By PresenterMedia.com
Introduction to Childhood
Mental Illness
Review
Paradigms in Psychopathology
A Paradigm is a set of basic assumptions, a general
perspective, that defines how to conceptualise and study
a subject, how to gather and interpret relevant data
Useful to organise our thinking
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Genetics
Neuroscience
Psychodyamics
Cognitive Behaviourism
Diathesis-Stress
Nature Vs Nurture
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Stress
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Relationships
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Culture
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Genetic coding
Genetic regultation
and expression
Leads to Neurobiology
and behaviour
Genetics
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Almost all behaviour is heritable to some degree
Genes do not operate independently from the
environment
- Gene-environment Interaction
Environment can alter gene expression
- Genes may predispose us to seek out
certain
environments that then increase
our risk for
developing a particular disorder
Psychopathology is polygenic (not caused by one
gene but rather the interaction of many)
Genetics
Psychopathology is polygenic (not caused
by one gene but rather the interaction of
many)
Quantitative Genetics identifies
specific DNA sequences
responsible for genetic influence
Neuroscience
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Depression, anxiety, dementia and other
psychopathologies all show associations with
neurological dysfunction
Neuron: The neural cell, stimulated through a
change in electrical potential to cause a nerve
impulse which releases a chemical
Neurotransmitter: The chemical release to
allow communication between neural synapses,
usually generating an excitatory or an
inhibitory signal
Psychodynamics
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Childhood experiences help shape adult
personality
There are unconscious influences on behaviour
The causes and purposes of human behaviour are
not always obvious
Freud: Psychopathology results from unconscious conflict
Anecdotal evidence, not the scientific method
Benefits of gameplay, maintenance of negative schema  internal
cognitive processes
Cognitive Behaviourism
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Thorndike (1874-1949): Law of Effect
Behaviour that is followed by consequences
satisfying to the organism will be repeated,
and behaviour that is followed by noxious or
unpleasant consequences will be discouraged
Skinner (1904-1990): operant conditioning
-Positive reinforcement
-Negative reinforcement
-Automatic reinforcement
Cognitive Behavioural Therapy
(CBT)
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Restructuring a pattern of thought that is
presumed to be causing a disturbed
emotion or behaviour
Self-efficacy: a belief that one can achieve
desired goals
Differing levels of extremity in treatment
Diathesis-Stress: An Integrative
Paradigm
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Diathesis: Predisposition
Genetic
Neurobiological diathesis:
- Oxygen deprivation at birth
- Poor nutrition
- Maternal viral infection
- Smoking during pregnancy
Psychological Diathesis:
- Sexual or physical abuse in childhood
- Sociocultural influences (e.g. anorexia nervosa)
- Other childhood experience  dysfunctional or
destructive cognitive sets (e.g. hypnotizability)
Diathesis-Stress
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Stress: Noxious or unpleasant
environmental stimulus that triggers
psychopathology
- Traumatic events: Death, divorce etc
- Environmental Stress: Social
Psychology
Diathesis-Stress models focus on
interaction between predisposition
TOP-DOWN
Behaviour of the whole organism
Development of the organism
G-e interaction and correlation
THE BRAIN
Cell systems
Cells
Gene product function
DNA Sequence
Bottom-up
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Stage 1: Womb – 12 months
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Stage 2: 6 months – 2 years old
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Social contract
Stage 6: Adolescence
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Social Identity
Stage 5: 7 – 12 years old
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Will and action
Stage 4: 4 – 7 years old
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Mobility and emotion
Stage 3: 18 months – 4 years old
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Motor Functions and security
Reconstitution
Stage 7: Early Adulthood and Beyond
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Self-knowledge
Stage 1: Womb – 12 months
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Formation of the physical body during
prenatal development and infancy
Body growth is rapid at this stage
Motor operations: suck, eat, digest, grasp,
crawl, stand, walk, manipulate objects,
gravity
Little awareness of the outside world
Fused symbiosis with the mother
No separate sense of self
Awareness of survival and physical
comfort
Stage 1: Trauma
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Trauma may result in fear, insecurity, confusion
Symptoms of disorganisation or depression
Feelings of insanity, excessive thinking
Little “grounding” – detachment from body and
basic consensus reality structures
Anxiety in mundane tasks, hypervigilance (high
responsiveness to stimuli and constant scanning of
environment for threats)
Healthy development teaches security, focus, calm
and vigilance
Anxiety Disorders
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Specific Phobia
Panic Disorder
Separation Anxiety Disorder
Generalised Anxiety Disorder
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
Common Etiology of Anxiety
Disorders
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Genetic vulnerability
Increased activity in the fear circuit of the brain
(amygdala)
Decreased functioning of GABA and serotonin,
increased norepinephrine activity
Behavioural Inhibition – agitation to new stimuli in
infancy
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Neuroticism
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Predictive to a 30% level of development of social
anxiety
Personality trait with a tendency to react with greater
than average negative emotion
Twice as likely to develop into an Anxiety Disorder
Cognitive Factors (e.g. attention to cues of threat
and low perception of control)
Negative Life events
Major Depressive Disorder (MDD)
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Diagnosis
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MDD: Sad mood or loss of pleasure for 2 weeks, with
at least 4 other symptoms, such as
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Changes in sleep pattern
Change in appetite
Problems with attention
Feelings of worthlessness
Suicidality
Not just a single episode
Episodic Disorder: may be periodic, then clear
Subclinical depression can remain for years
Dysthymic Disorder (Dysthymia): Chronic depression
for more than half the time for 2 years
Bipolar Disorder
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Bipolar I Disorder: “Manic Depressive Disorder”
Bipolar II Disorder
Cyclothymic Disorder (Cyclothymia)
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Chronic mood disorders for at least 2 years
Mild alternative depression and mania
1% Prevalence rate for BPI, 40,000 in Ireland
4% for BPII and Cyclothymia
Etiology of Mood Disorders
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Neurobiology
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Amygdala – elevated
Hippocampus – diminished
Prefrontal cortex – diminished
Anterior cingulate – diminished
Assessment of how emotionally important a
stimulus is
Effective focus
Making plans based on emotionally relevant cues
Etiology of Mood Disorders
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Cortisol (Stress Hormone)
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Hypothalamus-Pituitary-Adrenocortical Axis (HPA)
Signals transmitted from the Amygdala
E.g. Cushings Syndrome
- Oversecretion of cortisol
- Frequent depressive symptoms
Dexamethasone Supression Test
- Should supress corticol secretion
- In some mood disorders, it does not
Etiology of Mood Disorders
Social Factors
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Stressful life events
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Long-term chronic stressors
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e.g. poverty
Vulnerability to stress
Lack of social support
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42-67% of depression occurs within a year of a major stressful
life event
Support minimises the effect of social stressors
E.g. 40% prevalence in women without confidants, 4% in
women with confidants
Interpersonal relations
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Depressive symptoms elicit negative reactions
Excessive reassurance seeking results in rejection
Nutritional Treatment
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Potential therapeutic benefit of n-3
polyunsaturated fatty acids (Omega 3)
Vitamin B12, B3 - necessary for the
synthesis of red blood cells, the maintenance of
the nervous system and growth and
development in children
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deficiency of this particular vitamin results in an build
up of a compound called homocysteine - this may
enhance depression.
Stage 2: 6 months – 2 years
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Visual acuity allows the child to focus on outside objects
and gain a wider visual perspective
Awareness grows of objects outside of immediate range
“Hatching” (Mahler) – moving away from mother in brief
episodes of independence
Begins to separate self from other eliciting
 Fear and excitement
 Diversity and choice
Obsessive-Compulsive Disorder
(OCD)
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2% prevalence, common onset around age
10
Obsessions:
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Intrusive and recurring thoughts, images or
impulses that are uncontrollable and come
unbidden
e.g. contamination, safety, religious issues
Compulsions:
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Repetitive, clearly excessive behaviours or
mental acts to reduce anxiety caused by
obsessive thoughts.
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e.g. elaborate rituals of orderliness, repetitive,
magically protective acts (superstitions)
Repeatedly checking that these acts are carried
out
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 lack of confidence in memory, unduly
concerned about gaps in memory
Stage 2: Separation and
Connection
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Separation from the mother corresponds with
separation of self from other
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Separation from primary attachment figure leads
to binary distinctions
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Duality:
good-bad,
 pleasure-pain,
 closeness-distance,
 self-other
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Stage 3: 18 months – 4 years
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Security in seperateness allows the child
to experiment with their own volition
Conscious self begins to emerge 
development of the ego
Beginning of control of impulses 
delayed gratification
Development of language
Stage 3: Language
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Sub-units of behaviour (stimulusresponse/response-consequence) are
organised into patterns/sets
 Cause & Effect according with environment
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Exploration of environment begins
formation of cognitive map
Operant units store in cognitive maps
Associated with neural learning networks
(enhanced with stimulation)
Stage 3: Operant Units
A
B
C
word
picture
object
Association of arbitrary units
C
A
Object
word
Backward association
Most important evolutionary leap in development
of human language which is apparently unique
to the human
Behaviourism
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Reinforcement
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Positive Reinforcement
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Negative Reinforcement
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Strengthening a tendency to respond in anticipation of a
pleasant event (reinforcer)
Strengthens a response by removing an aversive event
Modeling – e.g. sharing, aggression, fear.
Punishment
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Can lead to anxious responses, or be taken as a
reinforcer if followed by a reinforcer
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E.g. Child may seek punishment or abuse because the guilty
parent may follow it with love
Skinner (1948) The Superstitious
Pigeon
Eight pigeons received reward every 15 seconds
One bird conditioned to turn counter-clockwise
 One repeatedly thrust its head into the upper
corner of the cage
 Pendulum motion “dance”
 Incomplete pecking movements
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Reinforcement interval increased to one
minute
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Movements became more energetic
Extinction
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Took up to 10,000 responses before extinction
occurred in one case
Locus of Control
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As a child develops, behaviours are learned
which are followed by some form of
reinforcement
Reinforcement increases child’s expectancy that
behaviour will produce desired reinforcement
External locus of control
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Interpreting consequence as controlled by luck, fate
or powerful others
Internal locus of control
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Interpreting ones own behaviour and personality as
responsible for consequences
Attention Deficit/Hyperactivity Disorder
Attention Deficit: difficulty sitting still (e.g.
class/meals)
Hyperactivity: unable to stop moving or talking
Description:
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Disorganised, erratic, tactless, obstinate and bossy
Difficulty getting along with peers and establishing friendships
(in part due to: ) aggressiveness, annoying and intrusive behaviours
different social goals (e.g. sensation seeking over team-work)
Miss social cues (may recognise social cues in cognitive exercises but not in actuality)
3 – 7% of school-age children worldwide
Etiology of ADHD
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Genetics:
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Heritability estimates as high as 70-80%
50% of children from ADHD parents are likely to have it
Genetic evidence associated with Dopamine neurotransmitter
Neurobiology:
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Frontal Lobe Dysfunction:
Lobes are under-responsive, under-sized.
Cerebral blood flow is reduced
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Tobacco/Nicotine:
Environmental toxins, food additives, Lead
poisoning
Low birth weight and maternal coldness
Conduct Disorder
(Including Oppositional Defiant
Disorder)
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Description:
- Aggression and cruelty toward people or
animals, damaging property, lying and stealing
- Callousness, viciousness, lack of remorse
 Adult antisocial personality disorder
4-16% of boys, 1.2-9% of girls
Behaviour peaks at 17 and reduces in young
adulthood
Antisocial Personality Disorder and
Psychopathy
Antisocial personality
Disorder:
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1.
2.
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A pervasive pattern of disregard for the rights of
others since the age of 15.
The presence of a conduct disorder before the age
of 15. Truancy, running away from home, frequent
lying, theft, arson, and deliberate destruction of
property
Psychopathy
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Poverty of emotions.
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No sense of shame
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Superficial charm to manipulate others for personal
gain
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Lack of anxiety may make it impossible to learn
from their mistakes
Stage 4: 4 – 7 years
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Behaviours are consciously adapted to gain or express
love
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Ego development forms the foundation for relationship
with others
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Family provide the first model for relationship
formation
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Internalised family relationships are used for
interaction with peers
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Self-esteem is greatly influenced by these relationships
Stage 4: Social Identity
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Social identity (“Persona” – mask) created to
interact with others
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Self-concept initially based on how we are treated
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The part of ourselves that the ego allows to rise above the
surface, subsequent to consequence (response) control
Whether we are admired or criticised, identification of self
through relationships
Maturation includes perception of service to others
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Self-acceptance expands beyond self-centred needs and
embraces external awareness
Bowlby’s Attachment Theory
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John Bowlby (1969): Attachment Theory
Early emotional communication between
children and their significant attachment
figures
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Directly impacts mental health in later life
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Ainsworth’s Strange Situation
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Ainsworth (1973) : Strange Situation Paradigm
Assesses security of infant-adult attachment by
exposing infants to increasing amounts of stress
to observe their organisation of attachment
behaviours
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Secure
Insecure-avoidant
Anxious-ambivalent
Disorganised (Main & Solomon, 1990)
Predictive of behaviour and mental health in
later life
Love
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Harlow (1958)
Experimental Monkey mothers – groups with
surrogates made from cloth or wire, and
presented with fearful or stimulating objects
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Basic need in infant monkeys for close contact
with something soft and comforting
Babies seek out their mothers when afraid
Attachment persists after periods of seperation
Sexual disorders
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mental illnesses involving apparent violations of social norms of
sexuality
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orientation to include objects, concepts, or in some cases, elements
Paraphilias: eight major categories and seven subtypes
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include attraction to unusual objects or activities, sometimes involving
sexually deviant behaviours involving harm
Voyeurism, for example, which involves the intense and recurrent desire
for sexual gratification through watching others undress or have sex
Sadist needs to inflict physical suffering or humiliation in order to
achieve sexual gratification
only diagnosed if present without another axis-I disorder
observation, participation or fantasy must be necessary for the
individual to achieve sexual arousal and gratification
a diagnosis under the DSM-IV must be inclusive of subjective distress or
impairments in normal functioning
Childhood Sexual Abuse
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13.5% of women, 2.5% of men
About half of children exposed to CSA will
develop symptoms such as depression,
low self-esteem, conduct disorder or
anxiety disorders like PTSD.
 Almost half do not appear to experience
adverse short-term effects
Pedophilia
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Orientations are directed towards children under 13 years of age
Children deemed too young to understand the requirements for
informed consent
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What is sex, possibilities of psychological and social dilemmas
Any pedophile who does act on their fantasies then becomes a child
molester and, if legally convicted of this crime, a sex offender
Studies of pedophiles show less than 15% of them to be classifiable
as having a psychopathology under the Minnesota Multiphasic
Personality Inventory (Erickson, Luxenberg, Walbek & Seely, 1987).
Only a very small number of pedophiles are actually child molesters,
and many child molesters are not, in fact, pedophiles (Diamont &
McAnulty, 1995).
Inaccurate beliefs, such as a pedophile thinking that a child can
consent to and enjoy sex, may be a vital point for therapeutic
modulation
Stage 5: Social Contract
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Child identifies self as a role – teacher, mother,
artist, businessman
Child also identifies with failures and mistakes
Self is identified with social inspiration – role
models
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Acts of artists, poets, heroes, mythology,
great creations of civilisations etc
Creativity
Personality Disorders
An enduring pattern of inner
experience and behaviour that
deviates markedly from the
expectations of the culture of
the individual who exhibits it.
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- APA DSM
Personality Disorders
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Odd/Eccentric Cluster
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Dramatic/Erratic Cluster
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Paranoid Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
Histronic Personality Disorder
Antisocial Personality Disorder and Psychopathy
Narcissistic Personality Disorder
Anxious/Fearful Cluster
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Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
The Five Factor Model
Dimensions of personality with sample questions:
 Neuroticism
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Extraversion/Introversion
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– “I tend to be cynical and skeptical of others’ intentions”
Conscientiousness
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– “I have a very active imagination”
Agreeableness/Antagonism
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– “I really like most people I meet”
Openness to Experience
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– “I often feel tense or jittery”
– “I often come into situations without being prepared”
These dimensions of personality are moderately heritable
Linked to schizoid, borderline and avoidant personality disorders –
all high introversion with varying neuroticism
Most personality disorders are categorised by high neuroticism and
antagonism
Eating Disorders
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Anorexia Nervosa
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Bulimia Nervosa
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Binge Eating Disorder
Psychological Treatment
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Treatment varies between depression. Often comorbid
with depression and low self-esteem
Anorexia: Medical risk is high, and possibility of death
means that medical treatment must be a priority
Long term maintenance of weight game is a goal
Bulimia: CBT
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Normal body weight can be maintained without severe dieting
Unrealistic restriction can trigger binges
Alter the “all or nothing” thinking
Assertiveness to cope with unreasonable demands
Stage 6: Adolescence
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Recognition of behaviour and application of
knowledge to life decisions
Child re-examines their social identity, making a
more conscious choice rather than unconscious
reactions to family dynamics
May correspond with interest in wider material –
spirituality/religion, mythology, symbolism
through music, poetry, lyrics, archetypal figures
(celebrities), fashion.
Stage 6: Characteristics
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Intuition
Perception
Imagination
Memory
Dreams
Symbolic thought
Visualisation
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Insensitivity
Denial of reality
Dogmatic
(monopolarised)
Obsessive
Problems with
concentration
Hallucinations etc
Archetypes of Development
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Mother
Lover
Hero
Citizen/Healer
Artist
Manager/Seer
Sage/Master
APA DSM-IVTR
American Psychiatric Association (2000)
Diagnostic and Statistical Manual Revision IV, Text
Revision
General Criticisms
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Too many diagnoses (almost 300)
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Broad categories (e.g. religious doubt, non-compliance with
treatment, etc)
Comorbidity: 45% of people who meet criteria for at least one
psychiatric diagnosis will meet criteria for at least one more
Categorical (yes-no) diagnosis, rather than continuum (e.g.
Do you have high blood pressure (yes/no), where in the
range of blood pressure do you fall?)
Reliability: Vague language (e.g. “Mood is abnormally
elevated”)
Validity: Construct validity – inferred attribute (internal action,
e.g. anxiety)
DSM and Schizophrenia
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Two people may receive a diagnosis of
schizophrenia while having little, if
anything, in common
Panchreston – purports to explain
everything but actually obscures the truth
Dissociative Disorders
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Dissociative Amnesia
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Dissociative Fugue
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Depersonalisation Disorder
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Dissociative Identity Disorder
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Memory loss, typical of a
stressful experience
Memory loss, accompanied by
leaving home and establishing
a new identity
Alteration in the experience of
the self
At least two distinct
personalities that act
independently of each other
Schizophrenia in DSM
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Disorganised schizophrenia
Catatonic schizophrenia
Paranoid schizophrenia
Brief Disorders
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Schizophreniform disorder
Brief psychotic disorder
Shizoaffective disorder
Delusional disorder
Symptoms
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Positive: Excesses. Delusions,
Hallucinations
Negative: Avolition (apathy), Alogia
(poverty of speech or poverty of
content of speech), Flat affect,
Asociality, Anhedonia
Disorganised: Speech or behaviour
Neurobiology
Abnormalities in both brain structure and function
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enlarged ventricles (also in BP and often in nonpatients)
under activity of the prefrontal lobes during abstract
reasoning tasks, and abnormal functioning of the
temporal lobes
no single brain abnormality is pathognomonic for
schizophrenia, though abnormalities are probably
present in a large percentage
Treatment
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Medication:
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Neuroleptics
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4560 RP antihistamine were accidentally discovered
induced a state of indifference in schizophrenic patients,
which later led to the establishment of chlorpromazine
chloropromazine and phenothiazine, butyropenones
(haloperidol, “Haldol”), thioxanthenes (“Navane”)
good correlation between the neuroleptics to
dopamine receptors and their clinical effectiveness
as anti-psychotic drugs (for positive symptoms)
Medication

Atypical Antipsychotic drugs:

Clozapine (“Clozaril”) – alternative.

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Olanzapine (“Zyprexa”), Risperidone (“Risperdal”)

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Patients less likely to discontinue treatment
Some side-effects reduced
Early studies showed fewer side effects
May improve short term memory
Lieberman et al 2005:
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75% stop taking medication
Related to development of type 2 diabetes and
pancreatitis
Not more effective and not fewer side-effects
Paul
&
Lentz
(1977)
 Social learning and mileu therapy groups
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reduced in positive, negative and
disorganised symptoms
Groups 1 & 2 learned self-care,
housekeeping, social and vocational skills
10% of Social Learning and 7% of Mileu
therapy patients left the centre for
independent living
Antipsychotic use dropped to 18% in mileutherapy, 11% in social leaning, and
increased to 100% in Routine ward.
Stage 7: Early adulthood

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All new information is filtered through the
schemas of past behaviour and
experience. Knowledge is pursued in the
formation of a worldview
Pursuits of career or life-path
Stage 7: Self-knowledge

Transpersonal Psychology: The
movement of self from exclusively
individual identities (unique and single
organisms) toward a universal
commonality.

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Individuality is transformed and absorbed into
the Universal.
Individual personality is seen as part of a
unified and integrated whole
Character Structures (Alexander Lowen)

Typically develops from difficulties
experienced during developmental stages of
life

Six fundamental structures

Most people exhibit at least one of these
structures

Stage 1: Motor Functions

Foundation of security that enables selfpreservation and forms the physical
identity

Stage 2: Emotions


Emotional identity interested in selfgratification
Stage 3: Language

Ego identity develops inner authority and
freedom

Stage 4: Social relationships
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Stage 5: Creativity
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Career/Self expression forms creative identity
Stage 6: Self-reflection

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Social Identity formed to establish wider relationship
models and self-acceptance
Archetypal identity ascends from egoic personality
Stage 7: Knowledge

Self-knowledge forms a universal identity, learning an
teaching

Stage 8: Adult Development
The Scientific Method
Systematic pursuit of knowledge through
observation
 Forming a theory
 Systematically gathering data to test a
theory (Observations must be replicable)
 Forming a Hypothesis (what should occur
if the theory is true)
Nature

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Concordance: The presence of the same
genetic trait in two people
QTL set – multiple QTLs in a set can be
used as a genetic risk index (like
environmental risk index)

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Monozygotic (identical, MZ) twins
share 100% of genes
Dizygotic (fraternal, DZ) twins
share 50% of genes
Nature Vs Nurture

Twin and Adoption studies

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45% concordance for schiz
Genotype: Genetic constitution
Phenotype: Observable characteristics

Shared and non-shared environments
Epigenetics

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Genotype-environment Correlation:
Differential exposure to experience
Genotype-environment Interaction:
Differential sensitivity to experience
Nurture

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Developmental Psychology
Bowlby (1969): Attachment Theory
Early emotional communication between
children and their significant attachment
figures directly impacts mental health in
later life


Treatment should predictably influence the
child’s development
Internal working models
Freudian Theory

Id
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
Ego

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Basic biological urges – hunger, thirst, sexual
impulse
Limits and controls the impulses of the id
Superego

Limits the ego to moral and ethical
internalised rules between good and bad.
Freudian Theory

Defence Mechanisms


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
Repression - Forcing disturbing thoughts out
of consciousness
Regression - retreat to the behaviour of an
earlier stage of development
Projection - Unconscious urges are noted in
other people’s behaviour
Reaction Formation - opposite of the id’s real
urges
Sublimation - Finding socially acceptable ways
of discharging energy
Jungian Theory


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Social identity (“Persona” – mask) created
to interact with others
Transpersonal Psychology: The
movement of self from exclusively
individual identities (unique and single
organisms) toward a universal
commonality
Archetypes
Archetypes of Development


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



Mother
Lover
Hero
Citizen/Healer
Artist
Manager/Seer
Sage/Master









Anxiety Disorders
Mood Disorders
ADHD
Conduct Disorder (Oppositional Defiant
Disorder)
Paraphilias/Sexual Disorders
Somatoform & Factitious Disorders
Personality Disorders (Axis II)
Eating Disorders
Schizophrenia