Transcript symptom - David Lombard, PhD

David Lombard, Ph.D.
Center for Applied Behavioral Studies
www.DavidLombard.com






What Is AD/HD
What Causes AD/HD
How Common
Common Symptoms
Common Treatments
Comparison with Conduct Disorder

First called minimal brain damage

Afterwards called minimal brain dysfunction

Next called ADD

Finally called ADHD
…A medical condition characterized by inattention
and/or hyperactivity-impulsivity.
…One of the most common mental disorders
among children, affecting approximately 5 to 7 %
of school-age children and about 2-5% of adults

Persistent inability to pay attention

May have additional characteristics of
hyperactive motor movements and/or
impulsivity

Usually begin before age 7 but may not be
noticed until child is older

Symptoms of inattention and/or hyperactivity
must be present in at least two environments

Symptoms must cause problems for the
individual in their environment

Decreased amount of certain neurotransmitters

There may be a genetic association
 Appears more often in children whose parents suffer
from AD/HD, alcohol dependence and/or mood
disorders




Delayed in frontal and temporal lobe
Accelerated maturity of the motor cortex
SPECT shows reduce circulation
Pet Scan shows a decrease glucose metabolism
during activity


Preschool- Disruptive behavior, aggression
towards other children, hyperactivity, conduct
problems, inattentive and overactive
Middle Childhood- Unfinished tasks (unfinished
games, uncovered toothpaste), trouble with
school work, criticism from
parents/teachers/peers, low self esteem.
Depression and conduct disorders can develop
here.


Adolescence- higher rates of anxiety, depression,
oppositional behavior, social failure, substance
abuse
Adulthood- trouble at work, relationships,
difficulty following directions, remembering, and
concentrating, emotional and social problems


CDC estimates 4.4 million youth ages 4-17 have
been diagnosed with ADHD
In 2003, 2.5 million youth ages 4-17 are currently
receiving medication treatment for the disorder.
http://www.cdc.gov/ncbddd/ADHD/
http://www.cdc.gov/ncbddd/ADHD/adhdprevalence.htm
http://www.cdc.gov/ncbddd/ADHD/adhdmedicated.htm
 About 2 million children
 About 5 million adults
Australia
New Zealand
Germany
India
China
Netherlands
Puerto Rico
Japan
Mexico
Brazil
3.4% of kids
6.7% kids, 2-3% teens
4.2% children
5-29% children
6-9% children
1.3% teens
9.5% child & teens
7.7% children
approx. 5% children
5.8% of 12-14 year olds

More common in males than females with
studies showing a ratio of between 3:1 and 4:1

As many as 5 out of every 100 children may have
AD/HD

Three main symptoms (signs)
 Problem paying attention (distractibility)
 Being very active (hyperactivity)
 Acting before thinking (impulsivity)
Based on the these criteria, three
types of ADHD are identified:
1. ADHD, Combined Type: if both
criteria A and B are met for the
past 6 months.
Tigger type-Hyperactive,
restlessness, disorganized,
inattention, impulsivity
2. ADHD, Predominantly
Inattentive Type: if criterion
A is met but criterion B is not
met for the past six months
Pooh type- Inattentive,
sluggish, slow-moving,
unmotivated, daydreamer
3. ADHD, Predominantly
Hyperactive-Impulsive
Type: if Criterion B is met
but Criterion A is not met
for the past six months.
Rabbit Type- over focused,
obsessive, argumentative
ADHD, NOS is a category for people who have some
ADHD symptoms, but not enough to meet full
criteria for the condition.

Inattentive type (6 of 9 needed)









Fails to give close attention to details
Difficulty sustaining attention
Does not seem to listen
Does not follow through on instructions
Difficulty organizing tasks or activities
Avoids tasks requiring sustained mental effort
Loses things necessary for tasks
Easily distracted
Forgetful in daily activities

Hyperactive-impulsive type (6 of 9 needed)









Fidgets with hands or feet or squirms in seat
Leaves seat in classroom inappropriately
Runs about or climbs excessively
Has difficulty playing quietly
Is “on the go” or “driven by a motor”
Talks excessively
Blurts out answers before questions are completed
Has difficulty awaiting turn
Interrupts or intrudes on others

Combined type
 Symptoms of both types described

At times all children are inattentive, impulsive
and too active

With children with AD/HD these behaviors are the
rule not the exception







Developmentally Inappropriate Levels
Duration of 6 Months
Cross-setting Occurrence of Symptoms
Impairment in Major Life Activities
Onset of Symptoms/Impairment by 7
Exclusions: Severe MR, PDD, Psychosis
Subtyping into Inattentive, Hyperactive, or Combined
Types





Will power
Inadequate parenting
Lack of motivation
Lack of intelligence
Laziness

Without effective treatment AD/HD can result in
serious problems







Academic failure
Relationships
Legal difficulties
Smoking and SUD
Injuries
Motor vehicle accidents
Occupational/vocational

Education

Medication

Behavior Modification

Classroom/Workplace Accommodations


Primary Provider
Psycho-educational Consultant
 academic, aptitude, and psychometric testing
 IQ measurement
 (usually done through the school)


Social Services
Counseling Services
 Individual and Family
Methylphenidate (MPH) Products
Ritalin
Concerta
Metadate CD
Ritalin LA
Focalin
short & mid-acting forms
long-acting
mid-acting
mid-acting
mid-acting
Short acting = 3-5 hours; Mid-acting = 6-8 hours;
Long acting = 12 hours+
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/medications.shtml
Amphetamine Products
Adderall
Adderall XR
Dexedrine
Dextrostat
mid-acting
long-acting
mid-acting
mid-acting
Short acting = 3-5 hours; Mid-acting = 6-8 hours;
Long acting = 12 hours+

Nonstimulant Products
Strattera
long-acting

Other Nonstimulant Products
Wellbutrin
long-acting
Tenex
mid-acting
Clonidine
mid-acting
Short acting = 3-5 hours; Mid-acting = 6-8 hours;
Long acting = 12 hours+

Secondary choice

Long-acting
Short acting = 3-5 hours; Mid-acting = 6-8 hours;
Long acting = 12 hours+






Headache
Involuntary muscle movements
Loss of appetite
Mood changes as medication wears off
Sleep difficulty
Weight management problems


The term conduct disorder has traditionally been
used to characterize children who display a broad
range of behaviors that bring them into conflict with
their environment.
These include behaviors that are probably best
described as coercive or oppositional;
 temper tantrums,
 defiance,
 noncompliance


Also included under this general heading have
been behaviors of a more serious nature (e.g.,
cruelty to people or animals, aggressiveness,
stealing) .
These are more serious in that they
 represent a greater threat to those the child interacts
with and/or
 have the potential of bringing the child into contact
with the juvenile justice system

DSM V features usually associated with the general
label of conduct disorder are subdivided in order to
provide for the diagnosis of two specific patterns of
behavior;
 Oppositional Defiant Disorder (ODD)
 Conduct Disorder (CD)

Symptoms
 Bullies, threatens or intimidates others
 Often initiates physical fights
 Has used a weapon that could cause serious physical
harm to others (e.g. a bat, brick, broken bottle, knife
or gun)

Symptoms
 Is physically cruel to people or animals
 Steals from a victim while confronting them
(e.g. assault)
 Forces someone into sexual activity

Symptoms
 Deliberately engaged in fire setting with the intention
to cause damage
 Deliberately destroys other's property

Symptoms
 Broken into someone else's building, house, or car
 Lies to obtain goods, or favors or to avoid obligations
 Steals items without confronting a victim (e.g.
shoplifting, but without breaking and entering)

Symptoms
 Often stays out at night despite parental objections
 Runs away from home
 Often truant from school

For at least 6 months, shows defiant, hostile,
negativistic behavior; (4 or more of the following):
-Losing temper
-Arguing with adults
-Actively defying or refusing to carry out the rules or
requests of adults
-Deliberately doing things that annoy others
-Blaming others for own mistakes or misbehavior
-Being touchy or easily annoyed by others
-Being angry and resentful
-Being spiteful or vindictive
•
•
•
•
•
•
OVERT/DESTRUCTIVE
(Aggressive Behaviors)
Fights
Bullies
Assault
Spiteful
OVERT/NONDESTRUCTIVE
(Oppositional Features)
Annoys
Defies
Stubborn
Angry
•
•
•
•
•
•
•
COVERT/DESTRUCTIVE
(Property Violations)
Cruel to Animals
Vandalism
Steals
Fire setting
COVERT/NONDESTRUCTIVE
(Status Offenses)
Runaway
Truancy
Substance Use
Breaks Rules

In general, the literature suggests that:
 children who develop conduct disordered behavior later in
childhood have a somewhat better prognosis
 the severity and variety of early antisocial behavior is a
powerful predictor of serious antisocial behavior in
adulthood
 the prognosis may be worse for those who also have
comorbid disorders.
David Lombard, Ph.D.
Center for Applied Behavioral Studies
www.DavidLombard.com






What is Self-Injury, Cutting, Self-Mutilation
Theories of Why People S.I.
Is it Suicide, a Cry for Help, or Coping
How is it Treated
What to Ask to Assess Risk
What are Your Options for Intervention
Angelina Jolie
 Christina Ricci
 Courtney Love
 Princess Diana

There is a recent rise in SIB in
today’s society. Media
exposure through musicians
such Marilyn Manson, movies
such as Girl Interrupted, and
admissions of SIB from
celebrities such as Johnny
Depp and Angelina Jolie has
increased social acceptance
and awareness. In addition,
the phenomenon of “Cutter
Clubs” has further supported
the concept of social
remodeling.



Body Modification -piercings
and tattoos may be rituals or
practices.
Rituals reflect community
tradition, underlying
symbolism, healing,
expressions of spirituality,
social order marking
Practices may be fads, for
ornamentation, and
identification for a cultural
group
Culturally sanctioned forms of SIB can be seen as
rituals for country festivals, as government protests,
and religious customs.

Definition – Self directed acts which result in
tissue damage.


No suicidal intention in SIB
Many methods to self-injure:
-Cutting
-Skin picking
-Biting
-Toxic Ingestion
-Burning
-Hair pulling
-Head banging
-Auto castration
-Scratching
-Branding
-Hitting
S.I.B.
Culturally
Sanctioned
Ritual
Pathological
Practices
Suicidality
Self-Mutilation
Major
Stereotypic
Superficial/Moderate
Impulsive
(Impulse Control
D/O)
Compulsive
(OCD spectrum)
Episodic
Favazza, A. R. (1996). Bodies Under Siege: Self-Mutilation and Body
Modification in Culture and Psychiatry, 2nd ed. Baltimore: The Johns
Hopkins University Press.
Repetitive



Failure to resist impulse, drive, or temptation to
perform act that is harmful to self/others.
Relief of mounting tension or arousal with act
Includes







Intermittent Explosive Disorder
Kleptomania
Pyromania
Pathological Gambling
Trichotillomania
Impulse Control Disorder NOS
Repetitive Self-Mutilation?

Compulsive self-harm part of
OCD ritual involving obsessional
thoughts; person tries to relieve
tension and prevent bad things
from happening by engaging in
self-harm behaviors


Episodic self harm behavior is
engaged infrequently by people
who otherwise don’t think about
it and don’t perceive themselves
as “self-injurers”. Usually a
symptom of some other disorder.
Repetitive self-harm is a switch to
ruminating about self harm even
when doing the act, identify as
“self-mutilators”. Considered a
“disease” itself. Reflex response
to any sort of stress, positive or
negative.

Definition – Self directed acts which result in
tissue damage.


No suicidal intention in SIB
Many methods to self-injure:
-Cutting
-Skin picking
-Biting
-Toxic Ingestion
-Burning
-Hair pulling
-Head banging
-Auto castration
-Scratching
-Branding
-Hitting



12% to 14% of adolescents reported self-injury
behavior
 40% to 61% in adolescent inpatient settings
 Higher proportion of females (64%) than males
(36%)
750 per 100,000- general population
Typical onset-puberty
 Persist for five to ten years or longer


The few studies which have been done on
community samples of young adults and
adolescents vary in prevalence rates of SIB
between 4% to 38%
Conterio and Favazza estimate that 750 per
100,000 population exhibit self-injurious
behavior
Favazza, A. R. & Conterio, K. (1988). The plight of chronic self-mutilators. Community Mental Health Journal,
24, 22-30



In M.R. and Autistic populations, SIB is negatively
correlated with I.Q.
SIB seen in as many as 15-20% of people with
MR, and much higher in profound MR
Estimate of up to 2/3 of people with MR who
reside in public residential facilities show SIB
(Baumeister and Forehand, 1973)



The DSM-V only mentions self-injury as a
symptom or criterion for diagnosis in borderline
personality disorder, stereotypic movement
disorder (autism, MR), and factitious disorder.
Extreme forms can be present in psychotic and
delusional disorders.
Impulse Control Disorders

Estimated that 67% of self-injurers are female (Miller
1994).


Many other studies link increased rates of suicide
attempts and SIB in female whereas males show
greater suicide mortality rates.
Males select more dangerous methods of self harm
and are therefore more likely to receive medical
attention. Same number of males and females
present to the hospital (Cantor 2000).

Genital self-mutilation reported in higher
numbers in males than females. Reason may be
because castration is more dramatic than
cutting, so it’s reported more frequently.
Alao, O Adekola: Female Genital Mutilation. Psychiatric Services 50:971 1999

Sexual Orientation – A longitudinal study of a
cohort of 1037 individuals in New Zealand
showed a strong, statistically significant link
between same sex attraction and SIB. Men,
more so than women, showed higher risks for
self-harm with greater degree of same-sex
attraction.
Skegg, Karen: Sexual Orientation and Self Harm in Men and Women. Am J Psychiatry 160:541546, March 2003



Websites-“Blood Red”
-“Razor Blade Kisses”
-“The Cutting World”
Films- “Thirteen”
Genre of music- “emo”

Purposeful use of Sharp Objects for Goal of
Cutting Skin and Seeing Blood

Cutting Tools:
 Knives, Razors, Needles, Cut Glass, Fingernail, Surgical
Blades, Paper

Most Commonly – Arms, Shoulders & Thighs

More Advanced – Hips Below Belt Line (hidden
and felt more when walking), Top of Feet,
Underarms, Lower Buttock

More Dangerous – Inside of Mouth, Private
Areas, Pre-Existing Surgical Scars

Often Seen the Same as Cutting

Much Worse in Severity/Scope of Damage

Destruction of Large Sections of Tissue Through
Cutting, Tearing, Biting, or Repetitive Puncturing

Always Hospitalize
'to run away from my feelings'
'to feel pain on the outside instead of the inside'
'to cope with my feelings'
'to express my anger toward myself'
'to feel like I'm real'
'to turn off emotions and hide from reality'
'to tell people that I need help'
'to get people's attention'
'to tell people I need to be in hospital'
'to get people to care about me'
'to make other people feel guilty'
'to drive people away'
'to get away from stress and responsibility'
'to manipulate situations or people'

To Feel
 Due to Abuse, Neglect, or Other Significant Life
Trauma the Person Cannot Feel
 In Sad Situations, They Want to Feel Something…So
Cut.
 Allows Them to Feel Physical Pain When They Have No
Emotional Pain

Distraction
 Due to Overwhelming Emotional Pain or Problems
Dealing with Emotional Pain
 Allows the Shift in Focus From Emotional Pain to
Physical Pain
 Easier to Understand and Deal With

Punishment
 Person Has Failed at Something, Hurt Someone, Or
Displeased Themselves
 A Way to Punish…Clearly Defined…Clearly Punitive
 In These Cases, Severity of Cutting Increases to
Mutilation Frequently

Physical Reaction
 Person Discovers Cutting and Tries It
 They Feel the Emotional and Physical Rush
 Natural Pain Killers and Pleasure

Physical Reaction
 Want the Same Feeling Again
 These Individuals are Likely to Engage in Cutting Out
of Boredom

Control
 A strong Sense Of Helplessness
 Learned Helplessness
 Cutting Self is Completely in Their Control

Control
 More Frequent in Homes of Lives with Rigid Rules
 These People Less Likely to Use Drugs
“I would say it is just like a drug. It becomes
something that you feel you can’t live
without. When it works once to ‘fix’ a
problem, you will try it again and see that it
will work again. Eventually your small cuts
aren’t enough and you cut more and more.
You gain more ‘tolerance.’”
--Lia

Addiction to Cutting
 Emotional Release is Very Reinforcing
 Physical Release has Bio-Chemical Properties
 Under Control of Cutter

Addiction to Cutting
 Easy Access, Low Cost, Immediate Reaction
 These Individuals Tend to Be More Impulsive
 At Higher Risk for Substance Abuse

Suicides Attempts Include Intent to Die
 Most Cutters Do Not

Cry For Help
 Possibly if Cuts Are Visible
 However, Some Wear Cuts as A Badge

Coping Strategy
 Most Likely Reason
 Cutting Makes Sense to Them to Deal with Life
SI
Disassociation
Into the Void
Panic
Relief
Shame, guilt,
remorse, disgust
Mounting anxiety, anger
or self hatred, alienation
Muller 2005

Proper Diagnosis
 Depression, Anxiety, Abuse, Addiction, Personality
Disorder, Thought Disorder

Focus on Cutting as A Behavior

Medication to Treat Any Underlying Disorders

Pharmacological
SSRI’s – High doses appear to be effective in
many cases. Fluoxetine was studied in two
double blind placebo studies and shown to have
benefit in reducing SIB. First choice in OCD
spectrum disorders.
Coccaro, E. F., Kavoussi, R. J., & Hauger, R. L. (1997b). Serotonin function
and antiaggressive response to fluoxetine: a pilot study. Biological
Psychiatry, 42(7), 546-552

Pharmacological
Naltrexone (opiate antagonist) found to be effective in
about half the patients with stereotypic type of self
injury.
May have therapeutic window in dosing.
No one has yet done a placebo-controlled doubleblind crossover study that controls for type of behavior
as well as psychiatric diagnosis.
Buzan, R. D., Thomas, M., Dubovsky, S. L., & Treadway, J. (1995). The use of opiate antagonists for recurrent
self-injurious behavior. Journal of Neuropsychiatry and Clinical Neurosciences, 7(4), 437-444

Pharmacological
Anti-psychotics – Clozapine, Risperidone, Olanzapine,
Fluphenazine

Other medications studied







Lithium
Carbamazepine
Beta Blockers
Baclofen
Stimulants
Clonidine
Amantadine
Non-Pharmacological

ECT - has shown benefit in a few case reports for major or severe self-injury

Cognitive Behavioral Therapy – combat the cognitive distortions
and beliefs that SI is an acceptable form of managing feelings

Behavior Modification – eliminate some behaviors and develop
others, operant conditioning
Jones, A.B. (2001). Self-injurious behavior in children and adolescents, Part II: Now what? The
treatment of SIB, KidsPeace Healing Magazine

Non-pharmacological
Addiction Model – Used in more chronic cases to develop a
sense of regaining control over one’s life in realistic way. Emphasizes
techniques to build up time between having urges and acting upon urges.
Psychodynamic Therapy – help identify attachments
 Aims of Therapy - tolerate greater intensities w/o resorting to

self harm, develop ability to articulate emotions and needs, learn coping
skills, problem solving, anger management, conflict resolution, and
assertiveness training

Basic Questions…Keep it Easy

Can Easily Become Defensive

Fear of Being Labeled Mentally Sick

Can Easily Become Aggressive

Where
 Where have they cut on themselves
 Where are they when they cut

What
 What do they use
 What do they do afterwards

When
 When alone or with others (usually alone)
 When angry, sad, upset

Why
 Harder question…may not answer

Who
 Who knows they are cutting
 Can I talk to that person

Based on Estimated Level of Severity
 Nothing
 Rarely…only if person already getting help
 Speak to Significant Others
 To encourage family intervention and help
 Referral for Mental Health Services
 For evaluation and treatment planning
 Parkcenter, Parkview, Private Insurance
 Hospitalize
 If physical damage severe or mental Health Symptoms
are severe