The Atypical Child-Person a proposed special diagnositic entity.
Something Is Not Just Right!
The Atypical Child-Person and Treatment
There have always children, teens and adults referred for services that don’t fit diagnostically into any category easily including the NOS or not otherwise specified section of a class disorders such as anxiety, mood, or pervasive developmental , or psychosis. These people often have symptoms and problems from multiple classes that are episodic, unstable and are unpredictable in their presentation in regard to intensity, duration and the amount of impairment they may cause at any one time, age or during one stage of development. This presents a complex and perplexing diagnostic and therapeutic challenge and dilemma. What to call these presentation, what and when to treat, and for how long?
Often the patient, the parent, or the whoever the concerned party is goes from professional to professional, with varying complaints and concerns, knowing , “that something is just not right” and that help is needed. There is varying and changing amounts of distress and impairment socially, in the family, at home, at work, at school, based on multiple and seemingly changing complaints.
These people are often misdiagnosed and improperly medication managed for years if not decades, because individual symptoms or symptoms clusters are treated individually rather than the total disorder.
A typical presentation of this atypical presentation may be as follows. The person may have concentration problems, and is restless , therefore could it be ADHD, they have specific and changing fears , worries and nervous habits, so is it may be some sort of Anxiety problem, there are mood changes, with irritability, anger outbursts, and sadness, so maybe it some sort of Mood or even a Bipolar problem, they relate oddly at times and can have unusual speech and language patterns, they can be distant, or too close, under react or over react emotionally to people, could it be Autism , Asperger’s, or mild Schizophrenia. What in fact does all of this mean diagnostically? Does family history help? Does the child’s history help? Does trait analysis of the parents and siblings help? What about a medication trial? If any of these are helpful likely another typical diagnostic category would apply and should be treated as such.
What if there is no or little significant family history and trait analysis come up with nothing? Is there something common in the presentation, the individual history and treatment response that indicates a syndrome in a class by it self?
Let us assume the case is as follows, there is no family history of any mental health or drug and alcohol problem, or the family history that is present doesn’t fit with the presentation, and there are no traits in close family members that point to any usual mental health syndrome, symptom clusters, or actually possible diagnoses. Further there is nothing from pregnancy, labor and delivery, that would put the child at risk, what is it we may see? What might be the cardinal symptoms especially those that respond well to the usual medications used in mental health?
Not all of these that follow need to be present, and these are used for illustrative purposes only:
1. Shifting alertness, attention and concentration not related to mood or anxiety almost narcoleptic like at times, unlike ADHD the focus problems are intermittent not continuous.
2. Oversensitivity to emotional or environmental triggers, that could lead to anxiety, irritability, panic and mild rage, that the person is able to recover from in a reasonable length of time.
3. Trouble calming down more related to anxiety than mood dysregulation, with no extreme rage attacks.
4. Qualitative and quantitative difficulties in relatedness that are not continuous but related to anxiety and a Unipolar type mood changes, with the person going in and out of normal relatedness.
5. Gestural and non verbal communication that varies in appropriateness, e.g. inconsistent eye contact, body gestures and postures to communicate emotional responses. Blunted emotional responses may difficult for others to read, and be misread as calmness, when in fact there may be much emotional distress that has to be deduced from thought , dream and play content, and other representations of thoughts and feelings.
6. Mild thinking disturbances in process like mild looseness, blockin or odd speech patterns, but not in content like hallucinations, or overt paranoia. Though there may have problems similar to mild paranoia with friends, and loved ones people one would normally trust, the patient mis or over interprets when they are given certain looks, or there is something about the tone of voice, comments though benign on the surface to others to the patient may have hidden meanings meant to hurt or deceive. This can lead to holding grudges, and mild verbal and physical hostilities.
7. There may be feelings of unreality, depersonalization, that is things don't seem real, or they don' t feel or act like their normal self, or "dream like states" yet staying oriented; also ideas of reference , they believe things refer to them when is fact they don't. If there is anything that might appear like a psychotic like symptoms reality testing is intact, and doesn’t qualify for schizoid, schizotypal, or borderline personality disorder. Other near break downs in reality testing may only show in sleep related phenomenon like hypnopomic, or hypnogogic, hallucinations or as related to dreams or nightmares. There may be overly emotional dream content with a breakdown of the functions of dreams to awaken the person, like in a nightmare. Similar issues may be seen in fantasy, play and representations such as writings like poems, stories, and music, or in choice or these.
8. Can be overly or under emotional, too tuned in , or too tuned out, cold and distant to overly empathic and sensitive.
9. So called “soft neurological signs” may be present, like mild motor twitches or tics, mild problems with coordination, that can cause clumsiness, and bad hand witting , mild auditory and visual processing problem that can lead to mild. problems with reading, spelling, math, sometimes requiring special intervention
Below is a propose classification of mental health diagnoses based on medication responsiveness which includes the “Atypical” cluster.
Biologically Based Medication Responsive Diagnostic -Symptom Clusters
A) [ ] Unstable Mood: Mood swings, irritability, anger outburst, rage attacks, sad to glad to mad, big unrealistic ideas, need to be the boss, the bully, need little sleep, fast talker, too many ideas, difficult to live with, walking on egg shells, Dr Jeckle & Mr. Hyde
B) [ ] Thinking- Unusual Relatedness -Reality Testing: Blunted, shallow, inappropriate emotions, loss of interest, drive, motivation & ambition, little or disorganized speech, odd, peculiar, strange, paranoid behavior, loaner, isolates self, in their own world, voices, visions
C) [ ] Movement-Impulse: Tics, motor movements of face, eye blinking, twitches, sniffing, snorting, throat clear
D) [ ] Stable Depressive: Sad, tearful, depressed stable mood, lack of pleasure, little to no interest in things, tired, fatigue, mind slow, hard to think, negative about self, past, present , and future, hopeless, better off dead
E) [ ] Anxiety-Somatic: Worried too much about past , present , and future, tense, keyed up, easily fatigued, panic attacks, fears, phobias, shy, avoids things, afraid to sleep or be alone, trouble going and staying in places like school, rituals like hand washing, counting, sequencing, ordering, getting things just right.
F) [ ] Attention-Impulsive: Poor concentration, distractibility, overly active , doesn’t think before talking or acting
G) [ ] The “Atypical Cluster”: Not fitting into the above but yet having some features of many and having some unique sypmptom clusters.
Atypical Cluster –G or what I call “Category 7” – features of more than one other cluster and not fitting best into one, of the other six medication responsive clusters may in fact be a "Special" Class with it own unique brain chemistry and medication responses, and not a residual class at all, that is NOS or Not Otherwise Specified. Other problems or symptoms than may apply follow.
1) Uneven development as infant-child, loosing & gaining functions unpredictably like speech and language
2) Transitions cause panic anxiety or rage attacks, physical symptoms like hives, irritable bowel, headaches
3) Unusual sensitivities to touch, taste, positioning, sound, lights.
4) Poor eye contact, and poor non verbal communication using gestures, body language
5) Not getting social rules, and cues from other, not getting the point of jokes or riddles or social moves
6) Socially stiff, and awkward, verbally and non verbally, marches to his or her own drummer
7) Unusual or peculiar relatedness, but not overtly strange or bizarre, slightly off emotionally
8) Something just “not right” about how they relate, respond, react to people, even those they know well
9) Get stuck in doing something, and has to finish it, and if not panic, gets angry, or too upset
10) Unusually high and over developed abilities in some areas of usually in the area of the thinking and doing mind, with unusually low function if not actual deficits in other area especially those related to the experiencing relationship feeling mode of the mind.
Biochemically the symptoms cluster around severe anxiety, and Unipolar depression, to a point thinking may get derailed and blocked, with in and out appropriateness of relatedness, no evidence of bipolar, and gross reality testing remains intact. This can be classified as or similar to a” Non Psychotic Thought Process-Asperger’s like- Anxiety/Panic- Unipolar Affective Disorder”, that seems to respond preferentially and may be best be treated with atypical neuroleptic, like Risperdal in small doses, and SSRI medication may not make worse, and but perhaps helpful, if once covered by the atypical for which only very small doses may be helpful, the SSRI may be added carefully again in very small doses. There may be varying responses with Welbutrin and Strattera and the SSNRI’s, which if used may again have to be used with cautious watchfulness and starting at very small doses.
Basis may be serotonin-dopamine -norepinephrine, but rather then deficit, there may be a relative deficit based on imbalance and mal distribution. Perhaps based on an inborn idiopathic, that is self caused chemical imbalance like a very mild transient and self limiting. The response to medication has a more “organic” flavor as if due to direct CNS trauma, or the effects of a CNS toxin, rather than seen in process “functional” psychiatric disturbance. Almost as if having a bad reaction to psychotropic substances, and if fact these people often are extremely sensitive to both the good and bad effects of the usual psychotropic medication.
Medication management with an atypical neuroleptic should be based on symptom severity, resultant distress, and the amount of impairment that is occurring at home, school, work , socially and in relationships. Because of their CNS sensitivities to medications one may have to start even lower and go slower to avoid negative effects and get a positive result.
Problems at school, like bullying or work, like unfair boss, in relationships like cheating girlfriend, lover, spouse, disagreements with a sib or parent, may be responded to with severe anxiety and depression, with hopelessness and resultant suicidal despair, ideation. Alternately there may be anger and rage that can lead to severe aggressive outbursts to property and others, that is grossly out of character. This should be taken very seriously and treated with the appropriate medication and other supportive services, including crises intervention as needed. The lack of outward emotional response, the inability to share thoughts and feelings with others, the quiet slow burn these people experience often cause a delay for appropriate evaluation and treatment.