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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 - PowerPoint PPT Presentation
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How to Formulatea Diagnosis in
Complicated Youth
MICHAEL J. LABELLARTE, SR., M.D.Annapolis, Millersville, Towson, and
Columbia, [email protected]
cell:443-956-2463www.cpeclinic.com
2
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
•
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
5020
School Referral, “ADHD”, age 7
ASDS/L
ADHDLD
TicsAnxiety
MDDBPAD
SA
Personality
Behavior
51
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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