Psychopathology & Evidence-Based Interventions

1. Psychopathology & Evidence-Based Interventions A Case Study of Adolescent Anxiety & Depression Presented by: Jessica Stewart

2. The Case • Emma • 14 year old female • Patient at Amherst Pediatrics • Mom brought her in specifically because of mental health concerns: • Depression • Anxiety • After her first appointment, she was referred to CATS, but did not follow through on the referral… • Began being seen at Amherst Pediatrics

3. Medical History • Access to patient medical records • No major medical concerns…

4. Psychological Assessment • Mental Status • Patient presents as clean and well-groomed • Appropriate eye-contact • Clear speech • Appropriate thought process • No preoccupations or hallucinations • Slightly higher than average intelligence

5. Presenting Problems • Cutting • Main reason mom brought her in • Only 1 minor cut, a year ago – not on ongoing issue • Depression • Onset: about 1 year ago • Moderate Intensity • Anxiety • Onset: about 1 year ago • Moderate Intensity • No previous treatment for any issues

6. Family • Mom was recently hospitalized for several months due to mental health issues • Mom and Dad were separated but Dad moved back in to help with the family during Mom’s hospital stay • 10 year old sister; some rivalry • Negative relationships with both parents • Very high standards and little support for Emma (not the same for sister)

7. Substance Use • No serious substance use • Has tried alcohol a few times, but never in excess

8. Social Support • 1 genuine friend: Jenna • Mostly negative interactions with peers at school; some bullying • Mostly negative interactions with peers at cheerleading • No current romantic relationships • Poor social skills • Very little social support

9. Coping and Strengths • Good self-awareness • Music • Exercise • Confident • 1 positive friendship – someone Emma can talk to when she is feeling down • Paternal Aunt

10. Lethality • Cutting • Occasional passing thoughts of self-harm • No planning • No threats • No previous attempts • No history of violence

11. Clinical Assessments • Columbia Depression Scale • Completed by Emma and Mom • Scored “Moderately Likely” for depression • Screen for Anxiety Related Disorders (SCARED) • Completed by Emma and Mom • Scored significant for Panic Disorder (or significant somatic symptoms), Anxiety Disorder and Social Anxiety Disorder

12. Biopsychosocial Formulation • Emma has so much going on her in world right now that has contributed to her current state: • Family history of mental illness • Family structure going through so many dramatic changes • Mom hospitalized • Dad returning home • Emma’s parentified role • Social Struggles at school and extra-curricular activities

13. Diagnosis • 311 Other specified depressive disorder: depressive episode with insufficient symptoms • 300.02 Generalized Anxiety Disorder • V61.20 Parent-Child Relational Problem • V62.4 Social Exclusion or Rejection

14. 311 other specified depressive disorder: depressive episode with insufficient symptoms • This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive diagnosis class • Why Not Major Depressive Disorder? • Because patient only meets three of the required criteria (5 needed for diagnosis) • Depressed Mood most of the day, nearly everyday • Feelings or worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) • Diminished Ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) • Also could have used 311 Unspecified Depressive Disorder, but chose to be more detailed

15. 300.02 Generalized Anxiety Disorder • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). • The individual finds it difficult to control the worry. • The anxiety and worry are associated with three (or more) of the following symptoms (with at least some symptoms having been present for more days than not for the past 6 months). NOTE: Only one item is required in children • Restlessness or feeling keyed up or on edge. • Being easily fatigued. • Difficulty concentrating or mind going blank. • Irritability • Muscle Tension • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

16. 300.02 Generalized Anxiety Disorder • The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). • The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder (social phobia), contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

17. V61.20 Parent-Child Relational Problem • This category should be used when the main focus of clinical attention is to address the quality of the parent-child relationship or when the quality of the parent-child relationship is affecting the course, prognosis or treatment of a mental or other medical disorder. Typically the parent-child relational problem is associated with impaired functioning in behavioral, cognitive or affective domains. • Behavioral: • Inadequate parental control, supervision and involvement • Parental overprotection • Excessive parental pressure • Arguments that escalate to threats of physical violence • Avoidance without resolution of problems • Cognitive: • Negative attributions of others’ intentions • Hostility towards or scapegoating of the other • Unwarranted feelings of estrangement • Affective: • Feelings of sadness, apathy or anger about the other

18. V61.20 Parent-Child Relational Problem • Mom’s depression keeps her from fulfilling her role as mother and has caused stress between her and Emma. • Mom is overly attached to both daughters, not allowing them to “leave” her to spend time in social settings (particularly on weekends) • Explosive arguments with both parents • Dad has rigidly high expectations for Emma and is very critical of her. • Emma has had to step into a more parentified role during her family’s ongoing crisis which has shifted the family balance.

19. V62.4 Social Exclusion or Rejection • This category should be used when there is an imbalance of social power such that there is a recurrent social exclusion or rejection by others. Examples of social rejection include bullying, teasing, and intimidation by others; being targeted by others for verbal abuse and humiliation; and being purposefully excluded from the activities of peers, workmates, or others in one’s social environment. • Cheerleading • School

20. Evidence-based Interventions • Cognitive Behavioral Therapy • The “go-to” treatment for both Anxiety and Depression • Strongest Empirical Support for Anxiety • Higher global functioning in patients treated with CBT and SSRIs than those treated with medication alone • TORDIA trial • Medication and CBT • Continued treatment for depression among treatment-resistant adolescents results in remission in approximately one-third of patients • Person-Centered Therapy • As effective as CBT • Depression seen as a result of a discrepancy of self-image to self-ideal • Emphatic Understanding • Unconditional Positive Regard

21. Evidence-based Interventions • Pharmacologic Interventions • Selective Serotonin Reuptake Inhibitors (SSRIs) • First choice of medication for children • Anxiety • Depression • Ideally used in combination with therapy • Interpersonal Therapy for Adolescents (IPT-A) • Goal: reduce depressive symptoms by improving interpersonal functioning

22. Evidence-based Interventions • Attachment-based Family Therapy (ABFT) • Goal: to improve relationships, repair relational wounds and increase empathy among family members • Family factors that are linked to the development, maintenance, and relapse of child and adolescent depression: • disengagement or weak attachment bond • high levels of criticism and hostility • parental psychopathology • ineffective parenting • Five Tasks: • Relational Reframe Task - Shift the focus from fixing the problem family member to improving family relationships • Adolescent Alliance-Building Task – building the relationship between adolescent and counselor • Parent Alliance-Building Task – builds parental empathy for the adolescent • Attachment Task – Adolescent expressing emotions, parents being empathetic • Competence-Promoting Task – fostering the adolescents success and autonomy outside the home • 63 % saw clinical improvement (almost identical to the stats for CBT)

23. My Chosen Interventions • Person-Centered Therapy • Proven to be as effective as CBT • Emma is in need of support • Family Therapy - Eventually • Mom can’t currently participate • Once rapport is built I am hoping to get Dad involved • Potential paternal aunt involvement • Medication? • Potentially… • See where results are after therapy interventions are in place • Talk with her PCP

24. My Chosen Interventions • Relaxation Techniques • Deep Breathing and Progressive Muscle Relaxation to treat the somatic symptoms of anxiety • Found a few empirical articles, but UB did not own them • I use these techniques regularly with patients who experience panic attacks, or other somatic symptoms of anxiety • Why not CBT? • Distorted Thoughts?

25. Prognosis/Expectations • Fair-to-Good Prognosis • Actively Involved in treatment; good attendance and presence • Sincerely wants to improve • Resilient • Self-Aware • Possible Complications • Lack of support at home – work with family • Mom’s continued mental health crisis • Potential decrease in social involvement due to problems with cheerleading squad

26. References • Calati, R., Pedrini, L., Alighieri, S., Alvarez, M., Desideri, L., Durante, D., & ... De Girolamo, G. (2011). Is cognitive behavioural therapy an effective complement to antidepressants in adolescents? A meta-analysis. ActaNeuropsychiatrica, 23(6), 263-271. • Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, L., & Isaacs, L. (2002). Attachment-based family therapy for depressed adolescents: A treatment development study. Journal Of The American Academy Of Child & Adolescent Psychiatry, 41(10), 1190-1196. • Haimerl, D., Finke, J., & Luderer, H. (2009). Person-centered and experiential therapy of depression. International Journal Of Psychotherapy, 13(2), 18-25. • Labekkarte, M.J., Ginsburg, G.S., Walkup, J.T., & Riddle, M.A. (1999). The treatment of anxiety disorders in children and adolescents. Biological Psychiatry, 46, 1567-1578. • Maddux, J. E., & Winstead, B. A. (2012).Psychopathology: Foundations for a contemporary understanding. (3 ed.). New York: Routledge. • McCarty, C., Weisz, J. (2007). Effects of psychotherapy for depression in children and adolescents: What we can (and can’t) learn from meta-analysis and component profiling. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7), 879-886. • Ollendick, T.H & King, N.J. (1998) Empirically supported treatments for children with phobic and anxiety disorders. Journal of Clinical Child Psychology, 27, 156-157. • Reinecke, M., Curry, J., March, J. (2009) Findings from the Treatment of Adolescnets with Depression Study (TADS): What have we learned? What do we need to know? Journal of Clinical Child and Adolescent Psychology, 38 (6), 761-767 • Thomsen, P. (2011). Treating adolescents with depression and anxiety disorders, also looking at global functioning and general improvement. ActaNeuropsychiatrica, 23(6), 261-262. doi:10.1111/j.1601-5215.2011.00631.x