Human Life Cycle 7 - Puberty, Adolescence and Psychopathology
Anil Chopra
1. To know the main endocrine factors associated with the onset of pubertal
development.
2. To know the range of adolescent attitudes (males/females, ethnic variation) to
pubertal development
3. To demonstrate that that these attitudes and associated behaviours in the context
of other aetiological factors, may contribute to the onset of anorexia nervosa.
4. Describe the main features of anorexia nervosa.
5. To know selected features of treatment that may ameliorate the outcome of the
disorder.
6. Understand the principles of adolescent development of self concept and identity
in relation to biological, psychological, social and environmental changes during
adolescence.
7. Know the range of disorders of mood accompanying adolescent development
(dysthymia, depressive disorder, psychotic depression and bipolar disorder).
8. Know the main causes of depressive disorder in adolescence, encompassing
biological psychological, social and environmental factors.
9. To know the main features of antisocial behaviour, conduct disorder, and
offending.
10.To know some important aetiological and maintaining factors.
11.To know what interventions may ameliorate the problems.
Puberty, Adolescence and Psychopathology
There are a number of dynamic changes that occur in the brain as a result of adolescence:
• White matter increases
• Relative reduction in grey matter
• Dorsal lateral prefrontal cortex (important in controlling impulses) matures
until 20’s
• The differences in gender become apparent as females develop more than
males in the mesial temporal cortex, caudate thalamus.
This results in a number of psychological changes that involve the cognition,
understanding (e.g. morality), identity and personality. There are also a number of
social changes that occur:
• Family - parental surveillance, confiding
• Peers - increased importance
• Social role – education, occupation, etc
• Psychosexual developmental
These are thought to be influenced by school, work, culture, environment, social
class, housing neighbourhood etc as well as genes.
The psychology associated with adolescence mean that it is a time of:
• Increased risk of disorders related to neurodevelopmental processes eg
schizophrenia
• Improvement in some other e.g. hyperkinetic disorders (improved impulse
control)
• Increased risk of eating disorders eg AN
• Increased risk of depression (Females) or conduct problems/ delinquency
(Males)
Puberty, Body Shape and Anorexia
Anorexia Nervosa is defined as having a body weight of at least 15% below that
which is expected or a BMI of less than 17.5. It is characterised by the avoidance of
the patient from “fattening” foods and to have a desired body weight that is lower
than premorbid or healthy. Patients often have a dread of fatness and this often leads
to a number of endocrine problems. The male : female ration is 1:10.
Bulimia Nervosa is defined as a persistent preoccupation with eating, and an
irresistible craving for food. Patients often succumb to episodes of eating large
amounts of food in short periods of time and then go without food for long periods of
time. They often have other weight losing behaviours such as force-vomiting.
Male Pubertal Development
- increase in height and musculature
- often, slower maturing boys are dissatisfied with their height and musculature
- early maturing boys feel more attractive, popular, relaxed and superior to their
peers (better at sports); these feelings may persist
- studies show that boys often wanted to gain weight associated with built
musculature
Female Pubertal Development
- increase in height and body fat
- insecurity about menarche (first period)
- girls are often dissatisfied with their weight gain and fat proportion
- may lead to lower self-esteem
- being slim is perceived as desirable
- studies show that many girls perceive themselves as fat and many are dieting
Girls who are prone to having eating problems are often have early pubertal maturity
and subsequent higher body fat, usually accompanied by some psychological
disorders e.g. depression. They attribute slimmer body shapes as being attractive.
It is thought that:
- 20% of girls are obese
- 30-50% of girls are dieting or dislike their body shape
- 10% are severely dieting and using weight loss techniques e.g. vomiting,
laxatives
- 1% have anorexia nervosa or bulimia nervosa
Ethnic variation – white English girls are more negative about body shape and
weight than African Caribbean girls. Negative attitudes increase as weight and BMI
increase
Severe dieting is the main symptom of anorexia nervosa and studies have shown that
it can increase the risk by 16 times. Twin studies show that there is a 50% inheritance
and the disease is evident in personalities which are perfectionist and obsession.
Negative attitudes to body shape from parents also increases the risk of anorexia
development, along with maternal dieting. Experiences such as sexual abuse and other
adverse life events can also influence the risk of anorexia nervosa. There is also the
heavy influence of peers and the media.
Presentation of Anorexia Nervosa
- weight loss
- abnormally slow growth from self starvation
- nausea
- abdominal distension
- fainting and dizziness
- deliberate self harm (especially in bulimia)
- selective eating – fat avoidance
- vomiting, and laxatives
- low mood, irritability
- poor concentration
- sleep disturbance
Assessment of Anorexia Nervosa
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Family interview
Individual interview with child/adolescent
Physical examination
Data on growth
Physical examination & investigations
Differential diagnosis:
 Physical
o Gastro-intestinal disorder eg. crohns disease
o Metabolic eg diabetes
o Pituitary
 Psychiatric
o Bulimia nervosa
o Depression
o Psychosis
o Obsessive compulsive disorder
Treatment of Anorexia Nervosa
• Nutrition counselling
• Family therapy
- parents supervise eating, ensure weight gain
- discussion of family relationships
- family life-cycle issues
- most adolescents are significantly helped by family treatments
• Initially weight gain, then improvement in eating attitudes and mood
• Family conflict reduces and warmth between parents increases, relationships
become more harmonious
• Important problems in treatment are drop-out, depression/DSH, poor treatment
progress, low weight
• Separation of parents from Adolescent associated with better outcome in critical
families
• Cognitive Behavioural therapy to reduce weight preoccupations, challenge faulty
cognition
Self Concept, Mood and Depression
Self concept: what sort of person you are. This is a result of biologically based
behavioural propensities e.g. autonomic reactivity, thinking and feeling patterns are a
substrate for personality. The brain undergoes developmental programming following
severe experiences which lead to changes in the neuroendocrine structure and
function.
- Attachment theory: it is thought that negative relations in childhood lead to
negative thoughts about oneself and negative relationships in adulthood
- concepts of the world are influenced by the development of our standards and
values
- Abstract Thinking – Piaget described a change from concrete operational
thinking to the stage of formal operations.
- Negative cognitive sets – cause persistence of adverse effect of experiences.
Self efficacy is the ability to cope with different life challenges, depending on
expectations of how other people are likely to respond to you.
Environmental Factors
o Poverty and deprivation
o Disadvantaged schools and neighbourhoods with bullying
o Disasters and wars
Depressive Disorder: characterised by depression of mood, easy irritability plus any
2 or more of:
 Depressed mood, with sadness and tearfulness, misery and hopelessness
 Loss of energy and interest
 Self blame and feelings of unworthiness and guilt
 Change in sleep pattern – insomnia, early morning wakening, or sleepiness
 Changes in appetite, with diminished appetite/sometimes increased appetite
 Weight changes associated with the appetite changes
 Slowing of thought processes and bodily movements
 School problems academic and social problems, withdrawal or outbursts
 Suicidal thoughts or behaviour
All of which result in impaired functioning.
Psychotic Depression: patient may experience hallucinations with depressing content
e.g. thoughts of suicide, voices of evil, worthlessness
Bipolar Affective Disorder: characterised by alternating feelings of depression
(dysthymia) and mania (elation, overactivity, grandeur).
Epidemiology
- 0.2% of children aged 10 and under experience depression
o Male: female ratio is 1:1
- 3-5% of adolescents experience depression
o Females more so than males
There is also a high rate of comorbidity with 50% of children having at least one more
disorder.
Biological Factors
The risk of depression is higher in those families with other major defective disorders.
Twin studies also show a concordance for depression with monozygotic twins having
a 76% risk of development of the other having it.
It is thought that biochemically, depression is caused by lack of monoamine
production in the brain and hence lack of activity of reward systems.
Hormonally, it is thought that the rise in depression in adolescent females is due to
androgens and oestrogen production. These also indirectly affect the secretion of
hormones such as cortisol, thyroid hormone and growth hormone.
Depression may also complicate physical illness, such as Cushing’s Disease,
glandular fever, diabetes, asthma, rheumatoid arthritis, Crohn’s etc.
Social and Environmental Causes
Adolescent Depression may be a consequence of:
• acute life events
• chronic adversity
• vulnerability factors, such as early loss – bereavement, especially loss of a
parent leads to development of depression
• change of cognition: from operant thinking to a stage in of formal operations
involving abstract concepts, which may be depressive in nature
• another disease (secondary depression) e.g. conduct disorder, adjustment disorder,
separation anxiety, attention deficit, eating disorders and psychosomatic conditions
• drug abuse and alcoholism
• physical, sexual or emotional abuse at home or at school resulting in “learned helplessness”
• disturbed parents
• Bereavement, especially loss of a parent may lead to prolonged grief and depression
• The manner with which the bereavement is coped with by the surviving family
affects the outcome of depression
• Change from concrete operational thinking to the stage of formal operations
involving abstract concepts, which may be depressive in nature.
• Depressed individuals have a negative cognitive set in which they blame
themselves and develop negative attributions.
• ”Learned helplessness” may result when adolescents’ security and self-esteem
are impaired by chronic adverse circumstance such as discord or abuse at
home or bullying at school.
• domestic violence
• marital conflict between parents – family divorce is seen in a number of cases
often leading to secondary consequences such as financial instability, stress,
arrival of step parent
• loss of friendship or relationship with peers (especially boyfriend/ girlfriend)
• difficulty with classwork at school
• exam failure
• social disadvantage and poverty
• Depression may appear as a secondary condition accompanying and related to
conduct disorder, adjustment disorder, separation anxiety, attention deficit,
eating disorders and psychosomatic conditions.
• Substance misuse or early alcoholism may also be associated with depression.
Scarring: individuals are often affected by a primary episode of depression and hence
are more likely to have subsequent episodes. This is caused by long-lasting changes in
the biology and responsivity to stressors.
Sensitisation: a first depressive episode may sensitise people to more episodes. This
is caused by biochemical and microstructural changes in the brain.
Treatment
Depression is usually self limiting but can be decreased by treatment. Recurrence may
occur if depressive disorder is severe, these may be Unipolar or bipolar and result in
an increased risk of self harm.
Psychotherapy
– support and counselling, self-help,
– cognitive behaviour therapy (CBT) changes cognitive distortions
– interpersonal psychotherapy (IPT) modifies current relationships
Psychopharmacological
• Anti depressant medication - Fluoxetine (Prozac) a selective serotonin
reuptake inhibitor useful in moderate to severe depression.
• Lithium and anticonvulsants may be useful in Bipolar Affective Disorder.
Family Approaches
• Parental course for problem solving and communication
• Family therapy may lessen intra-family conflict
• Benefit risks associated with depression
Environment
• Improve the environment at home or school (eg bullying)
• Admission to an adolescent unit may be necessary if there is suicidality,
psychosis or refusal to eat or drink.
Group Therapy
• Supportive group therapy produces improved peer-relationships and social
skills.
Conduct Disorder, Antisocial Behaviour and Offending
Conduct disorders are characterised by a repetitive and consistent pattern of offensive,
antisocial, aggressive or defiant conduct.
Features of Conduct Disorder
• Disobedience/Defiance
• Spitefulness and Bullying
• Fighting and use or carrying of weapons
• Stealing and mugging
• Cruelty to people and animals
• Destruction of property
• Truancy and running away from home
• Arson
• Major violations of age-appropriate social expectations
Types of conduct disorder:
 Conduct Disorder confined to the family context
 Unsocialized Conduct Disorder
 Socialized Conduct disorder
 Oppositional Defiant disorder
 Depressive Conduct Disorder
 Other mixed disorders of conduct and emotions
 Hyperkinetic conduct disorder
Delinquency: failure to abide by the law.
Epidemiology
Child delinquency is the most common psychotic childhood condition:
o 5% 5 – 15 years
o 4% 5 - 10
o 6% 10 – 15
The boy: girl ratio is 2: 1.
Causes of Delinquency
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Genetic e.g. through difficult / impulsive temperament
Hyperactivity
Physical health problems
Developmental problems e.g. delayed language development
Association with deviant peer groups e.g. gangs
Poor parent supervision
Erratic, harsh discipline from parents
Parental rejection
Lack of positive reinforcement of prosocial behaviour from parents
Parental criminality
Family violence
Parental substance misuse
Large family size
Poor schooling e.g. inadequate law enforcement, or poorly defined laws
Poverty
Inner city crime and unemployment
Consequences of Conduct Disorder
For individual
- expulsion from school
- imprisonment
- suicide
- homicide
- alcoholism and drug dependence
- antisocial personality
- increased risk of unemployment
- difficulty in relationships
There are also a number of effects on the innocent victims and a huge financial cost to
society.
Treatment
Targeted at modifiable risk factors:
- parenting programmes
o play and positive parent-child interactions
o praise and reward for good behaviour
o clearly expressed rules and expectations
o consistent and calm consequences for misbehaviour
- cognitive problem solving skills
o Adolescents with conduct disorder sometimes have distorted
attributions of aggressive intentions in other people
o Techniques used to develop more accurate perceptions
o Teaching of problem-solving skills, including range of options and
their consequences.
- school intervention
o teaching teachers about how to deal with disruptive behaviour
o increasing school acheivment
- hyperactivity management
o medications used
- multi-systemic therapy
o intensive package of measures including parent management, social
and educational measures and family work
- mentoring
There is not a good prognosis if the prevention fails.
Psychological Changes in Adolescence
Hormonal Changes:
- it is risky to attribute all mood change to hormonal change during adolescence.
- activation of the hypothalamic-pituitary gonadal axis.
Tasks of Adolescence
 identity
 independence
 intimate relationships
 secure sexual identity
 employment
 leaving home
Cognitive and social Changes
 Achievement of independent identity is important in adolescence.
 In becoming independent, autonomy is keen. Adolescents want to make
boundaries themselves.
 Abstract thinking. Become more concerned with hypothetical & the future.
 Adolescents become increasingly self conscious.
 Need privacy.
 Quite egocentric – preoccupied with themselves.
 Worries about immediate issues rather than long term.
 Generally have an ideological mode of moral reasoning which addresses wider
social issues rather than just personal and interpersonal situations.
Peer and Family Relationships
 Peer relationship increasingly important
 Some risk taking ‘normal’.
Self Concept: a view of what sort of person you are.
 Influences thoughts, feelings and actions.
 Develops throughout childhood but becomes more sophisticated in adolescence
with the development of abstract thinking.
 Components of self concept include physical, psychological and social attributes.
 Development of self concept occurs through experiences, e.g.
o Biological factors
o Severe/traumatic experiences e.g. physical abuse
o Psychological factors.
o Social factors: self efficacy – ability to cope with life challenges.
o Environmental factors: bullying, war,
Challenges of Adolescence
 Stressful
 Social acceptances
 Friendships
 External pressures: school exams
 Vulnerable to mental health problems.
 Adolescents who have not learned adaptive ways of dealing with challenges. 
can lead to depressive disorder.
Features of Depressive Disorder
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Depressed mood lasting at least 2 weeks.
Depressive thinking. Hopelessness, suicidal thinking, negative about future.
Biological symptoms – sleep disturbance, appetite disturbance.
Associated functional impairment.
Irritable mood.
Social withdrawal.
Psychotic symptoms are rare before mid-adolescence (hearing voices)
Distinguish between mild, moderate and severe.
Epidemiology
- Prepubertal 0.2% prevalence
o Boys same as girls
- Postpubertal 6% prevalence
o Females more prevalent than males.
- 50% have more than 1 disorder.
- 20% of adolescent GP attendees have suffered a recent depressive episode.
- Increase in prevalence from pre to post pubertal due to
o Direct effect of hormones
o Cognitive changes
o The social impact of puberty e.g.
o Changes in life stress.
Causes of Depression
There is no one single cause, it is multifactorial.
Predisposing factors:
Genetic
Family environment
o Children of disturbed parents prone to depression
o This finding mat be via an association with social advantage/family adversity.
Early exposures
Temperament & personality
o Children who are slow to adapt to new experiences are prone to depression.
o Cognitive style: e.g. tendency to blame self for problems rather than others.
o Chronic causes e.g. bullying e.t.c. can lead to “learned helplessness”.
Stressful events
Acute, stressful life events often precede onset
o Family separation
o Loss of influential figure
o Bereavement
o Peer problems
Wide variation in response to such events e.g. the timing, consequence,
context of death of parent
Maintaining factors
Sub-syndromal symptoms
Direct persistence
Scarring of sensitisation
Persisting biological or cognitive vulnerability
Persisting adversity e.g. family dysfunction.
Prognosis
o Average length of mental health services = 9 months
o High risk of recurrence
o High risk of persistence into adulthood
Treatment
Individual Psychotherapy
Biological treatments
Family approaches
 Parental courses to improve problem solving skills and communication.
 Family therapy may lessen