PSYCHIATRY Part 2: Symptomatology

Part 3: Psychological Testing

UNIT IV
Indications for Psychological Testing
Part 1: What are the causes of Mental Illness?
1. Intelligence- IQ test
Predisposing/Conditioning factors: a. <90
• Age - older the person, the more predisposed he/she is to b. 90-110- normal intelligence
mental illness (i.e., adults most common than in children 2. To determine personality
and adolescents) 3. Organicity/brain damage
4. Vocational interests and aptitudes
• Sex - male or female; depends on the kind of mental illness;
females - diseases that belong to emotions or feelings ex.
anxiety or depression (psychological or emotional Psychiatric Interviewing
disorders); males - more on brain damage or infections 1. Establish a good relationship with interviewee so that
(structural or functional damage) ex. accidents or alcohol or patient will give more info “rapport”- good relationship
drugs (organic mental disorders) a. Introduce self to patient
b. Ask background; would like to help you that’s why
• Civil status - singles (such as widows, nuns or priest),
we would like to ask questions
married; singles are more predisposed
2. Bring the patient to a comfortable place (comfort at ease)
• Hereditary/Genetics- ex. Schizophrenia (most severe);
3. Establish confidentiality
bipolar disorder / manic depressive disorder; depression;
4. Use open-ended questions
Alzheimer’s disease, alcoholism (substance dependency)
a. Ex. What do you remember about your childhood
• Environmental factors (urban areas more predisposed to
years
mental illness), pollution, dangerous type of environment
b. Tell me about your marital life
• Occupation - prone to danger or monotony such as police
work, medicine, and dentistry
Get psychiatric history (ANAMESIS)
• Physical defect / persons with disability 1. General data for patient info (name, age, marital status)
2. Chief Complaint
Precipitating factors or Immediate causes: a. 2 informants (patient, significant other, mother
• Organic factor reliability)
o Trauma to the brain b. Give reliability rating
o infection to the brain (involving brain and c. Write answer word for word- verbatim/exact
meninges; encephalitis and meningitis) quotation
o Endocrine (DM) 3. HPI- elaboration of chief complaint
o Metabolic such as endocrine ex. Hypothyroidism, a. When did the problem start?
hyperthyroidism, kidney disease b. What did you do?
c. What did he do?
• Psychogenic - emotional in nature coming from the brain; 4. Past Illnesses
anything that can precipitate mental illness 5. Family History
o Loss of a loved one a. Immediate family (parents, siblings)- name, age,
o Loss of a job or property occupations
o Stress related to injury b. Family orientation
c. Family values (strict, highly motivated)
>> Mental illness is produced by predisposing and precipitating d. Heredofamiliial diseases (DM, HPN)
factors 6. Personal and Social History (longest part)- “Biography of
>> biopsychosocial theory of mental illness - mental illness in general the patient”
are caused by biological, a. Infancy, childhood, adolescent, adulthood
sociological, and psychological factors; possibility of combinations b. Premorbid personality
>> no one factor can explain the causes of mental illness c. Educational background
d. Marital/sexual history
1. Biological (brain) e. If naapil bas military
>> Neurotransmitters - transmit nerve impulse from one neuron to 7. Physical and neurological examination
another (culprit)
• Excess of Dopamine - schizophrenia Mental status
• Lack of Acetylcholine - Alzheimer’s
• Excess of Norepinephrine and epinephrine – mood/ bipolar 1. General Appearance of the patient
disorders; deficiency can cause depression a. Does the patient look sick?
• Lack of Norepinephrine and epinephrine- depression b. Does the patient look his age?
i. Something to do with maturity
2. Psychological (Emotions) c. The way the patient appears to you physically
• Emotional disturbance 2. Interview behavior
• Loss of a loved one a. Cooperative
b. Hostile
3. Sociological (Environment) 3. Emotional Reaction (Mood (feeling) and affect (how the
• Danger in environment patient shows it)
• Most esp in third world countries; referring particularly to a. Congruent- similar
poverty; malnutrition, unemployment, family problems, lack b. Inappropriate
of support from family members, lack of friends, lack of c. Blunted/blanded
people who understand this person d. Include own emotional reaction when
interviewing patient
i. Give idea to the diagnosis

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 4. Perception and Cognition 10. Eating Disorder
a. Look for disturbances (illusions, hallucinations) 11. Internet Gaming Disorder
b. Disturbances of the thinking process
i. Form
ii. Flow
iii. Content of thought I. MENTAL RETARDATION
iv. Incoherence
• Significantly impaired cognitive functioning
v. Autistic thinkers
vi. Delusions • Deficits in adaptive behaviors
vii. Phobia • Onset before age 18

Classification
5. Mental Grasp and Capacity
1. Orientation- awareness of one surrounding • Mild (50-70 IQ)
a. Ex. Time, place, persons • Moderate (35-55 IQ)
b. Good, fair, poor • Severe (20-40 IQ)
2. Memory
• Profound (Below 20 IQ)
a. Recent- what did you eat for breakfast
b. Remote events- questions about childhood, past Also: educable, trainable, and custodial
history
3. Abstraction (very different portion) Manifestations
a. Similarities between objects
b. Proverbs, interpretation • Delays in oral language development
4. Reading and Writing • Deficits in memory skills
5. Mathematical ability (MDAS) • Difficulty learning social skills
a. Tailored to educational background of patient • Difficulty with problem-solving skills
b. *100-7*- test for college student • Delays in development of adaptive behaviors
6. Intelligence • Lack of social inhibitors
7. Judgement and Insight
a. the ability to solve problem
i. ex. What will you do if there is fire in II. AUTISM SPECTRUM DISORDERS (INFANTILE AUTISM)
the building
b. self-awareness • Complex neuro-psychiatric disorders characterized by
deficits in social interaction and communication
UNIT V: Psychiatric disorders in childhood and adolescence • Unusual and repetitive behaviors
• Diagnosed before age 4-6 years
Disorders of Childhood and Adolescence
Causes
• Studies in the United States and New Zealand suggest • Genetic
prevalence 17-22%
• Environmental
• More boys are diagnosed with childhood disorders than
• Prenatal factors
girls.
• Girls are more likely to have internalized problems (anxiety
and depression) and boys are more likely to have
externalized problems (ADHD, conduct disorder, etc…)
• ADHD and Separation Anxiety are most common.

Maladaptive Behaviors in Different Life Periods

• Developmental Psychopathology- Must be taken in the

context of normal developmental changes.
• Varying Clinical Picture (short lived and less specific than
adult disorders)
• Some childhood disorders may severely affect future
development (ADHD & I.Q. also excess mortality
associated with CD)
• Vulnerable due to less self-understanding.

Disorders of Childhood and Adolescence

1. Mental Retardation
2. Infantile Autism (Autism Spectrum Disorders)
3. ADHD
4. Learning Disorders
5. Conduct Disorder
6. Oppositional Defiant Disorder
7. Anxiety Disorders
8. Symptom Disorders
9. Post-Traumatic Stress Disorder
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III. Attention Deficit Hyperactivity Disorder ADHD Treatments and Outcomes

• Both Behavioral Therapy and Medication reduce

• Characterized by difficulties that interfere with effective
task-oriented behavior in children.
• Often score 7-15 I.Q points below average
• Hyperactive children are the most frequent psychological
referrals to mental health and pediatric facilities.
• 6-9% more prevalent with boys than girls
• Occurs with greatest frequency before age 8
• Most frequent psychological referral to mental health
facilities
Types
• Inattention
• Hyperactivity and Impulsivity
• Mixed Medications
symptoms.
• Medication
o 40% of junior high & 15% high school students
with emotional and behavioral problems are
prescribed medication.
o 75% effective rate in treating hyperactive child
o Reduces inattention but not impulsivity.
• Behavioral Treatment
o Demonstrates short-term gains. Reduces
symptoms.
• Hyperactive bx tends to diminish in some children. Impact
however may remain (less education, legal problems,
etc….)

ADHD Criteria 1. Stimulants – methylphenidate and amphetamine

2. Atomoxetine
• Either (1) or (2): 3. Others – clonidine, antidepressants
• six (or more) of the following symptoms of inattention have
persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level: Psychosocial Therapy
o often fails to give close attention to details or
makes careless mistakes in schoolwork, work, or 1. Psychotherapy
other activities 2. Behavior therapy
o often has difficulty sustaining attention in tasks or 3. Family therapy
play activities 4. Social skills training
o often does not seem to listen when spoken to 5. Support groups
directly 6. Parenting skills training
o often does not follow through on instructions and
fails to finish schoolwork, chores, or duties in the
IV. Learning Disorders
workplace (not due to oppositional behavior or
failure to understand instructions)
o often has difficulty organizing tasks and activities • no longer limits learning disorders to reading, mathematics
o often avoids, dislikes, or is reluctant to engage in and written expression.
tasks that require sustained mental effort (such • Rather, the DSM-5 criteria describe shortcomings in
as schoolwork or homework) often loses things general academic skills and provide detailed specifiers
necessary for tasks or activities (e.g., toys,
school assignments, pencils, books, or tools)
is often easily distracted by extraneous stimuli
is often forgetful in daily activities
o Hyperactivity
o often fidgets with hands or feet or squirms in seat
o often leaves seat in classroom or in other
situations in which remaining seated is expected
o often runs about or climbs excessively in
situations in which it is inappropriate (in
adolescents or adults, may be limited to
subjective feelings of restlessness)
o often has difficulty playing or engaging in leisure
activities quietly
o is often "on the go" or often acts as if "driven by
a motor" Stages of information processing used in learning
o often talks excessively
o Impulsivity • Input
o often blurts out answers before questions have • Integration
been completed • Storage
o often has difficulty awaiting turn • Output
often interrupts or intrudes on others (e.g., butts
into conversations or games)

ADHD Causal Factors

• Both biological and environmental

• Food additive theory unsupported
• Home environment may be a link in that some studies show
that parents of ADHD children are more likely to have
personality disorders.

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Learning Disabilities
• Reading
• Writing
• Mathematics
• Dyspraxia
Causes
• Heredity
• Problems in pregnancy
• Accidents
• Social/Environmental factors
Interventions
• Mastery model
• Direct instruction
• Classroom adjustments
• Special equipment
V. Conduct Disorder & Oppositional Defiant Disorder
• Characterized by aggressive or antisocial behavior.
• Virtually all who have conduct disorder have oppositional
defiant disorder first.
• Oppositional Defiant Disorder usually appears by age 6.
Conduct Dis. Age 9.
• Looks much like adult antisocial personality disorder.
VI. Oppositional Defiant Disorder Criteria
• A pattern of negativistic, hostile, and defiant behavior
lasting at least 6 months, during which four (or more) of the
following are present:
• often loses temper
• often argues with adults
• often actively defies or refuses to comply with adults'
requests or rules
• often deliberately annoys people
• often blames others for his or her mistakes or misbehavior
• is often touchy or easily annoyed by others
• is often angry and resentful
• is often spiteful or vindictive
Conduct Disorder Criteria
• A repetitive and persistent pattern of behavior in which the
basic rights of others or major age-appropriate societal
norms or rules are violated, as manifested by the presence
of three (or more) of the following criteria in the past 12
months, with at least one criterion present in the past 6
months: Aggression to people and animals
• often bullies, threatens, or intimidates others
• often initiates physical fights
• has used a weapon that can cause serious physical harm
to others (e.g., a bat, brick, broken bottle, knife, gun)
• has been physically cruel to people
• has been physically cruel to animals
• has stolen while confronting a victim (e.g., mugging, purse
snatching, extortion, armed robbery)
• has forced someone into sexual activity
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Destruction of property
• has deliberately engaged in fire setting with the intention of
causing serious damage
• has deliberately destroyed others' property (other than by
fire setting)
Deceitfulness or theft
• has broken into someone else's house, building, or car
often lies to obtain goods or favors or to avoid obligations
(i.e., "cons" others)
• has stolen items of nontrivial value without confronting a
victim (e.g., shoplifting, but without breaking and entering;
forgery)
Serious violations of rules
• often stays out at night despite parental prohibitions,
beginning before age 13 years
• has run away from home overnight at least twice while living
in parental or parental surrogate home (or once without
returning for a lengthy period)
• is often truant from school, beginning before age 13 years
• The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational functioning.
Causal Factors: Conduct Disorders
• Self-Perpetuating Cycle
• Parent-Child relations characterized by rejection and
neglect
• Conduct Disorder has been associated with divorce,
hostility, and lack of monitoring in the family.
Treatment
• Challenge is parent’s reluctance to become involved in
treatment and learn new parenting behaviors.
VII. Anxiety Disorders of Childhood
• Children typically cope with anxiety by becoming overly
dependent on others.
• Prevalence is higher in girls than boys.
• Separation Anxiety Disorder
o Most common childhood anxiety disorder
o Essential feature is excessive anxiety about
separation from major attachment figures.
o Characteristics Include: unrealistic
fears,oversensitivity, self-consciousness,
nightmares, lack confidence, chronic anxiety,
apprehensive in new situations, worry that
parents will become ill or die, difficulty sleeping,
school refusal problems .
Anxiety Disorders: Treatment
• Psychopharmacological treatment is questionable in its
effectiveness
• Behavioral Therapy Procedures are Effective
o Assertiveness Training, Mastering
Competencies, and Desensitization and In Vivo
Methods (using graded real life situations)
• Group Therapy as a Modality is Effective
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VIII. Childhood Depression
• Prevalence greater in girls than boys (2x)
• Causal Factors Include:
o Biological Factors
o Learning Factors
▪ (negative parental behavior, divorce,
modeling of depressed mother, marital
stress, mother-infant attachment,
depressed mothers are less
responsive)
▪ Children of depressed mothers are
more likely to become depressed
themselves and commit suicide
• Treatment
o Medication is no more effective than placebo
o Cognitive-Behavioral Therapy
o Providing a supportive emotional environment
Treatment Challenges for Childhood Disorders
• Most childhood disorders develop out of pathogenic family
interactions
• Treatment of childhood disorders relies a great deal on
teaching parents behavioral therapy interventions
• Parents are often key to the child’s treatment and many
parents are resistant.
• More difficult to get fathers involved than mothers.
IX. Post-Traumatic Stress Disorder
• includes a new subtype for children younger than 6.
• This change is based on recent research detailing what
PTSD looks like in young children.
• Adding the developmental subtype should help clinicians
tailor treatment in a more age-appropriate and age-effective
way
X. Eating Disorders
• previously listed among Disorders Usually First Diagnosed
in Infancy, Childhood, or Adolescence are now listed in the
Feeding and Eating Disorders chapter.
• They include pica, rumination and avoidant/restrictive food
intake disorder
XI. Internet Gaming Disorder
Under Section III. Conditions for Further Study of DSM V
Prevalence
• The prevalence of Internet gaming disorder is unclear
because of the varying questionnaires, criteria and
thresholds employed, but it seems to be highest in Asian
countries and in male adolescents 12-20 years of age.
• There is an abundance of reports from Asian countries,
especially China and South Korea, but fewer from Europe
and North America, from which prevalence estimates are
highly variable.
• The point prevalence in adolescents (ages 15-19 years) in
one Asian study using a threshold of five criteria was 8.4%
for males and 4.5% for females.
Risk and Prognostic Factors
• Environmental.
o Computer availability with Internet connection
allows access to the types of games with which
Internet gaming disorder is most often
associated.
• Genetic and physiological.
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o Adolescent males seem to be at greatest risk of
developing Internet gaming disorder, and it has
been speculated that Asian environmental and/or
genetic background is another risk factor, but this
remains unclear.
Functional Consequences
• Internet gaming disorder may lead to school failure, job
loss, or marriage failure. The compulsive gaming behavior
tends to crowd out normal social, scholastic, and family
activities.
• Students may show declining grades and eventually failure
in school. Family responsibilities may be neglected.
Differential Diagnosis
• Excessive use of the Internet not involving playing of online
games (e.g., excessive use of social media, such as
Facebook; viewing pornography online) is not considered
analogous
Internet Gaming Disorder Criteria
Persistent and recurrent use of the Internet to engage in games, often
with other players, leading to clinically significant impairment or
distress as indicated by five (or more) of the following in a 12-month
period:
1. Preoccupation with Internet games. (The individual thinks about
previous gaming activity or anticipates playing the next game; Internet
gaming becomes the dominant activity in daily life).
Note: This disorder is distinct from Internet gambling, which is
included under gambling disorder.
2. Withdrawal symptoms when Internet gaming is taken away. (These
symptoms are typically described as irritability, anxiety, or sadness,
but there are no physical signs of pharmacological withdrawal.)
3. Tolerance—the need to spend increasing amounts of time engaged
in Internet games.
4. Unsuccessful attempts to control the participation in Internet
games.
5. Loss of interests in previous hobbies and entertainment as a result
of, and with the exception of, Internet games.
6. Continued excessive use of Internet games despite knowledge of
psychosocial problems.
7. Has deceived family members, therapists, or others regarding the
amount of Internet gaming.
8. Use of Internet games to escape or relieve a negative mood (e.g.,
feelings of helplessness, guilt, anxiety).
9. Has jeopardized or lost a significant relationship, job, or educational
or career opportunity because of participation in Internet games.
Note: Only nongambling Internet games are included in this disorder.
Use of the Internet for required activities in a business or profession
is not included; nor is the disorder intended to include other
recreational or social Internet use. Similarly, sexual Internet sites are
excluded.
Specify current severity:
Internet gaming disorder can be mild, moderate, or severe depending
on the degree of disruption of normal activities. Individuals with less
severe Internet gaming disorder may exhibit fewer symptoms and less
disruption of their lives. Those with severe Internet gaming disorder
will have more hours spent on the computer and more severe loss of
relationships or career or school opportunities
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