.
Many patients with an Axis-II diagnosis can function at a level that maintains normal daily living. Patients with these conditions are unresponsive to treatment with medications and usually do not heal because Axis-II conditions currently have no cure.
Enrichment
The Child, the Therapist, and Play Therapy
Play is a natural means of expression for a child. Therapists working with children use play therapy in assessment and treatment interventions, assisting the child to cope with emotional stress and trauma. Children often cannot verbalize their thoughts and feelings, and play therapy becomes a nonverbal avenue for them to communicate with the therapist. This type of therapy creates a nonthreatening atmosphere for the children. Play therapy may be employed on a one-to-one basis or in the group setting. Children are allowed, and occasionally encouraged, to act out or express feelings and experiences. During play therapy sessions, the therapist establishes rapport with the child and encourages the child to act out any feelings of anxiety and tension he or she may be experiencing. The therapist’s goals are to give the child an opportunity to reveal feelings that he or she cannot verbalize, to understand the child’s interactions and relationships with important people in his or her life, and to teach the child appropriate coping mechanisms and adaptive socialization skills.
Children who have been exposed to abuse often will respond to the therapist in the nonthreatening environment of play therapy. The use of dolls and various toys gives the child a means of acting out the abuse and offering an avenue for positive interaction.
Therapists may use objects and toys during play therapy. All kinds of dolls, a doll house, stuffed animals, puppets, soft balls and foam bats, toy vehicles, punching toys, a sand box, and paper and markers or crayons may be used during play therapy. During these play sessions, family interactions and dynamics may become apparent. Sand therapy may include small plastic animals or people and allows the child to act out feelings.
Mental Retardation
Description
Mental retardation, or developmental disability, is not a disease but a wide range of conditions with many causes. A causative factor interferes with the developmental processes, resulting in changes in the acquisition of intellectual skills and adaptive functioning in a variety of areas, including social and interpersonal skills, self-care, communication, self-direction, health, and safety. In addition, the level of behavioral performance is reduced. General intellectual functioning is subaverage, and the individual has noticeable deficits in adaptive behavior. This condition is manifested during the developmental period and before the age of 18 years.
Symptoms and Signs
During early childhood, those with mild intellectual impairment often appear normal because they have no obvious physical defects. The first indication may be observed at school, where the individual fails to progress intellectually and socially at a normal rate. Those who have an underlying condition that is responsible for the impairment usually exhibit early symptoms of the underlying condition. Certain anomalies (e.g., Down syndrome) are found at birth. Occasionally, delayed development of communication and motor skills is suspected, but the disability is not confirmed until the child enters school. Delayed adaptive behavior, coupled with difficulties with schoolwork, lead to further evaluation and the diagnosis of mental retardation.
Patient Screening
Signs of mental retardation may appear on well-baby examinations or during preschool routine checkups. The first significant indications of mental retardation sometimes appear when the child begins school or preschool. When these parents contact the office, an appointment should be made for the earliest possible date when schedules will allow sufficient time for the physician to conduct a thorough assessment. The parents possibly will be feeling great anxiety, and the child should be assessed as soon as possible.
Etiology
Mental retardation has a variety of causes, many of which are unidentifiable. The predisposing factors include heredity (inborn errors of metabolism, genetic disorders, or chromosomal abnormalities); early alterations of embryonic development (Down syndrome or damage from toxins); prenatal, perinatal, or postnatal conditions (prematurity, hypoxia, viral infections, or trauma); general medical conditions (infections, trauma, or poisoning); and environmental influences. Any condition that compromises the blood supply to the developing brain, depriving it of oxygen and nutrients, can result in neurologic damage and mental retardation. Some examples are placental insufficiency, cord or head compression during the perinatal period, failure to breathe at birth, premature birth, and viral infections in the mother in the prenatal period or in the infant or child after birth. Trauma of any type that causes hypoxia or anoxia also may contribute to the deficit. Fetal alcohol syndrome also may result in mental retardation.
Diagnosis
Diagnosis requires observation and confirmation of the intellectual capabilities and adaptive behavior of the child. A lack of control of emotions and reduced socialization skills are noted. Intellectual testing with standardized tests, such as Wechsler Intelligence Scales for Children-Revised E14-4, Stanford-Binet, and Kaufman Assessment Battery for Children, to develop an intelligence quotient (IQ) also is considered. E14-5 Acceptable terms to describe intelligence based on the IQ determined by the Stanford-Binet test are:
The IQ measurement is only one factor to be considered, and a slight error can occur in testing, so allowances should be made for borderline scores. Possible testing with other instruments should be considered before a diagnosis is made.
Criteria for the diagnosis of mental retardation include subaverage general intellectual functioning accompanied by significant limitations in adaptive functioning. The diagnosis requires limitations in at least two of the following areas: communication, home living, self-care, social or interpersonal skills, self-direction, and health and safety. Onset must be before 18 years of age.
Treatment
When the deficit occurs, the brain cells die and cannot be restored. The child can be trained, however, and in some cases even educated to perform tasks of various levels. Underlying causes should be treated, and intervention may prevent or delay progression of the condition.
Many mildly to moderately retarded people can function in society. Patients whose retardation is severe or profound may be institutionalized to ensure the needed daily care. Mental retardation has no cure. However, psychotropic medication may be used for management of certain mood or behavioral problems, such as agitation, lack of impulse control, or ritualistic behavior.
Prevention
Preventing all mental retardation might not be possible, but early and good prenatal care and nutrition are encouraged for all pregnant women to reduce the occurrence. Fetal monitoring during labor may signal the labor and delivery staff when the fetus is deprived of adequate oxygen. In such a case, immediate intervention is necessary. Prompt attention to head injuries in children may prevent the onset of mental retardation during childhood. Genetic counseling may be desirable before pregnancy for parents with a family history of mental retardation.
Patient Teaching
Parents require encouragement to recognize that there is no cure. Some retarded individuals may be educable or trainable. Routines and consistency are important in enabling the individual to function at the highest possible level. Provide parents and family with electronically obtained data explaining various tests used to evaluate IQ.
Learning Disorders
Description
Learning disorders, sometimes referred to as learning differences or learning disabilities, are conditions that cause children to learn in a manner that is not normal. Performance on standardized tests is lower than expected for age, schooling, and intelligence level. The brain’s ability to receive and process information is affected.
Symptoms and Signs
The person with a learning disorder exhibits difficulty in acquiring a skill in a specific area of learning, such as reading, writing, or mathematics. This lower level of achievement occurs despite the child’s normal (sometimes above normal) intelligence and adequate schooling. Many of these individuals become school dropouts, have low self-esteem, and feel demoralized. They also may exhibit deficits in social skills. Individuals with learning disabilities may have problems listening or paying attention, reading or writing, speaking, and/or performing arithmetic problems. Individuals with learning disabilities experience difficulties performing specific types of skills or completing tasks. The disability is no indication of intelligence level.
Patient Screening
Most learning disorders are noted as the child begins the formal education process. At that point, the parent usually contacts the physician’s office for an evaluation and a treatment plan. The parents possibly will be feeling a high level of anxiety, and the child should be assessed as soon as possible.
Diagnosis
When the physician has established that the child has met all the diagnostic criteria listed in the DSM-IV, further evaluation is performed. In addition to ruling out normal variations in academic attainment, the physician eliminates inadequate schooling, language barriers, lack of opportunity, and poor teaching as causes. Hearing and vision must be tested. Other mental disorders are ruled out.
Treatment
Some children who are learning disabled also may be diagnosed with hyperactivity and therefore may respond to drug therapy, usually with stimulants. Other children may respond favorably to special instructional techniques (Figures 14-3 and 14-4). Continuing research is attempting to help develop additional treatments for children with learning disabilities. E14-6
Communication Disorders
Children often exhibit difficulties in communication. These disorders may be psychologically based and are listed in the DSM-IV. There are a variety of expressive language disorders, including mixed receptive or expressive language disorders.
Stuttering
Symptoms and Signs
The frequent repetition or prolongation of sounds or syllables constitutes a disturbance of the pattern and fluency of speech, a disturbance that is inappropriate for the child’s age. There also may be broken words, filled or unfilled pauses in speech, word substitutions, or word repetitions. The onset usually occurs between 2 and 7 years of age.
Etiology
Although the etiology is uncertain, genetic factors may be involved. Stuttering appears to have a familial tendency, with the condition occurring more often in males. Parents also may unwittingly cause anxiety in their child by overreacting to mild speech limitation. Anxiety appears to be a major factor that creates and maintains stuttering.
Pervasive Development Disorders (PDD)
Children diagnosed with PDD differ widely in abilities, intelligence, and behaviors. Principal characteristics of pervasive development disorders are severe impairments in several areas of development, including communication and social interaction skills. The disorders can include particular behaviors that cause the failure to develop peer relationships and interactions with others, including lack of nonverbal communication and lack of reciprocation of emotions. This impairment is related directly to the person’s developmental level or mental age. A category of disorders is referred to as “autism spectrum,” encompassing the broad group of developmental delays and disorders having an affect on social communication skills and possibly to a larger or smaller degree, motor and language skills. The group of five specific disorders is often referred to as pervasive development disorders (PPD). The following are the disorders listed: autism, pervasive developmental disorder not otherwise specified (PDD-NOS), Rett’s syndrome, childhood disintegrative disorder, and Asperger’s syndrome.
Autistic Disorder (Autism)
Description
Autistic disorder (autism) is a syndrome of extreme withdrawal and obsessive behavior. It has its onset in infancy, and manifestations are apparent by the second or third year of age. Autism is known to be highly heritable. There is a delay in onset of speech in this pervasive development disorder. In contrast, Asperger’s has no delay in speech.
ICD-9-CM Code 299.0 (Infantile and childhood autism) (Requires 5th digit)
ICD-10-CM Code F84.0 (Autistic disorder)
Autism is coded by active or residual status. When the activity status of the autism has been determined by diagnosis, refer to the physician’s diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM coding manuals to ensure the greatest specificity of pathology.
Symptoms and Signs
The autistic child will exhibit a notable impairment in socialization, communication, activities, and other interests. The impairment is noted in nonverbal behaviors, such as eye-to-eye gaze, facial expressions, and other forms of nonverbal communication. Seizures may occur. In addition, the child fails to establish normal peer relationships and to seek shared enjoyment. Communication impairments include delayed or absent verbal communication, inability to initiate a conversation, and repetitive use of inappropriate language. The child does not initiate age-appropriate play activities. Repetitive motions, often self-destructive, may be noted along with an inflexibility toward change and a compulsion for sameness. These youngsters display a persistent preoccupation with objects and may have a memory for certain lists or facts.
Four symptoms that are nearly always present are social isolation, cognitive (based on knowledge) impairment, language deficits (shortages or missing), and repetitive naturalistic motions. Aversion to physical contact or cuddling also can be a sign. The autistic child resists any change.
Patient Screening
The parent of the child with autistic behavior often is aware of problems that are developing. Often this issue will be discussed on regular well-child (toddler) visits. When the parents first become aware of a problem, an appointment should be scheduled as soon as schedules will allow for an extensive examination and history.
Etiology
The etiology is uncertain, but evidence indicates a possible organic factor or possible predisposing factors that may include maternal rubella, encephalitis, and phenylketonuria. In fact, recent research on autism suggests that autism is not a single disorder and that there is not a singular cause (Happé, F. Time to give up on a single explanation for autism. Nature Neuroscience (2006). Oct. 9 (10) pp. 1218-1220). The occurrence is four times more common in males than females.
Diagnosis
Observation of the behavior usually is all that is needed for the diagnosis. The child exhibits impairment in social interaction and communication; restricted, repetitive patterns of behavior; and delayed or abnormal patterns of symbolic or imaginative play. The physician may order blood and imaging studies to rule out any underlying physical cause.
Treatment
Behavioral therapy and self-instructed training have helped some autistic children. This therapy is most beneficial when parents also are trained in behavioral techniques and have the goal of helping these children to learn some adaptive responses, enabling the children to function outside of custodial care. Risperidone is the first drug approved for use for autism. Risperidone decreases irritability, tantrums, aggression, and mood swings. Other drugs that may be used for autism (but are not approved) include SSRI antidepressants, antiepileptics, and stimulants. SSRI antidepressants (mirtazapine) are believed to decrease repetitive thoughts and behaviors. Antiepileptics may help with impulsivity and decrease aggression. Stimulants are useful for attention deficit, etc.
Patient Teaching
Encourage parents to investigate community and educational resources and to seek out support groups. Use customized electronically generated educational materials when available to reinforce the treatment plan.
Enrichment
Asperger’s, Childhood Disintegrative Disorder, Rett’s Syndrome, Pervasive Development Disorder Not Otherwise Specified (PDD-NOS)
Similar to children with autism, children with Asperger’s syndrome experience problems with social interaction and communication. Additionally, they usually have a narrow range of interests. Usually, children experiencing Asperger’s tend to have average or above average intelligence. They also appear to develop normally in the spheres of language and cognition. Many times those with Asperger’s may have difficulty concentrating and may experience poor coordination. Children with Asperger’s syndrome, a milder form of autism, seem to adjust better as they get older.
Childhood Disintegrative Disorder
A rare condition, childhood disintegrative disorder (CDD) allows children to start developing normally in all areas, physical and mental. Sometime, typically between 2 and 10 years of age, the child loses many of the skills he or she has acquired. Additionally, the child tends to lose language and social skills, and may lose control of body functions, including bowel and bladder control. The long period of normal development before regression helps differentiate CDD from Rett’s syndrome.
A very rare disorder causes the child to experience symptoms associated with a PDD. Additionally the child also experiences problems with physical development. The child who commonly suffers the loss of many motor or movement skills, including ambulation and use of hands, along with development of poor coordination is placed in this category. The condition, usually affecting only girls, appears to be associated with a defect on the X chromosome.
Pervasive Development Disorder Not Otherwise Specified (PDD-NOS)
A child who has considerable problems with communication and play, along with certain difficulties interacting with others, and appears to be too social to be considered autistic is placed in the category of PDD-NOS.
As previously mentioned in autistic disorder, there is no known cure for PDD. Drug therapy may be used as a symptomatic treatment for irritability, aggression, serious behavioral problems, obsessive-compulsive behavior, anxiety, depression, seizure activity, inattention, and hyperactivity. Behavioral therapy is beneficial but should be specialized to the child’s needs. Specialized classrooms with a small class size and one-on-one instruction are sometimes helpful for certain children while regular classroom education serves others.
Attention-Deficit Hyperactivity Disorder
Description
Attention-deficit hyperactivity disorder (ADHD), previously referred to as attention-deficit disorder (ADD) is a condition of persistent inattention leading to hyperactivity and impulsivity. ADHD is traditionally considered a hyperactivity issue, but many children and adults simply have difficulty maintaining attention and have no hyperactivity problems. Therefore ADHD has been broken down into subtypes: ADHD combined type, ADHD predominately inattentive type, and predominately hyperactivity-impulsive type.
Symptoms and Signs
Typical ADHD behavior can be observed at any age, but symptoms are usually present before the age of 7 years. Failure to give close attention to details; careless mistakes; messy work, performed carelessly; and difficulty in sustaining attention and completing tasks are manifestations of the condition. The child avoids activities that require sustained attention, effort, concentration, and organization. An inability to sit quietly without fidgeting or squirming, or even to remain seated, denotes hyperactivity. Inappropriate running and climbing, difficulty in playing, and excessive talking are other signs of the condition. The APA has criteria for each of these disorders.
A display of impatience, difficulty in waiting for one’s turn, frequent interruptions, and failure to listen to directions are manifestations of impulsivity. The inability to organize activities and define goals creates difficulty in performing simple tasks, such as picking up toys. Sexual and relationship problems may occur as the child ages.
Any aspect of this behavior may be displayed at home, school, work, or social occasions. The behavior seems to be exaggerated in group situations.
The three subtypes are listed as follows:
Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type: This subtype is used if six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) have persisted for at least 6 months.
Attention-Deficit/Hyperactivity Disorder Predominantly Hyperactive-Impulsive Type: This subtype should be used if six (or more) symptoms of hyperactivity-impulsivity (but fewer than six of inattention) have persisted for at least 6 months.
Attention-Deficit/Hyperactivity Disorder Combined Type: This subtype should be used if six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity have persisted for at least 6 months.
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