Transcript Co-morbidity amplifies symptoms

How to Formulate
a Diagnosis in
Complicated Youth
MICHAEL J. LABELLARTE, SR., M.D.
Annapolis, Millersville, Towson, and Columbia, MD
[email protected]
cell:443-956-2463
www.cpeclinic.com
Transparency
• No current conflicts of interest
• Assistant Professor, Part Time
• Johns Hopkins Medical Institutions
• University of Maryland SOM
• University of Florida COM
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Interventions
Pharmacology
Psycho-Social
School-Based
Outline
• Traditions- highlight The Perspectives
• The Role of Bias
• Guild/setting approaches
• DSM-5 approach
• NIMH approach
Traditions of
Formulation
• Psychodynamic: Freud (1907)
• Psychobiology: Meyer (1948)
• DSM 1-5 (1952-- )
• Community Psychiatry
• Bio-psycho-social: Engel (1977); Grinker
(1954?)
• The Perspectives: McHugh and Slavney, 1983.
The Perspectives
• “... seeks to systematically apply the
best work of behaviorists,
psychotherapists, social scientists and
other specialists long viewed as at odds
with each other.”
The Perspectives
• Disease perspective
• Dimensional perspective
• Behavioral perspective
• Life Story perspective
The Disease Perspective
• A disease is a mechanistic syndrome
• What a person has
• A disease requires cure or amelioration
The Disease Perspective
• Parkinson’s
• Schizophrenia
• Autism spectrum disorder (ASD)?
• Bipolar Disorder
• Depression
• Obsessive compulsive disorder
• Tourette’s
• ADHD
The Dimensional Perspective
• Intelligence
• Learning Disorders
• Communication issues
• Personality
• ASD?
The Dimensional Perspective
• A dimension has relative value
• Who a person is
• Dimensional extremes require guidance
Temperament Example:
ADHD
• “Difficult”?
• “Defiant”?
• Unstable?
• Extroverted?
• Too open?
• Disagreeable?
• Not concientious?
The Dimension of Intelligence
Hulk
Dr. Bruce Banner
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Intelligence Quotient (IQ)
The Eysenck Circle (1958)
Unstable
Moody
Anxious
Introverted
Rigid
Sober
Pessimistic
Reserved
Unsociable
Quiet
Passive
Careful
Thoughtful
Peaceful
Controlled
Reliable
Even
Calm
Touchy
Restless
Aggressive
Excitable
Changeable
Impulsive
Active
Sociable
Outgoing
Talkative
Responsive
Easygoing
Lively
Carefree
Leadership
Stable
Optimistic
Extroverted
The 5 Factor Model (FFM)
• Stable ---------- Unstable
• Extroverted ---------Introverted
• Open to new ---------- Closed to
new
• Agreeable ---------- Disagreeable
The Behavioral Perspective
• Motivated vs. Maladaptive behaviors
• What a person does
• Stop “bad” behavior
Motivated Behaviors
• Disorders of eating
• Disorders of sleep
• Disorders of sexual expression
• Substance misuse
Maladaptive Behaviors
• Oppositional
• Self-centered
• Contextual
• Often learned
Life Story Perspective
• The narrative of a person’s life
• What a person (or others) understands about a
person’s experiences
• Reframe negative life story concepts
Preferences and Bias
• Disease
• Dimension
• Behavior
• Lif Story
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Contrasting Dx Approaches
• Clinical diagnosis
• Standardized testing
• Setting specific
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Framing Bias:
Everyone is an Expert
Diagnosis Stakeholders
• Children and parents
• Teachers, administrators, school personnel
• Social workers and other therapists
• Psychologists and other evaluators
• Psychiatrists, pediatricians, neurologists
• Academia
• Pharmaceutica
• Insurance companies
• Pundits and politics
Pharmaceutical Controversy:
Stakeholders
• Federal Government
• Academic Community
• Treatment Community
Assessment Errors
• Cliché errors
• Desperation
• Insufficient data
• Lack of comprehension
• Misattribution errors
• Misinformation
• Oversimplification
• Relationship errors
• Reformulation to avoid labels/medications
“Expert” Errors
• Relationship errors
• Primary attribution error
• Misattribution errors
• Cliché errors
• Reformulated symptoms to avoid stimulants
Primary Attribution Error
• Your behavior is suspect, based on your flaws
• My behavior is a rational response to a situation
(including your flaws)
ADHD: Cliché Errors
• “S/He can concentrate when it’s something that
s/he wants to do..”
• “S/He can sit still if s/he wants to…”
• “Too much ____ (e.g. TV, video, computer, cell
phone, facebook, etc.) is all… ”
• “S/He started faking it this year, when school got
hard…”
More Cliché Errors
• “In our day we didn’t have ADHD…”
• “If ADHD exists, it’s not so bad…”
• “I had ADHD and I turned out fine…”
• “ADHD is over-diagnosed…”
• “ADHD is over-treated…”
Still More Cliché Errors
• “The real problem is the drug companies…
• … the doctors…
• … the teachers…
• … the times we live in…
• … those darn kids/parents... short cuts”
ADHD: Misattribution Errors
• Bad seed
• Boys will be boys
• Poor parenting
• Normal response to stress
What is ADHD, Really?
• Attention deficit: cannot ignore competing stimuli
• Hyperactive/Impulsive: equivalent
• Disorder of executive function (EF)
• EF frames the ADHD symptoms
What is Executive Fx, Really?
• “Whatever the frontal lobes do”- Denkla
• “Conscious direction … efficient processing of
info.” -Stuss and Benson
• “Maintenance of behavior on a goal ...
calibration... to context” - Pennington
• “Self regulation across time for the attainment
of one’s goal... - Barkley
•
Self-Regulatory Mini-Modules
(Barkley 2012)
• Inhibition
• Self-directed sensory-motor actions
• Self-directed attention
• Working memory
• Planning and problem solving
• Self-motivation
• Emotional self-regulation
Impairment of Executive
Function
• Activation
• Attention
• Effort
• Emotion/Affect
• Memory
• Action
•
•
Brown TE, 2000, 2008
DSM Evolution
• I (1952) : Atheoretical, standardized definitions
• II (1968): “Legitimacy”, patient education
• III (1980): More ICD, more reliability; Axis I-V
• III-R (1987): Same trends
• IV (1994)/IV-TR (2000): Same trends, behind
quickly
DSM-5
• “Transcend limitations... beyond current ways
of thinking”- but field not ready for a paradigm
shift
• Empirical evidence grounds
• Continuity
• “Living, evolving document”
• Aspirations: etiological, objective, dimensional
DSM-5 Field Trial
Design
• 11 centers,Test-retest reliability or
agreement:
• Cohen’s Kappa: inter-rater reliability
• DSM-5: 0.6-1 “very good”, cutoff-- 0.4-0.6
“good”
• 0.2-0.4 “questionable”-- <0.2 “unacceptable”
• DSM-III: cutoff-- 0.7-1 “good-very good”
DSM-5 Controversy
• NIMH distancing from DSM-5
• Strength in reliability, weakness in validity
• Will no longer fund research projects that
rely exclusively on DSM criteria
• Research Domain Criteria (RDoC): NIMH
Research Domain Criteria
(RDoC):
Assumptions
• Dx approach based on biology and symptoms
(not constrained by DSM-5)
• Biological disorders/brain circuits implicate
specific domains of cognition, emotion, or
behavior
• Each level of analysis... across a dimension of
function
• Mapping cognitive, circuitry, and genetic aspects
will yield new/better targets for treatment
RDoC
• Negative Valence Systems
• Positive Valence Systems
• Cognitive Systems
• Social Processing Systems
• Arousal/Modulatory Systems
Overview of Changes
• Categorical to dimensional; early detect/prevent
• Dimensional measures included, e.g. “crosscutting symptom measure”, “WHODAS”, and
“severity scale for schizophrenia”
• Axis I-V dismantled
• NOS replaced: Other specified disorder,
Unspecified disorder
• New disorders, “renamed” disorders
DSM-5: Axis I-V
Replaced
• Non-axial documentation
• Important psychosocial /contextual factors (V
and Z codes)
• Disability (may be replaced with the
“WHODAS”)
• GAF is eliminated (see above)
DSM-5
Metastructure
Changes
• Regrouping of disorders
• Putative underlying factors
• Underlying vulnerabilities
• Groups juxtaposed by relationship
• Within groups, ordered by age of onset
Pediatric Modifications
• Shortened duration: cyclothymia- 1 year vs. 2
year
• Alternative symptom expression: MDD- irritable
mood...
• Lowered symptom threshold: GAD- 1 from “C” in
children
• Suspended criterion: OCD- behavior not aimed at
alleviating anxiety
• Special criteria: PTSD age <6- only 1 symptom
required- avoidance plus negative cognition/mood
Life Cycle: ADHD
Symptoms
• Preschool: more hyperkinesis
• School age: inattention appears
• Adolescence: inner restlessness
• Adulthood: inattentive complaints, but
impulsivity reigns
Elements of a
DSM-5 Diagnosis
• Dx criteria
• Dx subtypes and specifiers
• Severity qualifiers are gone
• Principal Dx
• Provisional Dx - “strong presumption full
criteria will be met”
Co-morbid vs. Diff. Dx?
• Common disorders co-exist w ADHD
• Common disorders also masquerade as
ADHD
• Co-morbidity amplifies symptoms
SA
BPAD
MDD
Anxiety
Tics
Behavior
LD
ADHD
S/L
ASD
Personality
School Referral, “ADHD”, age 7
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Psychiatric Diagnosis
• Medical model psychiatric history/MSE
• Corroborative data
• Rating Scales
• Neuropsych/Cognitive-Eductaional testing
• Ruling in/ruling out other syndromes
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Rating Scales
Rating scales are screening and measuring
tools
Rating scales are not diagnostic scales
ADHD/behavior: Connors, ADHD IV, Vanderbilt,
BASC, CBCL; Executive Function: (CBS) Barkley,
Brown, (BRIEF) Gioia 2000
Useful Rating Scales
Pediatric Anxiety Rating Scale (PARS), RUPP 2002
Autism Spectrum Screening Questionnaire (ASSQ):
Possreud etal
Children’s Aggression Scale-Parent (CAS-P):
Halperin, 2000
Conduct Disorder Rating Scale (CDRS):
Waschbusch 2007
Useful Rating Scales
II
• Brief Psychotic Rating Scale-C (BPRS-C):
Lacher, 2001
• Children’s Depression Rating Scale (CDRS-R):
Poznanski/Mokros
• Children’s Yale-Brown Obsessive Compulsive
Scale (CYBOCS)
• Young Mania Rating Scale (YMRS): Young et
al., 2000
Useful Rating Scales
III
• Personality Assessment Inventory-Adolescent
(PAI-A): ages 12-18; Morey 2007
• Colorado Children’s Temperament Inventory
(CCTI): ages 2-7; Buss and Plomin, 1984
• Junior Temperament and Character Inventory
(JTCI): ages 7-11; Luby et al., 1999 and Lyoo
et al., 2004
Junior Temperament
and Character Inventory
(JTCI)
•
Novelty seeking (NS): impulsivity,
extravagance, disorderliness
• Harm avoidance (HA): worry, shyness,
fatigueability
• Reward dependence (RD): sentimentality,
social connection, dependance
• Persistance (P): obstacle or frustration
tolerance
Colorado Children’s
Temperament Inventory
(CCTI)
• Emotionality
• Activity Level
• Shyness/Sociability
Formulation
• Chief complaint: “concerns” vs. “positions”
• Clinicians “attribute”
• Discern among DSM-5 nuances
• Symptom presentation varies with age
• Let the Perspectives dictate interventions
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