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

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 Destruction of property

• has deliberately engaged in fire setting with the intention of

• Reading causing serious damage
• Writing • has deliberately destroyed others' property (other than by
• Mathematics fire setting)
• Dyspraxia
Deceitfulness or theft

• has broken into someone else's house, building, or car

Causes often lies to obtain goods or favors or to avoid obligations
(i.e., "cons" others)
• Heredity • has stolen items of nontrivial value without confronting a
• Problems in pregnancy victim (e.g., shoplifting, but without breaking and entering;
• Accidents forgery)
• Social/Environmental factors
Serious violations of rules

• often stays out at night despite parental prohibitions,

Interventions
beginning before age 13 years
• Mastery model • has run away from home overnight at least twice while living
• Direct instruction in parental or parental surrogate home (or once without
• Classroom adjustments returning for a lengthy period)
• Special equipment • is often truant from school, beginning before age 13 years
• The disturbance in behavior causes clinically significant
V. Conduct Disorder & Oppositional Defiant Disorder impairment in social, academic, or occupational functioning.

Causal Factors: Conduct Disorders

• Characterized by aggressive or antisocial behavior.
• Virtually all who have conduct disorder have oppositional • Self-Perpetuating Cycle
defiant disorder first. • Parent-Child relations characterized by rejection and
• Oppositional Defiant Disorder usually appears by age 6. neglect
Conduct Dis. Age 9. • Conduct Disorder has been associated with divorce,
• Looks much like adult antisocial personality disorder. hostility, and lack of monitoring in the family.

Treatment
VI. Oppositional Defiant Disorder Criteria
• Challenge is parent’s reluctance to become involved in
• A pattern of negativistic, hostile, and defiant behavior treatment and learn new parenting behaviors.
lasting at least 6 months, during which four (or more) of the
following are present:
• often loses temper VII. Anxiety Disorders of Childhood
• often argues with adults
• often actively defies or refuses to comply with adults'
requests or rules
• Children typically cope with anxiety by becoming overly
• often deliberately annoys people dependent on others.
• often blames others for his or her mistakes or misbehavior • Prevalence is higher in girls than boys.
• is often touchy or easily annoyed by others • Separation Anxiety Disorder
• is often angry and resentful o Most common childhood anxiety disorder
• is often spiteful or vindictive o Essential feature is excessive anxiety about
separation from major attachment figures.
o Characteristics Include: unrealistic
Conduct Disorder Criteria
fears,oversensitivity, self-consciousness,
• A repetitive and persistent pattern of behavior in which the nightmares, lack confidence, chronic anxiety,
basic rights of others or major age-appropriate societal apprehensive in new situations, worry that
norms or rules are violated, as manifested by the presence parents will become ill or die, difficulty sleeping,
of three (or more) of the following criteria in the past 12 school refusal problems .
months, with at least one criterion present in the past 6
Anxiety Disorders: Treatment
months: Aggression to people and animals
• often bullies, threatens, or intimidates others • Psychopharmacological treatment is questionable in its
• often initiates physical fights effectiveness
• has used a weapon that can cause serious physical harm • Behavioral Therapy Procedures are Effective
to others (e.g., a bat, brick, broken bottle, knife, gun) o Assertiveness Training, Mastering
• has been physically cruel to people Competencies, and Desensitization and In Vivo
• has been physically cruel to animals Methods (using graded real life situations)
• has stolen while confronting a victim (e.g., mugging, purse • Group Therapy as a Modality is Effective
snatching, extortion, armed robbery)
• has forced someone into sexual activity

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VIII. Childhood Depression o Adolescent males seem to be at greatest risk of
developing Internet gaming disorder, and it has
• Prevalence greater in girls than boys (2x) been speculated that Asian environmental and/or
• Causal Factors Include: genetic background is another risk factor, but this
o Biological Factors remains unclear.
o Learning Factors
▪ (negative parental behavior, divorce, Functional Consequences
modeling of depressed mother, marital
stress, mother-infant attachment, • Internet gaming disorder may lead to school failure, job
depressed mothers are less loss, or marriage failure. The compulsive gaming behavior
responsive) tends to crowd out normal social, scholastic, and family
▪ Children of depressed mothers are activities.
more likely to become depressed • Students may show declining grades and eventually failure
themselves and commit suicide in school. Family responsibilities may be neglected.
• Treatment
Differential Diagnosis
o Medication is no more effective than placebo
o Cognitive-Behavioral Therapy • Excessive use of the Internet not involving playing of online
o Providing a supportive emotional environment games (e.g., excessive use of social media, such as
Facebook; viewing pornography online) is not considered
analogous
Treatment Challenges for Childhood Disorders

• Most childhood disorders develop out of pathogenic family

Internet Gaming Disorder Criteria
interactions
• Treatment of childhood disorders relies a great deal on
Persistent and recurrent use of the Internet to engage in games, often
teaching parents behavioral therapy interventions
with other players, leading to clinically significant impairment or
• Parents are often key to the child’s treatment and many distress as indicated by five (or more) of the following in a 12-month
parents are resistant. period:
• More difficult to get fathers involved than mothers.
1. Preoccupation with Internet games. (The individual thinks about
previous gaming activity or anticipates playing the next game; Internet
IX. Post-Traumatic Stress Disorder gaming becomes the dominant activity in daily life).
Note: This disorder is distinct from Internet gambling, which is
• includes a new subtype for children younger than 6.
included under gambling disorder.
• This change is based on recent research detailing what
2. Withdrawal symptoms when Internet gaming is taken away. (These
PTSD looks like in young children.
symptoms are typically described as irritability, anxiety, or sadness,
• Adding the developmental subtype should help clinicians
but there are no physical signs of pharmacological withdrawal.)
tailor treatment in a more age-appropriate and age-effective
3. Tolerance—the need to spend increasing amounts of time engaged
way
in Internet games.
X. Eating Disorders 4. Unsuccessful attempts to control the participation in Internet
games.
• previously listed among Disorders Usually First Diagnosed 5. Loss of interests in previous hobbies and entertainment as a result
in Infancy, Childhood, or Adolescence are now listed in the of, and with the exception of, Internet games.
Feeding and Eating Disorders chapter. 6. Continued excessive use of Internet games despite knowledge of
• They include pica, rumination and avoidant/restrictive food psychosocial problems.
intake disorder 7. Has deceived family members, therapists, or others regarding the
amount of Internet gaming.
XI. Internet Gaming Disorder 8. Use of Internet games to escape or relieve a negative mood (e.g.,
Under Section III. Conditions for Further Study of DSM V feelings of helplessness, guilt, anxiety).
Prevalence 9. Has jeopardized or lost a significant relationship, job, or educational
or career opportunity because of participation in Internet games.
• The prevalence of Internet gaming disorder is unclear
because of the varying questionnaires, criteria and Note: Only nongambling Internet games are included in this disorder.
thresholds employed, but it seems to be highest in Asian Use of the Internet for required activities in a business or profession
countries and in male adolescents 12-20 years of age. is not included; nor is the disorder intended to include other
• There is an abundance of reports from Asian countries, recreational or social Internet use. Similarly, sexual Internet sites are
especially China and South Korea, but fewer from Europe excluded.
and North America, from which prevalence estimates are
highly variable.
• The point prevalence in adolescents (ages 15-19 years) in Specify current severity:
one Asian study using a threshold of five criteria was 8.4%
for males and 4.5% for females.
Internet gaming disorder can be mild, moderate, or severe depending
on the degree of disruption of normal activities. Individuals with less
Risk and Prognostic Factors severe Internet gaming disorder may exhibit fewer symptoms and less
disruption of their lives. Those with severe Internet gaming disorder
• Environmental. will have more hours spent on the computer and more severe loss of
o Computer availability with Internet connection relationships or career or school opportunities
allows access to the types of games with which
Internet gaming disorder is most often
associated.
• Genetic and physiological.
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