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What is Clinical Neuroscience?

Introduction

Clinical neuroscience is a branch of neuroscience that focuses on the scientific study of fundamental mechanisms that underlie diseases and disorders of the brain and central nervous system.

It seeks to develop new ways of conceptualising and diagnosing such disorders and ultimately of developing novel treatments.

A clinical neuroscientist is a scientist who has specialised knowledge in the field. Not all clinicians are clinical neuroscientists. Clinicians and scientists – including psychiatrists, neurologists, clinical psychologists, neuroscientists, and other specialists – use basic research findings from neuroscience in general and clinical neuroscience in particular to develop diagnostic methods and ways to prevent and treat neurobiological disorders. Such disorders include addiction, Alzheimer’s disease, amyotrophic lateral sclerosis, anxiety disorders, attention deficit hyperactivity disorder, autism, bipolar disorder, brain tumours, depression, Down syndrome, dyslexia, epilepsy, Huntington’s disease, multiple sclerosis, neurological AIDS, neurological trauma, pain, obsessive-compulsive disorder, Parkinson’s disease, schizophrenia, sleep disorders, stroke and Tourette syndrome.

While neurology, neurosurgery and psychiatry are the main medical specialties that use neuroscientific information, other specialties such as cognitive neuroscience, neuroradiology, neuropathology, ophthalmology, otorhinolaryngology, anaesthesiology and rehabilitation medicine can contribute to the discipline. Integration of the neuroscience perspective alongside other traditions like psychotherapy, social psychiatry or social psychology will become increasingly important.

One Mind for Research

The “One Mind for Research” forum was a convention held in Boston, Massachusetts on 23 to 25 May 2011 that produced the blueprint document A Ten-Year Plan for Neuroscience: From Molecules to Brain Health. Leading neuroscience researchers and practitioners in the United States contributed to the creation of this document, in which 17 key areas of opportunities are listed under the Clinical Neuroscience section. These include the following:

  • Rethinking curricula to break down intellectual silos.
  • Training translational neuroscientists and clinical investigators.
  • Investigating biomarkers.
  • Improving psychiatric diagnosis.
  • Developing a “Framingham Study of Brain Disorders” (i.e. longitudinal cohort for central nervous system disease).
  • Identifying developmental risk factors and producing effective interventions.
  • Discovering new treatments for pain, including neuropathic pain.
  • Treating disorders of neural signalling and pathological synchrony.
  • Treating disorders of immunity or inflammation.
  • Treating metabolic and mitochondrial disorders.
  • Developing new treatments for depression.
  • Treating addictive disorders.
  • Improving treatment of schizophrenia.
  • Preventing and treating cerebrovascular disease.
  • Achieving personalized medicine.
  • Understanding shared mechanisms of neurodegeneration.
  • Advancing anaesthesia.

In particular, it advocates for better integrated and scientifically driven curricula for practitioners, and it recommends that such curricula be shared among neurologists, psychiatrists, psychologists, neurosurgeons and neuroradiologists.

Given the various ethical, legal and societal implications for healthcare practitioners arising from advances in neuroscience, the University of Pennsylvania inaugurated the Penn Conference on Clinical Neuroscience and Society in July 2011.

What is Clinical Neuropsychology?

Introduction

Clinical neuropsychology is a sub-field of psychology concerned with the applied science of brain-behaviour relationships.

Clinical neuropsychologists use this knowledge in the assessment, diagnosis, treatment, and or rehabilitation of patients across the lifespan with neurological, medical, neurodevelopmental and psychiatric conditions, as well as other cognitive and learning disorders. The branch of neuropsychology associated with children and young people is paediatric neuropsychology.

Clinical neuropsychology is a specialised form of clinical psychology. Strict rules are in place to maintain evidence as a focal point of treatment and research within clinical neuropsychology. The assessment and rehabilitation of neuropsychopathologies is the focus for a clinical neuropsychologist. A clinical neuropsychologist must be able to determine whether a symptom(s) may be caused by an injury to the head through interviewing a patient in order to determine what actions should be taken to best help the patient. Another duty of a clinical neuropsychologist is to find cerebral abnormalities and possible correlations. Evidence based practice in both research and treatment is paramount to appropriate clinical neuropsychological practice.

Assessment is primarily by way of neuropsychological tests, but also includes patient history, qualitative observation and may draw on findings from neuroimaging and other diagnostic medical procedures. Clinical neuropsychology requires an in-depth knowledge of: neuroanatomy, neurobiology, psychopharmacology and neuropathology.

Brief History

During the late 1800s, brain-behaviour relationships were interpreted by European physicians who observed and identified behavioural syndromes that were related with focal brain dysfunction.

Clinical neuropsychology is a fairly new practice in comparison to other specialty fields in psychology with history going back to the 1960s. The specialty focus of clinical neuropsychology evolved slowly into a more defined whole as interest grew. Threads from neurology, clinical psychology, psychiatry, cognitive psychology, and psychometrics all have been woven together to create the intricate tapestry of clinical neuropsychology, a practice which is very much so still evolving. The history of clinical neuropsychology is long and complicated due to its ties to so many older practices. Researchers like Thomas Willis (1621-1675) who has been credited with creating neurology, John Hughlings Jackson (1835-1911) who theorised that cognitive processes occurred in specific parts of the brain, Paul Broca (1824-1880) and Karl Wernicke (1848-1905) who studied the human brain in relation to psychopathology, Jean Martin Charcot (1825-1893) who apprenticed Sigmund Freud (1856-1939) who created the psychoanalytic theory all contributed to clinical medicine which later contributed to clinical neuropsychology. The field of psychometrics contributed to clinical neuropsychology through individuals such as Francis Galton (1822-1911) who collected quantitative data on physical and sensory characteristics, Karl Pearson (1857-1936) who established the statistics which psychology now relies on, Wilhelm Wundt (1832-1920) who created the first psychology lab, his student Charles Spearman (1863-1945) who furthered statistics through discoveries like factor analysis, Alfred Binet (1857-1911) and his apprentice Theodore Simon (1872-1961) who together made the Binet-Simon scale of intellectual development, and Jean Piaget (1896-1980) who studied child development. Studies in intelligence testing made by Lewis Terman (1877-1956) who updated the Binet-Simon scale to the Stanford-Binet intelligence scale, Henry Goddard (1866-1957) who developed different classification scales, and Robert Yerkes (1876-1956) who was in charge of the Army Alpha and Beta tests also all contributed to where clinical neuropsychology is today.

Clinical neuropsychology focuses on the brain and goes back to the beginning of the 20th century. As a clinician a clinical neuropsychologist offers their services by addressing three steps: assessment, diagnosis, and treatment. The term clinical neuropsychologist was first made by Sir William Osler on 16 April 1913. While clinical neuropsychology was not a focus until the 20th century evidence of brain and behaviour treatment and studies are seen as far back as the neolithic area when trephination, a crude surgery in which a piece of the skull is removed, has been observed in skulls. As a profession, clinical neuropsychology is a subspecialty beneath clinical psychology. During World War I (1914-1918) the early term shell shock was first observed in soldiers who survived the war. This was the beginning of efforts to understand traumatic events and how they affected people. During the Great Depression (1929-1941) further stressors caused shell shock like symptoms to emerge. In World War II (1939-1945) the term shell shock was changed to battle fatigue and clinical neuropsychology became even more involved with attempting to solve the puzzle of peoples’ continued signs of trauma and distress. The Veterans Administration or VA was created in 1930 which increased the call for clinical neuropsychologists and by extension the need for training. The Korean War (1950-1953) and Vietnam War (1960-1973) further solidified the need for treatment by trained clinical neuropsychologists. In 1985 the term post-traumatic stress disorder or PTSD was coined and the understanding that traumatic events of all kinds could cause PTSD started to evolve.

The relationship between human behaviour and the brain is the focus of clinical neuropsychology as defined by Meir in 1974. There are two subdivisions of clinical neuropsychology which draw much focus; organic and environmental natures. Ralph M. Reitan, Arthur L. Benton, and A.R. Luria are all past neuropsychologists whom believed and studied the organic nature of clinical neuropsychology. Alexander Luria is the Russian neuropsychologist responsible for the origination of clinical psychoneurological assessment after WWII. Building upon his original contribution connecting the voluntary and involuntary functions influencing behaviour, Luria further conjoins the methodical structures and associations of neurological processes in the brain. Luria developed the ‘combined motor method’ to measure thought processes based on the reaction times when three simultaneous tasks are appointed that require a verbal response. On the other side, environmental nature of clinical neuropsychology did not appear until more recently and is characterised by treatments such as behaviour therapy. The relationship between physical brain abnormalities and the presentation of psychopathology is not completely understood, but this is one of the questions which clinical neuropsychologists hope to answer in time. In 1861 the debate over human potentiality versus localisation began. The two sides argued over how human behaviour presented in the brain. Paul Broca postulated that cognitive problems could be caused by physical damage to specific parts of the brain based on a case study of his in which he found a lesion on the brain of a deceased patient who had presented the symptom of being unable to speak, that portion of the brain is now known as Broca’s Area. In 1874 Carl Wernicke also made a similar observation in a case study involving a patient with a brain lesion whom was unable to comprehend speech, the part of the brain with the lesion is now deemed Wernicke’s Area. Both Broca and Wernicke believed and studied the theory of localisation. On the other hand, equal potentiality theorists believed that brain function was not based on a single piece of the brain but rather on the brain as a whole. Marie J.P Flourens conducted animal studies in which he found that the amount of brain tissue damaged directly affected the amount that behaviour ability was altered or damaged. Kurt Goldstein observed the same idea as Flourens except in veterans who had fought in World War I. In the end, despite all of the disagreement, neither theory completely explains the human brains complexity. Thomas Hughlings Jackson created a theory which was thought to be a possible solution. Jackson believed that both potentiality and localisation were in part correct and that behaviour was made by multiple parts of the brain working collectively to cause behaviours, and Luria (1966-1973) furthered Jackson’s theory.

The Role

When considering where a clinical neuropsychologist works, hospitals are a common place for practitioners to end up. There are three main variations in which a clinical neuropsychologist may work at a hospital; as an employee, consultant, or independent practitioner. As a clinical neuropsychologist working as an employee of a hospital the individual may receive a salary, benefits, and sign a contract for employment. In the case of an employee of a hospital the hospital is in charge of legal and financial responsibilities. The second option of working as a consultant implies that the clinical neuropsychologist is part of a private practice or is a member of a physicians group. In this scenario, the clinical neuropsychologist may work in the hospital like the employee of the hospital but all financial and legal responsibilities go through the group which the clinical neuropsychologist is a part of. The third option is an independent practitioner whom works alone and may even have their office outside of the hospital or rent a room in the hospital. In the third case, the clinical neuropsychologist is completely on their own and in charge of their own financial and legal responsibilities.

Assessment

Assessments are used in clinical neuropsychology to find brain psychopathologies of the cognitive, behavioural, and emotional variety. Physical evidence is not always readily visible so clinical neuropsychologists must rely on assessments to tell them the extent of the damage. The cognitive strengths and weaknesses of the patient are assessed to help narrow down the possible causes of the brain pathology. A clinical neuropsychologist is expected to help educate the patient on what is happening to them so that the patient can understand how to work with their own cognitive deficits and strengths. An assessment should accomplish many goals such as; gage consequences of impairments to quality of life, compile symptoms and the change in symptoms over time, and assess cognitive strengths and weaknesses. Accumulation of the knowledge earned from the assessment is then dedicated to developing a treatment plan based on the patient’s individual needs. An assessment can also help the clinical neuropsychologist gauge the impact of medications and neurosurgery on a patient. Behavioural neurology and neuropsychology tools can be standardised or psychometric tests and observational data collected on the patient to help build an understanding of the patient and what is happening with them. There are essential prerequisites which must be present in a patient in order for the assessment to be effective; concentration, comprehension, and motivation and effort.

Lezak lists six primary reasons neuropsychological assessments are carried out: diagnosis, patient care and its planning, treatment planning, treatment evaluation, research and forensic neuropsychology. To conduct a comprehensive assessment will typically take several hours and may need to be conducted over more than a single visit. Even the use of a screening battery covering several cognitive domains may take 1.5-2 hours. At the commencement of the assessment it is important to establish a good rapport with the patient and ensure they understand the nature and aims of the assessment.

Neuropsychological assessment can be carried out from two basic perspectives, depending on the purpose of assessment. These methods are normative or individual. Normative assessment, involves the comparison of the patient’s performance against a representative population. This method may be appropriate in investigation of an adult onset brain insult such as traumatic brain injury or stroke. Individual assessment may involve serial assessment, to establish whether declines beyond those which are expected to occur with normal aging, as with dementia or another neurodegenerative condition.

Assessment can be further subdivided into sub-sections:

History Taking

Neuropsychological assessments usually commence with a clinical interview as a means of collecting a history, which is relevant to the interpretation of any later neuropsychological tests. In addition, this interview provides qualitative information about the patient’s ability to act in a socially apt manner, organise and communicate information effectively and provide an indication as to the patient’s mood, insight and motivation. It is only within the context of a patient’s history that an accurate interpretation of their test data and thus a diagnosis can be made. The clinical interview should take place in a quiet area free from distractions. Important elements of a history include demographic information, description of presenting problem, medical history (including any childhood or developmental problems, psychiatric and psychological history), educational and occupational history (and if any legal history and military history).

Selection of Neuropsychological Tests

It is not uncommon for patients to be anxious about being tested; explaining that tests are designed so that they will challenge everyone and that no one is expected to answer all questions correctly may be helpful. An important consideration of any neuropsychological assessment is a basic coverage of all major cognitive functions. The most efficient way to achieve this is the administration of a battery of tests covering: attention, visual perception and reasoning, learning and memory, verbal function, construction, concept formation, executive function, motor abilities and emotional status. Beyond this basic battery, choices of neuropsychological tests to be administered are mainly made on the basis of which cognitive functions need to be evaluated in order to fulfil the assessment objectives.

Report Writing

Following a neuropsychological assessment it is important to complete a comprehensive report based on the assessment conducted. The report is for other clinicians, as well as the patient and their family so it is important to avoid jargon or the use of language which has different clinical and lay meanings (e.g. intellectually disabled as the correct clinical term for an IQ below 70, but offensive in lay language). The report should cover background to the referral, relevant history, reasons for assessment, neuropsychologists observations of patient’s behaviour, test administered and results for cognitive domains tested, any additional findings (e.g. questionnaires for mood) and finish the report with a summary and recommendations. In the summary it is important to comment on what the profile of results indicates regarding the referral question. The recommendations section contains practical information to assist the patient and family, or improve the management of the patient’s condition.

Educational Requirements of Different Countries

The educational requirements for becoming a clinical neuropsychologist differ between countries. In some countries it may be necessary to complete a clinical psychology degree, before specialising with further studies in clinical neuropsychology. While some countries offer clinical neuropsychology courses to students who have completed 4 years of psychology studies. All clinical neuropsychologists require a postgraduate qualification, whether it be a Masters or Doctorate (Ph.D, Psy.D. or D.Psych).

Australia

To become a clinical neuropsychologist in Australia requires the completion of a 3-year Australian Psychology Accreditation Council (APAC) approved undergraduate degree in psychology, a 1-year psychology honours, followed by a 2-year Masters or 3-year Doctorate of Psychology (D.Psych) in clinical neuropsychology. These courses involve coursework (lectures, tutorials, practicals etc.), supervised practice placements and the completion of a research thesis. Masters and D.Psych courses involve the same amount of coursework units, but differ in the amount of supervised placements undertaken and length of research thesis. Masters courses require a minimum of 1,000 hours (125 days) and D.Psych courses require a minimum of 1,500 hours (200 days), it is mandatory that these placements expose students to acute neurology/neurosurgery, rehabilitation, psychiatric, geriatric and paediatric populations.

Canada

To become a clinical neuropsychologist in Canada requires the completion of a 4-year honours degree in psychology and a 4-year doctoral degree in clinical neuropsychology. Often a 2-year master’s degree is required before commencing the doctoral degree. The doctoral degree involves coursework and practical experience (practicum and internship). Practicum is between 600 and 1,000 hours of practical application of skills acquired in the programme. At least 300 hours must be supervised, face-to-face client contact. The practicum is intended to prepare students for the internship/residency. Internships/residencies are a year long experience in which the student functions as a neuropsychologist, under supervision. Currently, there are 3 CPA-accredited Clinical Neuropsychology internships/residencies in Canada, although other unaccredited ones exist. Prior to commencing the internship students must have completed all doctoral coursework, received approval for their thesis proposal (if not completed the thesis) and the 600 hours of practicum.

United Kingdom

To become a clinical neuropsychologist in the UK, requires prior qualification as a clinical or educational psychologist as recognised by the Health Professions Council, followed by further postgraduate study in clinical neuropsychology. In its entirety, education to become a clinical neuropsychologist in the UK consists of the completion of a 3-year British Psychological Society accredited undergraduate degree in psychology, 3-year Doctorate in clinical (usually D.Clin.Psy.) or educational psychology (D.Ed.Psy.), followed by a 1-year Masters (MSc) or 9-month Postgraduate Diploma (PgDip) in Clinical Neuropsychology. The British Psychological Division of Counselling Psychology are also currently offering training to its members in order to ensure that they can apply to be registered Neuropsychologists also.

United States

In order to become a clinical neuropsychologist in the US and be compliant with Houston Conference Guidelines, the completion of a 4-year undergraduate degree in psychology and a 4 to 5-year doctoral degree (Psy.D. or Ph.D.) must be completed. After the completion of the doctoral coursework, training and dissertation, students must complete a 1-year internship, followed by an additional 2 years of supervised residency. The doctoral degree, internship and residency must all be undertaken at American Psychological Association approved institutions. After the completion of all training, students must apply to become licensed in their state to practice psychology. The American Board of Clinical Neuropsychology, The American Board of Professional Neuropsychology, and The American Board of Paediatric Neuropsychology all award board certification to neuropsychologists that demonstrate competency in specific areas of neuropsychology, by reviewing the neuropsychologist’s training, experience, submitted case samples, and successfully completing both written and oral examinations. Although these requirements are standard according to Houston Conference Guidelines, even these guidelines have stated that the completion of all of these requirements is still aspirational, and other ways of achieving clinical neuropsychologist status are possible.

What is the Diagnostic Classification of Mental Health and Developmental Disorder of Infancy and Early Childhood?

Introduction

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC) is a developmentally based diagnostic manual that provides clinical criteria for categorising mental health and developmental disorders in infants and toddlers.

It is organised into a five-part axis system. The book has been translated into several languages and its model is widely adopted for the assessment of children of up to five years in age.

The DC 0-3R is meant to complement, but not replace, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health Organisation (WHO). It is intended to enhance the understanding of young children by making it possible to assess, diagnose, and treat mental health problems in infants and toddlers by allowing for the identification of disorders not addressed in other classification systems.

The DC is organised around three primary principles:

  1. That children’s psychological functioning unfolds in the context of relationships;
  2. That individual differences in temperament and constitutional strengths and vulnerabilities play a major role in how children experience and process events; and
  3. That the family’s cultural context is important for the understanding of the child’s developmental course.

Brief History

Originally published in 1994, ZERO TO THREE’s Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:03) was the first developmentally based system for diagnosing mental health and developmental disorders of infants and toddlers (i.e. 0 to 3).

The revised DC:03, published in 2005 (DC:03R) drew on empirical research and clinical practice that had occurred worldwide since the 1994 publication and extended the depth and criteria of the original DC:03.

DC:05 captures new findings relevant to diagnosis in young children and addresses unresolved issues in the field since DC:03R was published in 2005.

DC:05 is designed to help mental health and other professionals: recognize mental health and developmental challenges in infants and young children, through 5 years old; understand that relationships and psychosocial stressors contribute to mental health and developmental disorders and incorporate contextual factors into the diagnostic process; use diagnostic criteria effectively for classification, case formulation, and intervention; and facilitate research on mental health disorders in infants and young children. DC:05 enhances the professional’s ability to prevent, diagnose, and treat mental health problems in the earliest years by identifying and describing disorders not addressed in other classification systems and by pointing the way to effective intervention approaches. Individuals across disciplines, mental health clinicians, counsellors, physicians, nurses, early interventionists, social workers, and researchers will find DC:05 to be an essential guide to evaluation and treatment planning with infants, young children, and their families in a wide range of settings.

The Diagnostic Process

The diagnostic process is one that is ongoing and done over a period of time. The process includes gathering a series of information regarding the child’s behaviour and presenting problems. The information is collected by a clinician and pertains to the child’s adaptation and development across different occasions and contexts.

According to the DC, the diagnostic process consists of two aspects:

  1. The classification of disorders; and
  2. The assessment of individuals.

One of the primary reasons for the classification of disorders is to facilitate communication between professionals. Once a diagnosis has been made, a clinician can then make associations between their clients’ symptoms and previously existing knowledge regarding the disorders’ aetiology, pathogenesis, treatment, and prognosis. Furthermore, using the classification of disorders can facilitate the process of finding existing services and mental health systems that are appropriate for the particular needs of the affected child. The assessment of children thus becomes a pivotal process that is undertaken by clinicians in order to grant access to treatment and intervention services related to specified disorders.

Clinical assessment and diagnosis involves making observations and gathering information from multiple sources relating to the child’s life in conjunction with a general diagnostic scheme. Both the DSM and ICD classification systems have evolved to use a multiaxial scheme, thus, clinicians have been using them not only for the classification of disorder but also as a guide for assessment and diagnosis. The first three axes of the DSM and ICD relate to the classification of disorder, and the fourth and fifth relate to the assessment of the individual within their personal environment. Similarly, the DC also follows a multiaxial scheme.

Classification

The DC 0-3R provides a provisional diagnosis system, focusing on multi-axial classification. The system is a provisional system because it recognises the fluidity and change that may occur with more knowledge in the field. This classification system is not entirely synonymous with the DSM-IV and the ICD-10, because it concentrates on developmental issues. There is also an emphasis placed on dynamic processes, relationships, and adaptive patterns within a developmental framework. The use of this classification system imparts knowledge about the diagnostic profile of a child, and the various contextual factors that may contribute to difficulties.

The DC functions as a reference for the earlier manifestations of problems in infants and children, which can be connected to later problems in functioning. Secondly, the categorisation focuses on types of difficulties in young children that are not addressed in other classification models.

The diagnostic categories vary in description, with more familiar categories described less. Categories that are more specific to young childhood and infancy, and newly based on clinical approaches are described in more detail. Furthermore, some categories may have subtypes to promote research, clinical awareness, and intervention planning, whereas others do not. This is important information to keep in mind when reading the DC.

The Multi-Axial System

Axis I: Clinical Disorders

Axis 1 of the DC provides diagnostic classifications for the most primary symptoms of the presenting difficulties. These diagnoses focus on the infant or child’s functioning. The primary diagnoses include:

  1. Posttraumatic Stress Disorder:
    • This refers to children who may be experiencing or have experienced a single traumatic event (e.g. an earthquake), a series of traumatic events (e.g. air raids), or chronic stress (e.g. abuse).
    • Furthermore, the nature of the trauma and its effect on the child must be understood in the context of the child. Specifically, attention must be paid to factors such as social context, personality factors, and the caregivers’ ability to assist with coping.
  2. Disorders of Affect:
    • This classification of disorders is related to the infant or child’s affective and behavioural experiences.
    • This group of disorders includes mood disorders and deprivation/maltreatment disorder.
    • This classification focuses on the infant or child’s functioning in its entirety rather than a specific event or situation (refer to Affective spectrum).
  3. Adjustment Disorder:
    • When considering a diagnosis of adjustment disorder, one has to examine the situational factors to determine if it is a mild disruption in the child’s usual functioning (e.g. switching schools).
    • These difficulties must also not meet the criteria for other disorders included in the categories.
  4. Regulation Disorders of Sensory Processing:
    1. The child manifests difficulties in regulating behavioural, motor, attention, physiological, sensory, and affective processes.
    2. These difficulties can affect the child’s daily functioning and relationships (refer to Sensory processing disorder).
  5. Sleep Behaviour Disorder:
    • To diagnose a sleep disorder, the child should be showing a sleep disturbance and not be demonstrating sensory reactive or processing difficulties.
    • This diagnosis should not be used when sleep problems are related to issues of anxiety or traumatic events.
  6. Eating Behaviour Disorder:
    • This diagnosis may become evident in infancy and young childhood as the child may show difficulties in regular eating patterns.
    • The child may not be regulating feeding with physiological reactions of hunger. This diagnosis is a primary diagnosis in the absence of traumatic, affective, and regulatory difficulties (refer to eating disorder).
  7. Disorders of Relating and Communicating:
    • These disorders involve difficulties in communication, in conjunction with difficulties in regulation of physiological, motor, cognitive, and many other processes.

Axis II: Relationship Classification

Axis II focuses on children and infants developing in the context of emotional relationships. Specifically, the quality of caregiving can have a strong impact in nurturance and steering a child on a particular developmental course, either adaptive or maladaptive. This particular axis concentrates on the diagnosis of a clinical issue in the relationship between the child and the caregiver. The presence of a disorder indicates difficulties in relationships. These disorders include various patterns that highlight behaviour, affective, and psychological factors between the child and the caregiver.

  • Overinvolved.
  • Underinvolved.
  • Anxious/Tense.
  • Angry/Hostile.
  • Mixed Relationship Disorder.
  • Abusive.

Axis III: Medical and Developmental Disorders and Conditions

Axis III focuses on physical, mental, or developmental classification using other diagnosis methods. These disorders and conditions are not treated as a single diagnosis, but as a problem that may co-exist with others, as it may involve developmental difficulties.

Axis IV: Psychosocial Stressors

This axis allows clinicians to focus on the intensity of psychosocial stress, which may act as influencing agents in infant and childhood difficulties/disorders. Psychosocial stress can have direct and indirect influences on infants and children, and depends on various factors.

Axis V: Emotional and Social Functioning

Emotional and social functioning capacities can be assessed using observations of the child with primary caregivers. The essential domains of functioning can be used in these observations on a 5-point scale, that describes overall functional emotional level.

Rating Scales and Checklists

The DC contains four forms that aid clinicians in identifying disorders in infants and toddlers, in examining the extent of problem behaviours, and in determining the nature of external factors influencing the child.

  • Functional Rating Scale for Emotional and Social Functioning Capacities: to evaluate the child’s communication skills and expressions of thoughts and feelings.
  • The Parent-Infant Relationship Global Assessment Scale (PIR-GAS; from Axis II): to evaluate the quality of a caregiver-child relationship and identify relationship disorders.
  • Relationship Problems Checklist (RPCL; from Axis II): allows the clinician to identify the extent to which a caregiver-child relationship can be described by a number of criterion-based qualities.
  • Psychosocial and Environmental Stressors Checklist (from Axis IV): to provide information on the stressors experienced by the child in various contexts.

The Future of DC

Important questions remain to be answered, in spite of the revisions made in the DC. Such questions include the following:

  • How can the functional adaptation of infants and children be evaluated and described independent of diagnosis?
  • How can disruptive behaviours of typical development in infants and children be distinguished from disordered behaviours that lead to atypical development?
  • Should Excessive Crying Disorder be considered as a functional regulatory disorder? Other functional regulatory disorders include Sleeping Behaviour and Feeding Behaviour Disorders.
  • Should future editions of the DC include a Family Axis containing information about family history of mental illness, family structure and available supports, and family culture? These aspects are all central to assessment and treatment planning.

What is Child Psychopathology?

Introduction

Child psychopathology refers to the scientific study of mental disorders in children and adolescents.

Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organisation (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC) is used in assessing mental health and developmental disorders in children up to age five.

Causes

The aetiology of child psychopathology has many explanations which differ from case to case. Many psychopathological disorders in children involve genetic and physiological mechanisms, though there are still many without any physical grounds. It is absolutely imperative that multiple sources of data be gathered. Diagnosing the psychopathology of children is daunting. It is influenced by development and contest, in addition to the traditional sources. Interviews with parents about school, etc., are inadequate. Either reports from teachers or direct observation by the professional are critical. (author, Robert B. Bloom, Ph.D.) The disorders with physical or biological mechanisms are easier to diagnose in children and are often diagnosed earlier in childhood. However, there are some disorders, no matter the mechanisms, that are not identified until adulthood. There is also reason to believe that there is co-morbidity of disorders, in that if one disorder is present, there is often another.

Stress

Emotional stress or trauma in the parent-child relationship tends to be a cause of child psychopathology. First seen in infants, separation anxiety in root of parental-child stress may lay the foundations for future disorders in children. There is a direct correlation between maternal stress and child stress that is factored in both throughout adolescent development. In a situation where the mother is absent, any primary caregiver to the child could be seen as the “maternal” relationship. Essentially, the child would bond with the primary caregiver, and may exude some personality traits of the caregiver.

In studies of child in two age groups of pregnancy to five years, and fifteen years and twenty years, Raposa and colleagues (2011) studied the impact of psychopathology in the child-maternal relationship and how not only the mothers stress affected the child, but the child’s stress affected the mother. Historically, it was believed that mothers who suffered from post partum depression might be the reason their child suffers from mental disorders both earlier and later in development. However this correlation was found to not only reflect maternal depression on child psychopathology, but also child psychopathology could reflect on maternal depression.

Children with a predisposition to psychopathology may cause higher stress in the relationship with their mother, and mothers who suffer from psychopathology may also cause higher stress in the relationship with their child. Child psychopathology creates stress in parenting which may increase the severity of the psychopathology within the child. Together, these factors push and pull the relationship thus causing higher levels of depression, ADHD, defiant disorder, learning disabilities, and pervasive developmental disorder in both the mother and the child. The outline and summary of this study is found below:

In looking at child-related stress, the number of past child mental health diagnoses significantly predicted a higher number of acute stressors for mothers as well as more chronic stress in the mother-child relationship at age 15. These increased levels of maternal stress and mother-child relationship stress at age 15 then predicted higher levels of maternal depression when the youth were 20 years old.

Looking more closely at the data, the authors found that it was the chronic stress in the mother-child relationship and the child-related acute stressors that were the linchpins between child psychopathology and maternal depression. The stress is what fuelled the fires between mother and child mental health. Going one step further, the researchers found that youth with a history of more than one diagnosis as well as youth that had externalizing disorders (e.g. conduct disorder) had the highest number of child-related stressors and the highest levels of mother-child stress. Again, all of the findings held up when other potentially stressful variables, such as economic worries and past maternal depression, were controlled for.

Additionally, siblings- both older and younger and of both genders, can be factored into the aetiology and development of child psychopathology. In a longitudinal study of maternal depression and older male child depression and antisocial behaviours on younger siblings adolescent mental health outcome. The study factored in ineffective parenting and sibling conflicts such as sibling rivalry. Younger female siblings were more directly affected by maternal depression and older brother depression and anti social behaviours when the indirect effects were not place, in comparison to younger male siblings who showed no such comparison. However, if an older brother were anti-social, the younger child – female or male would exude higher anti-social behaviours. In the presence of a sibling conflict, anti social behaviour was more influential on younger male children than younger female children. Female children were more sensitive to pathological familial environments, thus showing that in a high-stress environment with both maternal depression and older- male sibling depression and anti social behaviour, there is a higher risk of female children developing psychopathological disorders. This was a small study, and more research needs to be done especially with older female children, paternal relationships, maternal-paternal-child stress relationships, and/or caregiver-child stress relationships if the child is orphaned or not being raised by the biological child to reach a conclusive child-parent stress model on the effects of familial and environmental pathology on the child’s development.

Temperament

The child-parent stress and development is only one hypothesis for the aetiology of child psychopathology. Other experts believe that child temperament is a large factor in the development of child psychopathology. High susceptibility to child psychopathology is marked by low levels of effortful control and high levels of emotionality and neuroticism. Parental divorce is often a large factor in childhood depression and other psychopathological disorders. This is more so when the divorce involves a long-drawn separation and one parent bad-mouthing the other. That is not to say that divorce will lead to psychopathological disorders, there are also other factors such as temperament, trauma, and other negative life events (e.g. death, sudden moving of home, physical or sexual abuse), genetics, environment, and nurture that correlate to the onset of a disorder. Research has also shown that child maltreatment may increase risk for various forms of psychopathology as it increases threat sensitivity, decreases responsivity to reward, and causes deficits in emotion recognition and understanding.

Found in “The Role of Temperament in the Etiology of Child Psychopathology”, a model for the aetiology of child psychopathology by Vasey and Dadds (2001) proposed that the four things that are important to the development of psychopathological disorders is:

  1. Biological factors: hormones, genetics, and neurotransmitters;
  2. Psychological: self-esteem, coping skills, and cognitive issues;
  3. Social factors: family rearing, negative learning experiences, and stress; and
  4. Child’s temperament.

Using an array of neurological scans and exams, psychological evaluations, family medical history, and observing the child in daily factors can help the physician find the aetiology of the psychopathological disorder to help release the child of the symptoms through therapy, medication use, social skills training, and life style changes.

Child psychopathology can cause separation anxiety from parents, attention deficit disorders in children, sleep disorders in children, aggression with both peers and adults, night terrors, extreme anxiety, anti social behaviour, depression symptoms, aloof attitude, sensitive emotions, and rebellious behaviour that are not in line of typical childhood development. Aggression is found to manifest in children before five years of age, and early stress and aggression in the parental-child relationship correlates with the manifestation of aggression. Aggression in children causes problematic peer relationships, difficulty adjusting, and coping problems. Children who fail to overcome acceptable ways of coping and emotion expression are put on tract for psychopathological disorders and violent and anti social behaviours into adolescence and adulthood. There is a higher rate of substance abuse in these children with coping and aggression issues, and causes a cycle of emotional instability and manifestation psychopathological disorders.

Neurology and Aetiology

Borderline personality disorder (BPD) is one of many psychopathology disorders a child can suffer from. In the neurobiological scheme, borderline personality disorder may have effects on the left amygdala. In a 2003 study of BPD patients versus control patients, when faced with expressions that were happy, sad, or fearful BPD patients showed significantly more activation versus control patients. In neutral faces, BPD patients attributed negative qualities to these faces. As stated by Gabbard, an experimenter in this study:

“A hyperactive amygdala may be involved in the predisposition to be hyper vigilant and over reactive to relatively benign emotional expressions. Misreading neutral faces is clearly related to transference misreadings that occur in psychotherapy and the creation of bad object experiences linked with projective identification.”

Also linked to BPD, is the presence of serotonin transporter (5-HTT) in a short allele demonstrated larger amygdala neuronal activity when presented with fearful stimuli as in comparison to individuals with a long allele of 5-HTT. As found in the Dunedin Longitudinal Study a short allele of 5-HTT predisposes the person to have hyperactivity in the amygdala in response to trauma, and thus moderated the impact of stressful life events leading to a higher risk of depression and suicidal idealities. These same qualities were not observed in individuals with long alleles of 5-HTT. However, the environment the child is in can change in impact of this gene, proving that correct treatment, intensive social support, and a healthy and nurturing environment can modify genetic vulnerability.

Possibly the most studied or documented of the child psychopathologies is attention deficit hyperactivity disorder (ADHD) which is marked with learning disabilities, mood disorders, and/or aggression. Though believed to be over diagnosed, ADHD is highly comorbid for other disorders such as depression and obsessive compulsive disorder. In studies of the prefrontal cortex in ADHD children, which is responsible for the regulation of behaviour, cognition, and attention; and in the dopamine system there has been identified a hidden genetic polymorphisms. More specific, the 7-repeat allele of the dopamine D4 receptor gene, responsible for inhibited prefrontal cortex cognition and less efficient receptors, causes more externalised behaviours such as aggression since the child has trouble “thinking through” seemingly ordinary and at level childhood tasks.

Agenesis of the Corpus Callosum and Aetiology

Agenesis of the corpus callosum (ACC) is used to determine the frequency of social and behavioural problems in children with a prevalence rate of about 2-3%. ACC is described as a defect in the brain where the 200 million axons that make the corpus collosum are either completely absent, or partially gone. In many cases, the anterior commissure is still present to allow for the passing of information from one cerebral hemisphere to the other. The children are of normal intelligence level. For younger children, ages two to five, Agenesis of the corpus callosum causes problems in sleep. Sleep is critical for development in children, and lack of sleep can set the grounds for a manifestation of psychopathological disorders. In children ages six to eleven, ACC showed manifestation in problems with social function, thought, attention, and somatic grievances. In comparison, of children with autism, children with ACC showed less impairment on almost all scales such as anxiety and depression, attention, abnormal thoughts, and social function versus autistic children. However, a small percentage of children with ACC showed traits that may lead to the diagnosis of autism in the areas of social communications and social interactions but do not show the same symptoms of autism in the repetitive and restricted behaviours category. The difficulties from ACC may lead to the aetiology of child psychopathological disorders, such as depression or ADHD and manifest many autistic-like disorders that can cause future psychological disorders in later adolescence. The aetiology of child psychopathology is a multi-factor path. A slew of factors must be taken into account before diagnosis of a disorder.

The child’s genetics, environment, temperament, past medical history, family medical history, prevalence of symptoms and neuro-anatomical structures are all factors that should be considered when diagnosing a child with a psychopathological disorder. Thousands of children each year are misdiagnosed and put on the wrong treatment, which may result in the manifestation of other disorders the child would have not have gotten else wise. There are hundreds of causes of psychopathological disorders, and each one manifests at different ages and stages in child development and can come out due to trauma and stress. Some disorders may “disappear” and reappear in the presence of a trauma, depression, or stress similar to the one that brought the disorder out in the child in the beginning.

Treatment

It is estimated that 5% of children under the age of eight suffer from a psychopathology disorder. Girls more frequently manifested disorders than boys in similar situations. By age sixteen about thirty percent of children will have fit the criteria for at least one psychopathology disorder. Only a small number of these children receive treatment for their disorder. Anxiety and depression disorders in children- whether noted or un-noted, are found to be a precursor for similar episodes in adulthood. Usually a large stressor similar to the one the person experienced in childhood brings out the anxiety or depression in adulthood.

Multifinality refers to the idea that two children can react to same stressful event quite differently, and may display divergent types of problem behaviour. Psychopathological disorders are extremely situational- having to take into account the child, the genetics, the environment, the stressor, and many other factors to tailor the best type of treatment to relieve the child of the psychopathology symptoms.

Many child psychopathology disorders are treated with control medications prescribed by a paediatrician or psychiatrist. After extensive evaluation of the child through school visits, by psychologists and physicians, a medication can be prescribed. A patient may need to go through several trials of medicines to find the best fit, as many cause uncomfortable and undesired side effects – such as dry mouth or suicidal thoughts can occur. There are many classes of drugs a physician can choose from and they are: psychostimulants, beta blockers, atypical antipsychotics, lithium, alpha-2 agonists, traditional antipsychotics, SSRIs, and anticonvulsant mood- stabilisers. Given the multifinality of psychopathological disorders, two children may be on the same medication for two completely different disorders, or have the same disorder and be taking two completely different medications.

ADHD is the most successfully treated disorder of child psychopathology, and the medications used have a high- abuse rate especially among college-aged students. Psycho stimulants such as Ritalin, amphetamine- related stimulant drugs: e.g. Adderall, and antidepressants such as Wellbutrin have been successfully used to treat ADHD with a 78% success rate. Many of these drug treatment options are paired with behavioural treatment such as therapy or social skills lessons.

Lithium has shown to be extremely effective in treating ADHD and bipolar disorder. Lithium treats both mania and depression and helps prevent relapse. The mechanism of lithium include the inhibition of GSK-3, it is a glutamate antagonism at NMDA receptors that together make lithium a neuroprotective medicine. The drug relieves bipolar symptoms, aggressiveness and irritability. Lithium has many, many side effects and requires weekly blood tests to tests for toxicity of the drug.

Medications that act on cell membrane ion channels, are GABA inhibitory neurotransmission, and also inhibit excitatory glutamate transmission have shown to be extremely effective in treating an array of child psychopathological disorders. Pharmaceutical companies are in the process of creating new drugs and improving those on the market to help avoid negative and possibly life altering short term and long term side effects, making drugs more safe to use in younger children and over long periods of time during adolescent development.

Psychotherapy Treatments for Common Psychological Disorders in Children

Some psychological disorders commonly found in children include depression, anxiety, and conduct disorder. For adolescents with depression, a combination of antidepressants and cognitive-behavioural or interpersonal psychotherapy is recommended, in contrast there is not much evidence for the efficacy of antidepressants in children under 12 years of age, therefore a combination of parent training and cognitive-behavioural psychotherapy is recommended. For children and adolescents suffering from anxiety disorders, cognitive-behavioural therapy in combination with exposure-based techniques is a highly recommended and evidence-based treatment. Research suggests that children and adolescents with conduct disorder or disruptive behaviour may benefit from psychotherapy that includes both a behavioural component and parental involvement.

Future of Child Psychopathology

The future of child psychopathology-aetiology and treatment has a two-way path. While many professionals agree that many children who suffer from a disorder do not receive proper treatment, at the rate of 5-15% that receive treatment leaving many children in the dark. In the same boat are the physicians who also say that not only do more of these disorders need to be recognised in children and treated properly, but also even those children who show some qualifying symptoms of a disorder but not to the degree of diagnosis should also receive treatment and therapy to avoid the manifestation of the disorder. By treating children even with slight degrees of a psychopathological disorder, children can show improvements in their relationships with peers, family, and teachers and also improvements in school, mental health, and personal development. Many physicians believe the best prevention and help starts in the home and the school of the child, before physicians and psychologists are contacted.

So while there is more awareness of child psychopathological disorders and more research to prevent and effectively treat these disorders to maintain healthy emotional health in children, there is also a negative factor in that parents, schools, and psychologists may be more sensitive and therefore over-diagnose children with these disorders. Mental health professionals and pharmaceutical marketing companies need to be cautious of making disorders too readily diagnosed and treated with medications.

Child psychopathology is a real thing that thousands of children suffer from. While hundreds of children are diagnosed with a new disorder daily, researchers are developing new strategies to beat these disorders in children to allow all children the right to a happy and healthy childhood. With further education on the symptoms and implications of child psychopathology, psychologists and physicians will improve their accuracy in diagnosing children – giving the right diagnosis and discovering the most helpful treatment and therapies for children.

The current trend in the US is to understand child psychopathology from a systems based perspective called developmental psychopathology. Recent emphasis has also been on understanding psychological disorders from a relational perspective with attention also given to neurobiology. Practitioners who follow attachment theory believe that early attachment experiences of children can promote adaptive strategies or lay the groundwork for maladaptive ways of coping which can later lead to mental health disorders.

Research and clinical work on child psychopathology tends to fall under several main areas: aetiology, epidemiology, diagnosis, assessment, and treatment.

Parents are considered a reliable source of information because they spend more time with children than any other adult. A child’s psychopathology can be connected to parental behaviours. Clinicians and researchers have experienced problems with children’s self-reports and rely on adults to provide the information.

On This Day … 21 June

People (Births)

  • 1880 – Arnold Gesell, American psychologist and paediatrician (d. 1961).
  • 1924 – Jean Laplanche, French psychoanalyst and academic (d. 2012).

Arnold Gesell

Doctor Arnold Lucius Gesell (21 June 1880 to 29 May 1961) was an American clinical psychologist, paediatrician and professor at Yale University known for his research and contributions to the field of child development.

Gesell served as a teacher and high school principal before seeking his psychological doctorate at Clark University, where the university’s president, G. Stanley Hall, had founded a child study movement. Arnold received his PhD from Clark in 1906.

Gessell worked at several educational facilities in New York City and Wisconsin before obtaining a professorship at the Los Angeles State Normal School, now known as The University of California, Los Angeles(UCLA)). There he met fellow teacher Beatrice Chandler who would become his wife. They later had a daughter and a son, Federal District Judge Gerhard Gesell.

Gesell also spent time at schools for the mentally disabled, including the Vineland Training School in New Jersey. Having developed an interest in the causes and treatment of childhood disabilities, Gesell began studying at the University of Wisconsin Medical School to better understand physiology. He later served as an assistant professor at Yale University while continuing to study medicine. He developed the Clinic of Child Development there and received his M.D. in 1915. He was later given a full professorship at Yale.

Gesell also served as the school psychologist for the Connecticut State Board of Education and helped to develop classes to help children with disabilities succeed. This historic appointment made Dr. Gesell the first school psychologist in the US He wrote several books, including The Preschool Child from the Standpoint of Public Hygiene and Education in 1923, The Mental Growth of the Preschool Child in 1925 (which was also published as a film), and An Atlas of Infant Behaviour (chronicling typical milestones for certain ages) in 1934. He co-authored with Frances Ilg two childrearing guides, Infant and Child in the Culture of Today in 1943, and The Child from Five to Ten in 1946.

Gesell made use of the latest technology in his research. He used the newest in video and photography advancements. He also made use of one-way mirrors when observing children, even inventing the Gesell dome, a one-way mirror shaped as a dome, under which children could be observed without being disturbed. In his research he studied many children, including Kamala, the wolf girl. He also did research on young animals, including monkeys.

As a psychologist, Gesell wrote and spoke about the importance of both nature and nurture in child development. He cautioned others not to be quick to attribute mental disabilities to specific causes. He believed that many aspects of human behaviour, such as handedness and temperament were heritable. He explained that children adapted to their parents as well as to one another. He advocated for a nationwide nursery school system in the United States.

Gesell’s popular books spread his ideas beyond academia. His core message, urging parents to “nourish the child’s trustfulness in life”, resonated with child advocates long before Dr. Benjamin Spock became America’s most prominent parental advisor. In The Child from Five to Ten, Gesell wrote, “It is no longer trite to say that children are the one remaining hope of mankind. . . If we could but capture their transparent honesty and sincerities! They still have much to teach us, if we observe closely enough”.

Gesell’s ideas came to be known as Gesell’s Maturational Theory of child development. Based on his theory, he published a series of summaries of child development sequences, called the Gesell Developmental Schedules.

The Gesell Institute of Human Development, named after him, was started by his colleagues from the Clinic of Child Development, Frances Ilg and Louise Bates Ames in 1950, after Gesell retired from the university in 1948. In 2012, the institute was renamed the Gesell Institute of Child Development.

Jean Laplanche

Jean Laplanche (21 June 1924 to 06 May 2012) was a French author, psychoanalyst and winemaker. Laplanche is best known for his work on psychosexual development and Sigmund Freud’s seduction theory, and wrote more than a dozen books on psychoanalytic theory. The journal Radical Philosophy described him as “the most original and philosophically informed psychoanalytic theorist of his day.”

From 1988 to his death, Laplanche was the scientific director of the German to French translation of Freud’s complete works (Oeuvres Complètes de Freud/Psychanalyse – OCF.P) in the Presses Universitaires de France, in association with André Bourguignon, Pierre Cotet and François Robert.

Laplanche attended the École Normale Supérieure in the 1940s, studying philosophy. He was a student of Jean Hyppolite, Gaston Bachelard and Maurice Merleau-Ponty. In 1943, during the Vichy regime, Laplanche joined the French Resistance, and was active in Paris and Bourgogne. In 1946-1947, he visited Harvard University for a year. Instead of joining that university’s philosophy department, he instead studied at the Department of Social Relations, and became interested in psychoanalytic theory. After returning to France, Laplanche began attending lectures and undergoing psychoanalytic treatment under Jacques Lacan. Laplanche, advised by Lacan, began studying medicine, and eventually earned his doctorate and became an analyst himself, joining the International Psychoanalytical Association, of which he remained a member until his death.

On This Day … 20 June

People (Births)

People (Deaths)

  • 1925 – Josef Breuer, Austrian physician and psychologist (b. 1842).

Johannes Heinrich Schultz

Johannes Heinrich Schultz (20 June 1884 to 19 September 1970) was a German psychiatrist and an independent psychotherapist. Schultz became world-famous for the development of a system of self-hypnosis called autogenic training.

Life

He studied medicine in Lausanne, Göttingen (where he met Karl Jaspers) and Breslau. He earned his doctorate from Göttingen in 1907. After receiving his medical license in 1908, he practiced at the polyclinic at the Medical University Clinic at Göttingen until 1911. Afterwards he worked at the Paul-Ehrlich Institute in Frankfurt, at the insane asylum at Chemnitz and finally at the Psychiatric University Clinic at Jena under Otto Binswanger, where he earned his habilitation in 1915.

During the First World War, he served as director of a sanitorium in Belgium. In 1919 he became a professor of Psychiatry and Neuropathology at Jena. In 1920 he became Chief Doctor and scientific leader at Dr. Heinrich Lahmann’s sanatorium Weisser Hirsch in Dresden. In 1924, he established himself as a psychiatrist in Berlin.

From 1925-26 he was a member of the founding committee for the first General Doctors’ Congress for Psychotherapy, board member of the General Medical Society for Psychotherapy (established in 1927). From 1928 he advised the organisation’s newsletter, and after 1930 he co-edited (with Arthur Kronfeld and Rudolf Allers) the journal, now named the Zentralblatt für Psychotherapie. In 1933 he became a board member of the renamed German Medical Society for Psychotherapy under Matthias Heinrich Göring and from 1936 under this vice-director a board member of the German Institute for Psychological Research and Psychotherapy (Deutsches Institut für psychologische Forschung und Psychotherapie) as well as director of the polyclinic.

Nazi Period

In 1933 he began research on his guidebook on sexual education, Geschlecht, Liebe, Ehe, in which he focused on homosexuality and explored the topics of sterilisation and euthanasia. In 1935 he published an essay titled Psychological consequences of sterilisation and castration among men, which supported compulsory sterilization of men in order to eliminate hereditary illnesses. Soon after he was appointed deputy director of the Göring Institute in Berlin, which was the headquarters of the Deutsches Institut für psychologische Forschung und Psychotherapie (German institute for psychological research and psychotherapy).

Through this institute, he had an active role in the extermination of mentally handicapped individuals in the framework of the Aktion T4 programme.

There he began to test many of his theories on homosexuality. Schultz strongly believed that homosexuality generally was not hereditary and that most homosexuals became so through perversion. He stated on numerous occasions that homosexuals displayed “scrubby and stunted forms of personality development”. Consequently, he also believed that homosexuality was curable through intense psychotherapy. During his time at the Göring Institute, 510 homosexuals were recorded to have received numerous psychotherapeutic treatments and 341 were deemed to be cured by the end of the treatments. Most of his subjects were convicted homosexuals brought in from concentration camps. After treating his patients, Schultz tested the treatments’ effectiveness by forcing them to have sex with prostitutes. In a case study he later released, in which he briefly discussed the process of determining whether a young SS soldier, who had been sentenced to death for homosexual acts, was ‘cured’, Schultz stated: “Those who were considered incurable were sent back to the concentration camps, but ‘cured’ homosexuals, such as the previously mentioned SS soldier, were pardoned and released into military service”. In this way Schultz actually saved numerous accused homosexuals from the hellish life of a concentration camp but he stated later that “successfully treated subjects were sent to the front, where they most probably were killed in action”.

After the war, the Göring Institute was disbanded but Schultz faced no repercussions for his more dubious research and methods during the past decade. In fact he released a case study on his work with homosexuals in 1952 titled Organstörungen und Perversionen im Liebesleben, in which he admitted to the inhumanity of some of his experiments but also still supported their results. In fact he continued to support his findings and even continued to advocate paragraph 175 for the rest of his life.

In 1956, he became editor of the journal Psychotherapie, and in 1959 founder of the German Society for Medical Hypnosis (Deutschen Gesellschaft für ärztliche Hypnose).

Josef Breuer

Josef Breuer (15 January 1842 to 20 June 1925) was a distinguished physician who made key discoveries in neurophysiology, and whose work in the 1880s with his patient Bertha Pappenheim, known as Anna O., developed the talking cure (cathartic method) and laid the foundation to psychoanalysis as developed by his protégé Sigmund Freud.

Neurophysiology

Breuer, working under Ewald Hering at the military medical school in Vienna, was the first to demonstrate the role of the vagus nerve in the reflex nature of respiration. This was a departure from previous physiological understanding, and changed the way scientists viewed the relationship of the lungs to the nervous system. The mechanism is now known as the Hering–Breuer reflex.

Independent of each other in 1873, Breuer and the physicist and mathematician Ernst Mach discovered how the sense of balance (i.e. the perception of the head’s imbalance) functions: that it is managed by information the brain receives from the movement of a fluid in the semicircular canals of the inner ear. That the sense of balance depends on the three semicircular canals was discovered in 1870 by the physiologist Friedrich Goltz, but Goltz did not discover how the balance-sensing apparatus functions.

What is Dissaffection?

Introduction

The term disaffectation was coined by noted French psychoanalyst Joyce McDougall as a strictly psychoanalytic term for alexithymia, a neurological condition characterised by severe lack of emotional awareness.

Background

McDougall felt that alexithymia had become too strongly classified as a neuroanatomical defect and concretised as an intractable illness leaving little room for a purely psychoanalytic explanation for this phenomenon.

In coining the term McDougall hoped to indicate the behaviour of people who had experienced overwhelming emotion that threatened to attack their sense of integrity and identity. Such individuals, unable to repress the ideas linked to emotional pain and equally unable to project these feelings delusively onto representations of other people, simply ejected them from consciousness by “pulverizing all trace of feeling, so that an experience which has caused emotional flooding is not recognized as such and therefore cannot be contemplated”. They were not suffering from an inability to experience or express emotion, but from “an inability to contain and reflect over an excess of affective experience.”

‘Disaffectation’ conveys a deliberate double meaning. The Latin prefix dis-, indicates separation or loss and suggests, metaphorically, that certain people are psychologically separated from their emotions and may have “lost” the capacity to be in touch with interior psychic reality. Also included in this prefix is the secondary meaning from the Greek dys- with its implication of illness.

According to Professor of Psychiatry of the University of Toronto, Graeme Taylor, this psychoanalytic conceptualisation departs from older, less applicable theories which emphasized the role of unconscious neurotic conflicts, and instead facilitates a psychoanalytic model of physical illness and disease based on the operation of primitive pre-neurotic pathology that has failed to achieve psychic representation. Henry Krystal Professor of Psychiatry at Michigan State University agreed, adding that it is useful to separate the consideration of psychotherapy for the “disaffected” individual from that of the classical psychosomatic neuroses. To Krystal this consideration is important because “since these patients may develop serious, even occasionally fatal exacerbations of illness during psychotherapy, treating them with psychotherapy for psychosomatic illness is not indicated”. This distinction has allowed the field of psychoanalysis to contribute constructively to the field of psychosomatic medicine.

What is the Diathesis-Stress Model?

Introduction

The diathesis-stress model, also known as the vulnerability-stress model, is a psychological theory that attempts to explain a disorder, or its trajectory, as the result of an interaction between a predispositional vulnerability, the diathesis, and a stress caused by life experiences. The term diathesis derives from the Greek term (διάθεσις) for a predisposition, or sensibility. A diathesis can take the form of genetic, psychological, biological, or situational factors. A large range of differences exists among individuals’ vulnerabilities to the development of a disorder.

The diathesis, or predisposition, interacts with the individual’s subsequent stress response. Stress is a life event or series of events that disrupts a person’s psychological equilibrium and may catalyse the development of a disorder. Thus the diathesis-stress model serves to explore how biological or genetic traits (diatheses) interact with environmental influences (stressors) to produce disorders such as depression, anxiety, or schizophrenia. The diathesis-stress model asserts that if the combination of the predisposition and the stress exceeds a threshold, the person will develop a disorder. The use of the term diathesis in medicine and in the specialty of psychiatry dates back to the 1800s; however, the diathesis-stress model was not introduced and used to describe the development of psychopathology until it was applied to explaining schizophrenia in the 1960s by Paul Meehl.

The diathesis-stress model is used in many fields of psychology, specifically for studying the development of psychopathology. It is useful for the purposes of understanding the interplay of nature and nurture in the susceptibility to psychological disorders throughout the lifespan. Diathesis-stress models can also assist in determining who will develop a disorder and who will not. For example, in the context of depression, the diathesis-stress model can help explain why Person A may become depressed while Person B does not, even when exposed to the same stressors. More recently, the diathesis-stress model has been used to explain why some individuals are more at risk for developing a disorder than others. For example, children who have a family history of depression are generally more vulnerable to developing a depressive disorder themselves. A child who has a family history of depression and who has been exposed to a particular stressor, such as exclusion or rejection by his or her peers, would be more likely to develop depression than a child with a family history of depression that has an otherwise positive social network of peers. The diathesis-stress model has also served as useful in explaining other poor (but non-clinical) developmental outcomes.

Protective factors, such as positive social networks or high self-esteem, can counteract the effects of stressors and prevent or curb the effects of disorder. Many psychological disorders have a window of vulnerability, during which time an individual is more likely to develop disorder than others. Diathesis-stress models are often conceptualised as multi-causal developmental models, which propose that multiple risk factors over the course of development interact with stressors and protective factors contributing to normal development or psychopathology. The differential susceptibility hypothesis is a recent theory that has stemmed from the diathesis-stress model.

Diathesis

The term diathesis is synonymous with vulnerability, and variants such as “vulnerability-stress” are common within psychology. A vulnerability makes it more or less likely that an individual will succumb to the development of psychopathology if a certain stress is encountered. Diatheses are considered inherent within the individual and are typically conceptualised as being stable, but not unchangeable, over the lifespan. They are also often considered latent (i.e. dormant), because they are harder to recognise unless provoked by stressors.

Diatheses are understood to include genetic, biological, physiological, cognitive, and personality-related factors. Some examples of diatheses include genetic factors, such as abnormalities in some genes or variations in multiple genes that interact to increase vulnerability. Other diatheses include early life experiences such as the loss of a parent, or high neuroticism. Diatheses can also be conceptualised as situational factors, such as low socio-economic status or having a parent with depression.

Stress

Stress can be conceptualised as a life event that disrupts the equilibrium of a person’s life. For instance, a person may be vulnerable to become depressed, but will not develop depression unless they are exposed to a specific stress, which may trigger a depressive disorder. Stressors can take the form of a discrete event, such the divorce of parents or a death in the family, or can be more chronic factors such as having a long-term illness, or ongoing marital problems. Stresses can also be related to more daily hassles such as school assignment deadlines. This also parallels the popular (and engineering) usage of stress, but note that some literature defines stress as the response to stressors, especially where usage in biology influences neuroscience.

It has been long recognised that psychological stress plays a significant role in understanding how psychopathology develops in individuals. However, psychologists have also identified that not all individuals who are stressed, or go through stressful life events, develop a psychological disorder. To understand this, theorists and researchers explored other factors that affect the development of a disorder and proposed that some individuals under stress develop a disorder and others do not. As such, some individuals are more vulnerable than others to develop a disorder once stress has been introduced. This led to the formulation of the diathesis-stress model.

Genetics

Sensory processing sensitivity (SPS) is a temperamental or personality trait involving “an increased sensitivity of the central nervous system and a deeper cognitive processing of physical, social and emotional stimuli”. The trait is characterised by “a tendency to ‘pause to check’ in novel situations, greater sensitivity to subtle stimuli, and the engagement of deeper cognitive processing strategies for employing coping actions, all of which is driven by heightened emotional reactivity, both positive and negative”.

Sensory processing sensitivity captures sensitivity to environment in a heritable, evolutionary-conserved trait, associated with increased information processing in the brain. Moderating sensitivity to environments in a for-better-and-for-worse fashion. Interaction with negative experiences increases risk for psychopathology. Whereas interaction with positive experiences (including interventions), increases positive outcomes. Mast cells are long-lived tissue-resident cells with an important role in many inflammatory settings including host defence to parasitic infection and in allergic reactions. Stress is known to be a mast cell activator.

There is evidence that children exposed to prenatal stress may experience resilience driven by epigenome-wide interactions.” Early life stress interactions with the epigenome show potential mechanisms driving vulnerability towards psychiatric illness. ancestral stress alters lifetime mental health trajectories via epigenetic regulation.

Carriers of congenital adrenal hyperplasia have a predeposition to stress, due to the unique nature of this gene. True rates of prevalence are not known but common genetic variants of the human Steroid 21-Hydroxylase Gene (CYP21A2) are related to differences in circulating hormone levels in the population.

Psychological distress is a known feature of generalised joint hypermobility (gJHM), as well as of its most common syndromic presentation, namely Ehlers-Danlos syndrome, hypermobility type (a.k.a. joint hypermobility syndrome – JHS/EDS-HT), and significantly contributes to the quality of life of affected individuals. Interestingly, in addition to the confirmation of a tight link between anxiety and gJHM, preliminary connections with depression, attention deficit (and hyperactivity) disorder, autism spectrum disorders, and obsessive-compulsive personality disorder were also found.

Protective Factors

Protective factors, while not an inherent component of the diathesis-stress model, are of importance when considering the interaction of diatheses and stress. Protective factors can mitigate or provide a buffer against the effects of major stressors by providing an individual with developmentally adaptive outlets to deal with stress. Examples of protective factors include a positive parent-child attachment relationship, a supportive peer network, and individual social and emotional competence.

Throughout the Lifespan

Many models of psychopathology generally suggest that all people have some level of vulnerability towards certain mental disorders, but posit a large range of individual differences in the point at which a person will develop a certain disorder. For example, an individual with personality traits that tend to promote relationships such as extroversion and agreeableness may engender strong social support, which may later serve as a protective factor when experiencing stressors or losses that may delay or prevent the development of depression. Conversely, an individual who finds it difficult to develop and maintain supportive relationships may be more vulnerable to developing depression following a job loss because they do not have protective social support. An individual’s threshold is determined by the interaction of diatheses and stress.

Windows of vulnerability for developing specific psychopathologies are believed to exist at different points of the lifespan. Moreover, different diatheses and stressors are implicated in different disorders. For example, breakups and other severe or traumatic life stressors are implicated in the development of depression. Stressful events can also trigger the manic phase of bipolar disorder and stressful events can then prevent recovery and trigger relapse. Having a genetic disposition for becoming addicted and later engaging in binge drinking in college are implicated in the development of alcoholism. A family history of schizophrenia combined with the stressor of being raised in a dysfunctional family raises the risk of developing schizophrenia.

Diathesis-stress models are often conceptualised as multi-causal developmental models, which propose that multiple risk factors over the course of development interact with stressors and protective factors contributing to normal development or psychopathology. For example, a child with a family history of depression likely has a genetic vulnerability to depressive disorder. This child has also been exposed to environmental factors associated with parental depression that increase their vulnerability to developing depression as well. Protective factors, such as strong peer network, involvement in extracurricular activities, and a positive relationship with the non-depressed parent, interact with the child’s vulnerabilities in determining the progression to psychopathology versus normative development.

Some theories have branched from the diathesis-stress model, such as the differential susceptibility hypothesis, which extends the model to include a vulnerability to positive environments as well as negative environments or stress. A person could have a biological vulnerability that when combined with a stressor could lead to psychopathology (diathesis-stress model); but that same person with a biological vulnerability, if exposed to a particularly positive environment, could have better outcomes than a person without the vulnerability.

What is Pharmacotherapy?

Introduction

Pharmacotherapy is therapy using pharmaceutical drugs, as distinguished from therapy using surgery (surgical therapy), radiation (radiation therapy), movement (physical therapy), or other modes. Among physicians, sometimes the term medical therapy refers specifically to pharmacotherapy as opposed to surgical or other therapy; for example, in oncology, medical oncology is thus distinguished from surgical oncology. Pharmacists are experts in pharmacotherapy and are responsible for ensuring the safe, appropriate, and economical use of pharmaceutical drugs.

Background

The skills required to function as a pharmacist require knowledge, training and experience in biomedical, pharmaceutical and clinical sciences. Pharmacology is the science that aims to continually improve pharmacotherapy. The pharmaceutical industry and academia use basic science, applied science, and translational science to create new pharmaceutical drugs.

As pharmacotherapy specialists and pharmacists have responsibility for direct patient care, often functioning as a member of a multidisciplinary team, and acting as the primary source of drug-related information for other healthcare professionals. A pharmacotherapy specialist is an individual who is specialised in administering and prescribing medication, and requires extensive academic knowledge in pharmacotherapy.

In the US, a pharmacist can gain Board Certification in the area of pharmacotherapy upon fulfilling eligibility requirements and passing a certification examination.

While pharmacists provide valuable information about medications for patients and healthcare professionals, they are not typically considered covered pharmacotherapy providers by insurance companies.

What is Dissociative Disorder Not Otherwise Specified?

Introduction

Dissociative disorder not otherwise specified (DDNOS) is a mental health diagnosis for pathological dissociation that matches the DSM-5 criteria for a dissociative disorder, but does not fit the full criteria for any of the specifically identified subtypes, which include dissociative identity disorder, dissociative amnesia, and depersonalisation/derealisation disorder, and the reasons why the previous diagnoses were not met are specified.

Refer to Depressive Disorder Not Otherwise Specified (DD-NOS).

Background

“Unspecified dissociative disorder” is given when the clinician does not give a reason. The International Statistical Classification of Diseases and Related Health Problems (ICD-10) refers to the diagnosis as “Other dissociative and conversion disorders”.

Examples of DDNOS include chronic and recurrent syndromes of mixed dissociative symptoms, identity disturbance due to prolonged and intense coercive persuasion, disorders similar to dissociative identity disorder, acute dissociative reactions to stressful events, and dissociative trance.

DDNOS is the most common dissociative disorder and is diagnosed in 40% of dissociative disorder cases. It is often co-morbid with other mental illnesses such as complex posttraumatic stress disorder, major depressive disorder, generalised anxiety disorder, personality disorders, substance use disorders, and eating disorders.