The Todd Family - Psych Week 2

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Contents

Background Information

The family includes Mr. and Mrs. Todd and their two children Mary and Bobby.

Mr. Todd is presently on disability as a result of a back injury suffered in a motor vehicle accident. He was employed in the building trades as a labourer. Mr. and Mrs. Todd separated some time ago when Mr. Todd left Mrs. Todd. He left the marriage because Mrs. Todd was not able to control Bobby�s behavior. Mr. Todd was physically assaultive to his wife and to Bobby. He is verbally abusive to all of the family members. He has a very limited ability to be reflective. Mr. Todd was raised in a home where his father was a rigid disciplinarian and regularly used spanking with a leather belt to discipline the children. The children often had bruises from the discipline. Mr. Todd�s father died several years ago and his mother is still living in the house where Mr. Todd was raised as a child. Mr. Todd moved into his mother�s home when he left his wife. Since living with his mother, Mr. Todd has taken over his mother�s finances. He has purchased a new car from her savings. He has had her sign over title to her house and her bank accounts to him. Mr. Todd�s siblings do not know about these financial transactions. Mr. Todd�s sisters visit their mother regularly and note that she has become very withdrawn since Mr. Todd moved into the home. She has become very unkempt and has a poor appetite. She spends much of the day sitting in her bedroom rather than tending her garden and knitting mittens for her church mission circle.

Mrs. Todd is a homemaker and has not worked outside of the home since she was married. She felt things were going well in their marriage prior to and for awhile after the birth of their first child, Mary. Mary was a cuddly infant and a happy child. Mrs. Todd described her as easy to raise. The Todd�s marriage started to deteriorate after the birth of Mary because Mrs. Todd no longer devoted all of her time to anticipating or complying with her husband�s requests. She was isolated from social supports including her family of origin. Her mother warned her against marrying her husband, whom she called "That Idiot". As Mrs. Todd�s marriage deteriorated, she started drinking. She became pregnant with Bobby. Bobby was very different from Mary in infancy. He was constantly irritable and would not settle at night. He looked different from his elder sister, having an unusually small head. Mrs. Todd became more despondent and her drinking increased. She was driving the car when the family was in a major accident. This accident resulted in the back injury that has prevented Mr. Todd from working. Mrs. Todd did not want to drive, as she was concerned about her alcohol consumption that evening. When she agreed to drive, she wanted to delay their departure until she was more sober but Mr. Todd insisted that they leave immediately. She was not physically injured in the accident. She has been treated for depression with medication and individual psychotherapy for a long time without any improvement. Family therapy was recommended as an adjunct to her therapy.

Mary, who has a long history of anxiety manifested by psychosomatic pain and phobias, moved out of the family home several years ago at the encouragement of a high school guidance counselor. She completed high school while living in a group home. She attended college and is employed. She resides in her own apartment but maintains a close relationship with her mother. She was in the car at the time of the accident but did not have serious physical injuries. She was wearing her seatbelt. She had some additional phobias after the accident and symptoms of post-traumatic stress disorder.

Bobby, an adolescent, resides with his mother. He was a sickly infant, appeared physically different than Mary at birth, and had a very difficult temperament. He had several fractures as a result of climbing trees. The family first sought help in relationship to Bobby when Bobby was 5 years old. During the assessment, he was diagnosed with fetal alcohol syndrome and attention deficit disorder. Stimulant medication was prescribed but was not very effective. Bobby was not wearing his seat belt when the family was in the car accident. He was thrown out of the car and sustained a head injury. He has residual brain damage. Following the accident he his functioning at school deteriorated and he quit school. He become involved with street drugs and has convictions related to theft as a Young Offender. He has spent time in jail.

Learning Issues

Disease

Discussion of disease topics this week should be limited to definitions and descriptions. Specific details of diagnosis and treatments for various psychiatric disorders are a major focus in 2nd year

Briefly define/describe/summarize affective disorders

From DSM-IV-TR The Mood Disorders section includes disorders that have a disturbance in mood as the predominant feature. The section is divided into three parts. The first part describes mood episodes (Major Depressive Episode, Manic Episode, Mixed Episode, and Hypomanic Episode) that have been included separately at the beginning of this section for convenience in diagnosing the various Mood Disorders. These episodes do not have their own diagnostic codes and cannot be diagnosed as separate entities; however, they serve as the building blocks for the disorder diagnoses. The second part describes the Mood Disorders (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar I Disorder). The criteria sets for most of the Mood Disorders require the presence or absence of the mood episodes described in the first part of the section. The third part includes the specifiers that describe either the most recent mood episode or the course of recurrent episodes.

The Mood Disorders are divided into the Depressive Disorders ("unipolar depression"), the Bipolar Disorders, and two disorders based on etiology�Mood Disorder Due to a General Medical Condition and Substance-Induced Mood Disorder. The Depressive Disorders (i.e., Major Depressive Disorder, Dysthymic Disorder, and Depressive Disorder Not Otherwise Specified) are distinguished from the Bipolar Disorders by the fact that there is no history of ever having had a Manic, Mixed, or Hypomanic Episode. The Bipolar Disorders (i.e., Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, and Bipolar Disorder Not Otherwise Specified) involve the presence (or history) of Manic Episodes, Mixed Episodes, or Hypomanic Episodes, usually accompanied by the presence (or history) of Major Depressive Episodes.

Generalized anxiety disorders

DSM-IV-TR Diagnostic criteria for 300.02 Generalized Anxiety Disorder

A. 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). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.

  1. restlessness or feeling keyed up or on edge
  2. being easily fatigued
  3. difficulty concentrating or mind going blank
  4. irritability
  5. muscle tension
  6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder. E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

Personality disorders

This section begins with a general definition of Personality Disorder that applies to each of the 10 specific Personality Disorders. A Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. The Personality Disorders included in this section are listed below.

Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent.

Schizoid Personality Disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.

Schizotypal Personality Disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.

Antisocial Personality Disorder is a pattern of disregard for, and violation of, the rights of others.

Borderline Personality Disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.

Histrionic Personality Disorder is a pattern of excessive emotionality and attention seeking.


Narcissistic Personality Disorder is a pattern of grandiosity, need for admiration, and lack of empathy.

Avoidant Personality Disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Dependent Personality Disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of.

Obsessive-Compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism, and control.

Personality Disorder Not Otherwise Specified is a category provided for two situations: 1) the individual's personality pattern meets the general criteria for a Personality Disorder and traits of several different Personality Disorders are present, but the criteria for any specific Personality Disorder are not met; or 2) the individual's personality pattern meets the general criteria for a Personality Disorder, but the individual is considered to have a Personality Disorder that is not included in the Classification (e.g., passive-aggressive personality disorder).

The Personality Disorders are grouped into three clusters based on descriptive similarities. Cluster A includes the Paranoid, Schizoid, and Schizotypal Personality Disorders. Individuals with these disorders often appear odd or eccentric. Cluster B includes the Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C includes the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders. Individuals with these disorders often appear anxious or fearful. It should be noted that this clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated. Moreover, individuals frequently present with co-occurring Personality Disorders from different clusters.

What is Fetal Alcohol Syndrome?

From Merck 17th edition: (See also Ch. 250.)

Maternal alcohol abuse during pregnancy is the most common cause of drug-induced teratogenesis. The most serious consequence is severe mental retardation due to impaired brain development, which is thought to be part of alcohol teratogenesis, given the number of infants of alcoholic women who are retarded. Severely affected newborns have growth retardation and are microcephalic. Malformations may include microphthalmia, short palpebral fissures, midfacial hypoplasia, abnormal palmar creases, cardiac defects, and joint contractures; no single finding is pathognomonic, and diagnosis of mild cases can be difficult because partial expression may occur.

Diagnosis is usually made in newborns born to chronic alcoholics who drank heavily during pregnancy. Lesser degrees of alcohol abuse result in less severe manifestations of the disorder.

Because it is unknown when during pregnancy alcohol is most likely to harm the fetus and whether there is a lower limit of ethanol use that is completely safe, pregnant women should be advised to avoid all alcohol intake. The siblings of an infant diagnosed with fetal alcohol syndrome should be examined for subtle manifestations of the disorder.

From Ch. 250 The incidence of fetal alcohol syndrome, one of the major consequences of drinking during pregnancy, is about 2.2 in 1000 live births. The syndrome includes growth retardation before or after birth; facial anomalies (eg, shortened palpebral fissures); joint contractures; cardiovascular defects; and CNS dysfunction, including microcephaly, varying degrees of mental retardation, and abnormal neurobehavioral development. The syndrome is a leading known cause of mental retardation; its incidence exceeds that of Down syndrome and cerebral palsy. In general, the extent of mental retardation is positively related to the severity of dysmorphogenesis. Microcephaly, a common feature, probably results from the overall decrease in brain growth. Perinatal mortality may occur, and the newborn may fail to thrive. The critical volume of ingested alcohol that results in this syndrome is unknown. In one study, the incidence of abnormalities did not increase until > 45 mL/day of alcohol (3 drinks/day) was ingested (see also Fetal Alcohol Syndrome under Metabolic Problems in the Newborn in Ch. 260).

What is Post-Traumatic Stress Disorder?

What is Attention Deficit Disorder?

From DSM-IV-TR

Attention-Deficit and Disruptive Behavior Disorders

Attention-Deficit/Hyperactivity Disorder

Diagnostic Features

The essential feature of Attention-Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development (Criterion A). Some hyperactive-impulsive or inattentive symptoms that cause impairment must have been present before age 7 years, although many individuals are diagnosed after the symptoms have been present for a number of years, especially in the case of individuals with the Predominantly Inattentive Type (Criterion B). Some impairment from the symptoms must be present in at least two settings (e.g., at home and at school or work) (Criterion C). There must be clear evidence of interference with developmentally appropriate social, academic, or occupational functioning (Criterion D). The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and is not better accounted for by another mental disorder (e.g., a Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder) (Criterion E).

Inattention may be manifest in academic, occupational, or social situations. Individuals with this disorder may fail to give close attention to details or may make careless mistakes in schoolwork or other tasks (Criterion A1a). Work is often messy and performed carelessly and without considered thought. Individuals often have difficulty sustaining attention in tasks or play activities and often find it hard to persist with tasks until completion (Criterion A1b). They often appear as if their mind is elsewhere or as if they are not listening or did not hear what has just been said (Criterion A1c). There may be frequent shifts from one uncompleted activity to another. Individuals diagnosed with this disorder may begin a task, move on to another, then turn to yet something else, prior to completing any one task. They often do not follow through on requests or instructions and fail to complete schoolwork, chores, or other duties (Criterion A1d). Failure to complete tasks should be considered in making this diagnosis only if it is due to inattention as opposed to other possible reasons (e.g., failure to understand instructions, defiance). These individuals often have difficulties organizing tasks and activities (Criterion A1e). Tasks that require sustained mental effort are experienced as unpleasant and markedly aversive. As a result, these individuals typically avoid or have a strong dislike for activities that demand sustained self-application and mental effort or that require organizational demands or close concentration (e.g., homework or paperwork) (Criterion A1f). This avoidance must be due to the person's difficulties with attention and not due to a primary oppositional attitude, although secondary oppositionalism may also occur. Work habits are often disorganized and the materials necessary for doing the task are often scattered, lost, or carelessly handled and damaged (Criterion A1g). Individuals with this disorder are easily distracted by irrelevant stimuli and frequently interrupt ongoing tasks to attend t trivial noises or events that are usually and easily ignored by others (e.g., a car honking, a background conversation) (Criterion A1h). They are often forgetful in daily activities (e.g., missing appointments, forgetting to bring lunch) (Criterion A1i). In social situations, inattention may be expressed as frequent shifts in conversation, not listening to others, not keeping one's mind on conversations, and not following details or rules of games or activities.

Hyperactivity may be manifested by fidgetiness or squirming in one's seat (Criterion A2a), by not remaining seated when expected to do so (Criterion A2b), by excessive running or climbing in situations where it is inappropriate (Criterion A2c), by having difficulty playing or engaging quietly in leisure activities (Criterion A2d), by appearing to be often "on the go" or as if "driven by a motor" (Criterion A2e), or by talking excessively (Criterion A2f). Hyperactivity may vary with the individual's age and developmental level, and the diagnosis should be made cautiously in young children. Toddlers and preschoolers with this disorder differ from normally active young children by being constantly on the go and into everything; they dart back and forth, are "out of the door before their coat is on," jump or climb on furniture, run through the house, and have difficulty participating in sedentary group activities in preschool classes (e.g., listening to a story). School-age children display similar behaviors but usually with less frequency or intensity than toddlers and preschoolers. They have difficulty remaining seated, get up frequently, and squirm in, or hang on to the edge of, their seat. They fidget with objects, tap their hands, and shake their feet or legs excessively. They often get up from the table during meals, while watching television, or while doing homework; they talk excessively; and they make excessive noise during quiet activities. In adolescents and adults, symptoms of hyperactivity take the form of feelings of restlessness and difficulty engaging in quiet sedentary activities.

Impulsivity manifests itself as impatience, difficulty in delaying responses, blurting out answers before questions have been completed (Criterion A2g), difficulty awaiting one's turn (Criterion A2h), and frequently interrupting or intruding on others to the point of causing difficulties in social, academic, or occupational settings (Criterion A2i). Others may complain that they cannot get a word in edgewise. Individuals with this disorder typically make comments out of turn, fail to listen to directions, initiate conversations at inappropriate times, interrupt others excessively, intrude on others, grab objects from others, touch things they are not supposed to touch, and clown around. Impulsivity may lead to accidents (e.g., knocking over objects, banging into people, grabbing a hot pan) and to engagement in potentially dangerous activities without consideration of possible consequences (e.g., repeatedly climbing to precarious positions or riding a skateboard over extremely rough terrain).

Attentional and behavioral manifestations usually appear in multiple contexts, including home, school, work, and social situations. To make the diagnosis, some impairment must be present in at least two settings (Criterion C). It is very unusual for an individual to display the same level of dysfunction in all settings or within the same setting at all times. Symptoms typically worsen in situations that require sustained attention or mental effort or that lack intrinsic appeal or novelty (e.g., listening to classroom teachers, doing class assignments, listening to or reading lengthy materials, or working on monotonous, repetitive tasks). Signs of the disorder may be minimal or absent when the person is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, or is in a one-to-one situation (e.g., the clinician's office). The symptoms are more likely to occur in group situations (e.g., in playgroups, classrooms, or work environments). The clinician should therefore gather information from multiple sources (e.g., parents, teachers) and inquire about the individual's behavior in a variety of situations within each setting (e.g., doing homework, having meals).

What is 'Mental Retardation'?

Illness

Are behaviours learned or inherited?

How are children encouraged to learn a variety of emotional responses?

What makes a disorder "life-long" and which disorders fall into this category?

What kinds of effects does alcoholism have in a family?

Discuss factors involved in abuse. What distinguishes an abuser, a victim?

How much should a physician involve others family members in the treatment of a single family member?

Person

What roles are necessary in a family?

Discuss roles and conflict resolution within the family

  • Always must keep in mind the Patterson Cycle of Coercion
  • Parents must present solid rules, not chaotic rule structures

How is 'parenting' learned?

  • Though an accreditation program administered by the government, without which individuals may not be licensed/accredited to have children

What is the role of a sibling to a "problem child"?

  • Could be coerced, as with sibling collusion

Context

What are the roles, qualifications and limitations of a psychologist vs. a psychiatrist vs. a psychotherapist?

Should psychologists be licensed to prescribe medications?

  • There has been good success with trained military psychologists
  • Psychologists in New Mexico *are* trained to prescribe medications
  • Coverage of the issue seems to depend on whether or not the person covering is a psychologist (approve) or a psychiatrist (disapprove)

How does the Children's Aid Society protect children? What is the law?

How are children "removed" by social services?

Discuss the background to and the recent Supreme Court decision in regard to spanking

  • More resources are below
  • Basically, the supreme court decided that it was outside its jurisdiction to try to dictate what people could do to their children in private
  • The court made a distinction between parents and teachers that had heretofore not existed
  • The government was very anxious not to be put in a situation where it was prosecuting loads of parents for hitting their childrens' bottoms
  • The decision makes it such that it is illegal to hit the children with objects, or give them blows on the face n shit.
  • The decision also states that the beating should be trifling

Discuss cultural/minority differences with respect to mental disorder prevalence/treatment differences/etc?

Discuss the depiction of families and family functioning by the media

What is a group home? Who goes there? What are the pros and cons of a group home?

  • Usually a home for older kids
  • Sometimes involves kids who are more aggressive or unwanted in foster homes
  • Advantages are that the kid is out of the home, if the home is bad
  • Disadvantages are that the person is in a place with no real role models

Resources

Mental Disorders

Spanking

Prescribing psychologists

Parenting

Fetal Alcohol Syndrome

Nature vs. Nurture

Miscellaneous