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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
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Conduct disorder is classified in the fourth edition of "Diagnostic and Statistical Manual of Mental Disorders" (DSM). It is diagnosed based on a prolonged pattern of antisocial behaviour such as serious violation of laws and social norms and rules in people younger than the age of 18. Similar criteria are used in those over the age of 18 for the diagnosis of antisocial personality disorder. No proposed revisions for the main criteria of conduct disorder exist in the "DSM-5"; there is a recommendation by the work group to add an additional specifier for callous and unemotional traits. According to DSM-5 criteria for conduct disorder, there are four categories that could be present in the child's behavior: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violation of rules.
Almost all adolescents who have a substance use disorder have conduct disorder-like traits, but after successful treatment of the substance use disorder, about half of these adolescents no longer display conduct disorder-like symptoms. Therefore, it is important to exclude a substance-induced cause and instead address the substance use disorder prior to making a psychiatric diagnosis of conduct disorder.
About 25-40% of youths diagnosed with conduct disorder qualify for a diagnosis of antisocial personality disorder when they reach adulthood. For those that do not develop ASPD, most still exhibit social dysfunction in adult life.
For a child or adolescent to qualify for a diagnosis of ODD, behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends, or placing him or her in harmful situations. These behaviours must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.
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.
Once the patient and family have been educated about the nature, management and treatment of the disorder and a decision has been made to treat, the European ADHD Guidelines group recommends medication rather than behavioral training as the first treatment approach; and the UK's National Institute for Health and Clinical Excellence recommends medication as first line treatment for those with hyperkinesis/severe ADHD, and the provision of group parent-training in all cases of ADHD.
SCT is currently not an official diagnosis in DSM-5. But there are rating scales that can be used to screen for SCT symptoms such as the "Concentration Inventory" (for children and adults) or the "Barkley Sluggish Cognitive Tempo Scale-Children and Adolescents (BSCTS-CA)". The "Comprehensive Behaviour Rating Scale for Children" (CBRSC), an older scale, can also be used for SCT as this case study shows.
Although having no diagnosic code either, ICD-10 mentions the SCT group as a reason for why it did not replace the term ""Hyperkinetic Disorder"" with ""ADHD"."
Other mental disorders may produce similar symptoms to SCT (e.g. excessive daydreaming or "staring blankly") and should not be confused with it. Examples might be conditions like depersonalization disorder, dysthymia, thyroid problems, absence seizures, Bipolar II disorder, Kleine–Levin syndrome, forms of autism or schizoid personality disorder. However, the prevalence of SCT in these clinical populations has yet to be empirically and systematically investigated.
ADHD is diagnosed by an assessment of a person's childhood behavioral and mental development, including ruling out the effects of drugs, medications and other medical or psychiatric problems as explanations for the symptoms. It often takes into account feedback from parents and teachers with most diagnoses begun after a teacher raises concerns. It may be viewed as the extreme end of one or more continuous human traits found in all people. Whether someone responds to medications does not confirm or rule out the diagnosis. As imaging studies of the brain do not give consistent results between individuals, they are only used for research purposes and not diagnosis.
In North America, DSM-5 criteria are used for diagnosis, while European countries usually use the ICD-10. With the DSM-IV criteria a diagnosis of ADHD is more likely than with the ICD-10 criteria. It is classified as neurodevelopmental psychiatric disorder. Additionally, it is classified as a disruptive behavior disorder along with oppositional defiant disorder, conduct disorder, and antisocial personality disorder. A diagnosis does not imply a neurological disorder.
Associated conditions that should be screened for include anxiety, depression, oppositional defiant disorder, conduct disorder, and learning and language disorders. Other conditions that should be considered are other neurodevelopmental disorders, tics, and sleep apnea.
Diagnosis of ADHD using quantitative electroencephalography (QEEG) is an ongoing area of investigation, although the value of QEEG in ADHD is currently unclear. In the United States, the Food and Drug Administration has approved the use of QEEG to evaluate the morbidity of ADHD.
Self-rating scales, such as the ADHD rating scale and the Vanderbilt ADHD diagnostic rating scale are used in the screening and evaluation of ADHD.
As with many other psychiatric disorders, formal diagnosis should be made by a qualified professional based on a set number of criteria. In the United States, these criteria are defined by the American Psychiatric Association in the DSM. Based on the DSM criteria, there are three sub-types of ADHD:
1. ADHD predominantly inattentive type (ADHD-PI) presents with symptoms including being easily distracted, forgetful, daydreaming, disorganization, poor concentration, and difficulty completing tasks.
2. ADHD, predominantly hyperactive-impulsive type presents with excessive fidgetiness and restlessness, hyperactivity, difficulty waiting and remaining seated, immature behavior; destructive behaviors may also be present.
3. ADHD, combined type is a combination of the first two subtypes.
This subdivision is based on presence of at least six out of nine long-term (lasting at least six months) symptoms of inattention, hyperactivity–impulsivity, or both. To be considered, the symptoms must have appeared by the age of six to twelve and occur in more than one environment (e.g. at home and at school or work). The symptoms must be not appropriate for a child of that age and there must be evidence that it is causing social, school or work related problems.
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 rate in school age children is thought to be about 1.5%, compared with an estimated 5.3% for ADHD.
Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents. Several preventative programs have had a positive effect on those at high risk for ODD. Both home visitation and programs such as Head Start have shown some effectiveness in preschool children. Social skills training, parent management training, and anger management programs have been used as prevention programs for school-age children at risk for ODD. For adolescents at risk for ODD, cognitive interventions, vocational training and academic tutoring have shown preventative effectiveness. There is also limited evidence that the atypical antipsychotic medication risperidone decreases aggression and conduct problems in youth with disruptive behavioral disorders, such as ODD.
Despite recent initiatives to study psychopathology along dimensions of behavior and neurobiological indices, which would help refine a clearer picture of the development and treatment of externalizing disorders, the majority of research has examined specific mental disorders. Thus, best practices for many externalizing disorders are disorder-specific. For example, substance use disorders themselves are very heterogeneous and their best-evidenced treatment typically includes cognitive behavioral therapy, motivational interviewing, and a substance disorder-specific detoxification or psychotropic medication treatment component. The best-evidenced treatment for childhood conduct and externalizing problems more broadly, including youth with ADHD, ODD, and CD, is parent management training, a form of cognitive behavioral therapy. Additionally, individuals with ADHD, both youth and adults, are frequently treated with stimulant medications (or alternative psychotropic medications), especially if psychotherapy alone has not been effective in managing symptoms and impairment. Psychotherapy and medication interventions for individuals with severe, adult forms of antisocial behavior, such as antisocial personality disorder, have been mostly ineffective. An individual's comorbid psychopathology may also influences the course of treatment for an individual.
The prognosis of SCT is unknown. In contrast, much is known about the adolescent and adult outcomes of children having ADHD. Those with SCT symptoms typically show a later onset of their symptoms than do those with ADHD, perhaps by as much as a year or two later on average. They have as much or more difficulty with academic tasks and far fewer social difficulties than do people having ADHD. They do not have the same risks for oppositional defiant disorder, conduct disorder, or social aggression and thus may have different life course outcomes compared to children with ADHD-HI and Combined subtypes who have far higher risks for these other "externalizing" disorders.
However, unlike ADHD, there are no longitudinal studies of children with SCT that can shed light on the developmental course and adolescent or adult outcomes of these individuals.
ADHD often precedes the onset of ODD, and approximately half of children with ADHD, Combined Type also have ODD. ODD is a risk factor for CD and frequently precedes the onset of CD symptoms. Children with an early onset of CD symptoms, with at least one symptom before age 10 years, are at risk for more severe and persistent antisocial behavior continuing into adulthood. Youth with early-onset conduct problems are particularly at risk for ASPD (note that an onset of CD prior to age 15 is part of the diagnostic criteria for ASPD), whereas CD is typically limited to adolescence when youth's CD symptoms begin during adolescence.
In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM and ICD, were created out of clinical and parental experience within the field known as attachment therapy. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either DSM-IV-TR or ICD-10. Many children are being diagnosed with RAD because of behavioral problems that are outside the criteria. There is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as attachment disorder whereas mainstream theorists view these behaviors as comorbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment disorders. However, knowledge of attachment relationships can contribute to the cause, maintenance and treatment of externalizing disorders.
The Randolph Attachment Disorder Questionnaire or RADQ is one of the better known of these checklists and is used by attachment therapists and others. The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties. Critics assert that it is unvalidated and lacks specificity.
ASPD commonly coexists with the following conditions:
When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition.
The past DSM-IV criteria for IED were similar to the current criteria, however verbal aggression was not considered as part of the diagnostic criteria. The DSM-IV diagnosis was characterized by the occurrence of discrete episodes of failure to resist aggressive impulses that result in violent assault or destruction of property. Additionally, the degree of aggressiveness expressed during an episode should be grossly disproportionate to provocation or precipitating psychosocial stressor, and, as previously stated, diagnosis is made when certain other mental disorders have been ruled out, e.g., a head injury, Alzheimer's disease, etc., or due to substance abuse or medication. Diagnosis is made using a psychiatric interview to affective and behavioral symptoms to the criteria listed in the DSM-IV.
The DSM-IV-TR was very specific in its definition of Intermittent Explosive Disorder which was defined, essentially, by exclusion of other conditions. The diagnosis required:
1. several episodes of impulsive behavior that result in serious damage to either persons or property, wherein
2. the degree of the aggressiveness is grossly disproportionate to the circumstances or provocation, and
3. the episodic violence cannot be better accounted for by another mental or physical medical condition.
The diagnostic complexities of RAD mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential. Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, post traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with RAD, leading to over and under diagnosis. RAD can also be confused with neuropsychiatric disorders such as autism, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization. Autistic children are likely to be of normal size and weight and often exhibit a degree of intellectual disability. They are unlikely to improve upon being removed from the home.
Similar to adult personality disorders there are multiple causes and causal interactions for personality development disorders. In clinical practice it is important to view the disorder multi-perspectively and from an individual perspective. Biological and neurological causes need to be observed just as much as psychosocial factors. Looking at the disorder from only one perspective (e.g. (s)he had a bad childhood) often results in ignorance of important other factors or causal interactions. This might be one of the main reasons why traditional treatment methods often fail with these disorders. Only a multi-perspective view can provide for a multi-dimensional treatment approach which seems to be the key for these disorders.
The diagnosis personality development disorder should only be given carefully and after a longer period of evaluation. Also a thorough diagnostic evaluation is necessary. Parents should be questioned separately and together with the child or adolescent to evaluate the severity and duration of the problems. In addition standardized personality tests might be helpful. It is also useful to ask the family what treatment approaches they have already tried so far without success.
Two epidemiological studies of community samples approximated the lifetime prevalence of IED to be 4–6%, depending on the criteria set used. A Ukrainian study found comparable rates of lifetime IED (4.2%), suggesting that a lifetime prevalence of IED of 4–6% is not limited to American samples. One-month and one-year point prevalences of IED in these studies were reported as 2.0% and 2.7%, respectively. Extrapolating to the national level, 16.2 million Americans would have IED during their lifetimes and as many as 10.5 million in any year and 6 million in any month.
Among a "clinical" population, a 2005 study found the lifetime prevalence of IED to be 6.3%.
Prevalence appears to be higher in men than in women.
Of US subjects with IED, 67.8% had engaged in direct interpersonal aggression, 20.9% in threatened interpersonal aggression, and 11.4% in aggression against objects. Subjects reported engaging in 27.8 high-severity aggressive acts during their worst year, with 2–3 outbursts requiring medical attention. Across the lifespan, the mean value of property damage due to aggressive outbursts was $1603.
A study in the March 2016 "Journal of Clinical Psychiatry" suggests a relationship between infection with the parasite "Toxoplasma gondii" and psychiatric aggression such as IED.
Personality development disorders usually need a complex and multi-dimensional treatment approach (Adam & Breithaupt-Peters, 2010). Since the problems are complex, treatment needs to affect the conditions in all impaired functional and social areas. Both educational and therapeutic methods are helpful and problem and strength based approaches work hand in hand. Parents need to be included as well as the school environment. Treatment methods need to be flexible and adjustable to the individual situation. Even elements of social work can be helpful when supporting the families and in some cases medication might be necessary. When suicidal behaviors or self-injuries are prominent treatment might best be done in a hospital.
For some personality development disorders (e.g. borderline personality disorder) treatment methods from adults can be adapted (e.g. dialectical behavior therapy, Miller et a., 2006).
According to Professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience, "childhood hyperactivity and conduct disorder showed equally strong prediction of antisocial personality disorder (ASPD) and criminality in early and mid-adult life. Lower IQ and reading problems were most prominent in their relationships with childhood and adolescent antisocial behaviour."
Emotional and behavioral disorders (EBD; sometimes called emotional disturbance or serious emotional disturbance) refer to a disability classification used in educational settings that allows educational institutions to provide special education and related services to students that have poor social or academic adjustment that cannot be better explained by biological abnormalities or a developmental disability.
The classification is often given to students that need individualized behavior supports to receive a free and appropriate public education, but would not be eligible for an individualized education program under another disability category of the Individuals with Disabilities Education Act (IDEA).
The basis of the diagnosis is the presence of a precipitating stressor and a clinical evaluation of the possibility of symptom resolution on removal of the stressor due to the limitations in the criteria for diagnosing AD. In addition, the diagnosis of AD is less clear when patients are exposed to stressors long-term, because this type of exposure is associated with AD and major depressive disorder (MDD) and generalized anxiety disorder (GAD).
Some signs and criteria used to establish a diagnosis are important. First, the symptoms must clearly follow a stressor. The symptoms should be more severe than would be expected. There should not appear to be other underlying disorders. The symptoms that are present are not part of a normal grieving for the death of family member or other loved one.
Adjustment disorders have the ability to be self-limiting. Within five years of when they are originally diagnosed, approximately 20%–50% of the sufferers go on to be diagnosed with psychiatric disorders that are more serious.
Impulse-control disorders have two treatment options: psychosocial and pharmacological. Treatment methodology is informed by the presence of comorbid conditions.