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How to Formulate a Diagnosis in Complicated Youth

How to Formulate a Diagnosis in Complicated Youth. MICHAEL J. LABELLARTE, SR., M.D. Annapolis, Millersville, Towson, and Columbia, MD dr.labellarte@cpeclinic.com cell:443-956-2463 www.cpeclinic.com. Transparency. No current conflicts of interest Assistant Professor, Part Time

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How to Formulate a Diagnosis in Complicated Youth

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  1. How to Formulatea Diagnosis in Complicated Youth • MICHAEL J. LABELLARTE, SR., M.D. • Annapolis, Millersville, Towson, and Columbia, MD • dr.labellarte@cpeclinic.com • cell:443-956-2463 • www.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

  3. Interventions Pharmacology Psycho-Social School-Based

  4. Outline • Traditions- highlight The Perspectives • The Role of Bias • Guild/setting approaches • DSM-5 approach • NIMH approach

  5. 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.

  6. 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.”

  7. The Perspectives • Disease perspective • Dimensional perspective • Behavioral perspective • Life Story perspective

  8. The Disease Perspective • A disease is a mechanistic syndrome • What a person has • A disease requires cure or amelioration

  9. The Disease Perspective • Parkinson’s • Schizophrenia • Autism spectrum disorder (ASD)? • Bipolar Disorder • Depression • Obsessive compulsive disorder • Tourette’s • ADHD • Etc.

  10. The Dimensional Perspective • Intelligence • Learning Disorders • Communication issues • Personality • ASD?

  11. The Dimensional Perspective • A dimension has relative value • Who a person is • Dimensional extremes require guidance

  12. Temperament Example: ADHD • “Difficult”? • “Defiant”? • Unstable? • Extroverted? • Too open? • Disagreeable? • Not concientious?

  13. The Dimension of Intelligence Hulk Dr. Bruce Banner * * 100 130 70 Intelligence Quotient (IQ)

  14. The Eysenck Circle (1958) Unstable Moody Anxious Rigid Sober Pessimistic Reserved Unsociable Quiet • Touchy • Restless • Aggressive • Excitable • Changeable • Impulsive Optimistic • Active Introverted Extroverted Passive Careful Thoughtful Peaceful Controlled Reliable Even Calm Sociable Outgoing Talkative Responsive Easygoing Lively Carefree Leadership Stable

  15. The 5 Factor Model (FFM) • Stable ---------- Unstable • Extroverted ---------- Introverted • Open to new ---------- Closed to new • Agreeable ---------- Disagreeable • Conscientious ---------- Not conscientious

  16. The Behavioral Perspective • Motivated vs. Maladaptive behaviors • What a person does • Stop “bad” behavior

  17. Motivated Behaviors • Disorders of eating • Disorders of sleep • Disorders of sexual expression • Substance misuse

  18. Maladaptive Behaviors • Oppositional • Self-centered • Contextual • Often learned

  19. 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

  20. Preferences and Bias • Disease • Dimension • Behavior • Lif Story 20

  21. Contrasting Dx Approaches • Clinical diagnosis • Standardized testing • Setting specific 21

  22. Framing Bias:Everyone is an Expert

  23. 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

  24. Pharmaceutical Controversy:Stakeholders • Federal Government • Academic Community • Treatment Community

  25. Assessment Errors • Cliché errors • Desperation • Insufficient data • Lack of comprehension • Misattribution errors • Misinformation • Oversimplification • Relationship errors • Reformulation to avoid labels/medications

  26. “Expert” Errors • Relationship errors • Primary attribution error • Misattribution errors • Cliché errors • Reformulated symptoms to avoid stimulants

  27. Primary Attribution Error • Your behavior is suspect, based on your flaws • My behavior is a rational response to a situation (including your flaws)

  28. 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…”

  29. 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…”

  30. 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”

  31. ADHD: Misattribution Errors • Bad seed • Boys will be boys • Poor parenting • Normal response to stress

  32. What is ADHD, Really? • Attention deficit: cannot ignore competing stimuli • Hyperactive/Impulsive: equivalent • Disorder of executive function (EF) • EF frames the ADHD symptoms

  33. 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

  34. 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

  35. Impairment of Executive Function • Activation • Attention • Effort • Emotion/Affect • Memory • Action • Brown TE, 2000, 2008

  36. 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

  37. 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

  38. 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”

  39. 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

  40. 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

  41. RDoC • Negative Valence Systems • Positive Valence Systems • Cognitive Systems • Social Processing Systems • Arousal/Modulatory Systems

  42. 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

  43. 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)

  44. DSM-5 Metastructure Changes • Regrouping of disorders • Putative underlying factors • Underlying vulnerabilities • Groups juxtaposed by relationship • Within groups, ordered by age of onset

  45. 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

  46. Life Cycle: ADHD Symptoms • Preschool: more hyperkinesis • School age: inattention appears • Adolescence: inner restlessness • Adulthood: inattentive complaints, but impulsivity reigns

  47. 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”

  48. Co-morbid vs. Diff. Dx? • Common disorders co-exist w ADHD • Common disorders also masquerade as ADHD • Co-morbidity amplifies symptoms

  49. SA BPAD MDD Personality Anxiety Tics Behavior LD ADHD S/L ASD School Referral, “ADHD”, age 7 20

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