Stereotypic Movement Disorder [childhood disorder]

Many childhood disorders, especially those of a psychiatric form are controversial in nature.  For one, medicating children is a sensitive topic, which some adults highly disagree with.  In addition, no one wants their child to suffer the stereotypes of having a mental disorder and some may even deny their child has a problem. Studies may even be less conclusive because of the limited amount of years in childhood compared to adulthood. 

Stereotypic movement disorder, which consists of seemingly compulsive, repetitive, and nonfunctional behavior, is thought to occur in 2 to 3 percent of children and adolescents (Sadock, 2003).  While most children show some type of repetitive movements in early childhood, children with this disorder have behaviors that interfere with normal functioning or that cause self-inflicted bodily injury (2003). Stein & Christenson (1998) report this disorder is often overlooked and unseen in most psychiatric literature because it occurs most frequently in children with mental retardation; however, this disorder can occur in children of normal intelligence.

 

Because this diagnosis is often overlooked, it is rarely made (AACAP, 1999).  Stereotyped behaviors are seen frequently in other childhood disorders such as autism, but currently a comorbid diagnosis of both autism and stereotypic movement disorder cannot be made.  There is ongoing controversy over whether these stereotypic movements constitute the addition of an extra diagnosis (1999). In addition, the diagnosis criteria can be interrupted in a manner of ways. Freeman (2006) states one of the main diagnostic problems to occur is “The pattern itself can look indistinguishable from autistic stereotypies, but is much more prolonged than tics. Comorbidty (other disorders) are common, including tics, just to confuse everyone.”  Unfortunately, this disorder is likely under-diagnosed, while other similar disorders may be over-diagnosed.

 

To make matters even more difficult, in Stereotypic Movement Disorder there is a fine line between normal and irregular behavior.  Nail biting for instance, can be considered a symptom; but only when it is severe (Sadock, 2003). Other children exhibit behaviors such as head banging for a period of time, but the problem disappears as the child grows older.  Should they be diagnosed with this disorder? How long should you wait before the diagnosis should be made?  Though the DSM criteria lists “the behavior persists for 4 weeks or longer” (Sadock, 2003), when should body rocking or picking at the skin be considered a real danger? 

All of these aforementioned issues make the diagnostic process for Stereotypic Movement Disorder even more difficult.  Though the vast majority of the population has heard of disorders such as autism or schizophrenia, this disorder is widely unknown in individuals outside of the medical profession.  Further research and publications need to be put into place to raise awareness, and the next version of the DSM may benefit from clarification of this diagnosis.

 

References:

American
Academy of Child and Adolescent Psychiatry (AACAP).  (1999). Practice Parameters for The Assessment and Treatment of Children Adolescents, and Adults With Autism And Other Persuasive Developmental Disorders. Retrieved November 29, 2006 from http://www.aacap.org/galleries/PracticeParameters/Autism.pdf

Freeman, Roger.  (2006). Stereotypic Movement Disorder can be confused with tics and TS. Retrieved November 29, 2006 from http://www.tourette-confusion.blogspot.com/

 

Sadock, Benjamin & Sadock, Virginia. (2003). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

 

Stein, Dan & Christenson, Gary. (1998). Stereotypic movement disorder: A neglected problem.  Psychiatric Annals, vol. 28, p. 304. 

 

 

 

Methamphetamine dependence

 

Along with the normal criteria for substance dependence, individuals with methamphetamine dependence often present with dysphoria, insomnia, hostility, irritability, restlessness, and confusion (Sadock, 2003). Symptoms may resemble those of an anxiety disorder, but also include paranoid delusions and hallucinations (2003). A patient that comes with flushing or pallor, headache, fever, grinding of the teeth, shortness of breath, tremor, and/or ataxia may be suffering from methamphetamine dependence (2003). In addition, the increase of insomnia and restlessness, along with the decreased appetite, often induces anorexia.

The DSM-IV-TR includes categories for amphetamine-induced mood, anxiety, sleep, and sexual dysfunction disorders. The criterion for methamphetamine withdrawal is the same as that in cocaine withdrawal, as well as that of intoxication.

Sadock, Benjamin & Sadock, Virginia. (2003). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

Marijuana Dependence

 

The criteria for marijuana dependence can be best illustrated by the normal criteria for substance dependence. While the DSM-IV-TR lists cannabis dependence as a disorder, the only specific criteria it holds is for cannabis intoxication (Sadock, 2003). As in other substance disorders, individuals dependent on marijuana feel as if they must have the drug and will likely abstain from situations where they will be without it for any length of time. The use of marijuana is very controversial, and while it has been proven it produces psychological dependence in heavy abusers, there has not been solid proof that it causes physical dependence. However, cannabis has been known to produce symptoms of anxiety and in rare causes, cannabis-induced psychotic disorder (Sadock, 2003). While some symptoms of anxiety or restlessness may accompany the withdrawal of heavy marijuana use, there is no specific criterion or extreme withdrawal symptoms as seen with other substances.

Sadock, Benjamin & Sadock, Virginia. (2003). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

Cocaine Abusers

 

When a patient comes in with unexplained personality changes including irritability, lack of concentration, compulsive behaviors, insomnia and weight loss, then cocaine abuse should be considered (Sadock, 2003). Like alcoholics who will only participate in situations where drinking is acceptable or where they can “sneak a drink” in, cocaine abusers frequently run to a private area once or twice an hour to get high.

In some ways, cocaine abuse may be easier to recognize than alcohol abuse because of physical symptoms apparent even when an individual is sober and not experiencing withdrawal symptoms. The most common form of cocaine ingestion, “snorting”, often causes extreme damage to nasal cavity, in which users will often try to self-medicate with nasal decongestants (Sadock, 2003).

As in alcohol abuse, cocaine abuse can also cause psychotic, mood, anxiety, and sleep disorders. Symptoms of withdrawal include fatigue, unpleasant dreams, insomnia, increased appetite, or psychomotor irregularities (Sadock, 2003). Withdrawal symptoms are apt to be much less severe than those seen in heavy alcohol abusers, and with mild or moderate abuse, regularly reside within 18 hours (2003).

Sadock, Benjamin & Sadock, Virginia. (2003). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

Alcohol Dependence

 

Individuals suffering from alcohol dependence will experience an intense craving for alcohol, regardless of the hazardous effects they are experiencing due to its use. Once alcoholics start drinking, it becomes very difficult for them to stop. When they do stop for any period of time, withdrawal symptoms will occur (Sadock, 2003). Once a person has reached a tolerance to alcohol, he or she has to drink more and more to get the same “buzz” or “high”.

Alcohol becomes a person’s “best friend” and starts to take the place or other things that were once important: friends, family, career, church, hobbies, etc. Individuals with alcohol dependence may sustain from going anywhere alcohol is not allowed and plan their day around alcohol. However, they may hide a bottle or liquor in their attire and frequently retreat to a place where they can drink.

While most individuals who use, but don’t abuse, alcohol drink on special occasions or during dinner, for example; alcoholics will likely wake up with the urge for an alcoholic beverage as a substitute for coffee, per say. Whereas the occasional drinker likely enjoys the company of others while drinking, the alcoholic often drinks alone because he or she does not want others to know about his or her problem.

The need for alcohol is easily induced by stressful situations. Many alcoholics feel ill at ease, and not just physically, when they are without a drink. Guilt often arises, but this normally causes an individual to drink even more so they no longer feel responsible for their actions. Becoming extremely intoxicated to the point of experiencing blackouts is common for individuals suffering from alcohol dependence (Sadock, 2003). This dependence often leads to a plethora of problems- DUIs, spousal or child abuse, etc.

When alcoholic dependent individuals are required to abstain from drinking, the withdrawal symptoms can be severe. Tremors, nausea or vomiting, increased heart rate, insomnia, hallucinations, anxiety, and even seizures can occur (Sadock, 2003). Many mental disorders, including persisting amnestic disorder, psychotic disorder, anxiety disorder, and sleep disorder, can be caused by alcohol dependence (2003). When a history of excessive alcohol use is apparent or suspected along with a mental disorder, clinicians should create a time-line to differentiate whether the alcohol or mental disorder arose first to establish the correct treatment plan.

Sadock, Benjamin & Sadock, Virginia. (2003). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

When Does the Diagnosis Change from Substance Use to Abuse or Dependence?

 

When the excessive desire and intake of a substance causes the loss of a job, divorce or marital discord, imprisonment or arrest, financial hardship, mental or physical health deterioration, or other noteworthy difficulties, then the situation should no longer be categorized as substance use. When a person experiences social difficulties due to a substance, but no health or psychological problems, then he or she is likely suffering from substance abuse. When tolerance or withdrawal occurs simultaneously with social impediment, then the diagnosis of substance dependence is to be expected. There has been much debate regarding the real difference between substance abuse and dependence; and there is a fine line between the two, though they both cause substantial tribulations. However, when a person actually depends on a substance on a daily or hourly basis, physically or mentally, in a way that nothing else will suffice, then substance dependence is warranted.

Distinguishing Characteristics of Substance Use, Abuse, and Dependence

The term substance use can be defined as the intake through various means of both legal and illegal substances with the intention of producing a different state of mind or overall feeling, also known as “getting high”. In this context, the word “substance” has become the replacement for the word “drug”, because “drug” implies a manufactured chemical (Sadock, 2003). Substances such as opium or spray paint are often used to get high, but do not fit the technical criteria for the term “drug”. The topic of substance use is controversial in many respects; including, but not limited to, the areas of government religion, and the legal system.

If an individual has never met the criteria for substance dependence, but his or her substance use leads to social consequences, including the failure to complete responsibilities at school, home, or work; continual substance use in hazardous situations; recurrent legal problems related to substance use; or sustained substance use albeit experiencing persistent problems caused or aggravated by the effects of the substance, then he or she is suffering from substance abuse (Sadock, 2003).

While substance abuse is typically exposed by the social difficulties involved, substance dependence is related to the physiological and behavioral symptoms, commonly known as addiction. To meet the criteria for substance dependence, an individual must be experiencing impairment or distress in three or more of the following areas within a year (Sadock, 2003):
A. Tolerance: needing an increase in dosage to experience the same effect
B. Withdrawal: meeting the criteria for withdrawal or taking another substance to suppress withdrawal symptoms
C. Often taking the substance in excessive amounts or for a lengthy period of time
D. Having a constant desire or failed efforts to abstain from the substance
E. Spending an extensive amount of time in acquiring, using, or recovering from the substance
F. Reduction or absence in meaningful activities due to the substance use
G. Sustained substance use even after experiencing physical or psychological problems caused or aggravated by the effects of the substance
Substance abuse is often the precursor for substance dependence. However, in some cases, substance abuse may never turn into full-fledged substance dependence; likewise, preexisting substance abuse is not a requirement for substance dependence (Medical, 2003).

Disorganized or Residual Schizophrenia

The presentation of an individual with disorganized schizophrenia compared to one with residual schizophrenia will likely be quite opposite. A patient with disorganized schizophrenia will probably appear unkempt and display an inappropriate, silly, and childlike behavior (Sadock, 2003). They may laugh at the most serious of statements, as well as grinning and grimacing frequently. However, the extreme happiness may develop into extreme rage very quickly. The emotional liability of these patients is high. Before sedated or restrained, these patients may seem very anxious because of their constant activity, which normally consists of meaningless and often repetitive movements. Their speech will also come across in the same fashion. Though fairly spontaneous, it is normally unintelligible and may include rhyming and clanging. The break with reality is generally intense; and delusions and hallucinations may also accompany (2003).

On the other hand, someone with residual schizophrenia may seem to be withdrawn and show little emotions about anything (Sadock, 2003). They may appear very passive and even depressed because of their lack of initiative in speech or behavior. Speech is normally understandable, unlike in disorganized schizophrenia. However, one may link completely unrelated thoughts together or use nonverbal communication when possible. These patients usually have strange mannerisms or ways of thinking. They may wear eccentric clothing or have peculiar philosophies. Positive symptoms are very mild or infrequent. While delusions and hallucinations can occur, these are not prominent (2003).

While individuals with the paranoid schizophrenic subtype normally have a better prognosis, there is little variation on prognosis by subtype alone. If this was the first hospitalization for each patient, I would start by explaining the general prognosis for schizophrenia. I would inform them that only ten to twenty percent have a favorable outcome, but that the disorder does not always run a debilitating course (Sadock, 2003). In addition, I would tell them it is likely that their family member will have to be readmitted to the hospital within the next two years even with treatment.

After the general prognosis is described, I would then look at some of the other factors affecting the patient. If the patient is extremely young, has a family history of schizophrenia or perinatal trauma, a prior history of violence, or primarily negative symptoms (as seen in the residual type), then the outlook is probably going to be poor. I would then inform them that having the support or a family, friends, or spouse will improve the prognosis. On the other hand, if the patient is older, has a sudden onset, a positive social history, affective symptoms, or positive symptoms then I would say the prognosis is going to be brighter.

Reference:

Sadock, Benjamin & Sadock, Virginia. (2003). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

Schizophreniform vs. Schizoaffective Disorder

Schizophreniform and schizoaffective disorders share many of the same characteristics, but the main difference is that schizophreniform disorder is characterized by primary symptoms of schizophrenia, while schizoaffective disorder has to include both schizophrenic and mood disorder characteristics. In schizophreniform disorder, either no major affective episodes have occurred during the active phase of symptoms, or their total duration has been brief (Bhalla, 2006), compared to schizoaffective disorder where the affective symptoms must have occurred for a significant part of the disorder normally at a minimum of 15-20% (Sadock, 2003).

For an individual to be diagnosed with schizophreniform disorder, the symptoms of psychosis, those affecting speech and behavior, and the negative symptoms will last at a minimum of one month. To be diagnosed with schizoaffective disorder, a patient only has to have psychosis for 2 weeks without symptoms of a mood disorder (Sadock, 2003).

Both disorders have a prognosis somewhere between schizophrenia and mood disorders (Sadock, 2003). While schizophreniform disorder has an equal distribution among the sexes, schizoaffective disorder is more predominant in women. The age of onset, in early adulthood, is comparable in both disorders (2003). Schizoaffective disorder is thought to be around 2.5 to 4 times as prevalent as schizophreniform disorder, 0.2% to .05-.08%. Perhaps this is because the majority of schizophreniform cases evolve into schizophrenia before consultation?

Individuals with schizophreniform disorder can have the same symptoms as those with schizophrenia, but the symptoms must only last between one to six months. However, the onset in schizophreniform disorder is usually more rapid than that of schizophrenia. Unfortunately, sixty to eighty percent of patients with schizophreniform disorder progress to full blown schizophrenia (Sadock, 2003), while this does not seem to be the case in schizoaffective disorder.

While there is much disagreement about whether schizophreniform and schizoaffective disorders should have two different sets of criteria, the different methods of treatment support the idea that these disorders are separate occurrences. In schizophreniform disorder, the mainstay of treatment is an atypical psychotic for a period of three to six months (Sadock, 2003). In schizoaffective disorder, a combination of anti-depressant and anti-psychotic for the depressed subtype, or a combination of mood stabilizer and antipsychotic is utilized for the manic subtype (Brannon, 2005). This coincides with the criteria that schizophreniform is composed of primarily schizophrenic symptoms, while schizoaffective disorder is composed of both schizophrenic and mood disorder symptoms.

If someone presented with his or her first episode of symptoms that resolved within six months, the diagnosis would still be based on the symptoms themselves. Schizophrenia is automatically ruled out because of the short length of time, but either schizophreniform or schizoaffective diagnoses could be made. Though it would be easy to jump to the conclusion that the patient was experiencing schizophreniform disorder, someone with schizoaffective disorder could be in remission. In the patient has an equal, or significant, proportion of mood symptoms occurring along with the schizophrenic criteria, then a diagnosis of schizoaffective disorder would be warranted. Otherwise, the diagnosis would be schizophreniform disorder.

References:

Bhalla, Ravinder. (2006). Schizophreniform Disorder. Retrieved November 15, 2006 from http://www.emedicine.com/med/topic3350.htm

Brannon, Guy E. (2005). Schizoaffective Disorder. Retrieved November 15, 2006 from http://www.emedicine.com/med/topic3514.htm

Sadock, Benjamin & Sadock, Virginia. (2003). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

ADHD Diagnosis Controversy

While the majority of clinicians and health agencies recognize ADHD as a real disorder, there is a great deal of ongoing controversy within the general public. A Frontline television program entitled “Medicating Kids” showcased some of these controversial views (Gaviria, 2001). One interviewee, Fred Baughman, has been a child neurologist for 36 years and is an active opponent of the ADHD diagnosis. Baughman says while the American Psychiatric Association views ADHD as a neurobiologic disorder, the psychiatry field has never “validated ADHD as a biologic entity” (2001). He also declares that these children are all normal and it is the parents and teachers who do not want to accept the responsibility for being unable to control the child. Russell Barker, a professor of psychiatry and neurology at the University of Massachusetts and another interviewee, continues with the discussion of parent responsibility (2001). Barker states:

But there’s also concern because ADHD is a disorder that appears to violate a very deeply held assumption that laypeople have about children’s behavior. All of us were brought up believing, almost unconsciously, that children’s misbehavior is largely due to the way they’re raised by their parents and the way they’re educated by their teachers. If you wind up with a child who is out of control and disruptive and not obeying, that that has to be a problem with child rearing. … Well, along comes this disorder that produces tremendous disruption in children’s behavior, but it has nothing to do with learning, and it isn’t the result of bad parenting. And therefore it violates these very deeply held ideas about bad children and their misbehavior (Gaviria, 2001).

This statement by Barker provides a valid explanation for the continuous controversy over whether ADHD is, in fact, a real disorder. In opposition to Baughman’s opinion, Barker states that ADHD is a valid condition; and if other mental disorders such as Schizophrenia, Bipolar Disorder, etc. required proof, there would be no such thing as psychiatry (2001).

Peter Jensen, the head of child psychiatry for the National Institute of Mental Health, attributes much of this controversy to the fact that “there isn’t good consensus about the best way to draw the boundaries between ADHD and other syndromes” (Gaviria, 2001).
Another article also states that critics of the diagnosis argue that the criterion is vague enough to allow most children to be diagnosed with this disorder (Answers, 2006). For example, psychiatrist Simon Sobo M.D. disputes that the symptoms of ADHD depict children when they are uninterested and unconnected to a task (2006).

There are many other reasons for the controversy surrounding the ADHD diagnosis. Some individuals conclude that teachers consider any child who cannot be controlled in the classroom to have ADHD, while others go on to say that these stimulants given to children diagnosed with ADHD have an affect on anyone (Answers, 2006). Regardless, the psychiatry field supports the diagnosis of ADHD. The aforementioned concerns may be valid and too many children may receive the diagnosis of ADHD. However, there is overwhelming evidence some individuals are affected with ADHD, and that the diagnosis is real.

References:

Answers Corporation. (2006). Controversy about ADHD. Retrieved November 22, 2006 from http://www.answers.com/topic/controversy-about-adhd

Gaviria, Marcela. (2001, April 10). Medicating Kids [Television broadcast]. Boston, MA: Frontline of WGBH.

National Institute of Mental Health (NIMI). (2006). Attention Deficit Hyperactivity Disorder. Retrieved November 22, 2006 from http://www.nimh.nih.gov/publicat/adhd.cfm#intro

ADHD Diagnosis Difficulties

 

As most all children have periods of restlessness, impulsivity, and daydream from time to time, diagnosing ADHD can be difficult (NIMH, 2006).  Symptoms vary so much in different situations, which can make this diagnostic process even harder, especially when the primary symptom in inattentiveness. However, whenever these behaviors start affecting school performance or relationships with other children, for example, ADHD may be suspected. Due to this difficulty, the diagnostic process requires behavior that is inappropriate for the child’s age, and as aforementioned, have at least 2 areas of life affected by these behaviors (2006).  If either schoolwork or family life is the only thing affected, then a child should not be diagnosed with ADHD. In addition, clinicians should check to make sure these behaviors are not situational.  For example, a child may begin to show inattentiveness if a family member dies or his or her parents are divorced.  Medical problems should also be considered such as petit mal or temporal lobe seizures, hearing problems, or a different type of learning disability (2006).

 

National Institute of Mental Health (NIMI). (2006). Attention Deficit Hyperactivity Disorder.  Retrieved November 22, 2006 from http://www.nimh.nih.gov/publicat/adhd.cfm#intro

ADHD Subtypes

There are three recognized subtypes of ADHD:  hyperactive-impulsive type (does not show noteworthy inattention), predominately inattentive type (does not show noteworthy hyperactive-impuslive behavior), and the combined type (displays both inattentive and hyperactive-impulsive symptoms) (NIMH, 2006). Children with the hyperactivity-impulsivity type seem to be in constant motion, whether it be with talking, fidgeting, touching everything, etc. Impulsive children may utter inappropriate comments, be unable to wait their turn, and require immediate attention (2006).   Children with the inattentive type may get bored very easily, causing them to skip from one activity to another, become distracted by sounds or other irrelevant things, make careless mistakes, or forget things needed to complete a certain task.  These children, suffering from the inattentive type, are often overlooked because they may be very quite, get along sufficiently with other children, and appear to only be daydreaming (2006). 

National Institute of Mental Health (NIMI). (2006). Attention Deficit Hyperactivity Disorder.  Retrieved November 22, 2006 from http://www.nimh.nih.gov/publicat/adhd.cfm#intro

ADHD Overview

 

 

ADHD, or Attention-Deficit Hyperactivity Disorder, affects approximately 3 to 5 percent of children (NIMH, 2006).  Inattention, hyperactivity, and impulsivity are the three primary symptoms of the disorder, which can appear over many months. Various situations may cause an exacerbation of different symptoms (2006).  Teachers are often the first individuals to recognize a child’s symptoms, because a parent may think all children go through “phases” such as this. For a child to be diagnosed with ADHD, their symptoms must appear before the age of 7, consist for at least 6 months, and create a handicap in two areas of the child’s life (such as in the schoolroom and in social situations) (2006). 

National Institute of Mental Health (NIMI). (2006). Attention Deficit Hyperactivity Disorder.  Retrieved November 22, 2006 from http://www.nimh.nih.gov/publicat/adhd.cfm#intro