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

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Psychopathology & Evidence-Based Interventions. A Case Study of Adolescent Anxiety & Depression Presented by: Jessica Stewart. The Case. Emma 14 year old female Patient at Amherst Pediatrics Mom brought her in specifically because of mental health concerns: Depression A nxiety - PowerPoint PPT Presentation

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Page 1: Psychopathology &  Evidence-Based Interventions

Psychopathology & Evidence-Based Interventions

A Case Study of Adolescent Anxiety & Depression

Presented by: Jessica Stewart

Page 2: Psychopathology &  Evidence-Based Interventions

The CaseEmma

14 year old femalePatient at Amherst PediatricsMom brought her in specifically because of

mental health concerns: Depression Anxiety

After her first appointment, she was referred to CATS, but did not follow through on the referral…

Began being seen at Amherst Pediatrics

Page 3: Psychopathology &  Evidence-Based Interventions

Medical HistoryAccess to patient medical recordsNo major medical concerns…

Page 4: Psychopathology &  Evidence-Based Interventions

Psychological AssessmentMental Status

Patient presents as clean and well-groomedAppropriate eye-contactClear speechAppropriate thought processNo preoccupations or hallucinationsSlightly higher than average intelligence

Page 5: Psychopathology &  Evidence-Based Interventions

Presenting ProblemsCutting

Main reason mom brought her inOnly 1 minor cut, a year ago – not on ongoing

issueDepression

Onset: about 1 year agoModerate Intensity

AnxietyOnset: about 1 year agoModerate Intensity

No previous treatment for any issues

Page 6: Psychopathology &  Evidence-Based Interventions

FamilyMom was recently hospitalized for several

months due to mental health issuesMom and Dad were separated but Dad moved

back in to help with the family during Mom’s hospital stay

10 year old sister; some rivalryNegative relationships with both parentsVery high standards and little support for

Emma (not the same for sister)

Page 7: Psychopathology &  Evidence-Based Interventions

Substance UseNo serious substance use

Has tried alcohol a few times, but never in excess

Page 8: Psychopathology &  Evidence-Based Interventions

Social Support1 genuine friend: JennaMostly negative interactions with peers at

school; some bullyingMostly negative interactions with peers at

cheerleadingNo current romantic relationshipsPoor social skillsVery little social support

Page 9: Psychopathology &  Evidence-Based Interventions

Coping and StrengthsGood self-awarenessMusicExerciseConfident1 positive friendship – someone Emma can

talk to when she is feeling downPaternal Aunt

Page 10: Psychopathology &  Evidence-Based Interventions

LethalityCutting Occasional passing thoughts of self-harmNo planningNo threatsNo previous attemptsNo history of violence

Page 11: Psychopathology &  Evidence-Based Interventions

Clinical AssessmentsColumbia Depression Scale

Completed by Emma and MomScored “Moderately Likely” for depression

Screen for Anxiety Related Disorders (SCARED)Completed by Emma and MomScored significant for Panic Disorder (or

significant somatic symptoms), Anxiety Disorder and Social Anxiety Disorder

Page 12: Psychopathology &  Evidence-Based Interventions

Biopsychosocial FormulationEmma has so much going on her in world

right now that has contributed to her current state:Family history of mental illnessFamily structure going through so many

dramatic changes Mom hospitalized Dad returning home Emma’s parentified role

Social Struggles at school and extra-curricular activities

Page 13: Psychopathology &  Evidence-Based Interventions

Diagnosis311 Other specified depressive disorder:

depressive episode with insufficient symptoms

300.02 Generalized Anxiety DisorderV61.20 Parent-Child Relational ProblemV62.4 Social Exclusion or Rejection

Page 14: Psychopathology &  Evidence-Based Interventions

311 other specified depressive disorder: depressive episode with insufficient symptoms

This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive diagnosis class Why Not Major Depressive Disorder?

Because patient only meets three of the required criteria (5 needed for diagnosis) Depressed Mood most of the day, nearly everyday Feelings or worthlessness or excessive or inappropriate guilt (which may

be delusional) nearly every day (not merely self-reproach or guilt about being sick)

Diminished Ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

Also could have used 311 Unspecified Depressive Disorder, but chose to be more detailed

Page 15: Psychopathology &  Evidence-Based Interventions

300.02 Generalized Anxiety DisorderA. Excessive anxiety and worry (apprehensive expectation),

occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.C. The anxiety and worry are associated with three (or more) of

the following symptoms (with at least some symptoms having been present for more days than not for the past 6 months). NOTE: Only one item is required in children

1. Restlessness or feeling keyed up or on edge.2. Being easily fatigued.3. Difficulty concentrating or mind going blank.4. Irritability5. Muscle Tension6. Sleep disturbance (difficulty falling or staying asleep, or restless,

unsatisfying sleep).

Page 16: Psychopathology &  Evidence-Based Interventions

300.02 Generalized Anxiety DisorderD. The anxiety, worry or physical symptoms cause clinically

significant distress or impairment in social, occupational or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder (social phobia), contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Page 17: Psychopathology &  Evidence-Based Interventions

V61.20 Parent-Child Relational Problem This category should be used when the main focus of clinical attention is to

address the quality of the parent-child relationship or when the quality of the parent-child relationship is affecting the course, prognosis or treatment of a mental or other medical disorder. Typically the parent-child relational problem is associated with impaired functioning in behavioral, cognitive or affective domains.

Behavioral: Inadequate parental control, supervision and involvement Parental overprotection Excessive parental pressure Arguments that escalate to threats of physical violence Avoidance without resolution of problems

Cognitive: Negative attributions of others’ intentions Hostility towards or scapegoating of the other Unwarranted feelings of estrangement

Affective: Feelings of sadness, apathy or anger about the other

Page 18: Psychopathology &  Evidence-Based Interventions

V61.20 Parent-Child Relational ProblemMom’s depression keeps her from fulfilling her role

as mother and has caused stress between her and Emma.

Mom is overly attached to both daughters, not allowing them to “leave” her to spend time in social settings (particularly on weekends)

Explosive arguments with both parentsDad has rigidly high expectations for Emma and is

very critical of her.Emma has had to step into a more parentified role

during her family’s ongoing crisis which has shifted the family balance.

Page 19: Psychopathology &  Evidence-Based Interventions

V62.4 Social Exclusion or RejectionThis category should be used when there is

an imbalance of social power such that there is a recurrent social exclusion or rejection by others. Examples of social rejection include bullying, teasing, and intimidation by others; being targeted by others for verbal abuse and humiliation; and being purposefully excluded from the activities of peers, workmates, or others in one’s social environment.CheerleadingSchool

Page 20: Psychopathology &  Evidence-Based Interventions

Evidence-based InterventionsCognitive Behavioral Therapy

The “go-to” treatment for both Anxiety and Depression Strongest Empirical Support for Anxiety Higher global functioning in patients treated with CBT and SSRIs

than those treated with medication alone TORDIA trial

Medication and CBT Continued treatment for depression among treatment-resistant

adolescents results in remission in approximately one-third of patients

Person-Centered Therapy As effective as CBT Depression seen as a result of a discrepancy of self-image to self-

ideal Emphatic Understanding Unconditional Positive Regard

Page 21: Psychopathology &  Evidence-Based Interventions

Evidence-based InterventionsPharmacologic Interventions

Selective Serotonin Reuptake Inhibitors (SSRIs) First choice of medication for children

Anxiety Depression Ideally used in combination with therapy

Interpersonal Therapy for Adolescents (IPT-A)Goal: reduce depressive symptoms by

improving interpersonal functioning

Page 22: Psychopathology &  Evidence-Based Interventions

Evidence-based Interventions Attachment-based Family Therapy (ABFT)

Goal: to improve relationships, repair relational wounds and increase empathy among family members 

Family factors that are linked to the development, maintenance, and relapse of child and adolescent depression: disengagement or weak attachment bond high levels of criticism and hostility parental psychopathology ineffective parenting

Five Tasks: Relational Reframe Task - Shift the focus from fixing the problem family member to

improving family relationships Adolescent Alliance-Building Task – building the relationship between adolescent and

counselor Parent Alliance-Building Task – builds parental empathy for the adolescent Attachment Task – Adolescent expressing emotions, parents being empathetic Competence-Promoting Task – fostering the adolescents success and autonomy

outside the home 63 % saw clinical improvement (almost identical to the stats for CBT)

Page 23: Psychopathology &  Evidence-Based Interventions

My Chosen InterventionsPerson-Centered Therapy

Proven to be as effective as CBTEmma is in need of support

Family Therapy - EventuallyMom can’t currently participateOnce rapport is built I am hoping to get Dad involvedPotential paternal aunt involvement

Medication?Potentially…See where results are after therapy interventions are

in placeTalk with her PCP

Page 24: Psychopathology &  Evidence-Based Interventions

My Chosen InterventionsRelaxation Techniques

Deep Breathing and Progressive Muscle Relaxation to treat the somatic symptoms of anxiety

Found a few empirical articles, but UB did not own them

I use these techniques regularly with patients who experience panic attacks, or other somatic symptoms of anxiety

Why not CBT?Distorted Thoughts?

Page 25: Psychopathology &  Evidence-Based Interventions

Prognosis/ExpectationsFair-to-Good Prognosis

Actively Involved in treatment; good attendance and presence

Sincerely wants to improveResilientSelf-Aware

Possible ComplicationsLack of support at home – work with familyMom’s continued mental health crisisPotential decrease in social involvement due to

problems with cheerleading squad

Page 26: Psychopathology &  Evidence-Based Interventions

References Calati, R., Pedrini, L., Alighieri, S., Alvarez, M., Desideri, L., Durante, D., & ... De Girolamo, G. (2011).

Is cognitive behavioural therapy an effective complement to antidepressants in adolescents? A meta-analysis. Acta Neuropsychiatrica, 23(6), 263-271.

Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, L., & Isaacs, L. (2002). Attachment-based family therapy for depressed adolescents: A treatment development study. Journal Of The American Academy Of Child & Adolescent Psychiatry, 41(10), 1190-1196.

Haimerl, D., Finke, J., & Luderer, H. (2009). Person-centered and experiential therapy of depression. International Journal Of Psychotherapy, 13(2), 18-25.

Labekkarte, M.J., Ginsburg, G.S., Walkup, J.T., & Riddle, M.A. (1999). The treatment of anxiety disorders in children and adolescents. Biological Psychiatry, 46, 1567-1578.

Maddux, J. E., & Winstead, B. A. (2012).Psychopathology: Foundations for a contemporary understanding. (3 ed.). New York: Routledge.

McCarty, C., Weisz, J. (2007). Effects of psychotherapy for depression in children and adolescents: What we can (and can’t) learn from meta-analysis and component profiling. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7), 879-886.

Ollendick, T.H & King, N.J. (1998) Empirically supported treatments for children with phobic and anxiety disorders. Journal of Clinical Child Psychology, 27, 156-157.

Reinecke, M., Curry, J., March, J. (2009) Findings from the Treatment of Adolescnets with Depression Study (TADS): What have we learned? What do we need to know? Journal of Clinical Child and Adolescent Psychology, 38 (6), 761-767

Thomsen, P. (2011). Treating adolescents with depression and anxiety disorders, also looking at global functioning and general improvement. Acta Neuropsychiatrica, 23(6), 261-262. doi:10.1111/j.1601-5215.2011.00631.x