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Chronic illness can affect a child’s development at any stage. During infancy and childhood chronic illness can be detrimental to the development of secure attachment, interpersonal trust, self-regulation, and/or peer relation skills. During middle adolescence, chronic illness can prevent a child from being in school on a regular basis. This can affect a child’s academic and social competence. During adolescence, chronic illness can affect the development of autonomy and self-image. It can also interfere with peer & romantic relationships, and the desire for independence can lead to poor treatment compliance.
Notable definitions include:
- Centers for Disease Control and Prevention (CDC) definition (1994), the most widely used clinical and research description of CFS, is also called the Fukuda definition and is a revision of the "Holmes" or "CDC 1988" scoring system. The 1994 criteria require the presence of four or more symptoms beyond fatigue, while the 1988 criteria require six to eight.
- The ME/CFS 2003 Canadian Clinical working definition states: "A patient with ME/CFS will meet the criteria for fatigue, post-exertional malaise and/or fatigue, sleep dysfunction, and pain; have two or more neurological/cognitive manifestations and one or more symptoms from two of the categories of autonomic, neuroendocrine, and immune manifestations; and the illness persists for at least 6 months".
Clinical practice guidelines are generally based on case descriptions, with the aim of improving diagnosis, management and treatment. An example is the CFS/ME guideline for the National Health Services in England and Wales, produced in 2007 by the National Institute for Health and Clinical Excellence (NICE).
"See Adverse Childhood Experiences Study"
Adverse childhood experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and well-being. Adverse childhood experiences range from abuse to neglect to living in a household where the mother is treated violently or there is a parent with a mental illness. Kaiser Permanente and the Centers for Disease Control and Prevention's 1998 study on adverse childhood experiences determined that traumatic experiences during childhood are a root cause of many social, emotional, and cognitive impairments that lead to increased risk of unhealthy behaviors, risk of violence or re-victimization, chronic health conditions, low life potential and premature mortality. As the number of adverse experiences increases, the risk of problems from childhood through adulthood also rises. Nearly 30 years of study following the initial study has confirmed this. Many states, health providers, and other groups now routinely screen parents and children for ACEs.
There are no characteristic laboratory abnormalities to diagnose CFS; testing is used to rule out other conditions which could be responsible for the symptoms. When symptoms are attributable to certain other conditions, the diagnosis of CFS is excluded. As such, a diagnosis of CFS/ME is generally one of exclusion (of alternative diagnoses).
Some common childhood onset chronic illnesses are cystic fibrosis, cerebral palsy, juvenile diabetes, juvenile rheumatoid arthritis, and cancer. Chronic illness is often a risk factor for developing psychopathologies, due to the psychological toll it takes on the children and their developing brains. Approximately 10 million children in the United States suffer from a childhood onset chronic illness.
Trauma affects all children differently (see Stress in early childhood). Some children who experience trauma develop significant and long-lasting problems, while others may have minimal symptoms and recover more quickly. Studies have found that despite the broad impacts of trauma, children can and do recover, and that trauma-informed care and interventions produce better outcomes than “treatment as usual”. Trauma-informed care is defined as offering services or support in a way that addresses the special needs of people who have experienced trauma.
Psychiatrists seek to provide a medical diagnosis of individuals by an assessment of symptoms, signs and impairment associated with particular types of mental disorder. Other mental health professionals, such as clinical psychologists, may or may not apply the same diagnostic categories to their clinical formulation of a client's difficulties and circumstances. The majority of mental health problems are, at least initially, assessed and treated by family physicians (in the UK general practitioners) during consultations, who may refer a patient on for more specialist diagnosis in acute or chronic cases.
Routine diagnostic practice in mental health services typically involves an interview known as a mental status examination, where evaluations are made of appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of other professionals, relatives or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in rare specialist cases neuroimaging tests may be requested, but such methods are more commonly found in research studies than routine clinical practice.
Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations. It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice. In addition, comorbidity is very common in psychiatric diagnosis, where the same person meets the criteria for more than one disorder. On the other hand, a person may have several different difficulties only some of which meet the criteria for being diagnosed. There may be specific problems with accurate diagnosis in developing countries.
More structured approaches are being increasingly used to measure levels of mental illness.
- HoNOS is the most widely used measure in English mental health services, being used by at least 61 trusts. In HoNOS a score of 0–4 is given for each of 12 factors, based on functional living capacity. Research has been supportive of HoNOS, although some questions have been asked about whether it provides adequate coverage of the range and complexity of mental illness problems, and whether the fact that often only 3 of the 12 scales vary over time gives enough subtlety to accurately measure outcomes of treatment.
Though there is no clear-cut way to prevent dysthymia from occurring, some suggestions have been made. Since dysthymia will often first occur in childhood, it is important to identify children who may be at risk. It may be beneficial to work with children in helping to control their stress, increase resilience, boost self-esteem, and provide strong networks of social support. These tactics may be helpful in warding off or delaying dysthymic symptoms.
The Institute of Medicine reviewed the evidence for treatments for symptoms associated with Gulf War syndrome and related conditions. They concluded that selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors and cognitive behavioural therapy were most likely to be beneficial to patients.
Since the 1980s, Paula Caplan has been concerned about the subjectivity of psychiatric diagnosis, and people being arbitrarily “slapped with a psychiatric label.” Caplan says because psychiatric diagnosis is unregulated, doctors are not required to spend much time interviewing patients or to seek a second opinion. The Diagnostic and Statistical Manual of Mental Disorders can lead a psychiatrist to focus on narrow checklists of symptoms, with little consideration of what is actually causing the patient’s problems. So, according to Caplan, getting a psychiatric diagnosis and label often stands in the way of recovery.
In 2013, psychiatrist Allen Frances wrote a paper entitled "The New Crisis of Confidence in Psychiatric Diagnosis", which said that "psychiatric diagnosis… still relies exclusively on fallible subjective judgments rather than objective biological tests." Frances was also concerned about "unpredictable overdiagnosis." For many years, marginalized psychiatrists (such as Peter Breggin, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality." More recently these concerns have come from insiders who have worked for and promoted the American Psychiatric Association (e.g., Robert Spitzer, Allen Frances). A 2002 editorial in the "British Medical Journal" warned of inappropriate medicalization leading to disease mongering, where the boundaries of the definition of illnesses are expanded to include personal problems as medical problems or risks of diseases are emphasized to broaden the market for medications.
The "Diagnostic and Statistical Manual of Mental Disorders IV" (DSM-IV), published by the American Psychiatric Association, characterizes dysthymic disorder. The essential symptom involves the individual feeling depressed for the majority of days, and parts of the day, for at least two years. Low energy, disturbances in sleep or in appetite, and low self-esteem typically contribute to the clinical picture as well. Sufferers have often experienced dysthymia for many years before it is diagnosed. People around them often describe the sufferer in words similar to "just a moody person". Note the following diagnostic criteria:
1. During a majority of days for two years or more, the adult patient reports depressed mood, or appears depressed to others for most of the day.
2. When depressed, the patient has two or more of:
1. decreased or increased appetite
2. decreased or increased sleep (insomnia or hypersomnia)
3. Fatigue or low energy
4. Reduced self-esteem
5. Decreased concentration or problems making decisions
6. Feelings of hopelessness or pessimism
3. During this two-year period, the above symptoms are never absent longer than two consecutive months.
4. During the duration of the two-year period, the patient may have had a perpetual major depressive episode.
5. The patient has not had any manic, hypomanic, or mixed episodes.
6. The patient has never fulfilled criteria for cyclothymic disorder.
7. The depression does not exist only as part of a chronic psychosis (such as schizophrenia or delusional disorder).
8. The symptoms are often not directly caused by a medical illness or by substances, including drug abuse or other medications.
9. The symptoms may cause significant problems or distress in social, work, academic, or other major areas of life functioning.
In children and adolescents, mood can be irritable, and duration must be at least one year, in contrast to two years needed for diagnosis in adults.
Early onset (diagnosis before age 21) is associated with more frequent relapses, psychiatric hospitalizations, and more co-occurring conditions. For younger adults with dysthymia, there is a higher co-occurrence in personality abnormalities and the symptoms are likely chronic. However, in older adults suffering from dysthymia, the psychological symptoms are associated with medical conditions and/or stressful life events and losses.
Dysthymia can be contrasted with major depressive disorder by assessing the acute nature of the symptoms. Dysthymia is far more chronic (long lasting) than major depressive disorder, in which symptoms may be present for as little as 2 weeks. Also Dysthymia often presents itself at an earlier age than Major Depressive Disorder.
Multisymptom illness is more prevalent in Gulf War veterans than veterans of previous conflicts, but the pattern of comorbidities is similar for actively deployed and nondeployed military personnel.
Whether a given medical condition is termed a "functional disorder" depends in part on the state of knowledge. Some diseases, including epilepsy, schizophrenia, and migraine headaches were once considered functional disorders, but are no longer generally classified that way.
Chronic critical illness is a disease state which affects intensive care patients who have survived an initial insult but remain dependent on intensive care for a protracted period, neither dying nor recovering. The most characteristic clinical feature is a prolonged requirement for mechanical ventilation. Other features include profound weakness associated with critical illness polyneuropathy, increased susceptibility to infection, metabolic changes and hormonal changes. There may be protracted or permanent delirium, or other marked cognitive impairment. The physical and psychological symptoms of the disease are very severe, including a propensity to develop post traumatic stress syndrome.
Strict definitions of chronic critical illness vary. One definition is the requirement for mechanical ventilation for 21 days or more. It is estimated that 5-10% of patients who require mechanical ventilation as part of their initial illness will go on to develop chronic critical illness. Overall prevalence has been estimated at 34.4 per 100 000 of the population. Most adult patients do not survive chronic critical illness, and furthermore even those who are discharged from hospital frequently die soon after discharge. One-year mortality in adults is 48-68%. However, children fare better with two-thirds surviving to 5 years or beyond.
Diagnosing factitious disorder imposed on self requires a clinical assessment. Clinicians should be aware that those presenting with symptoms (or persons reporting for that person) may malinger, and caution should be taken to ensure there is evidence for a diagnosis. Lab tests may be required, including complete blood count (CBC), urine toxicology, drug levels from blood, cultures, coagulation tests, assays for thyroid function, or DNA typing. In some cases CT scan, magnetic resonance imaging, psychological testing, electroencephalography, or electrocardiography may also be employed. A summary of more common and reported cases of factitious disorder (Munchausen syndrome), and the laboratory tests used to differentiate these from authentic disease is provided below:
There are several symptoms that together point to factitious disorder, including frequent hospitalizations, knowledge of several illnesses, frequently requesting medication such as pain killers, openness to extensive surgery, few or no visitors during hospitalizations, and exaggerated or fabricated stories about several medical problems. Factitious disorder should not be confused with hypochondria, as people with factitious disorder syndrome do not really believe they are sick; they only want to be sick, and thus fabricate the symptoms of an illness. It is also not the same as pretending to be sick for personal benefit such as being excused from work or school.
People may fake their symptoms in multiple ways. Other than making up past medical histories and faking illnesses, people might inflict harm on themselves by consuming laxatives or other substances, self-inflicting injury to induce bleeding, and altering laboratory samples.” Many of these conditions do not have clearly observable or diagnostic symptoms and sometimes the syndrome will go undetected because patients will fabricate identities when visiting the hospital several times. Factitious disorder has several complications, as these people will go to great lengths to fake their illness. Severe health problems, serious injuries, loss of limbs or organs, and even death are possible complications.
No true psychiatric medications are prescribed for factitious disorder. However, selective serotonin reuptake inhibitors (SSRIs) can help manage underlying problems. Medicines such as SSRIs that are used to treat mood disorders can be used to treat FD, as a mood disorder may be the underlying cause of FD. Some authors (such as Prior and Gordon 1997) also report good responses to antipsychotic drugs such as Pimozide. Family therapy can also help. In such therapy, families are helped to better understand patients (the individual in the family with FD) and that person's need for attention.
In this therapeutic setting, the family is urged not to condone or reward the FD individual's behavior. This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. These sessions should focus on the psychiatrist's establishing and maintaining a relationship with the patient. Such a relationship may help to contain symptoms of FD. Monitoring is also a form that may be indicated for the FD patient's own good; FD (especially proxy) can be detrimental to an individual's health—if they are, in fact, causing true physiological illnesses. Even faked illnesses/injuries can be dangerous, and might be monitored for fear that unnecessary surgery may subsequently be performed.
Some individuals experience only a few outbreaks of the disorder. However, in most cases, factitious disorder is a chronic and long-term condition that is difficult to treat. There are relatively few positive outcomes for this disorder; in fact, treatment provided a lower percentage of positive outcomes than did treatment of individuals with obvious psychotic symptoms such as people with schizophrenia. In addition, many individuals with factitious disorder do not present for treatment, often insisting their symptoms are genuine. Some degree of recovery, however, is possible. The passage of time seems to help the disorder greatly. There are many possible explanations for this occurrence, although none are currently considered definitive. It may be that an FD individual has mastered the art of feigning sickness over so many years of practice that the disorder can no longer be discerned. Another hypothesis is that many times an FD individual is placed in a home, or experiences health issues that are not self-induced or feigned. In this way, the problem with obtaining the 'patient' status is resolved because symptoms arise without any effort on the part of the individual.
Because there is uncertainty in treating suspected factitious disorder imposed on self, some advocate that health care providers first explicitly rule out the possibility that the person has another early-stage disease. Then they may take a careful history and seek medical records to look for early deprivation, childhood abuse, or mental illness. If a person is at risk to themself, psychiatric hospitalization may be initiated.
Healthcare providers may consider working with mental health specialists to help treat the underlying mood or disorder as well as to avoid countertransference. Therapeutic and medical treatment may center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient's prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication and/or cognitive behavioral therapy, whereas borderline personality disorder, like all personality disorders, is presumed to be pervasive and more stable over time, and thus offers a worse prognosis.
People affected may have multiple scars on their abdomen due to repeated "emergency" operations.
Although medication is the first-line treatment for most psychiatric disorders, it does not always improve every aspect of a patient's life, and for the negative symptoms in schizophrenia, the responses to anti-psychotics are less favourable than for positive symptoms. As a result, psychotherapy might be an alternative for the treatment of these symptoms, even if medication has a good effect on other manifestations of the disorder.
Cognitive behavioural therapy (CBT), is the kind of psychotherapy that shows most promise in treating avolition (and other negative symptoms of schizophrenia), but more research is needed in the area. CBT focuses on understanding how thoughts and feelings influence behaviour, in order to help individuals develop methods and strategies to better handle the implications of their disorder. Some research suggests that CBT focusing on social skills and practice of interpersonal situations, like job interviews, seeing a doctor (to discuss medication, for example), or interacting with friends and co-workers, as well as seemingly simple things like riding a bus, might reduce negative symptoms of schizophrenia and be beneficial to patients with avolition.
Other forms of psychotherapy might also complement the role of medication and help patients, their families, and friends to work through emotional and other challenges of living with a chronic psychological disorder, including avolition.
A functional disorder is a medical condition that impairs the normal function of a bodily process, but where every part of the body looks completely normal under examination, dissection or even under a microscope. This stands in contrast to a structural disorder (in which some part of the body can be seen to be abnormal) or a psychosomatic disorder (in which symptoms are caused by psychological or psychiatric illness). Definitions vary somewhat between fields of medicine.
Generally, the mechanism that causes a functional disorder is unknown, poorly understood, or occasionally unimportant for treatment purposes. The brain or nerves are often believed to be involved. It is common that a person with one functional disorder will have others.
The diagnosis of an anxiety disorder requires first ruling out an underlying medical cause. Diseases that may present similar to an anxiety disorder, including certain endocrine diseases (hypo- and hyperthyroidism, hyperprolactinemia), metabolic disorders (diabetes), deficiency states (low levels of vitamin D, B2, B12, folic acid), gastrointestinal diseases (celiac disease, non-celiac gluten sensitivity, inflammatory bowel disease), heart diseases, blood diseases (anemia), and brain degenerative diseases (Parkinson's disease, dementia, multiple sclerosis, Huntington's disease).
Also, several drugs can cause or worsen anxiety, whether in intoxication, withdrawal, or from chronic use. These include alcohol, tobacco, cannabis, sedatives (including prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs like heroin), stimulants (such as caffeine, cocaine and amphetamines), hallucinogens, and inhalants.
The prognosis varies on the severity of each case and utilization of treatment for each individual.
If these children are left untreated, they face risks such as poor results at school, avoidance of important social activities, and substance abuse. Children who have an anxiety disorder are likely to have other disorders such as depression, eating disorders, attention deficit disorders both hyperactive and inattentive.
Avolition, as a symptom of various forms of psychopathology, is the decrease in the motivation to initiate and perform self-directed purposeful activities. Such activities that appear to be neglected usually include routine activities, including hobbies, going to work and/or school, and most notably, engaging in social activities. A person experiencing avolition may stay at home for long periods of time, rather than seeking out work or peer relations.
Cognitive deficit or cognitive impairment is an inclusive term to describe any characteristic that acts as a barrier to the cognition process.
The term may describe
- deficits in overall intelligence (as with intellectual disabilities),
- specific and restricted deficits in cognitive abilities (such as in learning disorders like dyslexia),
- neuropsychological deficits (such as in attention, working memory or executive function),
- or it may describe drug-induced impairment in cognition and memory (such as that seen with alcohol, glucocorticoids, and the benzodiazepines.)
It usually refers to a durable characteristic, as opposed to altered level of consciousness, which may be acute and reversible. Cognitive deficits may be inborn or caused by environmental factors such as brain injuries, neurological disorders, or mental illness.
Bipolar disorder is commonly diagnosed during adolescence or early adulthood, but onset can occur throughout the life cycle. The disorder can be difficult to distinguish from unipolar depression and the average delay in diagnosis is 5–10 years after symptoms begin. Diagnosis of bipolar disorder takes several factors into account and considers the self-reported experiences of the symptomatic individual, abnormal behavior reported by family members, friends or co-workers, observable signs of illness as assessed by a clinician, and often a medical work-up to rule-out medical causes. In diagnosis, caregiver-scored rating scales, specifically the mother, has been found to be more accurate than teacher and youth report in predicting identifying youths with bipolar disorder. Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others. The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's (APA) "Diagnostic and Statistical Manual of Mental Disorders", Fifth Edition (DSM-5) and the World Health Organization's (WHO) "International Statistical Classification of Diseases and Related Health Problems", 10th Edition (ICD-10). The ICD-10 criteria are used more often in clinical settings outside of the U.S. while the DSM criteria are used clinically within the U.S. and are the prevailing criteria used internationally in research studies. The DSM-5, published in 2013, included further and more accurate specifiers compared to its predecessor, the DSM-IV-TR. Semi structured interviews such as the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) and the Structured Clinical Interview for DSM-IV (SCID) are used for diagnostic confirmation of bipolar disorder.
Several rating scales for the screening and evaluation of bipolar disorder exist, including the Bipolar spectrum diagnostic scale, Mood Disorder Questionnaire, the General Behavior Inventory and the Hypomania Checklist. The use of evaluation scales cannot substitute a full clinical interview but they serve to systematize the recollection of symptoms. On the other hand, instruments for screening bipolar disorder tend to have lower sensitivity.