Lesson 1: Clinical Disorders - Part A

Common; caused by a problem or event; usually not severe (may be severe); usually short lasting ; professional help not usually needed; professional help can be useful;

DIAGNOSIS NOT NEEDED.

Less common; may happen without any stress; often with high severity; usually long lasting; professional help usually needed. 

NEEDS TO BE DIAGNOSED.

GENETICS (the effect of genes on brain development and brain function)

and

ENVIRONMENT (the effect of things outside the brain on the brain -- such as infection; malnutrition; severe stress etc.)

• 20% of Canadians will experience a mental illness in their lifetime
• Mental illness affects people of all ages, educational and income levels, and cultures.
• Almost on half (49%) of those who feel they have suffered from depression or anxiety have never gone to see a doctor about this problem.
• Today, approximately 5% of male youth and 12% of female youth, age 12 to 19, have experienced a major depressive episode.
• Once depression is recognized, help can make a difference for 80% of people who are affected, allowing them to get back to their regular activities.
• Surpassed only by injuries, mental disorders in youth are ranked as the second highest hospital care expenditure in Canada.
• In Canada, only 1 our of 5 children who need mental health services receives them.
                                                                           Canadian Mental Health Association.

Teen Mental Health

http://teenmentalhealth.org/learn/mental-disorders/panic-disorder/

Description

A 78 year-old retired president of a lumber company presented himself for treatment following a series of episodes in which he felt apprehensive and restless. To decrease his feelings of discomfort, he insisted upon being outdoors. He described his most recent episode as occurring at 3:00 a.m., a week prior to seeing the doctor. He awoke from his sleep with a feeling that the walls were coming in on him. He claimed he was fully awake; he got up, dressed himself, and went outside. He felt much better once outdoors, but he claimed it took an entire day to feel “normal” again.

During the assessment of his symptoms, the patient denied that he had laboured breathing, heart palpitations, nausea, and choking sensations, but admitted that he did have trembling, sweating, light-headedness, and a fear that he would die if he did not get outside. The patient reported that he had a need to be “active.” Upon further investigation by the doctor, the man remembered a similar series of episodes almost thirty years earlier following eye surgery. The patient was confined to his bed for days with eye patches and an apparatus to prevent head movement. Once the confinement was over, the patient experienced the recurring symptoms for more than a year.

The retired lumberman said that he was sleeping and eating well and had not gained or lost weight. He told the doctor that he did not have crying spells, urinary incontinence (loss of bladder control), or a decrease in energy. He did state that he had been taking Valium each day (5 to 10 mg) for the last two months to help decrease feelings of nervousness and tension. He also noted mild memory problems, some difficulty with balance, and pain in his right arm. His difficulty with balance prevented him from summer gardening as did his difficulty with the co-ordination of brisk walking and other movement. He was also found to have a “beefy” red tongue which gave him considerable discomfort. A medical examination discovered a form of anemia (macrocytic) and a vitamin B12 deficiency. The patient was given a B12 replacement that effectively stopped his panic attacks.

Diagnosis

The patient described symptoms typical of panic disorder; however, laboratory findings showed a vitamin B12 deficiency. Consequently, a diagnosis of organic anxiety disorder was made because the B12 replacement therapy effectively stopped the episodes. Regarding the episodes of panic earlier in his life (in the absence of a known organic cause), it is assumed that he then had panic disorder. The current organic anxiety disorder may be a manifestation of an underlying vulnerability to panic attacks. See below for a DSM summary.

Axis I: Organic Anxiety Disorder

Axis II: No diagnosis or condition

Axis III: Vitamin B12 deficiency

Axis IV: Severity: 1 – none

Axis V: Current GAF: 0
            (insufficient information)
            Highest GAF past year: 0
            (insufficient information)

Teen Mental Health

http://teenmentalhealth.org/learn/mental-disorders/obsessive-compulsive-disorder-ocd/

Description

At an interview, a 14 year-old girl was recalling how her life was just one year earlier. As a 13 year-old, she was obsessed with germs. She was afraid they were all over her clothes and other belongings. She shook the germs from her clothes for thirty minutes before wearing them. She would wash her hands before washing her face. She would then wash her hands again before getting dressed. At her worst point, she used rubbing alcohol for washing – this caused her hands to bleed. These rituals often left no time for breakfast before going to school. At the most severe point with the disorder, she had to get up at 6:00 a.m. just to get ready for an event at 11:00 a.m., but her disorder was so severe that, on occasion, even five hours were insufficient to prepare to leave the house.

The teen also had some obsessions and compulsions regarding numbers. For example, she would often re-read things three times. She would also mentally say “three” (or a multiple of three) to “clean” germs from “dirty” words. In one day she might say a multiple of three over 124 times! She was very much afraid that something bad would happen if she did not perform her rituals – although her friends told her that the behaviour was “stupid,” to which she agreed. She even began worrying that something bad would happen to her family if she did not perform her rituals.

After treatment, the girl was much better. On occasion, she still reads things three times if she has trouble understanding the content the first time, but she is able to get up, brush her teeth, shower, and get dressed in half an hour!

Diagnosis

The girl vividly displays symptoms of severe obsessive compulsive disorder. Her obsessions and compulsions are a major source of stress to her and interfere with her daily functioning. Her obsessions are based on ideas that interject themselves into her consciousness and are experienced as senseless. Her need to neutralize such thoughts has led to repetitive and persistent compulsions. For example, washing hands for hours at a time to prevent infection by germs (to the point that her hands were bleeding) was clearly excessive. She reacted as though the dangers were real despite knowing they were not.

While she does display evidence of OCD, she does not display obsessive compulsive personality disorder – a disorder that involves such traits as perfectionism, indecisiveness, and a restricted ability to express warm and tender emotions. She did, however, admit to an episode of major depression – a common occurrence with OCD sufferers. Her DSM diagnosis for Axis I is obsessive compulsive disorder - Severe

Teen Mental Health

http://teenmentalhealth.org/learn/mental-disorders/generalized-anxiety-disorder/

Teen Mental Health

http://teenmentalhealth.org/learn/mental-disorders/social-anxiety-disorder/

Description

Voluntarily seeking treatment, a 28 year-old computer programmer describes fears that prevent him from going to see his terminally ill father-in-law in the hospital. He explains that he is afraid of situations relating to bodily injury or illness. He does not like to have a blood sample taken or to see or hear about sick people. He does not seek medical treatment when he is sick nor does he visit sick friends or family members. He avoids listening to descriptions of medical procedures, bodily trauma, or disease. He even became a vegetarian to avoid thinking about killing animals.

When the programmer was nine years-old, his Sunday school teacher gave a descriptive account of a leg operation. As the teacher spoke, the patient began to feel anxious and light-headed. He then began to sweat profusely until he fainted. He also told of his dislike of vaccinations and other regular medical procedures throughout his school career. He recounted frequent fainting episodes and near-fainting episodes whenever he saw a sick or disfigured person. Even into adulthood, he would faint if he observed the slightest physical wound or heard of an injury or illness. He told the doctor of his recent encounter in a store with someone who was confined to a wheelchair. He started to wonder if the person was in pain – so much so that he became distressed and fainted. He was very embarrassed when he regained consciousness. The patient described no other emotional problems, enjoyed work, had a good marriage, and had many friends.

Diagnosis

The computer programmer had a fear of thinking about or being near any situation involving physical injury or illness. While he continued to avoid situations that may elicit an episode of fainting, he acknowledged that his fear was irrational. Although the avoidance behaviour did not appear to affect his normal routines and social life, he was distressed about his fear and wished to rectify the situation. The programmer did not have an obsession regarding germs, so an OCD diagnosis was not warranted. Post-traumatic stress disorder was also not implied because he did not observe mutilation or injury on the battlefield. The diagnosis, therefore, was simple phobia - specifically, a blood-injury phobia. Like many others who have this phobia, the patient felt faint in the presence of the phobic stimulus. His DSM diagnosis for Axis I is simple phobia.

Description

After watching a television show relating to eating disorders, a 23 year-old woman requested admittance to the treatment program highlighted on the TV show. To be admitted, she had to describe her eating behaviour. She began her story describing her desire to lose weight in college. She started to use a few laxatives but, with continued use, her current dose became ineffective. She gradually increased the dosage until she was taking 250-300 pills at one time, downing 20 pills with one swallow of water. She lost weight – as much as 20 pounds in a 24-hour period (mostly water), but became so dehydrated that she could not stand and could barely talk. Sometimes the woman would not eat for days. Then, with the first bite of food, she would be so overcome with guilt and hunger that she would binge. After speaking with a friend from the same dormitory at college, she learned that vomiting after the binges would prevent weight gain. She learned that she could eat large amounts of food, then induce vomiting, and still lose weight. Her weight dropped to 90 pounds. At this time her hair started to come out in handfuls and her teeth were loose.

Despite how she looked to others, the patient never felt happier about her appearance. She was flat everywhere and each rib and back vertebra could be seen when she bent over. The more weight she lost, the more worried she became about becoming fat. She was afraid of drinking water for days at a time because it added pounds on the scale. She did drink, however, to help her vomit after a binge. Binging was so successful that she stopped using the laxatives despite complaining of constipation. In fact, the mere sight of laxatives made her nauseated.

The patient exercised for many hours each day to tone her figure. She even joined the college track team, but she had to quit because she could not complete one lap. She vomited before practice which made her too dizzy to run. At this time she had not menstruated in two years. During her last semester before she dropped out of college she read an article on anorexia nervosa. The article scared her into trying to eat and digest healthy food.

While she loathed eating nutritious food items, she forced herself to do so and accepted a new attitude regarding food. At 5’6” and fighting panic, she inched her weight to a range of 105 and 115 pounds. She would only eat nutritious food (no junk food or sweets) but became reclusive in her home as she was embarrassed to be “so fat.” She also began to push away friends and activities that used to make her life complete. The patient, however, was able to hold a job despite binging, purging, and feeling sick all the time.

Her binging and purging was harder to perform each time, and the act took longer to complete. She needed to use different instruments (e.g., electric cords) to help her vomit as well as six to ten doses of ipecac (a substance that induces vomiting). Her knees became calloused from the time she spent kneeling while throwing up. Sometime a session of vomiting would last two to three hours but could also last as long as eight hours. A vomiting session left her dehydrated, cold, and shaking with broken blood vessels in her eyes.

In her letter to the treatment centre, the patient described her desire to break free from her overwhelming eating disorder. She cried for help from behaviours such as isolation, taking Aspirin® for the pain in her hands, taking potassium supplements (to counteract the diuretics she took), shoving cords down her throat, and spending hours heaving into the toilet. It was easily decided that she was a suitable candidate for treatment.

Upon her inclusion in the treatment program it was learned that her eating disorder began during her teen years. At 14 years-old, and at her adult height of 5’6”, she believed she was fat at 128 pounds. She began to diet, unsuccessfully, soon reaching 165 pounds. Not wanting to gain any more weight, she began to diet seriously and dropped to 130 pounds. At this time she felt depressed, overwhelmed, and insignificant. She also wanted to maintain an “A” average at school, so she avoided difficult classes and began to lie to avoid humiliation. She had extreme anxiety regarding the opposite sex and thus transferred to a girls’ school for her last year of high school. As attested to in her letter, her eating and dieting became drastically worse in college. Although she decided to gain weight from her low of 88 pounds, her binging and purging got worse and she dropped out of college. The patient is the only daughter of four children. She comes from an upper-middle-class family with an alcoholic father. The parents have a strained relationship, and the relationships between her parents and her brothers are strained. No other family member has had psychiatric treatment.

Diagnosis

The patient obviously displayed the features of anorexia nervosa. She had an intense and irrational fear of becoming fat although she was dramatically underweight. Her self-perceived body image was so unrealistic that while she thought she was fat, others thought she was normal. When she thought she was beautiful, others saw a grotesquely thin skeleton. Despite being hungry, the woman lost 30% of her body weight through dieting, vomiting, excessive exercise, and the use of drugs. This information resulted in a diagnosis of anorexia nervosa. Because she also binged and purged at least twice a week for three months, the additional diagnosis of bulimia nervosa was made.

Her DSM diagnosis is as follows:

Axis I: Anorexia Nervosa, Severe
          Bulimia Nervosa, Severe

Follow Up

During her treatment the patient was able to give up diuretics and other medication completely. After returning home, she continued psychiatric treatment for about six months until her family withdrew their support. During that period she had made some progress, but she was unable to change most of her behaviour. Two years after leaving treatment, she wrote to the hospital saying that she was “much better”, that she had returned to college and was seeing a nutritionist and counsellor. Her weight was normal and she was menstruating regularly despite the occasional episode of binging and purging. She was no longer using diuretics or laxatives.

Description

A small five year-old boy was admitted to hospital for nutritional anemia, the cause of which appeared to be his ingestion of paint, plaster, dirt, wood, and paste. He began adding non-food items to his diet at 19 months of age when he ingested lighter fluid. The patient came from a poor welfare family – his parents were young, immature, and dependent. He was the result of the unplanned pregnancy to a 16 year-old mother. Although his mother began eating dirt when she was pregnant, the pregnancy itself was uneventful. His father periodically used drugs and alcohol.

Diagnosis

The eating of non-nutritive non-food items can be seen in other disorders such as autism, schizophrenia, and Klein-Levin syndrome. When there are no other symptoms of such disorders, a diagnosis of pica is made. Pica is often associated with a common history in the mother and low socioeconomic status – much like this case. The DSM diagnosis for Axis I is pica.

Description

A 34 year-old woman came for counselling regarding problems in her marriage. She was wealthy and she had married a successful businessman. She felt her husband was demanding and insensitive; he accused her of being a self-centred compulsive liar. During their marriage, each partner had numerous affairs, which each confessed to, and both partners resolved to stop. The affairs, however, would eventually begin again, on and off, for most of their ten-year marriage. The woman also described a special problem that caused her much concern. She had urges to go to expensive clothing stores and steal an item of clothing. Without her husband’s knowledge, she had over the last few years stolen several items. Although she had more than enough money to buy the items, she rarely stole expensive items. Some stolen items she did not even wear. She realized that her behaviour was irrational.

The patient would become aware of a craving to steal several days before she went “shopping.” Gradually, the desire built in her mind until, impulsively, she walked into a store and stuffed an item of clothing under her coat or in a bag. Once she was safely out of the store, she experienced a great sense of relief and contentment. When she arrived home, however, she felt tense and guilty.

She also told the doctor about how successful and accomplished she was – that she was superior, beautiful, and talented.

She also noted that her husband was handsome, aggressive, and successful – a perfect match for her. Because their marriage was not trouble-free, she decided that it was due to her husband’s unreasonable expectations of her and his not spending enough time with her. She did, however, confess to telling “white lies” to her husband instead of admitting that she had done something “stupid.”

Diagnosis

While the reason for seeking treatment was marital difficulties, the information makes obvious that the woman was a kleptomaniac. She could not resist the urge to steal items (most of which she didn’t like or need) and felt both relief and remorse after doing so. The acts of theft were not due to revenge or anger. Her kleptomania did not seem related to her marital difficulties. She did display some narcissistic personality traits (such as exaggerated sense of superiority, lack of empathy, lying) that also linked to her need for admiration and attention from various lovers through her numerous affairs. Her lack of other traits (such as indifference, rage, preoccupation with envy), however, did not warrant a narcissistic personality disorder diagnosis.

Because the patient’s main concern is her marital difficulties, not kleptomania, marital problems are noted first on the DSM diagnosis below.

Axis I: Marital Problem
          Kleptomania

Axis II: Narcissistic personality traits

Description

A distraught mother brought her six year-old son into a hospital emergency room because she was afraid that she could no longer prevent him from setting fires.

She was especially afraid that he would set their house on fire while she and her 10 year-old daughter slept. Since the boy was four, he had shown an unhealthy fascination with fire. He had set several fires in the past two years, all of which his mother had found and extinguished. She noted that her son was sneaky about setting the fires, making it increasingly difficult for her to monitor.

The boy told the doctor that he sets fires because a “man in his head” tells him to – and that he is afraid to disobey the man for fear of physical punishment. The mother does not take this reason seriously as he has given a variety of other reasons in the past, depending on to whom he was speaking. Both mother and son agreed that he started the fires in retaliation against his mom when he was angry with her.

The first fire the boy set involved burning holes in plastic bed sheets. When his mother found out, she hit him on the hands and told him about the dangers of fire. The second incident occurred after the mother painted a door frame. Her son tried to burn the door frame with a lighter. He was not hit, but he had his bicycle privileges revoked for one week. The third episode occurred when the mother was asleep. Her son had set the garbage on fire and then beat the fire out with a broom. She awoke to an odd smell and found her son running around the house in a peculiar manner. With the fourth fire, the boy burned a dishtowel and threw it in the garbage. When his mother found out, she sent him to bed. Afterwards she explained how dangerous fires were. The last fire involved a toy in a Styrofoam® box. The boy burned holes in the box where the toy’s feet and arms would be. The mother also found her son attempting to smoke in the bathroom. Once again, she talked about the dangers of fire. She explained that fires get bigger with alcohol and smaller with water. In these discussions, the boy became very excited but promised to stop playing with fire.

The mother remarked that her son missed his friends from their old neighbourhood and that he was unhappy in school. She believed that her son had no friends outside of school and that both her children often complained of being bored. Other than the fire-setting behaviour, no other aggressive behaviours were exhibited by the boy. He was occasionally difficult to discipline, but the mother said that was because he ignored her. The boy’s teacher was surprised to hear of the fires. The teacher described the six year-old as lovely, bright, and obedient – a student who worked and played well with others.

The 26 year-old mother admitted to becoming violently angry at times, so much so that she was not able to control herself. She even said that she had made her son put his hand in a gas flame to teach him that fire hurts. Later, however, she denied this fact despite the fact that her son confirmed her original story.

The boy, except for the burn, was physically healthy. Emotionally, however, he was guarded and distrustful when interviewed. This distrust was due, in part, to fear of his mother’s reaction. Eventually, he shared that he loves to talk about fires. Although he knew that he could get hurt or even killed by fire, he was fascinated by them. When speaking about fires, the boy’s affect was inappropriate. He laughed at the wrong times and/or have blunted emotion when he should have more passionate feelings. He also appeared genuinely frightened of the “man in his head.”

Diagnosis

The setting of fires can be symptomatic of conduct disorder. The six year-old, however, has no other antisocial problems and performed well at school – working well with both peers and his teacher. It is doubtful that he set fires as political statements or for insurance purposes, but evidently he derived much pleasure and excitement from fire and fire-setting. Although documenting such information in a young child is difficult, it can be inferred that there was tension before the boy set the fires. Therefore, the diagnosis is pyromania, an ICD. Because he had no other signs of psychotic behaviour apart from the “man in his head,” and because his reasons for setting the fires varied, an additional diagnosis of a psychotic disorder is not made.

His overall diagnosis in Axis I is pyromania.

Description

A young woman sought treatment at a dermatology clinic for her increasing baldness at the crown of her scalp. The clinician did not find any disease relating to a dermatological cause, so the 25 year-old was referred to a psychiatrist. She told the psychiatrist that, since she was a child, she pulled out single hairs from the top of her head after twisting the strand of hair around her finger.

She generally performed the behaviour when alone, tired, bored, or reflecting over a stressful event.

After pulling the single hair from her scalp, she would inspect it and run it over her lips. She would continue this behaviour for several minutes at a time. The plucking of the hair did not hurt – in fact, it produced a sense of release. The woman hid her “thinning” hair by wearing it up, but eventually the baldness was too difficult to hide. She sought help when she realized that she may have to wear a wig.

The woman also spoke of temper problems, drinking too much, and having unsatisfying relationships. Other than linking her hair-pulling to the childhood absences of her mother, she described no other causal link or health problem. As her treatment sessions progressed, it was learned that the patient had experienced many traumatic events as a child. For example, her father (who was a barber) died from cancer. The patient described herself as clean and orderly, but noted that she smoked a pack of cigarettes per day. She also admitted to experimenting with drugs such as speed and marijuana, but because they made her paranoid, she discontinued their use.

Diagnosis

While stroking and fussing with hair is a common practice for many people, in this case the behaviour of hair pulling increased to the point of alopecia (baldness). The patient was unable to control the desire to pull out her hair, and she experienced a sense of relief from the action. Because no dermatological reason is apparent for the hair loss, these symptoms are sufficient for a trichotillomania diagnosis. Although not in this case, this disorder often begins in childhood and is frequently connected with intellectual disorders (mental retardation).

Her DSM diagnosis is Axis I: trichotillomania.