How to Formulate a Diagnosis in Complicated Youth

How to Formulatea Diagnosis in

Complicated Youth

MICHAEL J. LABELLARTE, SR., M.D.Annapolis, Millersville, Towson, and

Columbia, MDdr.labellarte@cpeclinic.com

cell:443-956-2463www.cpeclinic.com

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Transparency• No current conflicts of interest

• Assistant Professor, Part Time• Johns Hopkins Medical Institutions• University of Maryland SOM• University of Florida COM

School-BasedPsycho-Social

Pharmacology

Interventions

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• Etc.

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

100 130 70

* *

Dr. Bruce BannerHulk

Intelligence Quotient (IQ)

The Eysenck Circle (1958)Unstable

Introverted Extroverted

Touchy Restless Aggressive Excitable Changeable

Impulsive Optimistic Active

Sociable Outgoing Talkative Responsive Easygoing Lively CarefreeLeadership

Moody Anxious

Rigid Sober Pessimistic Reserved Unsociable Quiet

Passive Careful Thoughtful Peaceful Controlled Reliable Even Calm

Stable

The 5 Factor Model (FFM) • Stable ---------- Unstable

• Extroverted ---------- Introverted

• Open to new ---------- Closed to new

• Agreeable ---------- Disagreeable

• Conscientious ---------- Not conscientious

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

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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

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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.

“cross-cutting 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

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School Referral, “ADHD”, age 7

ASDS/L

ADHDLD

TicsAnxiety

MDDBPAD

SA

Personality

Behavior

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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 toolsRating scales are not diagnostic scales

Useful Rating ScalesADHD/behavior: Connors, ADHD IV, Vanderbilt, BASC, CBCL; Executive Function: (CBS) Barkley, Brown, (BRIEF) Gioia 2000 Pediatric Anxiety Rating Scale (PARS), RUPP 2002Autism Spectrum Screening Questionnaire (ASSQ): Possreud etal Children’s Aggression Scale-Parent (CAS-P): Halperin, 2000Conduct 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

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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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