Baker mental health talk part iPresentation Transcript
Mental Health Conditions-Part-I Presentation made to Baker College January 29, 2013 9:30-12:00 Stuart S Segal, Ph.D. Director of the Office of Services for Students with Disabilities University of Michigan (734)- 764-7485 firstname.lastname@example.org
Anxiety Disorders Among College Students Anxiety disorders are extremely common on college campuses 40 million Americans suffer from anxiety disorders and 75% experience first episode of anxiety before age 22 Evidence based treatments are available and effective Treatment frequently includes Cognitive Behavioral Therapy and medication
Anxiety Disorders Among College Students GAD Achievement worries, critical thinking, unrealistic expectations Social Anxiety Disorder Avoidance of group social events/ parties, difficulty public speaking, test anxiety Panic Disorder Fear of being stuck in class or with roommate and having panic OCD – presentations are not specific to setting Trichotillomania Studies show may occur in 1-3% of college populations
Types of Anxiety Disorders continued Phobias Acute Traumatic Stress Disorder Post Traumatic Stress Disorder Adjustment Reaction with mixed Anxiety and Depression
Cognitive Behavioral Therapy for Anxiety Disorders Short-term, evidence based treatment Based on the idea that thoughts and behaviors affect the way we feel Often includes Exposure therapy Studies show CBT and medication are more effective together than either are separately
General Goals in CBT treatment of Anxiety Disorders Understand the function of anxiety, triggers of anxiety and safety behaviors (anxiety fuel) Focus on seeing anxiety as uncomfortable rather than dangerous Not just thinking positive – what is the evidence for a fear? Realistic or not? Gather evidence through experience Learning to accept a lack of control / safety for a better quality of life
What’s “Normal” Anxiety? When does it become a “real” problem? Anxiety is a normal and necessary response Key issues for when you need help for anxiety: Is anxiety interfering with your life? Are you avoiding things or having to endure with dread? Is anxiety happening too often? (you judge) Is your anxiety more severe than the actual danger/risk present?
Social Anxiety Disorder Fear/avoidance of social situations Feared situations avoided or endured with intense anxiety or distress Fear recognized as excessive or unreasonable Fear/avoidance interferes with work, social, school, family activitiesAmerican Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC,American Psychiatric Association, 1994.
Social Anxiety Disorder Common Fears Participating in small groups Eating, drinking, writing in public Talking to authority figures Performing or giving a talk Attending social events Meeting strangers or dating Using public bathroom Being center of attention/ being observed by others
Social Anxiety Disorder Test Anxiety Often caused by fears of judgment by others, fear of failure and other negative beliefs Classified and treated as a social anxiety issue CBT focus is on restructuring negative thoughts around test performance and using practice to desensitize anxiety response Treatment may include improvement of study skills in addition to cognitive behavioral therapy treatment
CBT for Social Anxiety Exposure : Gradual confrontation of progressively more challenging social encounters Prolonged sessions (60-90 minutes) Frequent sessions (daily is best) End session only when anxiety improves Common cognitive distortions Magnification - “It would be horrible if I didn’t know what to say” All or Nothing Thinking - “Why did I say that… I made a complete fool of myself” Mind Reading - “He looked away, he must think I am weird” Fortune Telling - “Why bother to talk to her, she will just reject me like all the others” Social Skills Training
Diagnostic Criteria For Obsessive-Compulsive DisorderObsessions: (1) recurrent or persistent thoughts, impulses, or images are experienced as intrusive or inappropriate and cause distress (2) not simply excessive worries about real-life problems (3) person attempts to ignore or suppress thoughts or neutralize them with another thought or action (4) person recognizes that obsessions are product of his/her mind, not imposed from withoutCompulsions: (1) repetitive behaviors or mental acts performed in response to an obsession or according to certain rules (2) designed to neutralize or prevent discomfort or some dreaded event or situationThe obsessions and compulsions cause marked distress, are time-consuming, or significantly interfere with normal routine, usual social activities or relationships with others American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.
Obsessive-Compulsive Personality Disorder A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost Shows perfectionism that interferes with task completion Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
Obsessive-Compulsive Personality Disorder (cont.) Is over conscientious , scrupulous, and inflexible about matters of morality, ethics, or values Is unable to discard worn-out or worthless objects even when they have no sentimental value Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes Shows rigidity and stubbornness
OCD vs. OCPD OCD involves ego-dystonic thoughts and urges to neutralize The person realizes the symptoms are senseless Symptoms are distressing and anxiety- evoking OCPD involves ego-syntonic behavior Symptoms are consistent with person’s world view Often associated with rigidity, inflexibility, and anger
Behavioral Treatment of Obsessive Compulsive Disorder Exposure and Response Prevention Therapy - 70 % Effective Requires Substantial Effort Durable Treatment Effective For Both Obsessions and Compulsions
Exposure and Response Prevention for OCD Exposure Therapy Graded Hierarchy Continuous Exposure is Best Watch for patients Attempts at Avoidance of Exercises Response Prevention Rapid over very gradual Make rituals inconvenient to do Enlist family as a response prevention team Do not compromise on time… make the exposure exercise less difficult
Diagnostic Criteria for GAD Excessive anxiety and worry, for more days than not for ≥6 months, about many subjects Worry is difficult to control Anxiety, worry, physical symptoms impair social, occupational, and other functioning Associated with ≥3 of the following restlessness/keyed-up easily fatigued difficulty concentrating irritability muscle tension sleep disturbancesAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC:American Psychiatric Association; 1994.
Generalized Anxiety Disorder Worries, negative thoughts, or predictions that are future oriented Many worries around many topics with significant difficulty managing anxiety triggered by worry What if I don’t pass this class? I’ll never catch up. I’m not working hard enough. I should have known that answer. Failing would be terrible.
CBT for GAD Focus is on 3 areas: Lifestyle change: creating balance of work & leisure, exercise, sleep hygiene, etc. Relaxation Training : to address physical symptoms of anxiety such as muscle tension Cognitive Restructuring: Try to identify cognitive distortions in negative thinking, understand a situation in a realistic way, and develop a more balanced life perspective
Diagnostic Criteria For Panic Attack A discreet period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes: • Palpitations, pounding heart • Dizziness • Sweating • Chills or hot flushes • Trembling or shaking • Feelings of unreality • Shortness of breath or • Fear of losing control or smothering going crazy • Choking feeling • Fear of dying • Chest pain or discomfort • Paresthesias (tingling / • Abdominal distress numbness)American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.Washington, DC, American Psychiatric Association, 1994.
Panic DisorderRecurrent, unexpected panic attacks followed by more than 1 month of persistent concern about another panic attack, worry about possible implications or consequences of panic attacks, or significant behavioral change related to attacksMay Occur with or without Agoraphobia * Agoraphobia is an intense fear of being alone in a place where help might not be available or escape might be difficultMany times is exacerbated or onset during substance use (alcohol, marijuana, hallucinogens)
CBT for Panic Exposure to external panic cues Places where previously experienced panic or other avoidance cues Exposure to internal panic cues Panic patients avoid activities that create feelings similar to panic Create exercise to produce panic sensations Cognitive Therapy for panic fears Collect information to dispute distorted thoughts in panic by using: -BEHAVIORAL TESTS: Experience panic attacks without intervention to see if catastrophe takes place -AWFUL TESTS : Pretend to experience catastrophe and test whether it is really so awful, terrible -Patient’s previous experiences with panic -Information about symptoms
Impulse Control Disorders Trichotillomania – compulsive pulling of hair Pulling often occurs from scalp, eyelashes and/or eyebrows Compulsive Skin Picking While both are common problems, access to evidence based treatment is limited Both are treated with habit reversal therapy and medication
CBT for Impulse Control Disorders Focus is on using Habit Reversal Therapy to reduce the intensity of the urges Learn coping skills to use during high risk situations – very behavioral Gain an understanding of this as a neurobiological problem Engage in cognitive restructuring around negative self-talk related to pulling behaviors
Economic Burden of Anxiety Disorders Total Costs = $42.3 Billion Per Year Total Mortality Workplace Costs (3%) Pharmaceutical Costs Costs (10%) (2%) Direct Nonpsychiatric Total Direct Medical Treatment Psychiatric Costs Treatment (54%) Costs (31%)Greenberg et al. J Clin Psychiatry. 1999;60:427.
Post-Tramatic Stress Disorder- PTSD An Anxiety Disorder. 3-6% of adults in the United States. Twice as common in women as in men. Rates as high as 58% in heavy combat 1-14% non combat Torture/POW 50-75% Natural Disaster victims 4-16%
DSM-IV diagnostic criteria for PTSD Exposure to a traumatic event in which the person Experienced, witnessed, or was confronted by death or serious injury to self or others AND Responded with intense fear, helplessness, or horror Features Appear in 3 clusters: re-experiencing, avoidance/numbing, hyperarousal Last for > 1 month Cause clinically significant distress or impairment in functioning
DSM-IV Diagnostic Criteria of PTSD- Re- experiencing Persistent Re-experiencing of > 1 of the following: Recurrent Distressing Recollection of the Event Recurrent Distressing Dreams of the Event Acting or Feeling that Event was reocurring Psychological Distress of Cues Resembling Event Physiological Reactivity to Cues Resembling Event
DSM-IV Diagnostic Criteria for PTSD- Avoidance and Numbing Avoidance of Stimuli & Numbing of General Responsiveness indicated by >3 of the following: Avoid Thoughts, Feelings or Conversations related to trauma Avoid Activities, Places or People Related to Trauma Inability to Recall Parts of the Trauma Decreased Interests in Activities Estrangement from Others Restricted Range of Affect Sense of Foreshortened Future
Summary of Symptoms of PTSD Spontaneous re-experiencing of the trauma Startle responses Irritability Depression and Guilt Phobias Multiple physical complaints Numbing Impaired concentration and memory Disturbed sleep and distressing dreams
Depression is complex!• Genetics ▫ Often runs in families• Medical Condition ▫ Injury (stroke, brain injuries) ▫ Illness (heart attacks, diabetes)• Neurotransmitters (brain chemicals) ▫ Abnormal levels or not functioning as they should ▫ Drug abuse• Stress and environment ▫ Abuse ▫ Trauma
Depression? Depression (majordepression (“little d”) of A temporary feeling depressivelow mood or Constant disorder) sadness anhedonia (lack of “Normal” pleasure) Other symptoms present A common and potentially destructive illness
Historical Names for Diagnosis:NostalgiaFright NeurosisCombat/War NeurosisShell ShockSurvivor SyndromeOperational FatigueCompensation Neurosis
Brain function changes in depression http://www.mayoclinic.com/health/medical/IM00356A PET scan can compare brain activity during periods of depression (left) with normal brainactivity (right). An increase of blue and green colors, along with decreased white and yellowareas, shows decreased brain activity due to depression.
Types of depression: Adjustment disorder Depression NOS (depression) Dysthymic disorder Major depressive disorder Bipolar disorder (cycles of depression and mania)- Will be dealt with in Part II of this discussion
What are the symptoms and signs of clinical depression? Prolonged sadness, crying spells Loss of pleasure, social withdrawal, loss of motivation, decreased energy, pessimism Unexplained pains, fears, apprehension Significant changes in appetite, sleep and other physical functions (e.g., dry mouth, constipation, loss of taste) Irritability, anger, excessive worry, anxiety, guilt Inability to concentrate or make decisions Recurring thoughts of death or suicide Monthly or seasonal cycling is common Excessive consumption of alcohol or other chemical substances to seek relief These worsen rather than help clinical depression
Reasons for Depression 1. 2. Early Widesprea Symptom d Onset Prevalence8. Brain Tissue 3. Underdiagnosis Degenerative and Changes Undertreatment Depression ’s 4. Genetic7. Stigma and BURDEN: Vulnerability Poor Stress- REASONS Adherence genetic interactions 5.Recurrences 6. Little , Recurrence Increased Prevention Cycles, Severity
Depression is underdiagnosed and undertreated at all ages 5% 5% No diagnosis / No treatment10% Diagnosis, but no treatment 50% Diagnosis, inaccurate treatment (BZD) 30% Diagnosis, proper treatment but inadequate dose, duration or discontinuation Successfully treated
Symptoms of Major Depression S - Sleep changes (too much or too little) I - loss of Interests G - excessive Guilt E - lack of Energy C - loss of Concentration A - change in Appetite P - Psychomotor (movement) slowing or agitation S - Suicidal thoughts
Depression affects many! 1-2% prepubertal children Both sexes equally affected 3-8% teenagers 3:1 female to male ratio Lifetime prevalence ~20% by end of adolescence CDC (2007): Suicide is the third leading cause of death people aged 15-24 years
Types of Depression Treatment1. Psychotherapy (“talk therapy”)2. Antidepressant medication (selective serotonin reuptake inhibitors or SSRI)• Other (sleep, exercise and nutrition) interventions may be helpful• The best treatment is combination (medication and psychotherapy)
Prefrontal Cortex Raphe Nuclei (5-HT source)Cooper JR, Bloom FE. The Biochemical Basis of Neuropharmacology. 1996.
Heightened Risk of Suicide Feeling of hopelessness and desperation Extreme anxiety, agitation or enraged behavior Severe insomnia Increased alcohol/drug use
Warning Signs of Suicide Suicidal Thought/Expressions Obsession with death Decreased interest in friends Dramatic change in personality or appearance Irrational, bizarre behavior Overwhelming sense of guilt, shame or rejection Changes in eating or sleeping patterns Changes in school performance Worsening symptoms of depression
Overview:Asperger Disorder,High Functioning Autism, and Nonverbal Learning Disabilities: Diagnostic, and Post Secondary Educational Considerations
First Described Kanner 1943 Asperger 1944 Bettleheim1967 Asperger diagnosis in DSM-IV 1994
Kanner (1943) First to describe parents of children with autism as emotionally distant. Also stated that there was a considerable biological component which impacted the development of relationships.
Asperger (1944) Impairment in nonverbal communication. Verbose, one-sided communication style. Lack of friends despite interest in others. All-absorbing, circumscribed interests. Intellectualization of affect. Motoric clumsiness. Normal intelligence.
Bettelheim (1967)Wrote, “The Empty Fortress”Autistic symptoms represented a defensive reaction against cold and detached motherse.g., one patient’s obsession with weather could be understood by dissecting the word into we/eat/her – concerned that her mother and later, others, would devour herPromoted a policy of “parentectomy”After his suicide in 1990, it was discovered that his credential were fraudulent and the “successes” did not have autism in the first place.
DSM-IV Diagnostic and Statistical Manual of Mental DisordersAsperger’s Disorder first appeared in the fourth edition in 1994.
DSM-IV Qualitative Impairment in Social InteractionAt least two of the following:(a) Marked impairment in this use of multiple non verbal behaviors to regulate social interactions (e.g., eye-to-eye gaze, facial expression, body pressure, and gestures).(b) Failure to develop developmentally appropriate peer relationships.(c) A lack of spontaneous seeking to share enjoyment, interests, or achievements (e.g. pointing, joint attention)(d)A lack of social or emotional reciprocity.
COMMENT Qualitative Impairment in Social Interaction Often desire friendship but are isolated because their approaches to gain entry to social situations is ineffective. Often can recite social rules but have a lot of difficulty with generalization and application.
Deficits in Social InteractionOften desire friendship but are isolatedbecause their approaches to gain entry tosocial situations is ineffectiveOften can recite social rules but have a lotof difficulty with generalization andapplication.
COMMENT: Qualitative Impairment in Social InteractionMay reflect the tendency to focus on facts and finding relevance in what most others would find irrelevant. ME: Sorry I kept you waiting – I just spilled coffee all over my leg. JACOB: What kind of coffee? ME: Columbian Decafe. JACOB: Oh.
DSM-IV Deficits in Communication At least one of the following:(a) Delay in, or lack of, development of spoken language (not accompanied by attempts to compensate through alternative modes of communication).(b) In individuals with adequate speech, marked impairments in the ability to initiate or sustain a conversation with others.(c) Stereotyped and repetitive use of language or idiosyncratic language.(d) Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.
COMMENT: Deficits in Communication Good formal language skills but poor pragmatics Tangential & Circumstantial Speech ►Monologues ►Verbosity ►Failure to provide listener with context necessary for understanding Unusual prosody ►Restricted range of intonation patterns ►Volume, modulation, etc. that is not well orchestrated with communicative intent
Too Much Honesty
DSM-IV Restricted Range of Interests, Activities, or Behaviors At least one of the following:(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus(b) apparently inflexible adherence to specific, nonfunctional routines or rituals(c) stereotyped and repetitive motor mannerisms e.g., hand or finger flapping or twisting, or complex whole- body movements(d) persistent preoccupation with parts of objects
COMMENT: Restricted Range of Interests, Activities, or BehaviorsPreoccupation with parts over wholes has broader implications – ASD individuals tend to miss perceiving and communicating context.
Restricted Range of Activities or Behaviors – DSM-IVencompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focusapparently inflexible adherence to specific, nonfunctional routines or ritualsstereotyped and repetitive motor mannerisms, e.g., hand or finger flapping or twisting, or complex whole-body
Circumscribed Interests All-absorbing Unusual topics Amasses facts MUST interfere with learning and social adaptation
Motor Characteristics Often clumsy Poor motor planning Delayed acquisition of self-help skills Problems with climbing, team sports, catching Graph motor deficits Odd gait Proximity problems
Asperger’s has been used to describe: High Functioning Autism (HFA) without cognitive impairment Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) aka Atypical Autism Shyness, social anxiety (shades of normalcy) Distinct disorder In DSM-V all of these will become-Autism Spectrum Disorder (ASD)
Asperger’s v. HFAASPERGER’S HFADelays primarily in More severe language nonverbal communication delays and pragmatic language Atypical attachment patternsMore typical attachment patterns Earlier diagnosisDiagnosis common after Less VIQ/PIQ discrepancy age 7 Reduced social interestDistinct VIQ/PIQ split Failure of basicArea of special interest mechanisms of predominant socializationSocial motivation for relationshipsFailure to understand nonverbal communication
DSM-IV AS/Autism Distinction Significant delays across all areas There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood.
Volkmar (2004) DIFFERENTIAL DIAGNOSISFEATURE AS HFASocial Skills Poor Very PoorMotor Skills Clumsy GoodCircumscribed Usual VariableInterestsFamily History Usual OccasionalAge at >24 mos. <24 mos.Diagnosis
Nonverbal Learning Disabilities
Nonverbal Learning Disability A neuropsychological profile Not a DSM-IV diagnosis Overlaps with deficits associated with AS/HFA
NLD Characteristics DEFICITS STRENGTHSVisual-spatial Language-based organization thinking andNonverbal problem reasoning solving Rote memoryDifficulty relating parts Expressive language to wholes
The NLD Profile Results in:Adapting to novel and complex situationsover reliance on rote behaviors in such situationsRelative deficits in mechanical arithmetic as compared to proficiencies in single word readingPoor pragmaticsUnusual prosody in speechPoor social perception, social judgment, and social interaction skills.
Other Overlapping Concepts… Semantic-Pragmatic Language Disorder (from psycholinguistics) Hyperlexia Pathological Demand Avoidance
Important Things for Service Providers to remember :ASD and NLD individuals have trouble imposing organization on the internal and external environment. This underlies their rigid adherence to rules and their difficulties in simultaneously processing stimuli from multiple sources.Negative behaviors emerge primarily when the student is overwhelmed because the demands exceed their level of competence.
Common Co morbid ConditionsAD/HDObsessive Compulsive DisorderDepressionAnxietyDyspraxiaLearning Disabilities ◦ Written expression ◦ Math disability
Gender Issues Male to female ratio estimated at 4:1 Some evidence that females are less likely to develop autism, and when they do, they are generally less impaired. Tendency to view symptoms in females as psychologically based
Gender Issues-Continued Girls may be better at masking the symptoms. The DSM-IV criteria are based on male presentation of the disorder Tendency to view girls’ problems as psychological or emotional in nature
Family Issues and Diagnosis of ASD Strain on family time, energy, and financial resources Frustrated by the confusion of special education and medical terms and procedures. Finding the “right” educational fit
ASD-Lack of Social Reciprocity Social Co-Regulation Emotional Coordination Social Referencing Intersubjectivity Emotional Regulation
ASD-Stereotypic Movements/ Interests Hypersensitivity Inconsistent physical Responses can and emotional cause distraction modulation Strong preferences Poor episodic for certain types of memory sensory input Poor self regulation Inconsistent Reduced identity attentiveness development
Rigid Thinking Difficulty generalizing Misinterpretation of information Lack of symmetry between verbalizations and actions Preference for static systems Black and white thinking
Education Issues-Questions for Families and Transition Specialists to Consider How much structure does the student need and can the school provide it? Is there someone in the SSD office with a specialty in these conditions? How receptive are staff and faculty to students with this condition? What is the philosophical outlook of the SSD office? Given the students documentation and severity of disability what academic accommodations are available
Education Issues-Questions for Families and Transition Specialist to Consider Is tutoring, academic coaching, psychotherapy available at the school or in the community and what is the cost? Are there support groups? Are there workshops or professionals who teach study or social skills? Is there anyone to assist in academic advising, financial aid? Can a student take a reduced load and still be considered a full time student?