Mental Health Conditions-Part-IMental Health Conditions-Part-I

Presentation made to Baker CollegePresentation made to Baker College January 29, 2013January 29, 2013 9:30-12:009:30-12:00 Stuart S Segal, Ph.D.Stuart S Segal, Ph.D. Director of the Office of Services for Students Director of the Office of Services for Students

with Disabilitieswith Disabilities University of MichiganUniversity of Michigan (734)- 764-7485(734)- 764-7485 sssegal@umich.edusssegal@umich.edu

Anxiety Disorders Among College Anxiety Disorders Among College StudentsStudents

Anxiety disorders are extremely common Anxiety disorders are extremely common on college campuseson college campuses

40 million Americans suffer from anxiety 40 million Americans suffer from anxiety disorders and 75% experience first disorders and 75% experience first episode of anxiety before age 22episode of anxiety before age 22

Evidence based treatments are available Evidence based treatments are available and effective and effective

Treatment frequently includes Cognitive Treatment frequently includes Cognitive Behavioral Therapy and medicationBehavioral Therapy and medication

Anxiety Disorders Among College Anxiety Disorders Among College StudentsStudents

GADGAD Achievement worries, critical thinking, unrealistic Achievement worries, critical thinking, unrealistic

expectationsexpectations

Social Anxiety DisorderSocial Anxiety Disorder Avoidance of group social events/ parties, difficulty Avoidance of group social events/ parties, difficulty

public speaking, test anxietypublic speaking, test anxiety

Panic DisorderPanic Disorder Fear of being stuck in class or with roommate and Fear of being stuck in class or with roommate and

having panichaving panic

OCD – presentations are not specific to settingOCD – presentations are not specific to setting TrichotillomaniaTrichotillomania

Studies show may occur in 1-3% of college populationsStudies show may occur in 1-3% of college populations

Types of Anxiety Disorders Types of Anxiety Disorders continued continued

PhobiasPhobias Acute Traumatic Stress DisorderAcute Traumatic Stress Disorder Post Traumatic Stress DisorderPost Traumatic Stress Disorder Adjustment Reaction with mixed Anxiety Adjustment Reaction with mixed Anxiety

and Depressionand Depression

Cognitive Behavioral Therapy for Cognitive Behavioral Therapy for Anxiety DisordersAnxiety Disorders

Short-term, evidence based treatment Short-term, evidence based treatment Based on the idea that thoughts and behaviors Based on the idea that thoughts and behaviors

affect the way we feelaffect the way we feel Often includes Exposure therapyOften includes Exposure therapy Studies show CBT and medication are more Studies show CBT and medication are more

effective together than either are separately effective together than either are separately

General Goals in CBT treatment General Goals in CBT treatment of Anxiety Disordersof Anxiety Disorders

Understand the function of anxiety, triggers of Understand the function of anxiety, triggers of anxiety and safety behaviors (anxiety fuel)anxiety and safety behaviors (anxiety fuel)

Focus on seeing anxiety as uncomfortable Focus on seeing anxiety as uncomfortable rather than dangerousrather than dangerous

Not just thinking positive – what is the Not just thinking positive – what is the evidence for a fear? Realistic or not?evidence for a fear? Realistic or not?

Gather evidence through experienceGather evidence through experience Learning to accept a lack of control / safety for Learning to accept a lack of control / safety for

a better quality of lifea better quality of life

What’s “Normal” Anxiety? When What’s “Normal” Anxiety? When does it become a “real” problem?does it become a “real” problem?

Anxiety is a normal and necessary responseAnxiety is a normal and necessary response Key issues for when you need help for Key issues for when you need help for

anxiety:anxiety: Is anxiety interfering with your life? Are you Is anxiety interfering with your life? Are you

avoiding things or having to endure with dread?avoiding things or having to endure with dread? Is anxiety happening too often? (you judge)Is anxiety happening too often? (you judge) Is your anxiety more severe than the actual Is your anxiety more severe than the actual

danger/risk present?danger/risk present?

Social Anxiety DisorderSocial Anxiety Disorder Fear/avoidance of social situationsFear/avoidance of social situations

Feared situations avoided or endured Feared situations avoided or endured with intense anxiety or distresswith intense anxiety or distress

Fear recognized as excessive or Fear recognized as excessive or unreasonableunreasonable

Fear/avoidance interferes with work, Fear/avoidance interferes with work, social, school, family activitiessocial, school, family activities

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.American Psychiatric Association, 1994.

Social Anxiety DisorderSocial Anxiety Disorder

Participating in small groupsParticipating in small groups

Eating, drinking, writing in publicEating, drinking, writing in public

Talking to authority figuresTalking to authority figures

Performing or giving a talkPerforming or giving a talk

Attending social eventsAttending social events

Meeting strangers or datingMeeting strangers or dating

Using public bathroomUsing public bathroom

Being center of attention/ being observed by othersBeing center of attention/ being observed by others

Common FearsCommon Fears

Social Anxiety DisorderSocial Anxiety Disorder

Test AnxietyTest Anxiety Often caused by fears of judgment by others, Often caused by fears of judgment by others,

fear of failure and other negative beliefsfear of failure and other negative beliefs Classified and treated as a social anxiety issue Classified and treated as a social anxiety issue CBT focus is on restructuring negative thoughts CBT focus is on restructuring negative thoughts

around test performance and using practice to around test performance and using practice to desensitize anxiety responsedesensitize anxiety response

Treatment may include improvement of study Treatment may include improvement of study skills in addition to cognitive behavioral therapy skills in addition to cognitive behavioral therapy treatmenttreatment

CBT for Social AnxietyCBT for Social Anxiety Exposure :Exposure :

Gradual confrontation of progressively more challenging Gradual confrontation of progressively more challenging social encounterssocial encounters

Prolonged sessions (60-90 minutes)Prolonged sessions (60-90 minutes) Frequent sessions (daily is best)Frequent sessions (daily is best) End session only when anxiety improvesEnd session only when anxiety improves

Common cognitive distortionsCommon cognitive distortions Magnification - “It would be horrible if I didn’t know what to say”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 All or Nothing Thinking - “Why did I say that… I made a complete fool

of myself”of myself” Mind Reading - “He looked away, he must think I am weird”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 Fortune Telling - “Why bother to talk to her, she will just reject me like

all the others” all the others”

Social Skills TrainingSocial Skills Training

Diagnostic Criteria ForDiagnostic Criteria ForObsessive-Compulsive DisorderObsessive-Compulsive Disorder

Obsessions:Obsessions:(1)(1) recurrent or persistent thoughts, impulses, or images are experienced recurrent or persistent thoughts, impulses, or images are experienced

as intrusive or inappropriate and cause distressas intrusive or inappropriate and cause distress(2)(2) not simply excessive worries about real-life problemsnot simply excessive worries about real-life problems(3)(3) person attempts to ignore or suppress thoughts or neutralize them with person attempts to ignore or suppress thoughts or neutralize them with

another thought or actionanother thought or action(4)(4) person recognizes that obsessions are product of his/her mind, not person recognizes that obsessions are product of his/her mind, not

imposed from withoutimposed from without

Compulsions:Compulsions:(1)(1) repetitive behaviors or mental acts performed in response to an repetitive behaviors or mental acts performed in response to an

obsession or according to certain rulesobsession or according to certain rules(2)(2) designed to neutralize or prevent discomfort or some dreaded event or designed to neutralize or prevent discomfort or some dreaded event or

situationsituation

The obsessions and compulsions cause marked distress, are The obsessions and compulsions cause marked distress, are time-consuming, or significantly interfere with normal routine, time-consuming, or significantly interfere with normal routine, usual social activities or relationships with othersusual social activities or relationships with others

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.

Orderers/ArrangersOrderers/Arrangers

Sinners/DoubtersSinners/DoubtersHoardersHoarders

Washers/CleanersWashers/Cleaners Harmers/CheckersHarmers/Checkers

CommonCommonOCDOCD

SymptomSymptomClustersClusters

OCD Symptom Clusters

Obsessive-Compulsive Obsessive-Compulsive Personality DisorderPersonality Disorder

A pervasive pattern of preoccupation with orderliness, A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as early adulthood and present in a variety of contexts, as indicated by 4 or more of the following:indicated by 4 or more of the following:

Is preoccupied with details, rules, lists, order, organization, or Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is schedules to the extent that the major point of the activity is lostlost

Shows perfectionism that interferes with task completion Shows perfectionism that interferes with task completion Is excessively devoted to work and productivity to the Is excessively devoted to work and productivity to the

exclusion of leisure activities and friendshipsexclusion of leisure activities and friendships

Obsessive-Compulsive Personality Obsessive-Compulsive Personality Disorder (cont.)Disorder (cont.)

Is over conscientious , scrupulous, and inflexible about Is over conscientious , scrupulous, and inflexible about matters of morality, ethics, or valuesmatters of morality, ethics, or values

Is unable to discard worn-out or worthless objects even Is unable to discard worn-out or worthless objects even when they have no sentimental valuewhen they have no sentimental value

Is reluctant to delegate tasks or to work with others Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing unless they submit to exactly his or her way of doing thingsthings

Adopts a miserly spending style toward both self and Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for others; money is viewed as something to be hoarded for future catastrophesfuture catastrophes

Shows rigidity and stubbornnessShows rigidity and stubbornness

OCD vs. OCPDOCD vs. OCPD

OCD involves OCD involves ego-dystonic ego-dystonic thoughts and thoughts and urges to neutralizeurges to neutralize The person realizes the symptoms are The person realizes the symptoms are

senselesssenseless Symptoms are distressing and anxiety-Symptoms are distressing and anxiety-

evokingevoking OCPD involves OCPD involves ego-syntonic ego-syntonic behaviorbehavior

Symptoms are consistent with person’s world Symptoms are consistent with person’s world viewview

Often associated with rigidity, inflexibility, and Often associated with rigidity, inflexibility, and angeranger

Behavioral Treatment of Obsessive Behavioral Treatment of Obsessive Compulsive DisorderCompulsive Disorder

Exposure and Response Prevention Exposure and Response Prevention Therapy - 70 % EffectiveTherapy - 70 % Effective

Requires Substantial EffortRequires Substantial Effort Durable TreatmentDurable Treatment Effective For Both Obsessions and Effective For Both Obsessions and

CompulsionsCompulsions

Exposure and Response Exposure and Response Prevention for OCDPrevention for OCD

Exposure TherapyExposure TherapyGraded HierarchyGraded HierarchyContinuous Exposure is BestContinuous Exposure is BestWatch for patients Attempts at Avoidance of Watch for patients Attempts at Avoidance of

ExercisesExercises Response PreventionResponse Prevention

Rapid over very gradualRapid over very gradual Make rituals inconvenient to doMake rituals inconvenient to do Enlist family as a response prevention teamEnlist family as a response prevention team Do not compromise on time… make the exposure Do not compromise on time… make the exposure

exercise less difficultexercise less difficult

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994.

Diagnostic Criteria for GADDiagnostic Criteria for GADExcessive anxiety and worry, for more days than Excessive anxiety and worry, for more days than

not for not for 6 months, about many subjects6 months, about many subjectsWorry is difficult to controlWorry is difficult to controlAnxiety, worry, physical symptoms impair social, Anxiety, worry, physical symptoms impair social,

occupational, and other functioningoccupational, and other functioningAssociated with Associated with 3 of the following3 of the following

restlessness/keyed-uprestlessness/keyed-up easily fatiguedeasily fatigued difficulty concentratingdifficulty concentrating irritabilityirritability muscle tensionmuscle tension sleep disturbancessleep disturbances

Generalized Anxiety Disorder Generalized Anxiety Disorder Worries, negative thoughts, or predictions Worries, negative thoughts, or predictions

that are future oriented that are future oriented Many worries around many topics with Many worries around many topics with

significant difficulty managing anxiety significant difficulty managing anxiety triggered by worrytriggered by worry

What if I don’t pass this class? I’ll never What if I don’t pass this class? I’ll never catch up. I’m not working hard enough. I catch up. I’m not working hard enough. I should have known that answer. Failing should have known that answer. Failing would be terrible. would be terrible.

Roy-Byrne et al. J Clin Psychiatry. 1997;58(suppl 3):34.

• Depressed MoodDepressed Mood• InterestInterest• AppetiteAppetite• EsteemEsteem• SuicidalitySuicidality

• Depressed MoodDepressed Mood• InterestInterest• AppetiteAppetite• EsteemEsteem• SuicidalitySuicidality

DepressionDepression DepressionDepression• Agitation• Dysphoria• Sleep• Fatigue• Concentration• Restlessness• Irritability

• Agitation• Dysphoria• Sleep• Fatigue• Concentration• Restlessness• Irritability

• Worry• Anxiety• Tension

• Worry• Anxiety• Tension

GADGAD

Symptom Overlap in GAD Symptom Overlap in GAD and Depressionand Depression

CBT for GADCBT for GAD

Focus is on 3 areas:Focus is on 3 areas: Lifestyle change: creating balance of work & Lifestyle change: creating balance of work &

leisure, exercise, sleep hygiene, etc.leisure, exercise, sleep hygiene, etc. Relaxation Training : to address physical Relaxation Training : to address physical

symptoms of anxiety such as muscle tensionsymptoms of anxiety such as muscle tension Cognitive Restructuring: Try to identify Cognitive Restructuring: Try to identify

cognitive distortions in negative thinking, cognitive distortions in negative thinking, understand a situation in a realistic way, and understand a situation in a realistic way, and develop a more balanced life perspectivedevelop a more balanced life perspective

Diagnostic Criteria For Panic AttackDiagnostic Criteria For Panic Attack

• Palpitations, pounding heartPalpitations, pounding heart

• SweatingSweating

• Trembling or shakingTrembling or shaking

• Shortness of breath or Shortness of breath or smotheringsmothering

• Choking feelingChoking feeling

• Chest pain or discomfortChest pain or discomfort

• Abdominal distressAbdominal distress

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.

• DizzinessDizziness

• Chills or hot flushesChills or hot flushes

• Feelings of unrealityFeelings of unreality

• Fear of losing control or Fear of losing control or going crazygoing crazy

• Fear of dyingFear of dying

• Paresthesias (tingling / Paresthesias (tingling / numbness)numbness)

A discreet period of intense fear or discomfort, in which four or A discreet period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached more of the following symptoms developed abruptly and reached a peak within 10 minutes:a peak within 10 minutes:

Panic DisorderPanic DisorderRecurrent, unexpected panic attacks followed by more Recurrent, unexpected panic attacks followed by more

than 1 month of persistent concern about another than 1 month of persistent concern about another panic attack, worry about possible implications or panic attack, worry about possible implications or consequences of panic attacks, or significant consequences of panic attacks, or significant behavioral change related to attacksbehavioral change related to attacks

May Occur with or without AgoraphobiaMay 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 difficult

Many times is exacerbated or onset during substance Many times is exacerbated or onset during substance use (alcohol, marijuana, hallucinogens)use (alcohol, marijuana, hallucinogens)

CBT for Panic CBT for Panic Exposure to external panic cuesExposure to external panic cues

Places where previously experienced panic or other avoidance cuesPlaces where previously experienced panic or other avoidance cues Exposure to internal panic cuesExposure to internal panic cues

Panic patients avoid activities that create feelings similar to panicPanic patients avoid activities that create feelings similar to panic Create exercise to produce panic sensationsCreate exercise to produce panic sensations

Cognitive Therapy for panic fearsCognitive Therapy for panic fears Collect information to dispute distorted thoughts in panic by using:Collect information to dispute distorted thoughts in panic by using: -BEHAVIORAL TESTS: Experience panic attacks without intervention to -BEHAVIORAL TESTS: Experience panic attacks without intervention to

see if catastrophe takes placesee if catastrophe takes place-AWFUL TESTS : Pretend to experience catastrophe and test whether it is -AWFUL TESTS : Pretend to experience catastrophe and test whether it is

really so awful, terriblereally so awful, terrible-Patient’s previous experiences with panic-Patient’s previous experiences with panic-Information about symptoms-Information about symptoms

Impulse Control DisordersImpulse Control Disorders

Trichotillomania – compulsive pulling of Trichotillomania – compulsive pulling of hair hair Pulling often occurs from scalp, eyelashes Pulling often occurs from scalp, eyelashes

and/or eyebrowsand/or eyebrows Compulsive Skin PickingCompulsive Skin Picking While both are common problems, access While both are common problems, access

to evidence based treatment is limitedto evidence based treatment is limited Both are treated with habit reversal Both are treated with habit reversal

therapy and medicationtherapy and medication

CBT for Impulse Control DisordersCBT for Impulse Control Disorders

Focus is on using Habit Reversal Therapy Focus is on using Habit Reversal Therapy to reduce the intensity of the urgesto reduce the intensity of the urges

Learn coping skills to use during high risk Learn coping skills to use during high risk situations – very behavioralsituations – very behavioral

Gain an understanding of this as a Gain an understanding of this as a neurobiological problemneurobiological problem

Engage in cognitive restructuring around Engage in cognitive restructuring around negative self-talk related to pulling negative self-talk related to pulling behaviorsbehaviors

Greenberg et al. J Clin Psychiatry. 1999;60:427.

Direct Nonpsychiatric

Medical Treatment Costs (54%)

Pharmaceutical Costs(2%)

Total Workplace

Costs(10%)

Mortality Costs(3%)

Total Direct Psychiatric Treatment

Costs (31%)

Economic Burden of Anxiety DisordersEconomic Burden of Anxiety DisordersTotal Costs = $42.3 Billion Per YearTotal Costs = $42.3 Billion Per Year

Post-Tramatic Stress Disorder-Post-Tramatic Stress Disorder-PTSDPTSD

An Anxiety Disorder.An Anxiety Disorder.3-6% of adults in the United 3-6% of adults in the United States.States.Twice as common in women as Twice as common in women as in men.in men.Rates as high as 58% in heavy Rates as high as 58% in heavy combatcombat1-14% non combat1-14% non combatTorture/POW 50-75%Torture/POW 50-75%Natural Disaster victims 4-16%Natural Disaster victims 4-16%

DSM-IV diagnostic criteria for DSM-IV diagnostic criteria for PTSDPTSD

Exposure to a traumatic event in which the personExperienced, witnessed, or was confronted by death or serious injury to self or others

AND Responded with intense fear, helplessness, or horrorFeatures Appear in 3 clusters: re-experiencing, avoidance/numbing, hyperarousalLast for > 1 monthCause clinically significant distress or impairment in functioning

DSM-IV Diagnostic Criteria of PTSD- Re-DSM-IV Diagnostic Criteria of PTSD- Re-experiencingexperiencing

Persistent Re-experiencing of > 1 of the Persistent Re-experiencing of > 1 of the following:following:

Recurrent Distressing Recollection of the Recurrent Distressing Recollection of the EventEvent

Recurrent Distressing Dreams of the EventRecurrent Distressing Dreams of the Event Acting or Feeling that Event was reocurringActing or Feeling that Event was reocurring Psychological Distress of Cues Resembling Psychological Distress of Cues Resembling

EventEvent Physiological Reactivity to Cues Resembling Physiological Reactivity to Cues Resembling

EventEvent

DSM-IV Diagnostic Criteria for PTSD- DSM-IV Diagnostic Criteria for PTSD- Avoidance and NumbingAvoidance and Numbing

Avoidance of Stimuli & Numbing of General Avoidance of Stimuli & Numbing of General Responsiveness indicated by >3 of the Responsiveness indicated by >3 of the following:following:

Avoid Thoughts, Feelings or Conversations Avoid Thoughts, Feelings or Conversations related to traumarelated to trauma

Avoid Activities, Places or People Related to Avoid Activities, Places or People Related to TraumaTrauma

Inability to Recall Parts of the TraumaInability to Recall Parts of the Trauma Decreased Interests in ActivitiesDecreased Interests in Activities Estrangement from OthersEstrangement from Others Restricted Range of AffectRestricted Range of Affect Sense of Foreshortened FutureSense of Foreshortened Future

Summary of Symptoms of PTSDSummary of Symptoms of PTSD

Spontaneous re-experiencing of Spontaneous re-experiencing of the traumathe traumaStartle responsesStartle responsesIrritabilityIrritabilityDepression and GuiltDepression and GuiltPhobias Phobias Multiple physical complaintsMultiple physical complaintsNumbingNumbingImpaired concentration and Impaired concentration and memorymemoryDisturbed sleep and distressing Disturbed sleep and distressing dreamsdreams

Depression is complex!Depression is complex!• GeneticsGenetics

▫ Often runs in familiesOften runs in families• Medical ConditionMedical Condition

▫ Injury (stroke, brain injuries)Injury (stroke, brain injuries)▫ Illness (heart attacks, diabetes)Illness (heart attacks, diabetes)

• Neurotransmitters (brain chemicals)Neurotransmitters (brain chemicals)▫ Abnormal levels or not functioning as they shouldAbnormal levels or not functioning as they should▫ Drug abuseDrug abuse

• Stress and environmentStress and environment▫ AbuseAbuse▫ TraumaTrauma

Depression?Depression?

depression (“little d”)depression (“little d”) A temporary feeling of A temporary feeling of sadnesssadness

““Normal”Normal”

Depression (major Depression (major depressive disorder)depressive disorder)

Constant low mood or Constant low mood or anhedonia (lack of anhedonia (lack of pleasure)pleasure)

Other symptoms Other symptoms presentpresent

A common and A common and potentially destructive potentially destructive illness illness

Historical Names for Historical Names for Diagnosis:Diagnosis:

Nostalgia Nostalgia Fright NeurosisFright NeurosisCombat/War NeurosisCombat/War NeurosisShell ShockShell ShockSurvivor SyndromeSurvivor SyndromeOperational FatigueOperational FatigueCompensation NeurosisCompensation Neurosis

Brain function changes in Brain function changes in depressiondepression

A PET scan can compare brain activity during periods of depression (left) with normal brain activity (right). An increase of blue and green colors, along with decreased white and yellow areas, shows decreased brain activity due to depression.

http://www.mayoclinic.com/health/medical/IM00356

Types of depression:Types of depression:

Adjustment disorderAdjustment disorder Depression NOS (depression)Depression NOS (depression) Dysthymic disorder Dysthymic disorder Major depressive disorderMajor depressive disorder Bipolar disorder (cycles of depression and Bipolar disorder (cycles of depression and

mania)- Will be dealt with in Part II of this mania)- Will be dealt with in Part II of this

discussiondiscussion

What are the symptoms What are the symptoms and signs of clinical and signs of clinical

depression?depression?

Prolonged sadness, crying spellsProlonged sadness, crying spells Loss of pleasure, social withdrawal, loss of motivation, Loss of pleasure, social withdrawal, loss of motivation,

decreased energy, pessimismdecreased energy, pessimism Unexplained pains, fears, apprehensionUnexplained pains, fears, apprehension Significant changes in appetite, sleep and other physical Significant changes in appetite, sleep and other physical

functions (e.g., dry mouth, constipation, loss of taste)functions (e.g., dry mouth, constipation, loss of taste) Irritability, anger, excessive worry, anxiety, guiltIrritability, anger, excessive worry, anxiety, guilt Inability to concentrate or make decisionsInability to concentrate or make decisions Recurring thoughts of death or suicideRecurring thoughts of death or suicide Monthly or seasonal cycling is commonMonthly or seasonal cycling is common Excessive consumption of alcohol or other chemical Excessive consumption of alcohol or other chemical

substances to seek reliefsubstances to seek relief These worsen rather than help clinical depressionThese worsen rather than help clinical depression

7. Stigma and Poor

Adherence

6. Little Recurrence Prevention

1. Widesprea

d Prevalence

8. Brain Tissue Degenerative

Changes

2. Early Symptom

Onset

4. Genetic Vulnerability

Stress-genetic

interactions

3. Underdiagnosis

and Undertreatment

5.Recurrences,

Increased Cycles, Severity

Depression’s

BURDEN:REASONS

Reasons for Depression

5%

No diagnosis / No treatment

Diagnosis, but no treatment

Diagnosis, inaccurate treatment (BZD)

Diagnosis, proper treatment but inadequate dose, duration or discontinuation

Successfully treated

50%

30%

10%

5%

Depression is underdiagnosed and undertreated at all ages

Symptoms of Major DepressionSymptoms of Major Depression S - S - SleepSleep changes (too changes (too

much or too little)much or too little) I - loss of I - loss of InterestsInterests G - excessive G - excessive GuiltGuilt E - lack of E - lack of EnergyEnergy C - loss of C - loss of ConcentrationConcentration A - change in A - change in AppetiteAppetite P - P - PsychomotorPsychomotor

(movement) slowing or (movement) slowing or agitationagitation

S - S - SuicidalSuicidal thoughts thoughts

Depression affects many!Depression affects many! 1-2% prepubertal children1-2% prepubertal children

Both sexes equally affectedBoth sexes equally affected 3-8% teenagers3-8% teenagers

3:1 female to male ratio3:1 female to male ratio Lifetime prevalence ~20% by end of Lifetime prevalence ~20% by end of

adolescenceadolescence CDC (2007): Suicide is the (2007): Suicide is the thirdthird leading leading

cause of death people aged 15-24 yearscause of death people aged 15-24 years

Treating DepressionTreating Depression

Types of Depression TreatmentTypes of Depression Treatment1.1. Psychotherapy (“talk therapy”)Psychotherapy (“talk therapy”)

2.2. Antidepressant medication (selective Antidepressant medication (selective serotonin reuptake inhibitors or SSRI)serotonin reuptake inhibitors or SSRI)

• Other (sleep, exercise and nutrition) Other (sleep, exercise and nutrition) interventions may be helpfulinterventions may be helpful

• The best treatment is combination The best treatment is combination (medication and psychotherapy)(medication and psychotherapy)

Prefrontal Cortex

Raphe Nuclei (5-HT

source)

Cooper JR, Bloom FE. The Biochemical Basis of Neuropharmacology. 1996.

Heightened Risk of Suicide Heightened Risk of Suicide

Feeling of hopelessness and Feeling of hopelessness and desperationdesperation

Extreme anxiety, agitation or enraged Extreme anxiety, agitation or enraged behaviorbehavior

Severe insomniaSevere insomnia Increased alcohol/drug useIncreased alcohol/drug use

Warning Signs of SuicideWarning Signs of Suicide Suicidal Thought/ExpressionsSuicidal Thought/Expressions Obsession with deathObsession with death Decreased interest in friendsDecreased interest in friends Dramatic change in personality or appearanceDramatic change in personality or appearance Irrational, bizarre behaviorIrrational, bizarre behavior Overwhelming sense of guilt, shame or Overwhelming sense of guilt, shame or

rejectionrejection Changes in eating or sleeping patternsChanges in eating or sleeping patterns Changes in school performanceChanges in school performance Worsening symptoms of depression Worsening symptoms of depression

Overview:Overview:

Asperger Disorder, Asperger Disorder,

High Functioning Autism, and Nonverbal High Functioning Autism, and Nonverbal Learning Disabilities: Learning Disabilities:

Diagnostic, and Post Secondary Diagnostic, and Post Secondary Educational ConsiderationsEducational Considerations

Terms:Terms:

ASD: Autism Spectrum DisorderASD: Autism Spectrum Disorder AS: Asperger’s SyndromeAS: Asperger’s Syndrome HFA: High Functioning AutismHFA: High Functioning Autism NLD: Nonverbal Learning DisabilityNLD: Nonverbal Learning Disability DSM: Diagnostic & Statistical Manual of DSM: Diagnostic & Statistical Manual of

Mental Disorders 4Mental Disorders 4thth edition edition

First DescribedFirst Described

Kanner 1943Kanner 1943 Asperger 1944Asperger 1944 Bettleheim 1967Bettleheim 1967 Asperger diagnosis in DSM-IV 1994 Asperger diagnosis in DSM-IV 1994

Kanner (1943)Kanner (1943)

First to describe parents of children with autism as First to describe parents of children with autism as emotionally distant.emotionally distant.

Also stated that there was a considerable biological Also stated that there was a considerable biological component which impacted the development of component which impacted the development of relationships.relationships.

Asperger (1944)Asperger (1944)

Impairment in nonverbal communication.Impairment in nonverbal communication. Verbose, one-sided communication style.Verbose, one-sided communication style. Lack of friends despite interest in others.Lack of friends despite interest in others. All-absorbing, circumscribed interests.All-absorbing, circumscribed interests. Intellectualization of affect.Intellectualization of affect. Motoric clumsiness.Motoric clumsiness. Normal intelligence.Normal intelligence.

Bettelheim (1967)Bettelheim (1967)

Wrote, “Wrote, “The Empty FortressThe Empty Fortress””Autistic symptoms represented a defensive Autistic symptoms represented a defensive

reaction against cold and detached mothersreaction against cold and detached motherse.g., one patient’s obsession with weather could e.g., one patient’s obsession with weather could

be understood by dissecting the word into be understood by dissecting the word into we/eat/her – concerned that her mother and later, we/eat/her – concerned that her mother and later, others, would devour herothers, would devour her

Promoted a policy of “parentectomy”Promoted a policy of “parentectomy”After his suicide in 1990, it was discovered that his After his suicide in 1990, it was discovered that his

credential were fraudulent and the “successes” did credential were fraudulent and the “successes” did not have autism in the first place.not have autism in the first place.

DSM-IVDSM-IVDiagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental Disorders

Asperger’s Disorder first appeared in the Asperger’s Disorder first appeared in the fourth edition in 1994.fourth edition in 1994.

At 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.

DSM-IVDSM-IV

Qualitative Impairment in Social Qualitative Impairment in Social InteractionInteraction

COMMENTCOMMENT

Qualitative Impairment in Social InteractionQualitative Impairment in Social Interaction

Often desire friendship but are isolated because their Often desire friendship but are isolated because their approaches to gain entry to social situations is ineffective.approaches to gain entry to social situations is ineffective.

Often can recite social rules but have a lot of difficulty Often can recite social rules but have a lot of difficulty with generalization and application.with generalization and application.

Deficits in Social InteractionDeficits in Social Interaction

Often desire friendship but are isolated Often desire friendship but are isolated because their approaches to gain entry to because their approaches to gain entry to social situations is ineffectivesocial situations is ineffective

Often can recite social rules but have a lot of Often can recite social rules but have a lot of difficulty with generalization and application.difficulty with generalization and application.

COMMENT:COMMENT:

Qualitative Impairment in Social InteractionQualitative Impairment in Social InteractionMay reflect the tendency to focus on facts and finding relevance in May reflect the tendency to focus on facts and finding relevance in

what most others would find irrelevant.what most others would find irrelevant.

ME: Sorry I kept you waiting – I just spilled coffee all ME: Sorry I kept you waiting – I just spilled coffee all over my leg.over my leg.

JACOB: What kind of coffee?JACOB: What kind of coffee?

ME: Columbian Decafe.ME: Columbian Decafe.

JACOB: Oh.JACOB: Oh.

DSM-IVDSM-IV

Deficits in CommunicationDeficits in Communication

At least At least oneone of the following: of the following:

(a)(a) Delay in, or lack of, development of spoken language (not Delay in, or lack of, development of spoken language (not accompanied by attempts to compensate through alternative accompanied by attempts to compensate through alternative modes of communication).modes of communication).

(b)(b) In individuals with adequate speech, marked impairments in In individuals with adequate speech, marked impairments in the ability to initiate or sustain a conversation with others.the ability to initiate or sustain a conversation with others.

(c)(c) Stereotyped and repetitive use of language or idiosyncratic Stereotyped and repetitive use of language or idiosyncratic language.language.

(d)(d) Lack of varied, spontaneous make-believe play or social Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.imitative play appropriate to developmental level.

COMMENT:COMMENT:

Deficits in CommunicationDeficits in Communication Good formal language skills but poor pragmaticsGood formal language skills but poor pragmatics

Tangential & Circumstantial SpeechTangential & Circumstantial Speech►MonologuesMonologues

►VerbosityVerbosity

►Failure to provide listener with context necessary for understandingFailure to provide listener with context necessary for understanding

Unusual prosodyUnusual prosody►Restricted range of intonation patternsRestricted range of intonation patterns

►Volume, modulation, etc. that is not well orchestrated with Volume, modulation, etc. that is not well orchestrated with

communicative intentcommunicative intent

Too Much HonestyToo Much Honesty

DSM-IVDSM-IV

Restricted Range of Interests, Activities, or Restricted Range of Interests, Activities, or BehaviorsBehaviors

AtAt least least oneone of the following: of the following:

(a) encompassing preoccupation with one or more (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is stereotyped and restricted patterns of interest that is abnormal either in intensity or focusabnormal either in intensity or focus

(b) apparently inflexible adherence to specific, (b) apparently inflexible adherence to specific, nonfunctional routines or ritualsnonfunctional routines or rituals

(c) stereotyped and repetitive motor mannerisms e.g., (c) stereotyped and repetitive motor mannerisms e.g., hand or finger flapping or twisting, or complex whole-hand or finger flapping or twisting, or complex whole-body movementsbody movements

(d) persistent preoccupation with parts of objects(d) persistent preoccupation with parts of objects

COMMENT:COMMENT:

Restricted Range of Interests, Activities, or Restricted Range of Interests, Activities, or BehaviorsBehaviors

Preoccupation with parts over wholes has Preoccupation with parts over wholes has broader implications – ASD individuals broader implications – ASD individuals tend to miss perceiving and tend to miss perceiving and communicating context.communicating context.

Restricted Range of Activities or Behaviors –Restricted Range of Activities or Behaviors –DSM-IVDSM-IV

encompassing preoccupation with one or more encompassing preoccupation with one or more stereotyped and restricted patterns of interest stereotyped and restricted patterns of interest that is abnormal either in intensity or focusthat is abnormal either in intensity or focus

apparently inflexible adherence to specific, apparently inflexible adherence to specific, nonfunctional routines or ritualsnonfunctional routines or rituals

stereotyped and repetitive motor mannerisms, stereotyped and repetitive motor mannerisms, e.g., hand or finger flapping or twisting, or e.g., hand or finger flapping or twisting, or complex whole-body movementscomplex whole-body movements

persistent preoccupation with parts of objectspersistent preoccupation with parts of objects

Circumscribed InterestsCircumscribed Interests

All-absorbingAll-absorbing Unusual topicsUnusual topics Amasses factsAmasses facts MUST interfere with learning and social MUST interfere with learning and social

adaptation adaptation

Motor CharacteristicsMotor Characteristics

Often clumsy Often clumsy Poor motor planningPoor motor planning Delayed acquisition of self-help skillsDelayed acquisition of self-help skills Problems with climbing, team sports, Problems with climbing, team sports,

catchingcatching Graph motor deficitsGraph motor deficits Odd gaitOdd gait Proximity problemsProximity problems

Asperger’s has been used to describe:Asperger’s has been used to describe:

High Functioning Autism (HFA) without cognitive impairmentHigh Functioning Autism (HFA) without cognitive impairment Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) aka Atypical AutismPervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) aka Atypical Autism Shyness, social anxiety (shades of normalcy)Shyness, social anxiety (shades of normalcy) Distinct disorderDistinct disorder In DSM-V all of these will become-Autism Spectrum Disorder (ASD)In DSM-V all of these will become-Autism Spectrum Disorder (ASD)

Asperger’s v. HFAAsperger’s v. HFA

ASPERGER’S ASPERGER’S Delays primarily in Delays primarily in

nonverbal communication nonverbal communication and pragmatic languageand pragmatic language

More typical attachment More typical attachment patternspatterns

Diagnosis common after Diagnosis common after age 7age 7

Distinct VIQ/PIQ splitDistinct VIQ/PIQ splitArea of special interest Area of special interest

predominantpredominantSocial motivation for Social motivation for

relationshipsrelationshipsFailure to understand Failure to understand

nonverbal communicationnonverbal communication

HFAHFAMore severe language More severe language

delaysdelaysAtypical attachment patternsAtypical attachment patternsEarlier diagnosisEarlier diagnosisLess VIQ/PIQ discrepancyLess VIQ/PIQ discrepancyReduced social interestReduced social interestFailure of basic Failure of basic

mechanisms of mechanisms of socializationsocialization

DSM-IV AS/Autism DistinctionDSM-IV AS/Autism Distinction

There is no clinically significant delay in cognitive There is no clinically significant delay in cognitive development development or in the development of age-appropriate self-help or in the development of age-appropriate self-help skills, adaptive behavior (other than social skills, adaptive behavior (other than social interaction), and interaction), and curiosity about the environment in childhood.curiosity about the environment in childhood.

Significant delays across all areasSignificant delays across all areas

Volkmar (2004)Volkmar (2004) DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS

FEATURE AS HFA

Social Skills Poor Very Poor

Motor Skills Clumsy Good

Circumscribed Interests

Usual Variable

Family History Usual Occasional

Age at Diagnosis

>24 mos. <24 mos.

Nonverbal Learning Nonverbal Learning DisabilitiesDisabilities

Nonverbal Learning DisabilityNonverbal Learning Disability

A neuropsychological profileA neuropsychological profile Not a DSM-IV diagnosisNot a DSM-IV diagnosis Overlaps with deficits associated with Overlaps with deficits associated with

AS/HFAAS/HFA

NLD CharacteristicsNLD Characteristics

DEFICITSDEFICITS

Visual-spatial Visual-spatial organizationorganization

Nonverbal problem Nonverbal problem solvingsolving

Difficulty relating parts Difficulty relating parts to wholesto wholes

STRENGTHSSTRENGTHS

Language-based Language-based thinking and thinking and reasoningreasoning

Rote memoryRote memory

Expressive languageExpressive language

The NLD Profile Results in: The NLD Profile Results in:

Adapting to novel and complex situationsAdapting to novel and complex situationsover reliance on rote behaviors in such situationsover reliance on rote behaviors in such situationsRelative deficits in mechanical arithmetic as Relative deficits in mechanical arithmetic as

compared to proficiencies in single word readingcompared to proficiencies in single word readingPoor pragmatics Poor pragmatics Unusual prosody in speechUnusual prosody in speechPoor social perception, social judgment, and Poor social perception, social judgment, and

social interaction skills. social interaction skills.

Other Overlapping Concepts…Other Overlapping Concepts…

Semantic-Pragmatic Language Disorder (from Semantic-Pragmatic Language Disorder (from psycholinguistics)psycholinguistics)

HyperlexiaHyperlexia

Pathological Demand AvoidancePathological Demand Avoidance

Important Things for Service Providers to Important Things for Service Providers to remember :remember :

ASD and NLD individuals have trouble imposing ASD and NLD individuals have trouble imposing organization on the internal and external environment. organization on the internal and external environment. This underlies their rigid adherence to rules and their This underlies their rigid adherence to rules and their difficulties in simultaneously processing stimuli from difficulties in simultaneously processing stimuli from multiple sources.multiple sources.

Negative behaviors emerge primarily when the student is Negative behaviors emerge primarily when the student is overwhelmed because the demands exceed their level overwhelmed because the demands exceed their level of competence. of competence.

Common Co morbid ConditionsCommon Co morbid Conditions

AD/HDAD/HDObsessive Compulsive DisorderObsessive Compulsive DisorderDepressionDepressionAnxietyAnxietyDyspraxiaDyspraxiaLearning DisabilitiesLearning Disabilities

◦ Written expressionWritten expression◦ Math disabilityMath disability

Gender IssuesGender Issues

Male to female ratio estimated at 4:1Male to female ratio estimated at 4:1 Some evidence that females are less Some evidence that females are less

likely to develop autism, and when they likely to develop autism, and when they do, they are generally less impaired.do, they are generally less impaired.

Tendency to view symptoms in females as Tendency to view symptoms in females as psychologically basedpsychologically based

Gender Issues-ContinuedGender Issues-Continued

Girls may be better at masking the Girls may be better at masking the symptoms.symptoms.

The DSM-IV criteria are based on male The DSM-IV criteria are based on male presentation of the disorderpresentation of the disorder

Tendency to view girls’ problems as Tendency to view girls’ problems as psychological or emotional in naturepsychological or emotional in nature

Family Issues and Diagnosis of ASDFamily Issues and Diagnosis of ASD

Strain on family time, energy, and financial Strain on family time, energy, and financial resourcesresources

Frustrated by the confusion of special Frustrated by the confusion of special education and medical terms and education and medical terms and procedures.procedures.

Finding the “right” educational fitFinding the “right” educational fit

ASD-Lack of Social ASD-Lack of Social ReciprocityReciprocity

Social Co-RegulationSocial Co-Regulation

Emotional CoordinationEmotional Coordination

Social ReferencingSocial Referencing

IntersubjectivityIntersubjectivity

Emotional RegulationEmotional Regulation

ASD-Stereotypic Movements/ InterestsASD-Stereotypic Movements/ Interests

HypersensitivityHypersensitivity Responses can cause Responses can cause

distractiondistraction Strong preferences for Strong preferences for

certain types of certain types of sensory inputsensory input

Inconsistent Inconsistent attentivenessattentiveness

Inconsistent physical Inconsistent physical and emotional and emotional modulationmodulation

Poor episodic memoryPoor episodic memory Poor self regulationPoor self regulation Reduced identity Reduced identity

developmentdevelopment

Rigid ThinkingRigid Thinking

Difficulty generalizingDifficulty generalizing Misinterpretation of informationMisinterpretation of information Lack of symmetry between verbalizations and Lack of symmetry between verbalizations and

actionsactions Preference for static systemsPreference for static systems Black and white thinkingBlack and white thinking

Education Issues-Questions for Families and Education Issues-Questions for Families and Transition Specialists to ConsiderTransition Specialists to Consider

How much structure does the student need and can the school How much structure does the student need and can the school provide it?provide it?

Is there someone in the SSD office with a specialty in these Is there someone in the SSD office with a specialty in these conditions?conditions?

How receptive are staff and faculty to students with this condition?How receptive are staff and faculty to students with this condition? What is the philosophical outlook of the SSD office?What is the philosophical outlook of the SSD office? Given the students documentation and severity of disability what Given the students documentation and severity of disability what

academic accommodations are availableacademic accommodations are available

Education Issues-Questions for Families and Education Issues-Questions for Families and Transition Specialist to ConsiderTransition Specialist to Consider

Is tutoring, academic coaching, psychotherapy Is tutoring, academic coaching, psychotherapy available at the school or in the community and available at the school or in the community and what is the cost?what is the cost?

Are there support groups?Are there support groups? Are there workshops or professionals who teach Are there workshops or professionals who teach

study or social skills?study or social skills? Is there anyone to assist in academic advising, Is there anyone to assist in academic advising,

financial aid?financial aid? Can a student take a reduced load and still be Can a student take a reduced load and still be

considered a full time student?considered a full time student?