Mental Disorders



Mental Disorders



Learning Objectives


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.


20. List and discuss personality disorders.



Key Terms





















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


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FIGURE 14–1 DSM-IV manual. (Courtesy David Frazier, 2003.)

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.


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FIGURE 14–2 Counseling session in progress. (Courtesy Mark Boswell, 2003.)

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:



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.



image 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.






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.







Learning Disorders














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













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)





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 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.



image Enrichment


Asperger’s, Childhood Disintegrative Disorder, Rett’s Syndrome, Pervasive Development Disorder Not Otherwise Specified (PDD-NOS)






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:


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Apr 4, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Mental Disorders

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