A Christian Lawyer in California

Jesus Christ is our Lord and God

2012-01-28T20:47:00.000-08:00

The mystery and majesty of our God can be seen in Jesus' words recorded at John 5:21-23:

"For as the Father raises the dead and gives them life, so also the Son gives life to whom he will. The Father judges no one, but has given all judgment to the Son, that all may honor the Son, just as they honor the Father. Whoever does not honor the Son does not honor the Father who sent him."

John Calvin obliqely commented on this passage in his commens on John 11:4 where Jesus said Lazarus' death would be "for the glory of God, so that the Son of God may be glorified through it" (ESV): "For the glory, of God, that the Son of God may be glorified. This expression is highly emphatic; for we learn from it that God wishes to be acknowledged in the person of his Son in such a manner, that all the reverence which he requires to be given to his own majesty may be ascribed to the Son. Hence we were told formerly, He who doth not honor the Son doth not honor the Father, (John 5:23.)" (Emphasis Added, http://www.ccel.org/ccel/calvin/calcom34.xvii.i.html)

What this means is that Christians can worship God by worshipping Jesus. This is a great mystery which is beyond human understanding. God is Father, Son and Holy Spirit. Three in One, One in Three, the One in the middle died for me. As you pray and sing and worship God, you can confidently praise him as you praise Jesus Christ as Jesus Christ is God as is the Father and Holy Spirit. It is perfectly legitimate to worship God by worshiping Jesus. It is also perfectly legitimate to worship God by worshiping the Father or the Holy Spirit.

We Are Connected Even As The Parts of Our Body Are Connected

2012-01-12T06:56:00.000-08:00

Isolation and loss are inherently traumatizing.

“Lastly, it is important torecognize that attachment is essentially a theory of trauma. Bowlby began hiscareer as a health professional by studying maternal deprivation and separationand its effects on children.

Attachment theory describes andexplains the trauma of deprivation, loss, rejection, and abandonment by thosewe need the most and the enormous impact it has on us. Bowlby viewed thesetraumatic stressors, and the isolation that ensued, as having tremendous impacton personality formation and on a person's ability to deal with other stressesin life. He believed that when someone is confident that a loved one will bethere when needed, "a person will be much less prone to either intense orchronic fear than will an individual who has no such confidence" (1973, p.406).

The couple and family therapistknows the stress of deprivation and separation well. It is an essential part ofthe ongoing drama of "ordinary" relationship distress. Indeed,clients often speak of such distress in terms of trauma, that is, inlife-and-death terms. As a theory of trauma, attachment theory specificallyhelps us to understand the weight behind emotional hurts such as rejection orperceived abandonment by a loved one. Distressed partners who are dealing withthe traumatic helplessness induced by isolation and loss tend to adopt stancesof fight, flight, or freeze that characterize responses to traumatic stress.The trauma perspective, with its focus on the power of helplessness and fear,helps the couple therapist tune in to the reality of distressed partners anddeal with that reality constructively.” (Johnson, 2004, p. 32)

In 1Corinthians 12, the Apostle Paul spoke of the members of the church as the bodyof Christ. He says there that just as in our physical bodies, so too with ourrelationships with others, including our mates: “If one part suffers, everypart suffers with it; if one part is honored, every part rejoices with it” (v.26, NIV).

This samebody imagery is used by the Apostle in Ephesians 5 “He who loves his wife loveshimself. After all, no one ever hated their own body, but they feed and carefor their body, just as Christ does the church— for we are members of his body.“For this reason a man will leave his father and mother and be united to hiswife, and the two will become one flesh.”(vv. 28-31, NIV)

What difference would it make in the way you view your mate if you thought of her (or him) as part of you?

Schemas and God

2012-01-09T07:03:00.000-08:00

“9. Attachmentinvolves working models of self and other.

We defineourselves in the context of our most intimate relationships. As statedabove, attachment strategies reflect ways of processing and dealing withemotion. Some spouses catastrophize and complain when they feel rejected; somebecome silent for days. Bowlby outlined the cognitive content of therepresentations of self and other that are inherent in these response patterns.

Secure attachment is characterized by a working model ofself that is worthy of love and care and is confident and competent, and indeedresearch has found secure attachment to be associated with greaterself-efficacy (Mikulincer, 1995). Securely attached people, who believe otherswill be responsive when needed, also tend to have working models of others asdependable and worthy of trust.

These models of self and other, distilled out of a thousandinteractions, become expectations and biases that are carried forward into newrelationships. They are not one-dimensional cognitive schemas; rather they areprocedural scripts for how to create relatedness and ways of processingattachment information. These models involve goals, beliefs, and attachmentstrategies, and they are heavily infused with emotion. Working models areformed, elaborated, maintained, and, most important for the couple and familytherapist, changed through emotional communication. The couple therapist willrecognize in his or her clients' emotional self-disclosures the models of selfand other that naturally well up in highly charged interactions with lovedones. Once distressed partners step beyond their angry protests, for example,they often begin to disclose fears about their own lovableness and worth.”(Johnson, 2004, p. 31)

“I will never leave thee, nor forsake thee” (Hebrews 13:5)This fact of God’s faithfulness to us as his people both collectively and asindividuals, provides a foundation for security.

Your working model about yourself and others though reallyinfluences your relationship with your mate as well as your relationship withGod and others.

Ask yourself honestly: “How do I perceive myself? Am Iworthy of love and care? Am I confident? Am I competent? Are other peopledependable? Can I count on them to be there for me if I need them?

These sorts of questions are good ones to take to Godbecause growing from an insecurely attached person into one who is moresecurely attached to God and others changes your answers to these sorts ofquestions. In fact, these sorts of questions not only impact your relationshipwith your mate, the impact your relationship with God, your relationship withyour children and career.

Breaking the Patterns of Insecurity

2012-01-09T06:39:00.000-08:00

One of the most important things you can do to create andbuild POSITIVE connections your mate involves getting a handle on your anger.

Anger involves a shapeless cloud of emotion which mobilizesand focuses a person’s emotional energy into a narrow direction. Anger providesinstant explosive energy which feeds the fight, flight or freeze impulses andinstincts in humans.

Anger helps us protect ourselves. It helps us protect ourfamilies and others. Anger is a normalresponse to having your goals blocked. Anger is also a normal response tohaving your rights or expectations disregarded or violated. Anger is also anormal response to unfairness and injustice. Anger is also a normal response topain and injury. However, anger is asecondary emotion.

To get a handle on anger and use it to build positiveconnections with your mate, you will have to look beneath the anger andidentify the primary emotion and issue beneath. The anger itself is notsusceptible to being analyzed or corrected. As I said above, it is a naturaland probably response to everyday experiences in life.

For example, suppose your thinking you don’t get enough sexfrom your mate. This feeling deprived may involve a violation of yourexpectations about how much sex you deserve to have or it may involve feelinglike your mate doesn’t care about you or that your mate doesn’t love you. Primary feelings of hurt and injusticeemerge in this context. Emotional pain of some sort is felt and your anger fuseis lit.

You defuse the bomb by first recognizing that the anger isrelated to your underlying feelings of deprivation, lack of love or unfairnessand then processing this underlying feeling with God through personal prayerand with your spouse through straight talk about the real issue. Most peoplehowever don’t talk about things directly; rather, they engage in protestbehavior which has absolutely no logical relationship or likelihood toalleviate the underlying primary issue.

A classic illustration of such protest behavior involved Jim(not really me) who felt lonely and marginalized by his wife Dorothy (notreally my wife) because she went to a party after work without him the othernight. When she got home from the party, he started needling her aboutunfinished chores around the house. He then started bad mouthing her family. Thenatural and probable result was that her feelings were hurt (primary emotionassociated with having your mate criticize you and those you care about) andshe became angry. He then reciprocated and became angry at her audacity to beangry at him when she was the one who ignored him when she went to the party.

Jim later admitted that he was purposely attacking Dorothybecause he wanted to connect with her and felt hurt that she hadn’t invited himto the after work party. However, how in the world would she have reasonablyinferred that from his conduct which involved criticizing her and her family.In Jim’s mind, Dorothy’s natural response to his criticism only confirmed hisfeelings of neglect.

How could Jim defuse the bomb of his anger before Dorothygot home from the party? He could have asked God to help him figure out whathis primary emotions were underneath the anger he felt. He may have recognizedthat he felt the pain of loneliness and the fear of abandonment because hismate had gone to a party without him and without even inviting him. He would havebeen able to tell God in prayer. Ouch, Lord, that hurts. He could haveprocessed his primary emotions of hurt with God and asked that God would helphim. “Be careful for nothing; but in every thing by prayer and supplicationwith thanksgiving let your requests be made known unto God. And the peace ofGod, which passeth all understanding, shall keep your hearts and minds throughChrist Jesus.” (Philippians 4:6-7)

This preliminary analysis Jim performed intrapsychically(nice big word, meaning by thinking about it on his own—well, not actually onhis own because Jim, as a religious person, was also able to bring God into hisexperience) prepared him for Dorothy’s arrival home after the party. Instead ofattacking and criticizing her in a foul mood, Jim asked Dorothy if he couldtalk to her about something important to him. She warily agreed. Whereupon Jimtold her something as follows. I know this may sound insecure to you but I feltlonely and abandoned tonight because you went to the party without inviting me.The natural and probably response to this sort of communication would usuallybuild a positive emotional bond with increased understanding of one another.

"8. A finite number ofinsecure forms of engagement can be identified.

“The number of ways that human beings have to deal with theunresponsiveness of attachment figures is limited. There are only so many waysof coping with a negative response to the question "Can I depend on youwhen I need you?" Attachment responses seem to be organized along twodimensions, anxiety and avoidance (Fraley & Waller, 1998).

[1. The Anxiety Dimension]

When the connectionwith an irreplaceable other is threatened but not yet severed, the attachmentsystem may become hyperactivated or go into overdrive. Attachment behaviorsbecome heightened and intense as anxiousclinging, pursuit, and even aggressive attempts to control and obtain aresponse from the loved one escalate. From this perspective, most criticism,blaming, and emotionally loaded demands in distressed relationships areattempts to deal with and resolve attachment hurts and fears.

[2. The Avoidance Dimension]

[3. Both theAnxiety and Avoidance Dimension]

A third insecure strategy has been identified that isessentially a combination of seeking closeness and then fearful avoidance ofcloseness when it is offered. This strategy is usually referred toas disorganizedin the child literature and fearful avoidant in the adult literature(Bartholomew & Horowitz, 1991). This strategy is associated with chaoticand traumatic attachments where others are, at one time, the source of andsolution to fear (Johnson, 2002; Alexander, 1993).

[These Insecure Forms of Engagement Develop into HabitualStyles of Engaging with One Another]

These … basicstrategies-anxious preoccupied clinging [, disorganized,] and detachedavoidance-can develop into habitual styles of engagement with intimate others.

Angry criticism, viewed through the attachment lens, ismost often an attempt to modify the other partner's inaccessibility, and as aprotest response to isolation and perceived abandonment by the partner.

Avoidant withdrawal may be seen as an attempt to containthe interaction and regulate fears of rejection and confirmation of fears aboutthe unlovable nature of the self.

[Disorganized – Angry criticism followed by avoidant withdrawal whenthe other person moved toward may be seen as both an attempt tomodify the other person’s inaccessibility / as a protest response to isolation andperceived abandonment by the partner followed by an oscillating attempt tocontain the interaction and regulate the fears of rejection and confirmation offears about the unlovable nature of the self.]

….

Anxious partners are more prone to strong anger, whereasavoidants seem to experience intense hostility and to also attribute thishostility to their partners. Moreover, avoidant partners tend to feel hostilewhen the other partner expresses distress or seeks support.

Research suggests that avoidant partners can be sociallyskilled in general but avoid seeking or giving support when attachment needsarise within them or their partner. Avoidant partners also tend to be moreprone to promiscuous sexuality (Brennen & Shaver, 1995; Shaver &Mikulincer, 2002). In general,anxiety and avoidance foster a rigid hypervigilant attitude to novelty anduncertainty and an equation of letting down one's guard with helplessness. Allcouple therapists will recognize these factors as preludes to and part ofnarrow rigid patterns of interaction and a constriction of the flexibleopenness necessary for closeness and connection.

These insecure habitual forms of engagement can be modifiedby new relationships, but they can also mold current relationships and so caneasily become self-perpetuating. Theyinvolve [1] specific behavioral responses [a] to regulate emotions and [b] protect the selffrom rejection and abandonment, and [2] cognitive schemas or working models ofself and other. In the attachment literature the term attachmentstyles, which implies an individual characteristic, is often usedinterchangeably with the term attachment strategies, which implies behaviorthat is more context specific. The use of the third term, habitual forms of engagement(Sroufe, 1996), further stresses the interpersonal nature of this concept.These forms of engagement can and do change when relationships change and arebest thought of as continuous, not absolute (one can be more secure or lesssecure). The literature on these forms of engagement in the attachment dancehelps the couple therapist see past all the content issues and dramaticsubplots to the key moves and stances in that dance. The description of thesestrategies or patterns also fits with descriptive research on marital distress,for example, the delineation of theblame-pursue followed by defend-distance pattern as a prelude to relationshipbreakdown.

It is hardly surprising given the above that researchconfirms that attachment style affects marital satisfaction. Individuals withinsecurely attached spouses report lower satisfaction; couples where both aresecurely attached report better adjustment than couples in which either or bothpartners are insecurely attached (Feeney, 1994; Lussier, Sabourin &Turgeon, 1997). When we consider these habitual responses and self-perpetuatingpatterns of interaction, it is easy to see that attachment is a systemic theory(Johnson & Best, 2002), and is concerned with "a reality-regulatingand reality-creating not just a reality-reflecting system" (Bretherton& Munholland, 1999, p. 98).” (Johnson, 2004, pp. 28-31)” (Johnson, S. M.(2004). The Practice of Emotionally Focused Couple Therapy: CreatingConnection. Brunner-Routledge: New York)

Knowing your mate’s attachment style can inform your behavior and allows you to tailor your behavior so that it accomodates the way your mate perceives and receives it.

Often, people who have developed an avoidant style ofdealing with relational conflict pair up with people who have developed aninsecure style of dealing with conflict. It makes sense to me that this is so,because there is a natural affinity there akin to the fitting of two pieces ofa puzzle together.

When these styles result in a pattern of conflict which resultsin negative emotional patterns which have to be broken, I think of Galatians6:1-2 “Brothers, if anyone is caught in any transgression, you who arespiritual should restore him in a spirit of gentleness. Keep watch on yourself,lest you too be tempted. Bear one another's burdens, and so fulfill the law ofChrist.”

This passage says to me that even as Christ took theinitiative to restore us to God by dying on the cross at a time when we werehis enemies “God shows his love for us in that while we were still sinners,Christ died for us” (Romans 5:8, ESV) so too with our relationships.

Prototypes and Paths to Divorce

2012-01-05T10:28:00.000-08:00

7. The process ofseparation distress is predictable.

“If attachment behaviors fail to evoke comfortingresponsiveness and contact from attachment figures, a prototypical process ofangry protest, clinging, depression, and despair occurs, culminating eventuallyin detachment. Depression is a natural response to loss of connection. Bowlbyviewed anger in close relationships as often being an attempt to make contactwith an inaccessible attachment figure and distinguished between the anger ofhope and the anger of despair, which becomes desperate and coercive. In securerelationships, protest at inaccessibility is recognized and accepted. Anemotionally focused therapist sees the basic dramas of distress, such asdemand-withdraw, as variations on the theme of separation distress.” (Johnson,2004, pp. 27-28)

I like the phrase “prototypical process” (meaning “an originalupon which something is modeled” (OED)) used by Johnson in her observation thatthe emotions experienced by people when the connection they had with a lovedone is denied and emotional behavior associated with those emotions.

First: “angry protest”.

Second: “clinging”.

Third: “depression”.

Fourth: “despair”.

Fifth: “detachment”.

In my role as an attorney for my clients who are going throughdivorce—a setting where the clients have usually gone through the processdescribed by Johnson a thousand times, I like to share Kubler-Ross’s (1969)Stages of Grief. The loss of love is like a death in many ways. The stages of griefare as follows:

Stage Interpretation

1 - Denial Denialis a conscious or unconscious refusal to accept facts, information, reality,etc., relating to the situation concerned. It's a defence mechanism andperfectly natural. Some people can become locked in this stage when dealingwith a traumatic change that can be ignored. Death of course is notparticularly easy to avoid or evade indefinitely.

2 - Anger Angercan manifest in different ways. People dealing with emotional upset can beangry with themselves, and/or with others, especially those close to them.Knowing this helps keep detached and non-judgmental when experiencing the angerof someone who is very upset.

3 - Bargaining Traditionallythe bargaining stage for people facing death can involve attempting to bargainwith whatever God the person believes in. People facing less serious trauma canbargain or seek to negotiate a compromise. For example "Can we still befriends?.." when facing a break-up. Bargaining rarely provides asustainable solution, especially if it's a matter of life or death.

4 - Depression Alsoreferred to as preparatory grieving. In a way it's the dress rehearsal or thepractice run for the 'aftermath' although this stage means different thingsdepending on whom it involves. It's a sort of acceptance with emotionalattachment. It's natural to feel sadness and regret, fear, uncertainty, etc. Itshows that the person has at least begun to accept the reality.

5 - Acceptance Againthis stage definitely varies according to the person's situation, althoughbroadly it is an indication that there is some emotional detachment andobjectivity. People dying can enter this stage a long time before the peoplethey leave behind, who must necessarily pass through their own individualstages of dealing with the grief. (http://www.businessballs.com/elisabeth_kubler_ross_five_stages_of_grief.htm)

Of course a divorce is also a new beginning. A chance for a freshstart. One of my clients told me when he paid my final bill “Jim, why aredivorces so damn expensive?” [they are financially devastating] “I don’trightly know”, I said. He smiled, squeezed his new love’s hand. She smiled andlooked back at him with this serene dreamy look of love. He then said with ahuge toothy grin “Because their worth it!” Anyway, I digress.

Seriously though, Dr. Burns' in his book Feeling GoodTogether points out that there is a dark side to human nature which has to bechecked when couples are in conflict. It is a bit Pollyannaish to think thatall conflict between couples involves some sort of misguided attempt toconnect. Burns lists least 12 reasons people choose to continue the conflict ratherthan working toward love and intimacy:

1. Power and Control;

2. Revenge;

3. Justice and Fairness;

4. Narcissicm;

5. Pride and Shame;

6. Scapegoating;

7. Truth;

8. Blame;

9. Self Pity;

10. Anger and Bitterness;

11. Competition; and,

12. Hidden Agendas.

The foregoing motives compete with the motive for love andintimacy and unless these competitors for love are identified and the decisionis made to overcome them, the pay off associated with these behaviors andstates of being and perceiving reality will undermine and destroy any realprogress in love. As put by Burns (2008), a person in a couple conflict has tohonestly grapple with this question: “What do I want more--the rewards of thebattle, or the rewards of a close, loving relationship.” (p. 30)

Understanding that human beings are likely to go through aseries of otherwise perplexing stages when confronted with the loss ofconnection with the one they love can go a long way in helping alleviate thedouble trouble of feeling confused about one’s feelings.

This basic awareness about one’s feelings can also go a longway to enabling couples in conflict to break the patterns of disconnect.

God has made us. We are social beings who are hurt byisolation and the manifestation of that hurt is predictable. “I will praisethee; for I am fearfully and wonderfully made: marvellous are thy works; andthat my soul knoweth right well.” (Psalm 139:14) “For he knoweth our frame; heremembereth that we are dust.” (Psalm 103:14) “There hath no temptation takenyou but such as is common to man: but God is faithful, who will not suffer youto be tempted above that ye are able; but will with the temptation also make away to escape, that ye may be able to bear it.” (1 Corinthians 10:13)

References:

Burns, D. (2008) Feeling Good Together: The Secret of MakingTroubled Relationships Work. Broadway Books: New York.

Johnson, S. M. (2004). The Practice of Emotionally FocusedCouple Therapy: Creating Connection. Brunner-Routledge: New York

Death & Dying, Elisabeth Kübler-Ross, 1969

Counter-connection Conduct

2012-01-04T08:29:00.000-08:00

6. Fear anduncertainty activate attachment needs.

When the individual is threatened, either by traumaticevents, the negative aspects of everyday life such as stress or illness, or byany assault on the security of the attachment bond itself, powerful affect arises and attachment needs for comfort and connectionbecome particularly salient and compelling. Attachment behaviors, such asproximity seeking, are then activated. Asense of connection with a loved one is a primary inbuilt emotional regulationdevice. Attachment to key others is our "primary protection againstfeelings of helplessness and meaninglessness" (McFarlane & Van derKolk, 1996). This theory helps the couple therapist understand how a particularevent, such as a flirtation at a party or a short period of distance at a timeof need, can threaten a relationship and begin a downward spiral of distress. (Sue Johnson, 2004, p. 26)

Even in a state of innocence before any sin entered theworld, Adam was incomplete without Eve. I believe Adam’s breaking the ruleagainst eating of the tree of good and evil had to do with his fear of losingconnection with Eve since she had already eaten against God’s command. (Genesis3)

This idea that our lives have meaning in connection withother people is fundamental. It is everywhere assumed in Scripture. To belongand be valued by the group is fundamental to the whole scheme of discipline inthe church which operates upon this fundamental human need for caringconnection. The same is true with our penal system which utilizes incarcerationas the fundamental means of punishment and deterrence.

“A sense ofconnection with a loved one is a primary inbuilt emotional regulation device”and that a lack of this “sense of connection with a loved one” evokes “powerfulaffect”. This does indeed explain what probably went on Jesus when he “wept”(John 11:35). You will remember the story in John 11 where Jesus was gone whenLazarus died. This evoked strong emotion in Lazarus’ sister, Mary, who accusedJesus when he returned saying “if thou hadst been here, my brother had notdied.” (John 11:32)

One of the most important breakthroughs that takes place whichturns a couple from a vicious cycle of blame and hurt to one of healing andlove occurs when they begin to see every interaction as an opportunity to turntoward and connect with one another or to turn against and disengage.

I remember one client who, when he felt like he and his wifewere drifting apart, would purposely say things that would upset her. He toldher she was self-absorbed in her career and didn’t care about anyone butherself. He didn’t believe either of these statements but admitted later thathe said them as a way of getting her to connect with him. Of course the naturaland probable result of such conduct is just the opposite. A better way ofconnecting with her would have been to simply admit his need for connectionwith her and ask for a hug or kind word.

This sort of manipulation is the product of growing up in ahome where direct requests or disclosures of need were risky business. Manypeople learn never to reveal their needs to others because they grew up withsurly parents who were abusive, neglecting or critical. However, good parentslove giving good gifts to their children. (Luke 11:11-13)

Emotional Access and Responsiveness

2012-01-03T07:07:00.000-08:00

5. Emotionalaccessibility and responsiveness build bonds.

“In general, emotion activates and organizes attachmentbehaviors. More specifically, the building blocks of secure bonds are emotionalaccessibility and responsiveness. An attachment figure can be physicallypresent but emotionally absent. Separation distress results from the appraisalthat an attachment figure is inaccessible. It is emotional engagement that iscrucial and the trust that this engagement will be there when needed. Inattachment terms, any response (even anger) is better than none. If there is noengagement, no emotional responsiveness, the message from the attachment figurereads as "Your signals do not matter, and there is no connection. Betweenus. Emotion is central to attachment, and this theory provides a guide forunderstanding and normalizing many of the extreme emotions that accompanydistressed relationships. Attachment relationships are where our strongestemotions arise and where they seem to have most impact. Emotions tell us andcommunicate to others what our motivations and needs are; they are the music ofthe attachment dance (Johnson, 1996). As Bowlby has suggested, "thepsychology and psychopathology of emotion is … in large part the psychology andpsychopathology of affectional bonds" (1979, p. 130). (Sue Johnson, 2004, p. 26-27)

Men are often mystified by marital emotions. We come into marriagethinking that providing for our families is our main responsibility. However,that is merely one important role in marriage. It is also necessary that weprovide our wives a safe, secure place where they can be themselves withoutfear or walking on eggshells. We are completely blindsided by our wives’unhappiness when we fail to provide a loving environment for our wives andchildren where they can be themselves and where they feel emotionally connectedto us.

Dr. Harley, in his book His Needs Her Needs states that “asense of security is a bright golden thread woven through all of the woman'sfive basic needs. If the husband does not maintain honest and opencommunication with his wife, he undermines her trust and eventually destroysher sense of security." (p. 103) Of course, men need emotional connectionwith their wives too.

A couple of passages come to mind in terms of providing ourmate with safe, caring and nurturing emotional access and responsivity: 1. “Confessyour faults one to another, and pray one for another, that ye may be healed.The effectual fervent prayer of a righteous man availeth much” (Jas 5:16); and,2. “Husbands, love your wives, even as Christ also loved the church, and gavehimself for it; That he might sanctify and cleanse it with the washing of waterby the word, That he might present it to himself a glorious church, not havingspot, or wrinkle, or any such thing; but that it should be holy and withoutblemish. So ought men to love their wives as their own bodies. He that lovethhis wife loveth himself. For no man ever yet hated his own flesh; butnourisheth and cherisheth it, even as the Lord the church: For we are membersof his body, of his flesh, and of his bones. For this cause shall a man leavehis father and mother, and shall be joined unto his wife, and they two shall beone flesh.” (Eph 5:25-31)

The latter passage reminds me of the struggle I had inlearning just how was it that I was to love my wife and what things I was to dowhich would lead to nourishing and cherishing my wife. The most important dailyactivity husbands can give their wives and which wives can give their husbandsis emotional access and responsiveness. Attachment theory recognizes thatemotional access and responsiveness builds bonds and these bonds of love areessential to our overall sense of wellbeing as individuals and as a maritalunit.

The Gift of Security Promotes Exploration and Adaptivity

2012-01-02T07:07:00.000-08:00

4. Attachment offersa secure base.

“Secure attachment also provides a secure base from whichindividuals can explore their universe and most adaptively respond to theirenvironment. The presence of such a base encourages exploration and a cognitiveopenness to new information (Mikulincer, 1997). It promotes the confidencenecessary to risk, learn, and continually update models of self, others, andthe world so that adjustment to new contexts is facilitated. Secure attachmentstrengthens the ability to stand back and reflect on oneself, one's behavior,and one's mental states (Fonagy & Target, 1997). When relationships offer asense of felt security, individuals are better able to reach out to and providesupport for others and deal with conflict and stress positively. Theserelationships tend then to be happier, more stable, and more satisfying. Theneed for a secure emotional connection with a partner, a connection that offersa safe haven and a secure base, is the central theme of couple distress and theprocess of effective relationship repair.” (Johnson, 2004, p. 26)

An important word is used in the first sentence of SueJohnson’s description of this tenet of attachment theory. That word isadaptive. Adaptive behavior is "the level of everyday performance of tasksthat is required for a person to fulfill typical roles in society, includingmaintaining independence and meeting cultural expectations regarding personaland social responsibility. Specific categories in which adaptive behavior isusually assessed include self-help, mobility, healthcare, communication,domestic skills, consumer skills, community use, practical academic skills, andvocational skills.” Adaptive behavior is "any behavior that enables anindividual to adjust to the environment appropriately and effectively".(VandenBos, 2006, p. 18)

Much of what is said regarding an essential safe havenapplies here. The emphasis here, however, has to do with the empowering aspecta secure attachment imparts. Relational security and open-mindedness allowspeople to explore new ways of being and to adjust and accommodate change.

I was talking with a pastor the other day who works withcouples about these ideas and he referred me to Timothy’s secure base in his motherand grandmother. Timothy is that great young protégé of the Apostle Paul who becamethe pastor of Ephesus. It think it is very interesting to note that the famouspassage about the spirit of fear which Paul gave to Timothy is preceded by aremembrance of the secure base or foundation which was given to Timothy by thelove and care and guidance of his mother and grandmother:

“When I call to remembrance theunfeigned faith that is in thee, which dwelt first in thy grandmother Lois, andthy mother Eunice; and I am persuaded that in thee also.

Wherefore I put thee in remembrancethat thou stir up the gift of God, which is in thee by the putting on of myhands. For God hath not given us the spirit of fear; but of power, and of love,and of a sound mind.” (2 Timothy 1:5-7)

Notice the secure base and safe haven given Timothy by hismother and grandmother which allowed him to stir up the gift God had given himand was used by God to disperse the spirit of fear in favor of a spirit ofpower, love and of a sound mind.

References:

Johnson, S. M. (2004). The Practice of Emotionally FocusedCouple Therapy: Creating Connection. Brunner-Routledge: New York

Bringing the Ministry Home

2012-01-01T21:42:00.000-08:00

3. Attachment offersan essential safe haven.

“Contact with attachment figures is an innate survivalmechanism. The presence of an attachment figure, which usually means parents,children, spouses, and lovers, provides comfort and security, while theperceived inaccessibility of such figures creates distress. Proximity to aloved one tranquilizes the nervous system (Schore, 1994). It is the naturalantidote to the inevitable anxieties and vulnerabilities of life. For people ofall ages, positive attachments create a safe haven that offers a buffer againstthe effects of stress and uncertainty (Mikulincer, Florian & Weller, 1993)and an optimal context for the continuing development of the personality.”(Johnson, 2004, pp. 25-26)

This passage reminds me of Laurence J. Crabb’s 1982 book “TheMarriage Builder: A Blueprint for couples and Counselors”. There, Dr. Crabbdiscusses the need for us to change from seeking to manipulate our spouse intobeing what we want them to be and to start ministering to her spouse because intruth you are “God’s chosen minster to [our] spouse”. Crabb tells the story ofFred which I found very helpful in my own life through the years. He first cautionsthat “unless we deliberately adopt the goal of ministry on a moment-by-moment basis,our natural, reflexive goal will generally be to manipulate her spouse is forour advantage." (p. 63)

"Fred enters his home after along day at work. His automatic, unplanned, and perhaps unconscious goal likelyinvolves a desirable response from his wife, Joan, perhaps a friendly greeting,a warm hug, or prepare dinner. Suppose she welcomes him by asking, "Whyare you so late? You said you'd be home by six and its nearly seven."

Joan has blocked Fred’s goal. Reflectfor a moment. How do people feel whentheir goal is blocked? Most often, they become angry or base frustrated. Fredfeels anger toward his wife. He admits to himself that he feels like retorting witha snappy comment like "Hey, thanks for the warm welcome! Sure is nice tocome home!” ….

Fred's anger should be a strongwarning that his goal was manipulative. He was demanding a response from hiswife that would meet his need of the moment. If Fred is (1) committed to theprinciple of ministry, (2) aware of his wife is a woman who longs to feelloved, and (3) convinced that he is God's instrument to Ken Shipley representChrist's love to his wife, then he is able to change his goal. The actualoperation involves replacing thoughts like "Why can't she be pleasant whenI come home?" To "My goal right now is to let my wife know that sheis a loved and special woman."

Think again of the mind is a taperecorder. The automatic "tape" we play reflects for a minute select agoal of changing our spouse: "why can't she µ more warmly?" To changegoals, we must decisively eject the wrong tape and insert a new one intoposition, that is choose a new sentence to reflect our change goal: "Iwant to make her feel loved."

Changing tapes must be more than amechanical procedure. As replace our selfish thoughts with giving intentions,we need to remind ourselves that we are freely choosing the minister because webelieve God. Although our feelings may not immediately shift from anger tocompassion, we can convey noncritical acceptance to her spouse is it ministry isour freely selected purpose.

The crux of the matter is, do wereally want to accept the goal of ministry at this moment? The more we arewilling to do so, the more surely our marriage will move toward satisfyinglevels of Soul Oneness.” (pp. 63-64)

The keypassage along these lines cited by Dr. Crabb in his book is Ephesians 4:29 “Letno corrupt communication proceed out of your mouth, but that which is good tothe use of edifying, that it may minister grace unto the hearers.” Why is itthat we so readily apply this passage to our dealings with those in the churchon Sunday and how we talk to those we serve and the public in our occupationsbut neglected it in our marriages?

Whatchanges do you need to make in order to create an essential safe haven for yourspouse? How can you apply Dr. Crabb's manipulation versus ministry principlesto your conflicts? What tapes are you planning before your common conflictserupt? Dollars to donuts you're not in a ministry mindset.

The mostimportant characteristic of Christians is the love they show toward one anotherthis is true on Sunday morning, during the work week, and in the home. Jesussaid, “By this shall all men know that ye are my disciples, if ye have love oneto another.” (John 13:35)

References:

Crabb, L. J. (1982) The marriage Builder: a Blueprint forCouples and Counselors. Zondervan: Grand Rapids, MI

Johnson, S. M. (2004). The Practice of Emotionally FocusedCouple Therapy: Creating Connection. Brunner-Routledge: New York

The Bible, Christian Community & Self Actualization

2012-01-01T12:44:00.000-08:00

2. Secure dependencecompliments autonomy.

“According to attachment theory, there is no such thing ascomplete independence from others or overdependency (Bretherton &Munholland, 1999). There is only effective or ineffective dependency. Securedependence fosters autonomy and self-confidence. Secure dependence and autonomyare then two sides of the same coin, rather than dichotomies. Research tells usthat secure attachment is associated with a more coherent, articulated, andpositive sense of self (Mikulincer, 1995). The more securely connected we are,the more separate and different we can be. Health in this model meansmaintaining a felt sense of interdependency, rather than being self-sufficientand separate from others.”

This one is tough to explain because this little four wordsentence “secure dependence compliments autonomy” has two concepts which youmay or may not understand. The first one is “secure dependence” and the secondone is “autonomy”.

Secure dependence involves a conviction that the person youlove and care about will be there for you when you need her. Insecuredependence on the other hand involves uncertainty whether she’ll be there foryou or not when you need her.

The following diagram is one I use with my clients sometimesto help visualize the difference relational styles:

The way to understand this littlechart is to look at the horizontal axis as a continuum or range of ways that aperson habitually relates to his or her spouse or significant other. From leftto right we start with the person who is rather detached. When conflict arises,this person will habitually hunker down into a non-communicative loner style ofrelating to his (or her) spouse. To the right of the horizontal axis is theperson who is attached. This person includes their spouse / significant otherin the conflict.

Thevertical axis may be thought of as a continuum beginning at the bottom with theperson who is anxious or insecure about their relationship. This person hasvery little confidence that the relationship will last or that their lover willbe there for them if needed. This way of thinking comes from deep seatedschemas (i.e. outlooks and assumptions) about the reliability of primaryattachment figures in general. These schemas are developed as we make sense ofour experiences throughout life beginning with our childhood. A happy childhoodwould more naturally and probably result in a schema about others that would bemore secure, meaning a belief that those we love and depend upon will be therefor us when we need them. Whereas, a child who was abused or neglected by hisor her parents would be more anxious and insecure, meaning he or she wouldsuspect that their lover will leave them or hurt them.

Thus, aperson who is securely attached has a strong conviction that their loved onewill be there for them and includes them in his everyday life, thoughts and emotions.

Accordingto the DSM-IV-TR (2000) the extreme on the detachment scale would be a personwho might be diagnosed with a schizoid personality disorder. Such persons"lack of desire for intimacy, seem indifferent to opportunities to developclose relationships, and do not seem to derive much satisfaction from beingpart of the family or other social group. They prefer spending time bythemselves, rather than being with other people. They often appear to besocially isolated or "loners quote" and almost always choose solitaryactivities or hobbies that do not include interaction with others. They prefermechanical or abstract tasks, such as computer or mathematical games. They mayhave very little interest in having sexual experiences with another person andtake pleasure in few, if any, activities. There is usually a reduced experienceof pleasure from sensory, bodily, or interpersonal experiences, such as walkingon the beach at sunset or having sex. These individuals have no close friendsher confidence, except possibly a first-degree relative." (pp. 694-695) Suchpersons would not fit within the graphic above. They are also extremelyuncommon. Therefore, if you are having marital difficulties and you think yourspouse is detached it is unlikely that he (or perhaps she) has a schizoidpersonality disorder.

On theother extreme with regard to the anxious/insecure versus secure continuum ofrelating to primary attachment figures, the DSM-IV-TR (2000) describes thesigns and symptoms of a person suffering from borderline personality disorder."The essential feature of borderline personality disorder is a pervasivepattern of instability of interpersonal relationships, self-image, and affects,and marked impulsivity that begins by early adulthood and is present in avariety of contexts. Individuals with borderline personality disorder makefrantic efforts to avoid real or imagined abandonment. The perception of theimpending separation or rejection, or the loss of external social structure,can lead to profound changes in self-image, affect, cognition, and behavior.

These individuals are verysensitive to environmental circumstances. Experience intense abandonment fearsand inappropriate anger even when faced with a realistic time-limitedseparation or when there are unavoidable changes in plans (e.g., Sudden despairin reaction to a clinician's announcing the end of the hour; panic or fury whensomeone important to them is just a few minutes late for must cancel anappointment). They may believe that this "abandonment" implies thatthey are "bad." These abandonment fears are related to an intoleranceof being alone in a need to have other people with them. Their frantic effortsto avoid abandonment may include impulsive action such as self-mutilating orsuicidal behaviors … [they] have a pattern of unstable and intenserelationships. They may idealize potential caregivers are lovers at the firstor second meeting, demand to spend a lot of time together, and share the mostintimate details early in a relationship. However, they may switch quickly fromidealizing other people to devaluing them, feeling that the other person doesnot care enough, does not give enough, is not "there" enough. Theseindividuals can empathize with and nurture other people, but only with theexpectation that the other person will "be there" in return to meettheir own needs and on-demand.

These individuals are prone tosudden and dramatic shifts in their views of others, who may alternatively beseen as beneficent supports or is cruelly punitive. Such shifts often reflectdisillusionment with the caregiver whose nurturing qualities of an idealized orwhose rejection or abandonment is expected. There may be an identitydisturbance characterized by markedly and persistently unstable self-image orsense of self. There are sudden and dramatic shifts in self-image,characterized by shifting goals, values, and vocational aspirations. There maybe sudden changes in opinions and plans about career, sexual identity, values,and types of friends. These individuals may suddenly change from the role ofthe needy supplicant for help to a righteous avenger of past mistreatment.Although they usually have a self-image that is based on being bad or evilindividuals with this disorder may at times have feelings that they do notexist at all. Such experiences usually occur in situations in which individualsbills a lack of meaningful relationship, nurturing, and support. Theseindividuals may show worst performances unstructured work or school situations.Individuals with this disorder display impulsivity in at least two areas thatare potentially so damaging. They may gamble, spend money irresponsibly, bingeeating, abuse substances, engage in unsafe sex, or drive recklessly.

Individuals with borderlinepersonality disorder display recurrent suicidal behavior, gestures or threats,or self-mutilating behavior…. Self-mutilation may occur during dissociativeexperiences and often brings relief by reaffirming the ability to feel or byexecuting the individual's sense of being evil…." (pp. 706-707) Here too,as with a person with a schizoid personality disorder, she (or he) is off thecharts above. I would also caution anyone reading this that although borderlinepersonality disorders are more common than schizoid personality disorders, thiscondition should not be thrown around or diagnosed easily.

Ourability to achieve a securely attached relationship with another human being isvery much affected by our respective pasts. How we have integrated[1] orfailed to integrate past abuse and neglect (whether real or imagined, slight orgreat) into our view of ourselves, others and the world around us. This abilityto flexibly incorporate one’s experience of self, others and the world aroundinto a coherent meaningful whole is the essence of autonomy, or, as somepsychologists have called it, individuation. Autonomy is defined as a state ofindependence and self-determination in an individual, a group, or asociety." (VandenBos, 2006, p. 93). It is also the second stage of Erikson'seight stages of human development which takes place between the ages of one anda half and three years. According to Erikson during this stage children beginto acquire a degree of self-reliance and self-confidence if allowed to developat their own pace. However, if the parent is overly critical, overly protectiveor inconsistent the child acquires an important measure of shame and doubt. (Ibid.)A related concept, individuation, is worth noting at this point in the discussion.

Accordingto Carl Jung, individuation involves "the gradual development of aunified, integrated personality that incorporates greater and greater amountsof the unconscious, both personal and collective, and resolve any conflictsthat exist, such as those between introverted and extroverted tendencies. A,related concept, the differentiation of self (a phrase used to describe thesubject of the processes of individuation) has been defined as "theability to distinguish and maintain personal thoughts, feelings, goals and identityin the presence of emotional and societal pressures to do otherwise, especiallyin family systems." (VandenBos, 2007) From the American Psychological Association’sdefinition, I like to use the following acronym to remember what it means to bedifferentiated. Differentiation of self is a GIFT either good or bad impartedfrom one generation to another. This GIFT involves the ability to distinguishand maintain one's own distinctive Goals,Identity, Feelings and Thoughts.That is, the individuated personal has his or her own Goals, Identity, Feelingsand Thoughts separate and apart from his or her family of origin and/orsignificant others and society even if challenged or criticized.

Now, does the Bible teach thatsecure dependence compliments autonomy? I should say so. Solid and secure dependenceupon God in Christ is everywhere advised and extolled in Scripture. Christcompares our dependence to that of the branch being connected to the vine. “Iam the vine, ye are the branches: He that abideth in me, and I in him, the samebringeth forth much fruit: for without me ye can do nothing.” (John 15:5) It isa life that is so interwoven with God that it is described as being “hid withChrist in God. When Christ, who is our life, shall appear, then shall ye alsoappear with him in glory.” (Colossians 3:3-4) This confidence in God’sfaithfulness “God is faithful” (1 Corinthians 1:9, 10:13, and 1 John 1:9). Thisconfidence and conviction in the faithfulness and love of God is the foundationof our ability, as Christians, to make sense of our lives, our relationshipsand the world around us. The reason anyone in good faith affirms that “allthings work together for good to them that love God, to them who are the calledaccording to his purpose” (Romans 8:28) is because of an unshakeable confidencethat it is God himself who lovingly and unfailingly makes it so. Thus, as tosecure dependence in the Bible, it is a fundamental, if not the fundamental principal informing theChristian life.

Now, what about autonomy? Does theBible advocate the idea of autonomy as I have defined it above? In order todiscuss this concept, it is unfortunately necessary to deal with what Friesen (2009)calls a sacred cow (p. 6). Namely, I need to discuss with you knowing God’swill and then how the concept of how we come to know God’s will relates to suchconcepts as autonomy, individuation and differentiation.

Friesen (2009) proposes that ratherthan changing the question “How do I find the will of God?” to “How do I makegood decisions?” is the truly Biblical way of approaching life’s decisionsabout self, others and the world. The Bible, in this view is more a compassthan a detailed road map. As such, the importance of making one’s own decisionsin everyday life and taking responsibility for those decisions becomes apparent.For a good outline of Friesen’s book “Decision Making and the Will of God” goto http://www.gfriesen.net/sections/willofgod_principles.php.

A securedependence upon God as we walk in his will (i.e. our Goals, Identity, Feelings,Thoughts are infused with but not overruled or overpowered by his will for ourlives) we are empowered to reach our full potential in life. The teaching wereceive from the Bible both in private study, in sermons on Sunday and in themodeling of others in our community enables us to be all we can be and to trulydistinguish ourselves in our unique display of our God-given abilities. Thesecure dependence we have upon God and upon others is what makes it all work tothe edification of one another and the true expression of our uniqueness. 1Corinthians 12: “For as the body is one, and hath many members, and all themembers of that one body, being many, are one body: so also is Christ…. For thebody is not one member, but many.” (verses 12 and 14) is followed by 1Corinthians 13 which states that the greatest gift of all is love. The exerciseof our gifts requires security in our relationship which only comes with truegood will toward one another and love. I remember a while back while my wife,Dorothy and I, and some other couples were praying together about some stuff, oneof the people in the group started speaking in tongues. I thought that wasreally cool because it was a very special gift which could only be shared in anon-judgmental and safe environment.

The same istrue for any other gift that is given or shared. The fear of rejection and ridiculeis a serious impediment or obstacle to exercising one’s talents and actualizingoneself.

I have cometo believe in recent years that it is in relationship with one another that wetruly come to know and forge our identity and purpose. Harry Stack Sullivan putit this way: "The self may be said to be made up of reflected appraisals.If these were chiefly derogatory as in the case of an unwanted child was neverloved, of a child who is fallen into the hands of foster parents with no realinterest in him as a child; as they say, if the self-dynamism is made up ofexperience which is chiefly derogatory, it will facilitate hostile, disparagingappraisals of other people and it will entertain disparaging and hostileappraisals of itself." (Irvin Yalom quoting Sullivan in his book "Theoryand Practice of Group Psychotherapy, 5th Ed., Kindle Version, Location446-455).

“[S]peakingthe truth in love, may grow up into him in all things, which is the head, evenChrist: From whom the whole body fitly joined together and compacted by thatwhich every joint supplieth, according to the effectual working in the measureof every part, maketh increase of the body unto the edifying of itself in love.”(Ephesians 4:15-16) It seems to me that the Second Tenet of Attachmentarticulated by Sue Johnson captures a deeply rooted and fundamental source andcondition for true Christian Community and the realization of one’s truepotential and identity.

Footnote:

[1] I defineintegration as the incorporation of one’s experience in life as a coherentwhole infusing the same with meaning. See also Daniel Seigel (2010) “WHAT IS AHEALTHY MIND? Is it simply the absence of symptoms and dysfunctions, or isthere something more to a life well lived? How can we embrace the diversity ofbehavior, temperament, values, and orientation across a wide range of culturesand still come up with a coherent definition of health? Just as some scientistsare reluctant to define the mind, some people say that we shouldn’t definemental health at all, because it is authoritarian to do so—we shouldn’t tellothers how to be healthy. But how do we account for the universal striving forhappiness? How do we understand the cross-culturally recognizable ease ofwell-being? Positive psychology has offered an important corrective to thedisease model by identifying the characteristics of happy people, such asgratitude, compassion, open-mindedness, and curiosity, but is there someunnamed quality that underlies all of these individual strengths? Over the lasttwenty years, I’ve come to believe that integration is the key mechanismbeneath both the absence of illness and the presence of well-being.Integration—the linkage of differentiated elements of a system—illuminates adirect pathway toward health. It’s the way we avoid a life of dull, boringrigidity on the one hand, or explosive chaos on the other.” (pp. 64-65)

Siegel, Daniel J. (2010). Mindsight: The New Scienceof Personal Transformation Bantam. Kindle Edition.

God is Love: Attachment Theory is Biblical

2011-12-30T05:35:00.000-08:00

“Seeking and maintaining contact with significant others isan innate, primary motivating principle in human beings across the life span.Dependency, which has been pathologized in our culture, is an innate part ofbeing human rather than a childhood trait that we outgrow. Attachment and theemotions associated with it are the core defining feature of closerelationships; it is the "heart of the matter" for the coupletherapist. This theoretical perspective can claim considerable cross-culturalvalidity (van Ijzendoorn & Sagi, 1999). It also draws links to theevolution of humans as social animals and offers a universal perspective. It remindsus that when the wind blows, it stings the eyes of all. The fear of isolationand loss is found in every human heart.” (Johnson, 2004, p. 29)

Ephesians 5:24 states “we are members one of another.” Asmembers one of another we are connected and interdependent. This idea isbrought out by the Apostle Paul in Corinthians 12 where he compares the churchto a human body. “[B]y one Spirit are we all baptized into one body, whether webe Jews or Gentiles, whether we be bond or free; and have been all made todrink into one Spirit. For the body is not one member, but many.” (1Corinthians 12:13, 14) This central fact of the church – that it is a body ofindividuals who are, in a sense, parts of one another should never beoverlooked in how we do church. Treating the body like a corporation whosepurpose is profit within the bounds of law, will not very likely lead to edificationof the members of the body or the will and glory of Christ. More likely it willlead to exploitation and hurt.

I think of Samson when I consider this fact that “seekingand maintaining contact with significant others is an innate, primarymotivating principle in human beings across the life span.” How else do youexplain his interactions with Delilah? You’ll remember the story found inChapter 16 of the Book of Judges. The Scripture states that “he loved a woman …whose name was Delilah” (verse 4). Samson wasfeared of his enemies who offered Delilah 5 x 1,100 or (5,500) shekels ofsilver (which according to http://www.fordham.edu/halsall/ancient/mesopotamia-contracts.html

Ancient History Sourcebook was equivalent of 1 and ½ year’swages (10 shekels = 40 days’ wage). Samson was then deceived by Delilah threetimes and yet he nevertheless gave her the secret of his strength. His desireto maintain contact with Delilah motivated him to give her his secret eventhough it makes no sense for him to have done so outside an understanding ofthe power of this drive for attachment (i.e. love).

The source of attachment is a product of creation itself which in turn is seen in the very triune nature of God whereby the three persons of the one true God (Father, Son and Holy Spirit) commune one with another.

"For God so loved the world, that he gave his only begotten Son, that whosoever believeth in him should not perish, but have everlasting life." (John 3:16) The love we have for God is responsive to the love God showed us in Christ. Jesus' death upon the cross was for us and it was God's unselfish love that led to his giving of himself and his son.

In Job a fascinating discourse is recounted between God and Satan whereGod beams with pride about Job’s righteousness whereupon Satan replies “Skinfor skin, yea, all that a man hath will he give for his life. But put forththine hand now, and touch his bone and his flesh, and he will curse thee to thyface.” (Job 2:4, 5) Satan did not understand this love we have for God wherebywe seek and maintain contact with God. Nevertheless, it is the key to understandingthe life of the believer: “the love of Christ constraineth us” (2 Cor. 5:14); and,“Who [or what] shall separate us from the love of Christ?” (Romans 8:35). Notethe same theme found in the story of the woman who came to Jesus with costly ointment.She poured it on Jesus feet even as those who witnessed her do it, grew angryand murmured against her (Mark 14:4-9). Jesus rebuked her critics because heunderstood the motivation behind her act of love.

This first tenet or principal of attachment, that seekingand maintaining contact with significant others is an innate, primary motivatingprinciple in human beings across the life span is found everywhere in Scripture.I think of Genesis where it was determined that Adam needed Eve to be completeand Revelation where the ultimate union of God and his people as one iscompared to the joy and beauty we experience at our wedding celebrations.

Reference:

Johnson, S. (2004). The Practice of Emotionally FocusedCouple Therapy: Creating Connection. Brunner-Routledge: New York

Ten Tenets of Attachment

2011-12-29T05:27:00.000-08:00

A theory is "coherent set of logically related concepts that seeks to organize, explain and predict data." (Papalia, Olds & Feldman, 2007, p. 29) In 2011, I have been studying attachment theory in an effort to organize, explain and predict how couples might have more satisfying, healthy and loving relationships. I have found attachment theory to be very helpful in this regard. Sue Johnson (2004) lists the following 10 tenets of attachment theory:

1. Attachment is an innate motivating force.

Seeking and maintaining contact with significant others is an innate, primary motivating principle in human beings across the life span. Dependency, which has been pathologized in our culture, is an innate part of being human rather than a childhood trait that we outgrow. Attachment and the emotions associated with it are the core defining feature of close relationships; it is the "heart of the matter" for the couple therapist. This theoretical perspective can claim considerable cross-cultural validity (van Ijzendoorn & Sagi, 1999). It also draws links to the evolution of humans as social animals and offers a universal perspective. It reminds us that when the wind blows, it stings the eyes of all. The fear of isolation and loss is found in every human heart.

2. Secure dependence complements autonomy.

According to attachment theory, there is no such thing as complete independence from others or overdependency (Bretherton & Munholland, 1999). There is only effective or ineffective dependency. Secure dependence fosters autonomy and self-confidence. Secure dependence and autonomy are then two sides of the same coin, rather than dichotomies. Research tells us that secure attachment is associated with a more coherent, articulated, and positive sense of self (Mikulincer, 1995). The more securely connected we are, the more separate and different we can be. Health in this model means maintaining a felt sense of interdependency, rather than being self-sufficient and separate from others.

3. Attachment offers an essential safe haven.

Contact with attachment figures is an innate survival mechanism. The presence of an attachment figure, which usually means parents, children, spouses, and lovers, provides comfort and security, while the perceived inaccessibility of such figures creates distress. Proximity to a loved one tranquilizes the nervous system (Schore, 1994). It is the natural antidote to the inevitable anxieties and vulnerabilities of life. For people of all ages, positive attachments create a safe haven that offers a buffer against the effects of stress and uncertainty (Mikulincer, Florian & Weller, 1993) and an optimal context for the continuing development of the personality.

4. Attachment offers a secure base.

Secure attachmentalso provides a secure base from which individuals can explore their universe and most adaptively respond to their environment. The presence of such a base encourages exploration and a cognitive openness to new information (Mikulincer, 1997). It promotes the confidence necessary to risk, learn, and continually update models of self, others, and the world so that adjustment to new contexts is facilitated. Secure attachment strengthens the ability to stand back and reflect on oneself, one's behavior, and one's mental states (Fonagy & Target, 1997). When relationships offer a sense of felt security, individuals are better able to reach out to and provide support for others and deal with conflict and stress positively. These relationships tend then to be happier, more stable, and more satisfying. The need for a secure emotional connection with a partner, a connection that offers a safe haven and a secure base, is the central theme of couple distress and the process of effective relationship repair.

5. Emotional accessibility and responsiveness build bonds.

In general, emotion activates and organizes attachment behaviors. More specifically, the building blocks of secure bonds are emotional accessibility and responsiveness. An attachment figure can be physically present but emotionally absent. Separation distress results from the appraisal that an attachment figure is inaccessible. It is emotional engagement that is crucial and the trust that this engagement will be there when needed. In attachment terms, any response (even anger) is better than none. If there is no engagement, no emotional responsiveness, the message from the attachment figure reads as "Your signals do not matter, and there is no connection between us." Emotion is central to attachment, and this theory provides a guide for understanding and normalizing many of the extreme emotions that accompany distressed relationships. Attachment relationships are where our strongest emotions arise and where they seem to have most impact. Emotions tell us and communicate to others what our motivations and needs are; they are the music of the attachment dance (Johnson, 1996). As Bowlby has suggested, "the psychology and psychopathology of emotion is … in large part the psychology and psychopathology of affectional bonds" (1979, p. 130).

6. Fear and uncertainty activate attachment needs.

When the individual is threatened, either by traumatic events, the negative aspects of everyday life such as stress or illness, or by any assault on the security of the attachment bond itself, powerful affect arises and attachment needs for comfort and connection become particularly salient and compelling. Attachment behaviors, such as proximity seeking, are then activated. A sense of connection with a loved one is a primary inbuilt emotional regulation device. Attachment to key others is our "primary protection against feelings of helplessness and meaninglessness" (McFarlane & Van der Kolk, 1996). This theory helps the couple therapist understand how a particular event, such as a flirtation at a party or a short period of distance at a time of need, can threaten a relationship and begin a downward spiral of distress.

7. The process of separation distress is predictable.

If attachment behaviors fail to evoke comforting responsiveness and contact from attachment figures, a prototypical process of angry protest, clinging, depression, and despair occurs, culminating eventually in detachment. Depression is a natural response to loss of connection. Bowlby viewed anger in close relationships as often being an attempt to make contact with an inaccessible attachment figure and distinguished between the anger of hope and the anger of despair, which becomes desperate and coercive. In secure relationships, protest at inaccessibility is recognized and accepted. An emotionally focused therapist sees the basic dramas of distress, such as demand-withdraw, as variations on the theme of separation distress.

8. A finite number of insecure forms of engagement can be identified.

The number of ways that human beings have to deal with the unresponsiveness of attachment figures is limited. There are only so many ways of coping with a negative response to the question "Can I depend on you when I need you?" Attachment responses seem to be organized along two dimensions, anxiety and avoidance (Fraley & Waller, 1998).

When the connection with an irreplaceable other is threatened but not yet severed, the attachment system may become hyperactivated or go into overdrive. Attachment behaviors become heightened and intense as anxious clinging, pursuit, and even aggressive attempts to control and obtain a response from the loved one escalate. From this perspective, most criticism, blaming, and emotionally loaded demands in distressed relationships are attempts to deal with and resolve attachment hurts and fears.

The second strategy for dealing with the lack of safe emotional engagement, especially when hope for responsiveness is tenuous, is to attempt to deactivate the attachment system and suppress attachment needs. The most commonly observed ways of doing this are to focus obsessively on tasks, and limit or avoid distressing attempts at emotional engagement with attachment figures. These two basic strategies-anxious preoccupied clinging and detached avoidance-can develop into habitual styles of engagement with intimate others. Angry criticism, viewed through the attachment lens, is most often an attempt to modify the other partner's inaccessibility, and as a protest response to isolation and perceived abandonment by the partner. Avoidant withdrawal may be seen as an attempt to contain the interaction and regulate fears of rejection and confirmation of fears about the unlovable nature of the self. A third insecure strategy has been identified that is essentially a combination of seeking closeness and then fearful avoidance of closeness when it is offered. This strategy is usually referred to as disorganized in the child literature and fearful avoidant in the adult literature (Bartholomew & Horowitz, 1991). This strategy is associated with chaotic and traumatic attachments where others are, at one time, the source of and solution to fear (Johnson, 2002; Alexander, 1993).

The anxious and avoidant strategies were first identified in experimental separations and reunions with mothers and infants (Ainsworth, Blehar, Waters & Wall, 1978). Some infants were able to modulate their distress on separation, to acknowledge their distress and engage in clear support seeking when the mother returned. They were able to give clear signals and so make reassuring contact with the mother, and then, confident of her responsiveness if she was needed, to return to exploration and play. They were viewed as securely attached. Others became extremely distressed on separation. They did not seem to be confident that the mother would return and then clung to, or expressed anger to, the mother on reunion. They were difficult to soothe and were viewed as preoccupied with making contact with the mother and anxiously attached. Another group showed signs of significant physiological distress but showed very little emotion at separation or reunion. They focused on tasks and activities and were seen as avoidantly attached. These styles are "self maintaining patterns of social interaction and emotion regulation strategies" (Shaver & Clarke, 1994, p. 119). They echo the display rules for emotion that Ekman and Friesen identified (1975), namely exaggerating-substituting one feeling for another, as when we focus on anger rather than fear, and minimizing.

Recent research into adult attachment has added to our understanding of adult attachment style. For example, anxiously attached adults seem to experience separation from their attachment figure as a catastrophe that parallels death, while more secure adults are more open to new information and able to revise beliefs in relationships, as well as being able to seek reassurance more effectively. Anxious partners are more prone to strong anger, whereas avoidants seem to experience intense hostility and to also attribute this hostility to their partners. Moreover, avoidant partners tend to feel hostile when the other partner expresses distress or seeks support. Research suggests that avoidant partners can be socially skilled in general but avoid seeking or giving support when attachment needs arise within them or their partner. Avoidant partners also tend to be more prone to promiscuous sexuality (Brennen & Shaver, 1995; Shaver & Mikulincer, 2002). In general, anxiety and avoidance foster a rigid hypervigilant attitude to novelty and uncertainty and an equation of letting down one's guard with helplessness. All couple therapists will recognize these factors as preludes to and part of narrow rigid patterns of interaction and a constriction of the flexible openness necessary for closeness and connection.

These insecure habitual forms of engagement can be modified by new relationships, but they can also mold current relationships and so can easily become self-perpetuating. They involve specific behavioral responses to regulate emotions and protect the self from rejection and abandonment, and cognitive schemas or working models of self and other. In the attachment literature the term attachment styles, which implies an individual characteristic, is often used interchangeably with the term attachment strategies, which implies behavior that is more context specific. The use of the third term, habitual forms of engagement (Sroufe, 1996), further stresses the interpersonal nature of this concept. These forms of engagement can and do change when relationships change and are best thought of as continuous, not absolute (one can be more secure or less secure). The literature on these forms of engagement in the attachment dance helps the couple therapist see past all the content issues and dramatic subplots to the key moves and stances in that dance. The description of these strategies or patterns also fits with descriptive research on marital distress, for example, the delineation of the blame-pursue followed by defend-distance pattern as a prelude to relationship breakdown.

It is hardly surprising given the above that research confirms that attachment style affects marital satisfaction. Individuals with insecurely attached spouses report lower satisfaction; couples where both are securely attached report better adjustment than couples in which either or both partners are insecurely attached (Feeney, 1994; Lussier, Sabourin & Turgeon, 1997). When we consider these habitual responses and self-perpetuating patterns of interaction, it is easy to see that attachment is a systemic theory (Johnson & Best, 2002), and is concerned with "a reality-regulating and reality-creating not just a reality-reflecting system" (Bretherton & Munholland, 1999, p. 98).

9. Attachment involves working models of self and other.

We define ourselves in the context of our most intimate relationships. As stated above, attachment strategies reflect ways of processing and dealing with emotion. Some spouses catastrophize and complain when they feel rejected; some become silent for days. Bowlby outlined the cognitive content of the representations of self and other that are inherent in these response patterns. Secure attachment is characterized by a working model of self that is worthy of love and care and is confident and competent, and indeed research has found secure attachment to be associated with greater self-efficacy (Mikulincer, 1995). Securely attached people, who believe others will be responsive when needed, also tend to have working models of others as dependable and worthy of trust. These models of self and other, distilled out of a thousand interactions, become expectations and biases that are carried forward into new relationships. They are not one-dimensional cognitive schemas; rather they are procedural scripts for how to create relatedness and ways of processing attachment information. These models involve goals, beliefs, and attachment strategies, and they are heavily infused with emotion. Working models are formed, elaborated, maintained, and, most important for the couple and family therapist, changed through emotional communication. The couple therapist will recognize in his or her clients' emotional self-disclosures the models of self and other that naturally well up in highly charged interactions with loved ones. Once distressed partners step beyond their angry protests, for example, they often begin to disclose fears about their own lovableness and worth.

10. Isolation and loss are inherently traumatizing.

Lastly, it is important to recognize that attachment is essentially a theory of trauma. Bowlby began his career as a health professional by studying maternal deprivation and separation and its effects on children. Attachment theory describes and explains the trauma of deprivation, loss, rejection, and abandonment by those we need the most and the enormous impact it has on us. Bowlby viewed these traumatic stressors, and the isolation that ensued, as having tremendous impact on personality formation and on a person's ability to deal with other stresses in life. He believed that when someone is confident that a loved one will be there when needed, "a person will be much less prone to either intense or chronic fear than will an individual who has no such confidence" (1973, p. 406). The couple and family therapist knows the stress of deprivation and separation well. It is an essential part of the ongoing drama of "ordinary" relationship distress. Indeed, clients often speak of such distress in terms of trauma, that is, in life-and-death terms. As a theory of trauma, attachment theory specifically helps us to understand the weight behind emotional hurts such as rejection or perceived abandonment by a loved one. Distressed partners who are dealing with the traumatic helplessness induced by isolation and loss tend to adopt stances of fight, flight, or freeze that characterize responses to traumatic stress. The trauma perspective, with its focus on the power of helplessness and fear, helps the couple therapist tune in to the reality of distressed partners and deal with that reality constructively.

What I thought would be interesting, starting tomorrow is to see if I can find these tenets in the Bible taking them one per day for the next 10 days

Reference:

Johnson, S. (2004). The Practice of Emotionally Focused Couple Therapy: Creating Connection. Brunner-Routledge: New York

Papalia, D. E, Olds S.W., Feldman, R.D. (2007). Human Development, 10th Edition. McGraw-Hill: New York

Synaptogenesis and Sanctification

2011-08-31T07:04:00.000-07:00

1 John 2:28-3:10 “Children of God”

This fascinating passage points out that identity precedes sanctification. Our identity in Christ is referred to as God’s seed. The original readers of John’s letter would have understood the idea of planting a seed which then was watered and protected as it grew into a fruit or food bearing plant or tree. We bear the fruits of righteousness, says John, because it is in our nature as those who have been born again by the blood of our Lord Jesus Christ. The importance of fostering and fully developing your identity in Christ is obvious.

Jesus also spoke of our identity in Christ as seed. His discourse is recorded at Matthew 13. Jesus even explained the parable to his disciples at the time and to us in Scripture. The following chart outlines Jesus’ explanation for the parable of the sower

Matthew 13:1-9 – Jesus Matthew 13:18-23 – Jesus

Tells the Parable Explains the Parable

Mat 13:1 That same day Jesus went out of the house and sat beside the sea.

Mat 13:2 And great crowds gathered about him, so that he got into a boat and sat down. And the whole crowd stood on the beach.

Mat 13:3 And he told them many things in parables, saying: "A sower went out to sow.

Mat 13:4 And as he sowed, some seeds fell along the path, and the birds came and devoured them.

Mat 13:5 Other seeds fell on rocky ground, where they did not have much soil, and immediately they sprang up, since they had no depth of soil,

Mat 13:6 but when the sun rose they were scorched. And since they had no root, they withered away.

Mat 13:7 Other seeds fell among thorns, and the thorns grew up and choked them.

Mat 13:8 Other seeds fell on good soil and produced grain, some a hundredfold, some sixty, some thirty.

Mat 13:9 He who has ears, let him hear."

Mat 13:18 "Hear then the parable of the sower:

Mat 13:19 When anyone hears the word of the kingdom and does not understand it, the evil one comes and snatches away what has been sown in his heart. This is what was sown along the path.

Mat 13:20 As for what was sown on rocky ground, this is the one who hears the word and immediately receives it with joy,

Mat 13:21 yet he has no root in himself, but endures for a while, and when tribulation or persecution arises on account of the word, immediately he falls away.

Mat 13:22 As for what was sown among thorns, this is the one who hears the word, but the cares of the world and the deceitfulness of riches choke the word, and it proves unfruitful.

Mat 13:23 As for what was sown on good soil, this is the one who hears the word and understands it. He indeed bears fruit and yields, in one case a hundredfold, in another sixty, and in another thirty."

Notice that the operative fact here is the quality of the soil given to the seed. What this means as a practical matter is that one’s environment impacts his or her spiritual life. How obvious a statement? How equally profound? Can a person change her environment? We usually answer no on grounds that environment is interchangeable with nature and unlike nurture nature is genetically predisposed and hence cannot be changed.

Such mechanistic thinking contradicts the realities of life. Changing one’s environment is no easy task and involves something of a paradigm shift to achieve. It is more than simply getting a new house, going to a new school, changing jobs or spouse. It starts from the inside of one’s soul and can be seen in the idea contained in Romans 12:2:

Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect. (Crossway Bibles (2009). ESV Study Bible (p. 330). Good News Publishers/Crossway Books. Kindle Edition.)

This inner transformation by the renewal of your mind, this ability to test and discern what is the will of God, this capacity to know what is good and acceptable and perfect in your life today, this very moment, takes time and focus.

Recent studies in neuroscience indicates that focusing one’s thoughts and affections facilitates the neuronal growth. This implies that the renewal of one’s mind by focusing upon God’s word to apply it to our lives (i.e. “tak[ing] every thought captive to obey Christ” (2 Corinthians 10:5)) has a biological effect which changes the very structure of the brain. The term for this phenomenon is called synaptogenesis and draws on the neuroplasticity of the human brain. Daniel Seigel in his 2010 book, Mindsight: The New Science of Personal Transformation uses the mnemonic SNAG to describe these principles to his patient who happens to be 92 years old:

[SNAG] Stimulate Neuronal Activation and Growth. I said we could SNAG his brain to create and strengthen neural connections. Wherever neural firing occurs, existing neurons can make new or enhanced synaptic connections through the process called synaptogenesis. New neurons can be stimulated to develop, as well—a process called neurogenesis. I also explained how the myelin can thicken, which increases the electrical conduction among interconnected neurons. And, as I’d told Jonathon, among the keys to neuronal growth are novelty, attention, and aerobic exercise. Stuart liked the SNAG acronym, and I was happy his left mode seemed to appreciate the wordplay. Short of using an electrical probe, how can we strategically target a particular portion of the brain? The answer is attention. When we focus repeatedly on specific skills, moment-to-moment neural activity can gradually become an established trait through the power of neuroplasticity. (Siegel, Daniel J. (2010). Mindsight: The New Science of Personal Transformation (p. 110). Bantam. Kindle Edition.)

Original Intent and the Interpretation of Scripture

2011-06-23T07:28:00.000-07:00

As a lawyer I often see parallels to the way we as Christians interprets Scripture and the way we as a legal community (meaning Judges and Attorneys) interpret the Constitution.

In the interpretation of the Constitution there is what is called "original intent". As put by Bill Blum (1987) in an interesting ABA Journal article on the issue, original intent "says that to understand any document or the force that any piece of legislation has, you have to go back and capture the mental state the people responsible for enacting that leglislation had." Other doctrines mentioned by Bill Blum include "strict construction" and "majoritarianism" which are theories of interpretating the Constitution which limit the power of judges to constrain the legislature (elected representatives of the people).

Blum makes a very good point about original intent by citing the equal protection clause of the Constitution. It is quite clear to almost any honest American today that equal protection in 1787 when the Constitution was ratified did not extend to everyone.

It seems to me the better approach is to seek some understanding of the original intent because it helps inform our decisions about how the words were applied in its original context; however, it is also quite true that the Constitution is a living document in the sense that we allow it to have the final word on legislative and executive autonomy as it relates to the laws of the land and how they are carried out. With our government we have a final authority and an authority structure to which we, as the governed, consent--namely, the Supreme Court and the heirarchy of courts in each of the states.

Thus, for example, equal protection now extends to all equally 100% and original intent in that sense cannot and obviously should not undermine our confidence in the unconstitutionality of prejudice and racism. Why? Because the Supreme Court has ruled it in such cases as Brown v. The Board of Education and so forth.

The Church Universal (meaning the spiritual kingdom of Christ composed of all true believers in Christ without regard to their denomination) has much less heirarchy in its use of Scripture in governing itself. In a very real sense interpretative authority is subject to abuse and history is replete with such abuse. Jesus rebuked the Pharisees in his day because they abused their position of interpretative power over their flocks of people for their own purposes (Mark 7). Of course, we saw this problem too in the clash between the Catholic Authorities and the Scientific Revolution when Galileo and others were persecuted and censored because science at the time contradicted church dogma rooted in a literal reading of the Book of Psalms. The poetry of Scripture implied the earth was the center and the sun revolved around it; hence, when scientific publications began challenging this interpretation of the Bible a terrible conflict of authority ensued resulting in a huge credibility issue for Christians premised upon poor hermeneutics. The Psalms were never meant as scientific observations about creation.
It seems to me that the church must see the Scripture as a living document whose meaning remains tethered to a train of history but capable of interpretive meaning and expansion. In this sense I was thinking about Jesus words where he says that unless we become as little children we cannot enter the kingdom as it relates to recent brain science. Obviously Jesus, as a man of the first century, would not have known about plasticy (In psychology, when we talk about plasticity we're referring to "brain plasticity", which involves the ability for nerve cells to change through new experiences. The process of changing nerve cells is learning, and it was once believed that the only kind of change that could take place after childhood was related to the strength in nerve cell connections, not the ability for the cells to actually change. Most psychologists now believe that nerve cells actually can continue to change and function well into adulthood. What does this mean for you? Well, it seems that the old saying is wrong - you really can teach an old dog new tricks. (definition taken from http://www.alleydog.com/glossary/definition.php?term=Plasticity).

Nevertheless, think about the following quote from a book I was reading last night as it regards to Jesus' comments about being like little children. Is it legitimate to expand what Jesus said to new learning which clearly goes beyond the scope of what he could possibly have had in mind (as a man, of course) when he originally uttered the words?

"Human brains are at their most plastic during infancy. You can take away an entire hemisphere from a child's brain and the other will rewire itself to take on the tasks of both. It will even manage to develp functions that are usually exclusive to its other half. As we age, however, brain functions become more rigid and more distinctive." (Carter, 1999, pp. 23-24)

It seems to me that it is indeed legitimate to do so, provided of course that the expansion is in harmony with the corpus of Christian doctrine, morality and over time is confirmed by the Holy Spirit. Ultimately the Holy Spirit teaches us and brings us interpretations that meet the needs of our lives, organizations and movements from generation to generation. (1 Corinthians 2:13-14)

References

Blum, B. (1987) The hearings on original intent. ABA Journal, December 1, 1987, pp. 78-80.

Carter, R. (1999). Mapping the mind. Berkeley, CA: University of California Press.

Growth in Christ Includes Discipline, Faith and Repentance From Time to Time

2011-06-21T01:35:00.000-07:00

In our counseling with couples, my wife and I often talk about the importance of creating a safe environment for one another where you can share your feelings and needs without being punished for your honesty. Having an atmosphere of love and safety in this regard allows each partner to grow in their relationship because they are able to give and receive feedback that enables them to better adjust and live satisfied lives with one another. The same is true in our relationshp with God. If we recognize that God loves us as a good (note the adjective good) Father loves his children, we will find life an interesting training gound for growth in being Christ-like in every attitude of our hearts.

This was the basic background in mind as I studied Psalm 107 at verse 17 this morning where it says “because of their iniquities [the Israelites, God’s people and children at the time (circa 550 BCE) suffered affliction….” This is still true today. God loves us and will not allow us to continue in flagrant sin without disciplining us. He disciplines us as a good father disciplines his children. “[H]e disciplines us for our good, that we may share his holiness”(Hebrews 12:10) His discipline or training (Titus 2:11-14) causes faith and repentance which in turn brings relief from afflictions we foolishly create by our own sinful ways in departing from the Lord and his ways outlined in His Word (Deuteronomy 6:24 and 10:13). As Scripture says at 2 Corinthians 7:10 “godly grief produces a repentance that leads to salvation without regret”. This is a different sort of grief from the worldly grief which does not lead to repentance but merely upset at being caught. “God's kindness is meant to lead you to repentance” as indeed it does if we will humble ourselves in His sight (Romans 2:4).

This is a shocking study about just how human judges may really be!

2011-06-14T09:42:00.000-07:00

This is a fascinating finding of something that I see every now and then where a judge allows there bias or personal issues to interfere with good impartial decisions based solely on the facts and law.

From the Monitor on Psychology, June 2011, Vol. 42, No. 6, p. 14

Those of us who have been blessed by God to be in the legal system and have the privilege of practicing law and judging cases, need to vigilantly watch out for bias and personal issues that may affect our impartiality and efforts in the cause of justice.

Insubordination: An Important Trait to Avoid in a Church Elder

2011-05-30T10:51:00.000-07:00

I've been studying Titus 1 this morning where the Apostle Paul instructed Titus on what to look for and avoid when choosing Elders to lead the 1st Century Churches in Crete.

Titus 1:10 states "For there are many who are insubordinate, empty talkers and deceivers, especially those of the circumcision party." (ESV) the Greek word translated Insubordinate here is ανυποτακτοι. It is translated as “unruly” in the KJV and “rebellious” in the NIV. According to Kittle in the TDNT the word carries with it the idea that the anupotaktoi refuse to subordinate their lives to the leadership of the church and hence to the Lord. This is no small thing. In fact it is huge. Note Jesus’ marvel at the the Centurion who understood deeply the chain of command as it relates to the work of Christ. (Luke 7:1-9, Matthew 8:5-13)

Bill Gothard in his course regarding basic youth conflicts relates that a clear understanding of authority is "the basis of achieving great faith" (p. 19) he further relates that there are three basic purposes for authority:

1. To enable us to grow in wisdom and character (Luke 2:52);

2. To protect us from harm and temptation (Romans 13:1-2 and for Samuel 15:23); and,

3. To guide and direct us in life (Luke 7:1-9, Matthew 8:5-13). As Gothard explains it, "; that is, visualizing what God intends to do…. Our faith multiplies as we see how God speaks to us through those he has placed over us." (p. 20)

Conversely, our faith shrinks as we reject the notion that God speaks to us through those he has placed over us.

With regard to the qualifications of a leader in the church it is essential that the leader the one who recognizes his or her place in the chain of command knowing how to take and to give orders in the Lord. Great opportunities for spiritual growth are lost in our insubordination to our leaders.

Authority and responsibility coincide one with another. You cannot really have one without the other and a strong sense of authority and the chain of command produces a strong sense of responsibility and personal well-being for all.

Religify?

2011-05-25T07:36:00.000-07:00

Secularization is the process of using religious or spiritual principles toward secular ends and purposes. Examples of secularization are everywhere. For example, where do you suppose our laws against theft and deception come from? The Bible, that's where. Christians are generally disapprove of secularization. Why?

Anyway, this blog is not about secularization but about religification. Why not religify (i.e. use for spiritual and religious ends and purposes) principles discovered and developed by scientists (social, psychological, biological, geological, evolutionary and so forth) claiming no affiliation with the church or Christianity?

Daniel Siegel's (a medical doctor / psychiatrist / researcher and writer) 2010 book, Mindsight: The New Science of Personal Transformation defines integration in systemic terms where "a system that moves toward complexity is the most stable and adaptive" (p. 68) In this sense the individual, church or organization is a system in motion from a simpler to a more complex state. As this inevitable process takes place there is the Scylla of "chaos" on the one side and the Hydra of "rigidity" on the other. The key is to negotiate the two extremes and live in the flow of an integrated life. He then uses the acronym to describe the characteristics of integration: FACES "Flexible, Adaptive, Coherent, Energized and Stable" (p. 70)

Is it so bad to allow new ideas to mix with our religious ones if we are mature enough not to be tossed around in the faith but rather allow new ideas to help us explain and apply our faith along the lines Anselm's famous aphorism "faith seeking understanding"?

Today's Prayer

2011-05-23T05:50:00.000-07:00

Based upon Ephesians 3:14-20:
1. That God would give us the inner strength to deal with today’s challenges;
2. That God would further our understanding of the Love of Christ and what it means in practical terms as we relate to self and others;
3. That God would fill us with his fullness so that we may praise him in all we do and say today.

Prayer and the Word

2011-05-19T06:00:00.000-07:00

Last night my wife, Dorothy, and I spent some time reading the book of Philippians and Praying together last night because I needed it. I must tell you that is a good thing to do. The Word of God is very refreshing and enlightening. Bringing our prayers and petitions to the Lord is also a burden lightening activity. Give it a try with your friend or spouse when you get a chance. Suggest it and see where it goes.

Re: Arnold's Affair with Housekeeper

2011-05-17T06:17:00.001-07:00

There but for God's grace goes any one of us. Be warned by his weakness/fall but do not judge. The stars are not so different than any of us. Arnold worked very hard to achieve his success. I for one will be compassionately praying for Arnold and for Maria.

Day 35 -- Amphetamine-Related Disorders

2011-04-03T20:54:00.001-07:00

The amphetamine use disorders include amphetamine dependence and amphetamine abuse. Amphetamine is a "potent central nervous system stimulant with similar psychoactive and sympathomimetic effect" upon the abuser of the substance. Interestingly, some persons with amphetamine dependence began by using amphetamine like substances to assist them weight loss. "Aggressive or violent behavior is associated with amphetamine dependence, especially when high doses or smoked, ingested, or administered intravenously." "Tolerance to amphetamines develops and often leads to substantial escalation of the dose." On the other hand, on some occasions a sensitization occurs where "small doses may produce marked stimulant and other adverse mental and neurological effects." (DSM-IV-TR, 2000, p. 225)
Amphetamine abuse is often associated with legal difficulties typically arising as a result of behavior while intoxicated with amphetamines. "Individuals may continue to use the substance despite the knowledge that continued use resulting arguments with family members while the individual is intoxicated or presents a negative example to children or other close family members. When these problems are accompanied by evidence of tolerance, withdrawal, or compulsive behavior, a diagnosis of amphetamine dependence rather than abuse should be considered." (Ibid.)
The amphetamine-induced disorders include amphetamine intoxication and amphetamine withdrawal. With amphetamine intoxication a specifier of with perceptual disturbances is utilized "when hallucinations with intact reality testing for auditory, visual or tactile illusions occur in the absence of a delirium.” (Ibid., p. 226)
Amphetamine withdrawal "is characterized by the development of the sport mood and two or more of the following physiological changes: fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. Anhedonia and drug craving can also be present but are not part of the diagnostic criteria." After an episode of heavy use person may "crash". A crash "is characterized by intense and unpleasant feelings of lassitude and depression, generally requiring several days of rest and recuperation." (Ibid., pp. 227-228)
There are many amphetamine-induced disorders such as amphetamine-induced anxiety disorder, amphetamine-induced delirium, amphetamine-induced psychotic disorder, amphetamine-induced mood disorder, amphetamine-induced sexual dysfunction and amphetamine-induced sleep disorder.
All in all, amphetamines and other substance-related disorders are extremely debilitating for people inflicted by them, their families and society.

Day 34 -- Alcohol Related Disorders

2011-03-27T18:08:00.000-07:00

Alcohol dependence, abuse, intoxication and withdrawal are major problems in the United States.

Alcohol dependence is characterized by the following:
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to achieve Intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount of the substance
(2) Withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

Diagnostic criteria for 291.8 Alcohol Withdrawal (new code as of 10/01/96: 291.81)

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after Criterion A:
(1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
(2) increased hand tremor
(3) insomnia
(4) nausea or vomiting
(5) transient visual, tactile, or auditory hallucinations or illusions
(6) psychomotor agitation
(7) anxiety
(8) grand mal seizures
C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Specify if: With Perceptual Disturbances
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because of substance use
(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
While the core features of substance dependence is tolerance, withdrawal or compulsive use, the essential features of substance abuse is harmful consequences or recurrent use in spite of harmful consequences. Substance abuse does not include cigarette smoking or drinking coffee:
When repeated use of alcohol or other drugs leads to problems but does not include compulsive use or addiction, and stopping the drug does not lead to significant withdrawal symptoms the term substance abuse applies. This, along with Substance Dependence are considered substance use disorders.
Harmful use of a specific psychoactive substance. The term also applies to one category of psychoactive Substance Use Disorder. While recognizing that "abuse" is part of present diagnostic terminology, ASAM recommends that an alternative term be found for this purpose because of the pejorative connotations of the word "abuse."*
Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of Intoxication, physical fights)
B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
Note: “Because Withdrawal from alcohol can be unpleasant and intense, individuals with

Alcohol Dependence may continue to consume alcohol, despite adverse consequences, often to avoid or to relieve the symptoms of withdrawal.” (American Psychiatric Association, 2000, DSM-IV-TR, P. 213)
With chronic compulsive dependence upon alcohol individuals “may devote substantial periods of time to obtaining and consuming alcoholic beverages. These individuals often continue to use alcohol despite3 evidence of adverse psychological or physical consequences (e.g., depression, blackouts, liver disease, or other sequelae).” (Ibid)
Diagnostic Criteria for Alcohol Intoxication
A. Recent ingestion of alcohol.
B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, alcohol ingestion.
C. One (or more) of the following signs, developing during, or shortly after, alcohol use:

(1) slurred speech

(2) incoordination

(3) unsteady gait

(4) nystagmus

(5) impairment in attention or memory

(6) stupor or coma
D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
The difference between a Perceptual Disturbance and a Psychotic Disorder with Hallucinations has to do with whether the person’s reality testing ability remains intact or not.

Day 33 - Substance Withdrawal

2011-03-20T22:34:00.001-07:00

"The essential feature of Substance Withdrawal is the development of a substance-specific maladaptive behavioral change, with physiological and cognitive concomitants, that is due to the cessation of or reduction in heavy and prolonged substance use (Criterion A). The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion B). The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder (Criterion C). Withdrawal is usually, but not always, associated with Substance Dependence. (American Psychiatric Association, 2000, [DSM-IV-TR], p. 201)

The criteria for substance withdrawal are as follows:

A. The Development of a substance-specific syndrome due to the cessation of (or reduction in) substance abuse that has been heavy and prolonged.

B. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

The DSM-IV-TR makes the interesting observation that the route of administration of the substance is an important assessment factor. Routes of the ministration that quickly deliver higher levels of the substance being abused to the patient's brain are more likely to produce dependence, abuse and toxicity-related mental disorders. (Ibid., p. 202)

DSM-V

The Substance-Related Disorders Work Group has been responsible for addressing these disorders. Among the work group’s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions. Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as “Internet addiction” that will be considered as potential additions to this category as research data accumulate. Further, the work group has proposed to tentatively re-title the category, Addiction and Related Disorders. The work group had extensive discussions on the use of the word “addiction.” There was general agreement that “dependence” as a label for compulsive, out-of-control drug use has been problematic. It has been confusing to physicians and has resulted in patients with normal tolerance and withdrawal being labeled as “addicts.” This has also resulted in patients suffering from severe pain having adequate doses of opioids withheld because of fear of producing “addiction.” Accordingly, the word “dependence” is now limited to physiological dependence, which is a normal response to repeated doses of many medications including beta-blockers, antidepressants, opioids, anti-anxiety agents and other drugs. The presence of tolerance and withdrawal symptoms are not counted as symptoms to be counted for the diagnosis of substance use disorder when occurring in the context of appropriate medical treatment with prescribed medications. Finally, the work group is addressing the disorder pathological gambling, which is currently listed under the diagnostic category Impulse-Control Disorders Not Elsewhere Classified. (http://www.dsm5.org/ProposedRevisions/Pages/Substance-RelatedDisorders.aspx)

Day 32 -- Substance Abuse

2011-03-15T06:10:00.000-07:00

DSM-IV-TR
While the core features of substance dependence is tolerance, withdrawal or compulsive use, the essential features of substance abuse is harmful consequences or recurrent use in spite of harmful consequences. Substance abuse does not include cigarette smoking or drinking coffee:
When repeated use of alcohol or other drugs leads to problems but does not include compulsive use or addiction, and stopping the drug does not lead to significant withdrawal symptoms the term substance abuse applies. This, along with Substance Dependence are considered substance use disorders.
Harmful use of a specific psychoactive substance. The term also applies to one category of psychoactive Substance Use Disorder. While recognizing that "abuse" is part of present diagnostic terminology, ASAM recommends that an alternative term be found for this purpose because of the pejorative connotations of the word "abuse."*
Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of Intoxication, physical fights)
B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
DSM-V
DSM-V is going to do away with the distinction between substance dependence and substance abuse.

Day 31 -- Substance Dependence

2011-03-14T23:38:00.000-07:00

DSM-IV-TR

Substance dependence as defined below can be applied to every class of substance except caffeine (American Psychiatric Association, [DSM-IV-TR], 2000, p. 192).
When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders.
Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
(1) tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve Intoxication or desired effect

(b) markedly diminished effect with continued use of the same amount of the substance
(2) Withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because of substance use
(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
Specify if:
With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present)

Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)
Course specifiers (see text for definitions):

Early Full Remission

Early Partial Remission

Sustained Full Remission

Sustained Partial Remission

On Agonist Therapy

In a Controlled Environment
(http://www.behavenet.com/capsules/disorders/subdep.htm)

DSM-V

Among the work group’s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions. Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as “Internet addiction” that will be considered as potential additions to this category as research data accumulate. Further, the work group has proposed to tentatively re-title the category, Addiction and Related Disorders. The group is also considering adding diagnostic criteria for pathological gambling.

Another important and very large change coming in the DSM-V involved doing away with the bi-dimensional distinction between substance dependence and substance abuse the "large body of literature on the structure of abuse and dependence criteria in clinical and general population samples suggests that the DSM-IV abuse and dependence criteria can be considered to form a unidimensional structure, with abuse and dependence criteria interspersed across the severity spectrum."
(http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=36#)

Day 30 – Mental Disorders Due to a General Medical Condition

2011-03-11T06:43:00.000-08:00

DSM-IV-TR
In this section of the DSM-IV-TR the mental symptoms “are judged to be the direct physiological consequence of a general medical condition.” (American Psychiatric Association, [DSM-IV-TR], 2000) Applying this concept “requires two separate judgments: that a general medical condition is present (ascertained by history, physical examination, or laboratory assessment) and that the disturbance (e.g. psychotic, mood, anxiety symptoms) is etiologically related to the general medical condition through a physiological mechanism.” (pp. 181-182)
There are three disorders mentioned: 1. Catatonic Disorder Due to a General Medical Condition, 2. Personality Change Due to a General Medical Condition, and 3. Mental Disorder Not Otherwise Specified (NOS) Due to a General Medical Condition.
DSM-V
Catatonia in the DSM–V (Summary of Recommendations and Rationale)
A- Reasons to consider a change
There are three reasons for further change of the classification of catatonia in the next edition of the DSM. First, catatonia is often not recognized (van der Hejiden et al, 2005). Second, a better recognition of catatonia would facilitate proper treatment, which often requires early intervention with benzodiazepines and ECT. Third, a better recognition of catatonia as a diagnostic entity would catalyze the dormant research of the neural and genetic mechanisms of catatonia.
B- Proposed changes
The Work-Group considered two alternative possible modifications to de-emphasize the link between catatonia and schizophrenia with the hope to improve recognition, facilitate treatment and foster research: A- Establish a new diagnostic class in the psychoses chapter for catatonia. Add a specifier indicating with which diagnosis it is co-morbid. In text clarify that catatonia is most often associated with another diagnostic class (e.g., mood disorder, psychotic disorder, or general medical disorder). This would represent a major change, since it involves the addition of a new diagnostic category. B- Place catatonia criteria as specifier in the mood, general medical, and psychoses chapters rather than as a diagnostic class. This would represent a modest change, since it involves the addition of a new specifier (for schizophrenia) in a disorder that has not been widely studied (catatonia).
C- Summary of evidence for change
1- Antecedent validators (family aggregation).
Kendler and Hays (1983) found that catatonic symptoms were more severe in schizophrenia patients with a family history of bipolar disorder than in those without such a history. However patients with mood disorders were not studied. Peralta and Cuesta (2007) assessed psychotic inpatients for psychopathology as well as their family members; familial morbid risk of mood disorders was predicted by mania, depression and catatonia syndromes in patients. Hence, these two studies suggest a familial link between broadly defined catatonic symptoms in the context of schizophrenia and mood disorders.
2- Concurrent validators
a- Literature on the comorbidity of catatonia and other disorders.
A few studies have examined comorbidity and diagnostic stability. No studies have documented other concurrent validators like cognitive, personality or biological correlates. Abrams and Taylor (1976) studied psychiatric inpatients with catatonic signs. Only four of the 55 patients satisfied research criteria for schizophrenia, whereas over two thirds had diagnosable affective disorders, usually mania. In a related study of 123 acutely ill patients with bipolar affective disease, 28% exhibited clinical signs of catatonia (Taylor and Abrams, 1977). Peralta and Cuesta (2001) studied consecutive admissions of psychotic patients (n=187, 113 with DSM-IV schizophrenia) and examined catatonia with a reliable instrument. All catatonic symptoms improved with antipsychotic medications. Catatonia differentially correlated with the syndromes of psychoses, with the association between motor poverty and the negative syndrome being particularly strong. Residual motor pathology, but not the acute one, was related to various clinical variables. Residual symptoms of motor poverty and stereotypy/mannerisms were associated with poor premorbid adjustment, more illness severity and a diagnosis of schizophrenia.
Ungvari et al (2005 ) assessed chronically-ill inpatients (n=225; mean length of illness=20) with DSM-IV schizophrenia. Seventy-two subjects (32%) met criteria for catatonia. Catatonic subjects had a significantly earlier age of onset, more negative symptoms, suggesting worse prognosis in the chronic phase of schizophrenia.
In summary, these studies document that catatonic symptoms occur in the context of schizophrenia and mood-related psychosis. The relative proportion will depend on the criteria used to define the boundaries between the psychoses, as well as on the operational criteria to define what constitutes a legitimate catatonic symptom. Furthermore, broadly defined catatonia is likely heterogeneous, at least within schizophrenia. Large studies, with representative samples, mixed diagnoses, independent structured symptom assessments and prolonged follow-up, are necessary in order to delineate the boundaries and course of catatonia.
b- New analyses on the co-morbidity of catatonia (Catatonia in a birth cohort)

Malaspina, et al (Kleinhaus et al 2009, personal communication) examined the frequency of ICD-10 catatonia diagnoses at discharge in the Jerusalem Perinatal Cohort Schizophrenia Study (JPSS). The population is all births in Jerusalem from 1964 through 1976. There were 5366 psychiatric admissions for the JPSS offspring through 2004. In summary, 1.2 % of all psychiatric admissions could have included catatonia/stupor (111/5366 admissions). In 58.5% (65/111 admissions) it was catatonic schizophrenia; 40.5% of admissions were not schizophrenia related. However, 44% of the non-schizophrenia related possible stupor/catatonia admission cases had a schizophrenia diagnosis on another admission (20/45 cases). Only 23/111 possible admissions for catatonia were for cases that never received a schizophrenia diagnosis.
In conclusion, in this epidemiological cohort 73 % of possible stupor/catatonia in the psychiatric setting was in cases that had a current or other admission with a schizophrenia related condition. Limitations include questions of comparability between ICD-10 and DSM-III/IV and likely under-representation of neurological-related catatonia in psychiatric inpatient settings.
3- Predictive validators.
Few studies have been specifically designed to examine predictive validators. These have focused on response to biological treatments. Intervention research for catatonia has been originally focused in acute inpatient settings. Several clinical reports suggest that higher dose benzodiazepines are effective in acute catatonic syndromes, especially mute/stuporous presentations. However, no placebo-controlled, randomized trials have been published. Furthermore, the important issue of whether novel antipsychotics with less potent D2 blocking properties are better tolerated or even effective for acute catatonia is not settled. Case series suggest that acute catatonia also responds well to ECT (Caroff et al (2007). However, catatonia associated with schizophrenia appears less likely to respond than that with mood disorders (Pataki et al, 1992). In the one controlled study of ECT for catatonic schizophrenia, there were no significant differences between active and sham treatments (Miller et al, 1953).
In outpatients settings, only two controlled trials have examined pharmacotherapy for catatonia, both in DSM-IV schizophrenia. Ungavari et al, (1999) reported no effect of benzodiazepines in chronically-ill patients in a small (N=16), 12 week randomized cross-over controlled trial. More recently, Cuesta et al (in press) reported on antipsychotic efficacy for catatonic symptoms in never-medicated schizophrenia of (mean duration of illness of 2.3 years). In total, 173 patients completed one-month trials with haloperidol (n=23), risperidone (n=93) or olanzapine (n=57). There were no differences in response between the three groups and most patients benefited from their assigned medication. Furthermore, improvements in catatonia and other psychotic symptoms were directly related.
In summary, the efficacy of benzodiazepines, ECT and antipsychotics drugs has only been partially examined. For acute catatonia, benzodiazepines and ECT appear to be effective, perhaps more in the context of mood disorders. Conversely, in chronically-ill psychotic patients (almost exclusively schizophrenia in available reports), antipsychotic agents appear effective.
D- Work-Group recommendations
The limited available data documents that catatonic symptoms are heterogeneous and are primarily, though not exclusively linked to schizophrenia (similar to other psychotic symptoms). Our literature review and secondary analyses suggests that a smaller proportion of patients with catatonia will have a primary mood disorder. There is a valid clinical concern that maintaining a very robust association with schizophrenia, may result in worsening of catatonic symptoms for some patients treated with potent dopamine blocking agents, mainly in hospital settings. However, the very sparse treatment data does not support the view that antipsychotic medications are contraindicated for all catatonic symptoms. Hence, proposal A, to establish a new diagnostic class in the psychoses chapter for catatonia, a major change, is not supported. The more modest change, to place catatonia criteria as a specifier in the psychotic, mood, and general medical chapters is consistent with our literature review and by de-emphasizing the Kraepelinian link to schizophrenia, may be helpful to clinicians. This change actually fits well with another recommendation from the Psychosis Work-Group to eliminate the traditional schizophrenia subtypes, including schizophrenia, catatonic subtype in DSM-V (see corresponding document)
References
van der Heijden FM, Tuinier S, Arts NJ, Hoogendoorn ML, Kahn RS, Verhoeven WM. Catatonia: disappeared or under-diagnosed? Psychopathology. 2005 Jan-Feb;38(1):3-8.
Taylor MA, Fink M. Catatonia in psychiatric classification: a home of its own. Am J Psychiatry. 2003;160:1233–1241
Kendler and Hays, 1983 K.S. Kendler and P. Hays, Schizophrenia subdivided by the family history of affective disorder: a comparison of symptomatology and course of illness, Archives of General Psychiatry 40 (1983), pp. 951–955
Peralta V, Cuesta MJ. The relationship between syndromes of the psychotic illness and familial liability to schizophrenia and major mood disorders. Schizophr Res. 2007 Mar;91(1-3):200-9. Epub 2007 Feb 8.
Abrams R, Taylor MA. Catatonia. A prospective clinical study. Arch Gen Psychiatry. 1976 May;33(5):579-81.
Taylor MA, Abrams R. Catatonia, prevalence and importance in the manic phase of manic-depressive illness. Arch Gen Psychiatry 1977; 34:1223-1225.
Peralta V, Cuesta M. Motor features in psychotic disorders. I. Factor structure and clinical correlates. Schiz Res 47 (2001) 107-116
Ungvari GS, Leung SK, Ng FS, Cheung HK, Leung T. Schizophrenia with prominent catatonic features ('catatonic schizophrenia'): I. Demographic and clinical correlates in the chronic phase. Prog Neuropsychopharmacol Biol Psychiatry. 2005 Jan; 29(1):27-38.
Ungvari GS, Goggins W, Leung SK, Gerevich J. Schizophrenia with prominent catatonic features ('catatonic schizophrenia'). II. Factor analysis of the catatonic syndrome. Prog Neuropsychopharmacol Biol Psychiatry. 2007 Mar 30;31(2):462-8.
Caroff SN, Ungvari GS, Bhati MT, Datto CJ, O'Reardon JP. Catatonia and prediction of response to electroconvulsive therapy. Psychiatr Ann 2007;37:57-64.
Pataki J, Zervas IM, Jandorf L. Catatonia in a University in-patient service (1985-1990). Convulsive Ther 1992;8:163-173.
Miller DH, Clancy J, Cumming E. A comparison between unidirectional current nonconvulsive electrical stimulation given with Reiters machine, standard alternating current electroshock (Cerletti method), and Penthotal in chronic schizophrenia. Am J Psychiatry 1953;109:617-620.
Ungvari GS, Chiu HF, Chow LY, Lau BS, Tang WK.Lorazepam for chronic catatonia: a randomized, double-blind, placebo-controlled cross-over study. Psychopharmacology (Berl) 1999;142:393-398.
Victor Peralta V, Campos M, Garcia de Jalon E, Cuesta M. DSM-IV catatonia signs and criteria in first-episode, drug-naïve, psychotic patients: psychometric validity and response to antipsychotic medication. Schizophrenia Bulletin, in press.
A. The clinical picture is dominated by at least three of the following:
1. Catalepsy
2. Waxy flexibility
3. Stupor
4. Agitation
5. Mutism
6. Negativism
7. Posturing
8. Mannerisms
9. Stereotypies
10. Grimacing
11. Echolalia
12. Echopraxia
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition
C. The disturbance is not better accountedfor by another mental disorder (e.g., a Manic episode)
Coding Note: Include the name of the general medical condition on Axis 1, eg. 293.89 Cataonic disorder due to hepatice encephalopathy; also code the general medical condition on Axis III
The DSM-V proposes no changes to the Personality Change Due to a General Medical Condition or to Mental Disorder Not otherwise Specified Due to a General Medical Condition.

Why Family Therapists Focus on Family Strengths Rather Than Family Weaknesses and Pathologies

2011-03-08T07:55:00.000-08:00

One obvious reason why focusing on family strength when helping them through a crisis or other problem is that it is their strength that will help them through it, not their weakness. Another interesting thought along these lines involves the fact that the crisis or challenge becomes the very thing that results in the development of new strengths.

“Strengths are often developed in response to challenges. A family's strengths are tested by life's everyday stressors and also by the significant crises that all families face sooner or later. For many couples and families, it takes several years before they believe they have become a strong family; and they know this because they have been tested over time by the significant challenging events that life inevitably bring.”

From: Family Therapy Review: Preparing for Comprehensive and Licensing Examinations. Contributors: Robert H. Coombs - editor. Publisher: Lawrence Erlbaum Associates. Place of Publication: Mahwah, NJ. Publication Year: 2005. Page Number: 9 from Questia.com
This little idea that “strengths are often developed in response to challenges” reminds me of another principle I found very helpful in Kanel’s (2007) A Guide to Crisis Intervention (3d ed.) “In Chinese, crisis means both danger and opportunity…. This dichotomous meaning highlights the potentially beneficial aw well as the potentially hazardous aspects of a crisis state.” (p. 3)

Day 29 -- Amnestic Disorders

2011-03-08T07:46:00.003-08:00

The differential diagnosis for Amnestic Disorders caution the clinician that they should be distinguished from the less efficient memory characteristics of age-related cognitive decline. Age-related cognitive decline involves "an objectively identified decline in cognitive functioning consequent to the aging process that is within normal limits given the person's age. Individuals with this condition may report problems remembering names or appointments or may experience difficulty in solving complex problems." (American Psychiatric Association, [DSM-IV-TR], 2000, p. 740)

The differential diagnosis for Amnestic Disorders also cautions against confusing and Amnestic disorder with malingering or factitious disorders. Malingering and factitious disorders are distinguished from Amnestic disorders by utilizing "systematic memory testing" (ibid., p. 174)

One other differential diagnosis issue involves dissociative disorders. The Amnestic disorders the distinction between the dissociative disorders and amnesia can be seen in the fact that the dissociative disorders "individuals present with a circumscribed inability to recall previous memories, usually of a traumatic or stressful nature." (Ibid.) "The essential feature of the dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception." (Ibid., p. 519)

In this area of memory loss without multiple cognitive deficits etiology is generally quite important. For example with Amnestic disorder due to a general medical condition "there must be evidence from the history, physical examination, or laboratory findings at the memory disturbance is the direct physiological consequence of a general medical condition (including physical trauma)" (Ibid., p. 175)

DSM-IV-TR

Amnestic Disorder Due to . . . [Indicate the General Medical Condition]

A. The development of memory impairment as manifested by impairment in the ability to learn new information or the inability to recall previously learned information.

B. The memory disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning.

C. The memory disturbance does not occur exclusively during the course of a delirium or a dementia.

D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition (including physical trauma).

Specify if:

Transient: if memory impairment lasts for 1 month or less. When the diagnosis is made within the first month without waiting for recovery, the term “provisional” may be added.

Chronic: if memory impairment lasts for more than 1 month

Coding note: Include the name of the general medical condition on Axis I, e.g., 294.0 Amnestic Disorder Due to Head Trauma; also code the general medical condition on Axis III (see Appendix G for codes).

DSM-V

The work group is recommending that this disorder be subsumed into the new disorders: Major Neurocognitive Disorder and Mild Neurocognitive Disorder.

Day 28 – Substance Induced Persisting Dementia

2011-03-06T23:01:00.000-08:00

Substance-Induced Persisting Dementia is diagnosed if the symptoms [cognitive deficits and required impairment] persist beyond the usual duration of Substance Intoxication or Withdrawal and is not diagnosed if they occur exclusively during the course of the delirium. (American Psychiatric Association, [DSM-IV-TR], 2000, p. 168)

"This disorder is termed "persisting" because the dementia persist long after the individual has experienced the effects of Substance Intoxication or Substance Withdrawal." (Ibid., p. 169)

"Because these disorders persist long after use of the substance has stopped, blood or urine screens may be negative for the etiological substance." (Ibid.)

"Medications reported to cause dementia include anticonvulsants and intrathecal methotrexate. Toxins reported to evoke symptoms of dementia include lead, mercury, carbon monoxide, organophosphate insecticides, and industrial solvents." (Ibid.)

When Dementia persists beyond resolution of Intoxication, Delirium, or Withdrawal effects, either of medication, drugs of abuse, or exposure to toxic substances, this diagnosis applies.

Diagnostic criteria for Substance-Induced Persisting Dementia

A. The development of multiple cognitive deficits manifested by both

(1) memory impairment (impaired ability to learn new information or to recall previously learned information)

(2) one (or more) of the following cognitive disturbances:

(a) aphasia (language disturbance)

(b) apraxia (impaired ability to carry out motor activities despite intact motor function)

(c) agnosia (failure to recognize or identify objects despite intact sensory function)

(d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

C. The deficits do not occur exclusively during the course of a delirium and persist beyond the usual duration of Substance Intoxication or Withdrawal.

D. There is evidence from the history, physical examination, or laboratory findings that the deficits are etiologically related to the persisting effects of substance use (e.g., a drug of abuse, a medication).

Code [Specific Substance]-Induced Persisting Dementia:

(291.2 Alcohol; 292.82 Inhalant; 292.82 Sedative, Hypnotic, or Anxiolytic; 292.82 Other [or Unknown] Substance)

While both dementia and amnesia are characterized by significant memory impairments, dementia is also accompanied by multiple cognitive deficits; whereas amnesia is characterized by an absence of other significant accompanying cognitive impairments.

Day 27 – Dementia Due to Head Trauma, Parkinson’s Disease, Huntington’s Disease, Pick’s Disease, Creutzfeldt-Jacob’s Disease, and, Dementia Due to Other General Medical Conditions

2011-03-06T22:58:00.001-08:00

These dementias are etiologically related to other neurological diseases. The psychotherapist should be acquainted with them as he or she helps patients and family deal with the relational problems associated with them.

Christian Men Are Called to Love Their Wives and Children

2011-03-06T08:25:00.000-08:00

In studying Psalm 91, I was struck by what I have heard someone say at some time that every advance in the Christian life comes with a deeper understanding of how everything relates to God through our Lord Jesus Christ.

I believe that.

For example, I have recently been looking at the importance of a man creating an environment of non-sexual loving affection and kindness. The commandment to create this in one’s marital relationship is seen in Ephesians 5:28-29 “So ought men to love their wives as their own bodies. He that loveth his wife loveth himself. For no man ever yet hated his own flesh; but nourisheth and cherisheth it, even as the Lord the church….” Note that our loving affection for our wives is linked to our relationship with Christ.

I strongly believe that our relationships with others reflect our central relationship with God and that God is particularly concerned that men treat their families with tender kindness. Thus are we admonished at Ephesians 6:3 to refrain from provoking our children but bring them up in the “nurture and admonition of the Lord” and at 1 Peter 3:7 to “give honor” to our wives treating them “with understanding” as our “equal partner[s] in God’s gift of new life. Treat her as you should so your prayers will not be hindered.” The word translated as hindered comes from the Greek ἐκκόπτω which carries with it the idea of being struck out, excluded or repelled (See Kittel, Vol. III, Theological Dictionary of the New Testament, p. 858).

Day 26 -- Vascular Dementia

2011-02-28T07:09:00.000-08:00

DSM-IV-TR
When there is evidence that Dementia is caused by cardiovascular disease this diagnosis may apply. Computed imaging studies of the brain, such as CT (computed tomography) and MRI (magnetic resonance imaging), can usually detect evidence of vascular lesions.
Diagnostic criteria for 290.4x Vascular Dementia

A. The development of multiple cognitive deficits manifested by both

(1) memory impairment (impaired ability to learn new information or to recall previously learned information)

(2) one (or more) of the following cognitive disturbances:

(a) aphasia (language disturbance)

(b) apraxia (impaired ability to carry out motor activities despite intact motor function)

(c) agnosia (failure to recognize or identify objects despite intact sensory function)

(d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
C. Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white matter) that are judged to be etiologically related to the disturbance.
D. The deficits do not occur exclusively during the course of a Delirium.
Code based on predominant features:
290.41 With Delirium: if delirium is superimposed on the dementia

290.42 With Delusions: if delusions are the predominant feature

290.43 With Depressed Mood: if depressed mood (including presentations that meet full symptom criteria for a Major Depressive Episode) is the predominant feature. A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given.

290.40 Uncomplicated: if none of the above predominates in the current clinical presentation
Specify if: With Behavioral Disturbance

Coding note: Also code cerebrovascular condition on Axis III.

(http://www.behavenet.com/capsules/disorders/vasculardem.htm)

DSM-V

The DSM-5 Neurocognitive Disorders Work Group proposes that a new category of Neurocognitive Disorders replace the DSM-IV Category of ―Delirium, Dementia,
Amnestic, and Other Geriatric Cognitive Disorders".

The defining characteristics of these disorders are that their core or primary deficits are in cognition and that these deficits represent a decline from a previously
attained level of cognitive functioning; the latter feature distinguishes them from the neurodevelopmental disorders in which a neurocognitive deficit is present at birth
or interferes with development. However, it is possible to develop a neurocognitive disorder superimposed on a neurodevelopmental disorder, for example
Alzheimer's disease in a patient with mental retardation associated with Down Syndrome.
This section includes three broadly defined syndromes.
(1) Delirium,
(2) Major Neurocognitive Disorder,
(3) Minor Neurocognitive Disorder.

(http://www.dsm5.org/Proposed%20Revision%20Attachments/APA%20Neurocognitive%20Disorders%20Proposal%20for%20DSM-5.pdf)

Day 25 -- Alzheimer's Disease (290.x)

2011-02-26T07:53:00.000-08:00

DSM-IV-TR
“This form of progressive dementia named for Alois Alzheimer begins gradually, and is usually diagnosed after other specific causes have been ruled out through appropriate diagnostic procedures.
Diagnostic criteria for Dementia of the Alzheimer's Type (cautionary statement)

A. The development of multiple cognitive deficits manifested by both (1) memory impairment (impaired ability to learn new information or to recall previously learned information) (2) one (or more) of the following cognitive disturbances:

(a) aphasia (language disturbance)

(b) apraxia (impaired ability to carry out motor activities despite intact motor function)

(c) agnosia (failure to recognize or identify objects despite intact sensory function)

(d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
C. The course is characterized by gradual onset and continuing cognitive decline.
D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:

(1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)

(2) systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)

(3) substance-induced conditions
E. The deficits do not occur exclusively during the course of a delirium.
F. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Episode, Schizophrenia).
Code based on presence or absence of a clinically significant behavioral disturbance:
294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
294.11 With Behavioral Disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance. (e.g., wandering, agitation)
Specify subtype:
With Early Onset: if onset is at age 65 years or below
With Late Onset: if onset is after age 65 years
Coding note: Also code 331.0 Alzheimer's disease on Axis III. Indicate other prominent clinical features related to the Alzheimer's disease on Axis I (e.g., 293.83 Mood Disorder Due to Alzheimer's Disease, With Depressive Features, and 310.1 Personality Change Due to Alzheimer's Disease, Aggressive Type).”
http://www.behavenet.com/capsules/disorders/alzheimersTR.htm
DSM-V
The DSM-V proposes renaming what now is called Dementia in the DSM-IV-TR into two types of Neurocognitive Disorders (Major Neurocognitive Disorders and Minor Neurocognitive Disorders). See:
http://www.dsm5.org/Proposed%20Revision%20Attachments/APA%20Neurocognitive%20Disorders%20Proposal%20for%20DSM-5.pdf
“Alzheimer's Disease Subtype of Major and Mild Neurocognitive Disorders

A. Major: Meets criteria for Major Neurocognitive Disorder, with memory being one of the impaired domains.

Mild: Meets criteria for Mild Neurocognitive Disorder with memory impairment AND there is clear supporting evidence for the Alzheimer etiology (e.g., a positive test for a known mutation in an Alzheimer’s disease associated gene), or with evolving research, documentation based on biomarkers or imaging.

B. Early and prominent impairment in the Memory domain (rarely, other domains such as visuoconstructive perceptual domain may be prominently affected, but Alzheimer’s disease would not be diagnosed without clear supporting imaging, biomarker or genetic evidence).

Major: Deficits are observed in at least one other domain, often Executive Ability, and as the disease progresses, in additional domains.

Mild: Only Memory may be affected, but deficits in Executive Abilities are common.

C. The course is characterized by gradual onset and continuing cognitive decline

D. Evidence from history, examination, and investigations that deficits are not wholly or primarily attributable to other disorders. However, other such disorders may coexist.

The Alzheimer's Disease Subtype of Major and Mild Neurocognitive Disorders is similar to the previously independent diagnosis of Dementia of the Alzheimer's Type

A. The development of multiple cognitive deficits manifested by both

(1) memory impairment (impaired ability to learn new information or to recall previously learned information)

(2) one (or more) of the following cognitive disturbances:

(a) aphasia (language disturbance)

(b) apraxia (impaired ability to carry out motor activities despite intact motor function)

(c) agnosia (failure to recognize or identify objects despite intact sensory function)

(d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

C. The course is characterized by gradual onset and continuing cognitive decline.

D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:

(1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson’s disease, Huntington’s disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)

(2) systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)

(3) substance-induced conditions

E. The deficits do not occur exclusively during the course of a delirium.

F. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Disorder, Schizophrenia).

Code based on presence or absence of a clinically significant behavioral disturbance:

294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.

294.11 With Behavioral Disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., wandering, agitation).

Specify subtype:

With Early Onset: if onset is at age 65 years or below

With Late Onset: if onset is after age 65 years

Coding note: Also code 331.0 Alzheimer's disease on Axis III. Indicate other prominent clinical features related to the Alzheimer’s disease on Axis I (e.g., 293.83 Mood Disorder Due to Alzheimer’s Disease, With Depressive Features, and 310.1 Personality Change Due to Alzheimer’s Disease, Aggressive Type)”
(http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=421)

Day 24 - Dementia (General Considerations)

2011-02-24T05:29:00.000-08:00

As I grow older and as the Baby Boomers grow older this particular diagnostic category will become more and more personally and societally relevant.

"The disorders in the "dementia" section are characterized by the development of multiple cognitive deficits (including memory impairment) that are due to the direct physiological effects of a general medical condition, to the persisting effects of a substance, or to multiple etiologies (e.g., the combined effects of cerebrovascular disease and Alzheimer's disease). The disorders in this section share a common symptom presentation that are differentiated based on etiology." (American Psychiatric Association, [DSM-IV-TR], 2000, p. 147)

(The essential feature of the dementia is the development of multiple cognitive deficits that include memory impairment in at least one of the following cognitive disturbances: aphasia [deterioration of language function], apraxia [impaired ability to execute motor activities despite intact motor abilities, sensory function, and comprehension of the required task], agnosia [they are to recognize or identify objects despite intact sensory function], or disturbance in executive functioning [the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior]…. Memory impairment is required to make the diagnosis of a dementia and is a prominent early symptom (Criterion A1) individuals with dementia may become impaired in their ability to learn new material, or they forget previously learned material…. They may lose valuables like wallets and keys, forget food cooking on the stove, and become lost in unfamiliar neighborhoods. In advanced stages of dementia, memory impairment associated with a person forgets his or her occupation, schooling, birthday, family members, and sometimes even name." (Ibid., p. 148)
"The most common cause of dementia is Alzheimer's disease…. The age at onset of dementia depends on the eve geology, but is usually late in life, with highest prevalence above age 85 years…. A variety of epidemiological studies have shown that the prevalence of dementia, especially dementia of the Alzheimer's type, increases with age. The prevalence figures range from 1.4% to 1.6% for individuals ages 65-69 years, rising to 16% to 25% for those over age 85 years." (Ibid., pp. 151-152)
Dementia is differentiated from and Amnestic disorder by a lack in the latter of other significant pyramids of cognitive functioning (i.e., aphasia, apraxia, agnosia, or disturbances in executive functioning).

Day 23 - Delirium

2011-02-23T07:09:00.000-08:00

DSM-IV-TR

The first 22 days of this study covered the DSM-IV-TR's disorders usually first diagnosed in infancy, childhood, or adolescence. We now begin the DSM-IV-TR's section entitled "Delirium, Dementia, and Amnestic and other Cognitive Disorders". This section is particularly interesting to me personally because my profession as a lawyer relies almost entirely upon my cognitive and consequent communication capabilities. Moreover, as I continue to get older the fear of contracting dementia (which involves "the development of multiple cognitive deficits (including memory impairment)" (American Psychiatric Association, [DSM-IV-TR], 2000, p. 131). Recently, in connection with Dr. Collins' awesome class, Advanced Psychopathology, I downloaded Still Alice by Lisa Genova. That book is really good. If you listen to it from audio books or read it will give you chills and at the same time give you some glimpse into the beauty of life even as it deteriorates under the lash of dementia.
"A delirium is characterized by disturbance of consciousness and a change in cognition that develop over a short period time. The disorders included in the "delirium" section are listed according to presumed etiology: delirium due to a general medical condition, substance-induced delirium (i.e., due to a drug of abuse, a medication, or toxin exposure), delirium due to multiple etiologies, or delirium not otherwise specified (if the etiology is indeterminate)." (Ibid., p. 135)
With a delirium, "[t]he disturbance in consciousness is manifested by reduced clarity of awareness of the environment. The ability to focus, sustained, or shift attention is impaired (Criterion A). Questions must be repeated because the individual's attention wanders, for the individual may perseverate [to repeat something insistently and/or redundantly] with an answer to a previous question rather than appropriately shift attention. The person is easily distracted by irrelevant stimuli. Because of these problems, it may be difficult (or impossible) to engage the person conversation." (Ibid., p. 136)
"There is an accompanying change in cognition (which may include memory impairment, disorientation, or language disturbance) or development of a perceptual disturbance (Criterion B). (Ibid.)
"Perceptual disturbances may include misinterpretations, illusions, or hallucinations. For example, the banging of a door may be mistaken for gunshot (misinterpretation); the folds of the bedclothes may appear to be inanimate objects (illusion); or the person may "see" a group of people hovering over the bed when no one is actually there (hallucination)." (Ibid., p. 137)
It is particularly difficult to differentiate between a dementia and a delirium because both involve memory impairment. However, a person with dementia without delirium will generally be alert and conscious. The rapid or temple onset of the cognitive impairments also may be helpful in distinguishing between a delirium in a dementia. The onset of dementia is said to be insidious. Also, delirium symptoms tend to fluctuate over time; whereas, dementia symptoms may wax and wane somewhat but remain in relative stasis.
The difference between a delirium and a delusional disorder may be difficult to distinguish as well. Generally speaking, "in delirium, the psychotic symptoms are fragmented and unsystematized."
The DSM-IV-TR lists substance-induced delirium, delirium due to a general medical condition, substance intoxication delirium, and substance withdrawal. Each of these conditions have the following general criteria:
A. Disturbance of consciousness (i.e., reduce clarity of awareness of the environment) with reduced ability to focus, sustained, or shift attention.
B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by pre-existing, established, or evolving dementia.
C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
D. There is evidence from the history, physical examination, or laboratory findings of or that ….[And here's where the distinction between the etiological source of the delirium is made].
DSM-V
A. Disturbance in level of awareness and reduced ability to direct, focus, sustain, and shift attention.

B. A change in cognition, (such as deficits in orientation, executive ability, language, visuoperception, learning and memory)

-Cannot be assessed in face of severely reduced level of awareness

-Should not be better accounted for by a preexisting neurocognitive disorder

C. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiologic consequences of a general medical condition.

D. The disturbance develops over a short period of time (usually hours to a few days) and tends to fluctuate in severity during the course of a day.
Note: The following supportive features are commonly present in delirium but are not key diagnostic features: sleep-wake cycle disturbance, psychomotor disturbance, perceptual disturbances (e.g., hallucinations, illusions), emotional disturbances, delusions, labile affect, dysarthria and EEG abnormalities (generalized slowing of background activity)

Coding note: If delirium is superimposed on a pre-existing Neurocognitive Disorder, indicate the delirium as follows: _______

Coding note: Include the name of the general medical condition on Axis I e.g. 293.0 Delirium Due to Hepatic Encephalopathy

If the full criteria are currently met for delirium, specify its current clinical status and/or features:

Hyperactive, hypoactive or mixed

Short term vs. persistent duration

Day 22 - Stereotypic Movement Disorder

2011-02-22T07:50:00.000-08:00

I read Ephesians 5:29 "no man ever yet hated his own flesh; but nourisheth and cherisheth it" to reflect a creation norm whereby people in general are self-actualizing beings who nourish (provide the food, sleep, comfort, leisure necessary for growth and health) and cherish (lovingly protect and care) themselves. With this disorder, however, something has gone terribly wrong and rather than nourishing and cherishing their flesh (to the KJV wording) they harm and hurt themselves. If you were the parent of a child with this disorder, you can only imagine the horror at seeing your child bang his head (I use the male pronoun because males bang their heads at a ratio of 3:1 to females; whereas, females have a higher prevalence of biting themselves than males), bang his head, I was saying, against a concrete wall with such ferocity that unless physically restrained, would beat himself into a coma.
DSM-IV-TR"The essential feature of Stereotypic Movement Disorder is motor behavior that is repetitive, often seemingly driven, and nonfunctional (Criterion A). This motor behavior markedly interferes with normal activities or results in self-inflicted bodily injury that is significant enough to require medical treatment (or would result in such injury of protective measures were not used) (Criterion B)…." (American Psychiatric Association, [DSM-IV-TR], 2000, p. 131)
"The stereotypic movements may include hand waving, rocking, playing with hands, fiddling with fingers, twirling objects, head banging, self-biting, or hitting various parts of one's own body. Sometimes the individual uses an object in performing these behaviors. Behaviors may cause permanent and disabling tissue damage and may sometimes be life-threatening. For instance, severe head banging or hitting may lead to cuts, bleeding, infection, retinal detachment, and blindness."
This sort of behavior looks a lot like the stereotypic behavior which is part of the syndrome all cluster of autistic spectrum disorders; however, one of the exclusionary criteria for this diagnosis is that the behavior is not better accounted for by a stereotype be that is part of a pervasive developmental disorder. (Criterion D)
This particular disorder appears to be rare among children with average or above-average IQs; whereas, children with cognitive disabilities (mental retardation) the prevalence of this disorder runs from 2 to 3% to as high as 25% "in adults with severe or profound mental retardation living in institutions." (Ibid., p. 132)
DSM-V
Stereotypic Movement Disorder
The work group is recommending that this disorder be classified as a Neurodevelopmental Disorder (or another similar grouping of disorders) or an Anxiety and Obsessive-Compulsive Spectrum Disorder.

A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self biting).
B. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The motor behavior is not due to the direct physiological effects of a substance or a general medical condition.
D. The motor behavior is not restricted to the symptoms of another mental disorder (e.g., compulsions in Obsessive-Compulsive Disorder, tics in Tic Disorder, stereotypies in Autism Spectrum Disorder, hair pulling in Hair Pulling Disorder (Trichotillomania)). *
Specify if:
With Self-Injurious Behavior: If the behavior results in bodily damage (or would result in bodily damage if protective measures were not used).
*If Skin-Picking Disorder is added to DSM-5, it will also need to be mentioned in Criterion D.

Ainsworth's Strange Situation and Attachment

2011-02-21T05:47:00.000-08:00

Attachment theory captures an important Biblical truth (albeit Bowlby used an evolutionary paradigm to explain his research). Because of the centrality of Ainsworth's strange situation, I thought I would post it for my own and other's review.

"Based on the observations of a young child and parents during a brief separation and reunion, designated the "strange situation procedure" pioneered by Harry Ainsworth and colleagues, researchers have designated a child's basic pattern of attachment to be characterized as secure, insecure, or disorganized. Children who exhibit secure attachment behavior are believed to experience the caregivers as emotionally available and appear to be more exploratory and well-adjusted than children who exhibit insecure or disorganized attachment behavior. Insecure attachment is believed to result from a young child's perception that the caregiver is not consistently available, whereas a child with disorganized attachment behavior is believed to be experiencing the need for proximity to the caregiver with apprehension and approaching the caregiver. These early patterns of attachment are believed to influence a child's future complex capacities for affect regulation, self-soothing, and relationship building. According to DSM-IV-TR, RAD of infancy or early childhood was marked by an inappropriate social relatedness that occurs in most contexts. The disorder appears before the age of five years and is associated with "grossly pathological care." It is not accounted for solely by a developmental delay does not meet the criteria for pervasive developmental disorder." (Sadock & Sadock, 2007, p. 1250)
Papalia, Olds & Feldman (2007) define attachment as "a reciprocal, enduring emotional tie between infant and a caregiver, each of whom contributes to the quality of the relationship. Attachments have adaptive value for babies, ensuring their psychosocial as well as physical needs will be met." They also define attachment more generally as a "reciprocal, enduring tie between two people, especially between infant and caregiver, each of whom contributes to the quality of the relationship." (p. 205)
Papalia, Olds & Feldman (2007) further described Ainsworth's strange situation procedure as follows:

"The strange situation consists of a sequence of eight episodes and takes less than half an hour. During that time, the mother twice leads the baby in an unfamiliar room, the first time with a stranger. The second time she leaves the baby alone in the stranger comes back before the mother does. The mother that encourages a baby to explore and play again against comfort if the baby seems to need it (Ainsworth, Blehar, Waters, & wall, 1978). Of particular concern is the baby's response each time the mother returns.
When Ainsworth and her colleagues observed one-year-olds in the Strange Situation and at home, they found three main patterns of attachment. These are the secure attachment (the most common category into which about 60 to 75% of low-risk North American babies fall) and two forms of anxious or insecure, attachment: avoidant (15 to 25 percent) and ambivalence, or resistance (10 to 15 percent) (Vondra & Barnett, 1999).
Babies with secure attachment cry or protest when mother leaves and greet her happily when she returns. They use her as a secure base, leading her to go off and explore but returning occasionally for reassurance. They're usually cooperative and relatively free of anger. Babies with avoidant attachment rarely cry when the mother leaves but avoid her on her return. They tend to be angry and do not reach out in time of need. They dislike being held but dislike being put down even more. Babies with ambivalent (resistant) attachment become anxious even before the mother leaves and are very upset when she goes out when she returns, they showed their ambivalence by seeking contact with her for the same time resisted resisting it by kicking her squirming. Resistant babies do little exploration and are hard to comfort.
These three attachment patterns are universal and all cultures in which they have been studied….” (pp. 205-206)
Reference
Sadock, B. J. & Sadock, V. A. (2007). Kaplan & Sadock's synopsis of psychiatry:
Behavioral sciences/clinical psychiatry, 10th ed. New York: Wolters Kluwe
Papalia, D., Olds, D.W., Feldman, R.D., (2007). Human Development, 10th ed. Boston, Massachusetts: McGraw Hill

Day 21 - Reactive Attachment Disorder

2011-02-21T05:17:00.000-08:00

/
DSM-IV-TR
/
The Bible says that we should honor our father and mother for it is the first commandment with promise; moreover, it is a creation norm that parents care and love their children. With Reactive Attachment Disorder this creation norm whereby children are loved and cared for by their parents or primary caregivers has been seriously violated.
/
Reactive attachment disorder is unique in the DSM-IV-TR because insofar as I am aware it is the only diagnosis which unequivocally points the finger at parents and/or primary caretakers. "By definition, the condition is associated with grossly pathological care that may take the form of persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection (Criterion C1); persistent disregard of the child's ASIC physical needs (Criterion C2); or repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care) (Criterion C3). The pathological care is presumed to be responsible for the disturb social relatedness (Criterion D)." (American Psychiatric Association, [DSM-IV-TR], 2000, p. 128)
/
The prevalence of Reactive Attachment Disorder "appears to be very uncommon" (<1%?) (Ibid., p. 129)
/
"The essential feature of Reactive Attachment Disorder is markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 years and is associated with grossly pathological care (Criterion A). There are two types of presentations. In the Inhibited Type, the child persistently fails to initiate and to respond to most social interactions and developmentally appropriate way. The child shows a pattern of excessively inhibited, hypervigilant, or highly ambivalent responses (e.g., frozen watchfulness, resistance to comfort, or a mixture of approach and avoidance) (Criterion A1). In the disinhibited type, there is a pattern of diffuse attachments. The child exhibits indiscriminate sociability or lack of selectivity in the choice of attachment figures (Criterion A2).” (Ibid, p. 128)
/
DSM-V
/
DSM-V proposes dividing this mental disorder into two types.
/
The proposed revision for Reactive Attachment Disorder includes the division of the two DSM-IV types into two disorders: Reactive Attachment Disorder of Infancy and Early Childhood and Disinhibited Social Engagement Disorder.
/
Proposed DSM-V Criteria for Reactive Attachment Disorder of Infancy or Early Childhood
/
A. A pattern of markedly disturbed and developmentally inappropriate attachment behaviors, evident before 5 years of age, in which the child rarely or minimally turns preferentially to a discriminated attachment figure for comfort, support, protection and nurturance. The disorder appears as a consistent pattern of inhibited, emotionally withdrawn behavior in which the child rarely or minimally directs attachment behaviors towards any adult caregivers, as manifest by both of the following:
/
1) Rarely or minimally seeks comfort when distressed.
/
2) Rarely or minimally responds to comfort offered when distressed.
/
B. A persistent social and emotional disturbance characterized by at least 2 of the following:
/
1) Relative lack of social and emotional responsiveness to others.
/
2) Limited positive affect.
/
3) Episodes of unexplained irritability, sadness, or fearfulness which are evident during nonthreatening interactions with adult caregivers.
/
C. Does not meet the criteria for Autistic Spectrum Disorder.
/
D. Pathogenic care as evidenced by at least one of the following:
/
1) Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection (i.e., neglect).
/
2) Persistent disregard of the child’s basic physical needs.
/
3) Repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care).
/
4) Rearing in unusual settings such as institutions with high child/caregiver ratios that limit opportunities to form selective attachments.
/
E. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
/
F. The child has a developmental age of at least 9 months.
/
Proposed DSM-V Criteria for Disinhibited Social Engagement Disorder
/
A. A pattern of behavior in which the child actively approaches and interacts with unfamiliar adults by exhibiting at least 2 of the following:
/
1) Reduced or absent reticence to approach and interact with unfamiliar adults.
/
2) Overly familiar behavior (verbal or physical violation of culturally sanctioned social boundaries).
/
3) Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
/
4) Willingness to go off with an unfamiliar adult with minimal or no hesitation.
/
B. The behavior in A. is not limited to impulsivity as in ADHD but includes socially disinhibited behavior.
/
C. Pathogenic care as evidenced by at least one of the following:
/
1) Persistent failure to meet the child’s basic emotional needs for comfort, stimulation, and affection (i.e., neglect)
/
2) Persistent failure to provide for the child’s physical and psychological safety.
/
3) Persistent harsh punishment or other types of grossly inept parenting
/
4) Repeated changes of primary caregiver that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
/
5) Rearing in unusual settings that limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).
/
D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
/
E. The child has a developmental age of at least 9 months.

Day 20 - Selective Mutism

2011-02-20T08:39:00.000-08:00

DSM-IV-TR

/
“The essential feature of Selective Mutism is the persistent failure to speak in specific situation (e.g. school, with playmates) where speaking is expected, despite speaking in other situation…. Associated features of Selective Mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home… in clinical settings, children with Selective Mutism are almost always given an additional diagnosis of an Anxiety Disorder (especially Social Phobia).” (DSM-IV-TR, 2000, pp. 125-126)
/
Selective Mutism is a rare condition (<1%) and usually manifests itself by age 5.
/
The diagnostic criteria for Selective Mutism (313.23) are as follows:
/
“A. Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
/
B. The disturbance interferes with educational or occupational achievement or with social communication.
/
C. The duration of the disturbance is at least 1 month (not limited to the first month of school)
/
D. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
/
E. The disturbance is not better accounted for by a Communication Disorder (e.g. Stuttering) and does not occur exclusively during the course of a pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.” (Ibid, p. 127)
/
DSM-V
/
The DSM-V proposes no changes to this disorder. Let me take this opportunity to point out that “the term mental disorder unfortunately implies a distinction between “mental” disorders and “physical” disorders that is a reductionistic anachronism of mind/body dualism.” (DSM-IV-TR, 2000, p. xxx) Although the revisers of the DSM recognize the difficulties associated with the use of this term they have found no other term which might replace it. “All medical conditions are defined on various levels of abstraction—for example, structural pathology (e.g., ulcerative colitis), symptom presentation (e.g., migraine), deviance from a physiological norm (e.g. hypertension), and etiology (e.g. pneumococcal pneumonia) Mental disorders have also been defined by a variety of concepts (e.g., distress, dysfunction, dyscontrol, disadvantage, disability, inflexibility, irrationality, syndromal pattern, etiology, and statistical deviation).” Use of the term mental disorder helps “guide decisions regarding which conditions on the boundary between normality and pathology should be included in DSM-IV.” (Supra, p. xxxi)
/
The bottom line for inclusion has to do with levels of “present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” On the other hand the “syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event”; moreover, a distinction is made between “behavioral, psychological, or biological dysfunction in individuals” (which are the proper subject of diagnoses) and “deviant behavior (e.g. political, religious, or sexual and conflicts between the individual and society (which are not proper subjects of diagnosis unless the deviance or conflict is a symptom of dysfunction in the individual. (Ibid)
/
One final important point on the use of the term mental disorder is that having a mental disorder does not label the person. One is not “a schizophrenic” or “alcoholic”; rather, one has schizophrenia or an alcoholic condition.

Day 19 - Separation Anxiety Disorder

2011-02-19T22:12:00.000-08:00

According to the DSM-IV-TR separation anxiety disorder is common. Estimations average about 4% in children and young adolescents. What I think is interesting is that separation anxiety disorder is to statistically "more frequent in children of mothers with panic disorder." (DSM-IV-TR, 2000, p. 123)
/
A fundamental biblical truth about us as human beings is that we are inescapably relational. Separation Anxiety Disorder certainly reflects this fundamental aspect about us. We are created for intimacy with God and each other. While isolation would reflect one end of the spectrum of intimacy, fusion might reflect the other. Separation Anxiety Disorder would lie on the fusion and the intimacy spectrum.
/
DSM-IV-TR
Children with this mental disorder, display excessive anxiety when away from home or from those to whom they are emotionally attached.
Diagnostic criteria for 309.21 Separation Anxiety Disorder
/
A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
/
(1) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
/
(2) persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
/
(3) persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
/
(4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation
/
(5) persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
/
(6) persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
/
(7) repeated nightmares involving the theme of separation
/
(8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
/
B. The duration of the disturbance is at least 4 weeks.
/
C. The onset is before age 18 years.
/
D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
/
E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder With Agoraphobia.
/
Specify if:
/
Early Onset: if onset occurs before age 6 years
/
DSM-V
/
The DSM-V seeks to reclassify separation anxiety disorder from disorders usually first diagnosed in infancy childhood or adolescence to the anxiety disorders section. The following rationale is found at the DSM-V website:
/
To enable more consistent valid evaluations of the criterion by providing examples of worries
/
The examples in DSM-IV are restricted to untoward events happening to the child, but fail to capture untoward events to attachment figures that may lead to loss. Among those, worries about death and dying are common. The addition of the two words does not alter the meaning of the criterion. “Work” is added under 4 in order to include a relevant avoidance situation for adults with separation anxiety disorder. “without significant adults” is removed under 5 as attachment figures may not be always adults (e.g. for adults it can be partners or children).
/
B. Further secondary data analysis and/or testing is required to assess the cut off of 4 weeks
/
D. Field testing may establish the necessity of this criterion
/
E. As with the exclusion criteria for other anxiety disorders, further clinical utility testing is needed of the most appropriate strategy and phrasing
/
Specifier: Early onset before age 6 years is deleted as there is no evidence for such a specifier. Rather, in all anxiety disorders age of onset could be specified as a continuous variable.
/
Reference: Bögels SM et al. (in preparation)
/
Rationale for Severity Measure
/
The Spence Children’s Anxiety Scale-Separation Anxiety Disorder Subscale (Spence, 1997, 1998)
/
Forty-four items to assess symptoms of social anxiety disorder, generalized anxiety disorder, separation anxiety disorder, obsessive compulsive disorder, panic disorder/agoraphobia, and fears of physical injury, using a 4 point scale
/
This scale specifically assesses diagnostic criteria.
/
Criteria
/
Brief, self-report, diagnostic criteria linked if possible, adequate psychometric properties
The Spence Children’s Anxiety Scale-Separation Anxiety Disorder Subscale (Spence, 1997, 1998)
/
Below are alternative scales that have been developed and are being tested.
/
Anxiety Disorder Specific Severity Measure: Separation Anxiety Disorder
/
The following questions ask about thoughts, feelings, and behaviors that you may have had about being separated from home or from people who are important to you. Please rate how often the following statements are true for you:
/
During the past month, I have…
/
0 Never 1 Occasionally 2 Half of the Time 3 Most of the Time 4 All of the Time
/
1 felt moments of sudden terror, fear or fright when separated 0 1 2 3 4
/
2 felt anxious, worried, or nervous about being separated 0 1 2 3 4
/
3 had thoughts of bad things happening to people important to you (e.g., accidents) or bad things happening to you when separated from them (e.g., getting lost). 0 1 2 3 4
/
4 felt a racing heart, sweaty, trouble breathing, faint, or shaky when separated 0 1 2 3 4
/
5 felt tense muscles, on edge or restless, or trouble relaxing when separated 0 1 2 3 4
/
6 avoided going places where would be separated 0 1 2 3 4
/
7 when separated, left places early to go home 0 1 2 3 4
/
8 spent a lot of time preparing for how to deal with separation 0 1 2 3 4
/
9 distracted myself to avoid thinking about being separated 0 1 2 3 4
/
10 needed help to cope with being separated (e.g., alcohol or medications, superstitious objects) 0 1 2 3 4
/
Or
/
Severity Measure that could possible be used for all anxiety disorders instead of the measure above:
/
0 Never 1 Occasionally 2 Half of the Time 3 Most of the Time 4 All of the Time
/
1 felt moments of sudden terror, fear or fright 0 1 2 3 4
/
2 felt anxious, worried, or nervous 0 1 2 3 4
/
3 had thoughts of bad things happening 0 1 2 3 4
/
4 felt a racing heart, sweaty, trouble breathing, faint, or shaky 0 1 2 3 4
/
5 felt tense muscles, on edge or restless, or trouble relaxing or sleeping 0 1 2 3 4
/
6 avoided, or did not approach or enter, situations that made me anxious 0 1 2 3 4
/
7 moved away from or left situations early, remained near exits, or participated only minimally because of anxiety 0 1 2 3 4
/
8 spent a lot of time preparing for, or procrastinating about (putting off), things because of anxiety 0 1 2 3 4
/
9 distracted myself to avoid thinking about things that made me anxious 0 1 2 3 4
/
10 needed help to cope with anxiety (e.g., alcohol or medications, superstitious objects, other people) 0 1 2 3 4
/
Separation Anxiety Disorder
/
The work group proposes that this disorder be reclassified from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence to Anxiety Disorders.
/
A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
/
(1) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
/
(2) persistent and excessive worry about losing, or about possible harm befalling, major attachment figures (e.g., health, accidents, death)
/
(3) persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
/
(4) persistent reluctance or refusal to go to school, work, or elsewhere because of fear of separation
/
(5) persistent and excessive fear about or reluctance to be alone or without major attachment figures
/
(6) persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
/
(7) repeated nightmares involving the theme of separation
/
(8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
/
B. The duration of the disturbance is at least 4 weeks
/
C. The onset is before age 18 years.
/
D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
/
E. The separation anxiety is not restricted to the symptoms of another mental disorder, such as Autism Spectrum Disorder, Schizophrenia or another Psychotic Disorder and, in adolescents and adults, is not restricted to symptoms of Panic Disorder (e.g., anxiety about having panic attacks), Agoraphobia (e.g., avoidance of situations in which may become incapacitated), or Generalized Anxiety Disorder (e.g., worry about ill health of family members).

Day 18 - Enueresis

2011-02-18T08:25:00.000-08:00

Wetting the bed, similar to encopresis, tests the patience of parents to the nth degree. In my family there was some bedwetting going on when we were kids and I remember my dad becoming downright apoplectic (to be rendered unconscious from a cerebral hemorrhage, or, rendered speechless with deep, perplexing angry rage).
DSM-IV-TR
Children with this Elimination Disorder repeatedly urinate in the bed or into their clothes, usually, but not always involuntarily.
Diagnostic criteria for 307.6 Enuresis
A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional).
B. The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
C. Chronological age is at least 5 years (or equivalent developmental level).
D. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder).
Specify type:
Nocturnal Only

Diurnal Only

Nocturnal and Diurnal
DSM-V
The proposals for change in the DSM-V are as follows:
1. Confounding of Impairment/Distress and Frequency
Criterion B currently requires either a minimum frequency or subjective distress. This is not reasonable—an isolated instance of incontinence might well cause more distress than frequent enuresis for which tolerance or habituation has occurred. Conversely, it makes no sense to require distress in the presence of very frequent incontinence, when such habituation might have taken place.
Proposal: That the words “or the presence of clinically significant distress” be eliminated from Criterion B
2. Rule Out
Both the title of the disorder and Criterion D refer to enuresis as “not due to a general medical condition.” Associations with other disorders have been documented, but, with the exception of medication-induced enuresis, we have not been able to find any instances where the treatment of an associated medical condition results in relief of enuresis. This has been repeatedly documented in the case of urinary tract infections and anomalies.
Proposal: Amend the qualification in the name of the disorder and in Criterion D. Criterion D would change from: “The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder)” to “The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic, antipsychotic, or SSRI antidepressant), or to incontinence incurred as a result of polyuria or during loss of consciousness.”
3. Subtypes
Nocturnal and diurnal enuresis, while they often co-occur, are significantly different in their manifestations and treatment.
Proposal: That the existing subtypes be retained.
4. Text
Although there has been little novel research in mechanisms, the genetics of enuresis has been widely studied since DSM-IV.
Proposal: That the text be amended to include mention of advances in the genetics of enuresis.
Enuresis (Not Due to a General Medical Condition)
A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional).
B. The voiding of urine into bed or clothes occurs at a frequency of twice a week for at least 3 consecutive months.
C. Chronological age is at least 5 years (or equivalent developmental level).
D. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic, antipsychotic, or SSRI antidepressant) or to incontinence incurred as a result of polyuria or during loss of consciousness.
Specify Type
Nocturnal Only: passage of urine only during night-time sleep
Diurnal Only: passage of urine during waking hours
Nocturnal and Diurnal: a combination of the two subtypes above

Day 17 - Encopresis

2011-02-17T20:01:00.000-08:00

This must be one of the more exasperating disorders for parents to contend with. The yuck factor of this disorder is enormeous. Parents with children with this disorder truly deserve a medal for their saintliness in loving and caring for their child.

DSM-IV-TRChildren with this Elimination Disorder repeatedly pass feces into inappropriate places either intentionally or involuntarily.
Diagnostic criteria for Encopresis

A. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional.

B. At least one such event a month for at least 3 months.

C. Chronological age is at least 4 years (or equivalent developmental level).

D. The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.

Code as follows:

787.6 With Constipation and Overflow Incontinence

307.7 Without Constipation and Overflow Incontinence
DSM-V
No proposal for change as yet.

Day 16 - Tourette's Disorder

2011-02-16T10:26:00.000-08:00

With Tourette’s Disorder I remember a story my son told me about a boy in his class when my son was about 10 years order. The boy had cussed the teacher out and went to the principal. “He didn’t get in trouble though” my son told me “because he has Tourette’s”. Whether the diagnosis was accurate or not, I would not know.
I know now that the reason this child didn’t get in trouble was because his bad conduct was the product of a mental disorder rather than social maladjustment. See Day 2 on Learning Disabilities where the distinction is made between these items: “"Learning disabilities" are distinct from "emotional disturbances" and "social maladjustment" in the laws relating to the education of our children.”
DSM-IV-TR
This Tic Disorder is diagnosed when BOTH motor AND vocal tics ("sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization") are experienced persistently. (Named for Gilles de la Tourette)
Diagnostic criteria for 307.23 Tourette's Disorder
A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.)
B. The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
C. The onset is before age 18 years.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).
DSM-V
Tourette’s Disorder
The work group is recommending that this disorder be classified as a Neurodevelopmental Disorder or another similar grouping of disorders.
A. Both multiple motor tics and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.)
B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
C. The onset is before age 18 years.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., cocaine) or a general medical condition (e.g., stroke, Huntington’s disease, postviral encephalitis)

Day 15 - Chronic Motor or Vocal Tic Disorder

2011-02-15T07:31:00.000-08:00

DSM-IV-TR
This Tic Disorder is diagnosed when either motor or vocal (but not both – see Tourette’s) tics (“sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization”) are experienced persistently.
Diagnostic criteria for 307.22 Chronic Motor or Vocal Tic Disorder
A. Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations), but not both, have been present at some time during the illness.
B. The tics occur many times a day nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
C. The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
D. The onset is before age 18 years.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington’s disease or postviral encephalitis).
F. Criteria have never been met for Tourette’s Disorder.
Tics are defined as “sudden, spontaneous, involuntary, repetitive, brief contractions of muscles or groups of muscles which may produce observable movement or vocal utterance. They occur in normal individuals, but may also be associated with physical or mental illness.”
DSM-V
The work group is recommending that this disorder be classified as a Neurodevelopmental Disorder or another similar grouping of disorders.
A. Single or multiple motor tics or vocal tics, but not both, have been present at some time during the illness. (A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.)
B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
C. The onset is before age 18 years.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., cocaine) or a general medical condition (e.g., stroke, Huntington’s disease, postviral encephalitis)
E. Criteria have never been met for Tourette's disorder.
Specify if:
Motor tics only

Vocal tics only
The rationale for the proposed changes in the DSM-V is as follows:
Criterion A: The definition of a tic has been made consistent with the other tic disorders.
Criterion B: The changes to Criterion B for Chronic Motor or Vocal Tic Disorder are identical to those for Tourette’s Disorder.
Criterion D: The use of stimulant medication as an example of a substance induced movement disorder is not consistent with the evidence base and has been removed. Other examples have been added to assist with diagnosis.
Reference: Walkup JT et al: Tic Disorders: Some Key Issues for DSM-V. Depression & Anxiety, 2010; 27: 600-610 found at
http://www.dsm5.org/Documents/Anxiety,%20OC%20Spectrum,%20PTSD,%20and%20DD%20Group/OC%20Spectrum%20Disorders/Walkup_Tic.pdf

Day 14 - Rumination Disorder

2011-02-14T06:50:00.000-08:00

DSM-IV-TR
Infants and children with this Eating Disorder repeatedly bring up partially digested stomach contents to chew again.
Diagnostic criteria for 307.53 Rumination Disorder (cautionary statement)

A. Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning.
B. The behavior is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).
C. The behavior does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. If the symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental Disorders, they are sufficiently severe to warrant independent clinical attention.
DSM-V
The work group has proposed that this diagnosis be reclassified from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence to Eating Disorders
DSM-5 Proposed Diagnostic Criteria for Rumination Disorder

A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
B. There is no evidence that an associated gastrointestinal or other general medical condition (for example, gastroesophageal reflux) is sufficient to account alone for the repeated regurgitation.
C. The eating disturbance does not occur exclusively during the course of Anorexia Nervosa, Bulimia Nervosa, or Binge Eating Disorder, or Avoidant/Restrictive Food Intake Disorder.
D. If the symptoms occur in the context of another mental disorder (for example, Mental Retardation or a Pervasive Developmental Disorder), they are sufficiently severe to warrant independent clinical attention.

Day 13 - Pica

2011-02-13T21:10:00.000-08:00

DSM-IV-TR

Children with this Eating Disorder eat non-food materials.
Diagnostic criteria for 307.52 Pica
A. Persistent eating of nonnutritive substances for a period of at least 1 month.
B. The eating of nonnutritive substances is inappropriate to the developmental level.
C. The eating behavior is not part of a culturally sanctioned practice.
D. If the eating behavior occurs exclusively during the course of another mental disorder (e.g., Mental Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufficiently severe to warrant independent clinical attention.
DSM-V
DSM-5 Proposed Diagnostic Criteria for Pica
Pica is recommended for removal from the cluster of disorders first diagnosed in infancy and early childhood because it occurs across the age range.
A. Persistent eating of non-nutritive, non-food substances over a period of at least 1 month.
B. The eating of non-nutritive, non-food substances is inappropriate to the developmental level of the individual (a minimum age of 2 years is suggested for diagnosis).
C. The eating behavior is not part of a culturally sanctioned practice.
D. If the eating behavior occurs in the context of another mental disorder (for example, Mental Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufficiently severe to warrant independent clinical attention

Day 12 - Feeding Disorder of Infancy and Early Childhood

2011-02-12T16:50:00.000-08:00

DSM-IV-TR
This Eating Disorder may be diagnosed when an infant or very young child fails to eat and either loses weight or fails to gain weight.

Diagnostic criteria for 307.59 Feeding Disorder of Infancy or Early Childhood:

A. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month.

B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).

C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food.

D. The onset is before age 6 years.
DSM-V
The work group has proposed that this diagnosis be reclassified from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence to Eating Disorders, and renamed Avoidant/Restrictive Food Intake Disorder.
DSM-5 Proposed Diagnostic Criteria for Avoidant/Restrictive Food Intake Disorder
A: Eating or feeding disturbance (including but not limited to apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; or concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following:

1. Significant weight loss (or failure to gain weight or faltering growth in children);

2. Significant nutritional deficiency;

3. Dependence on enteral feeding;

4. Marked interference with psychosocial functioning.

B. There is no evidence that lack of available food or an associated culturally sanctioned practice is sufficient to account alone for the disorder.

C. The eating disturbance does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa, and there is no evidence of a disturbance in the way of which one's body weight or shape is experienced.

D. If the eating disturbance occurs in the context of a medical condition or another mental disorder, it is sufficiently severe to warrant independent clinical attention.

(Text will include description of three main subtypes: individuals who do not eat enough/show little interest in feeding; individuals who only accept a limited diet in relation to sensory features; and, individuals whose food refusal is related to aversive experience.)
Rationale for proposed changes:
It is recommended that the name of this disorder, previously called Feeding Disorder of Infancy or Early Childhood, be altered to reflect the fact that there are a number of types of presentation that occur across the age range rather than being restricted to infancy and early childhood. These presentations are characterized by restriction or avoidance of food intake. It is suggested that the accompanying text should include description of three main subtypes identified in the existing literature: individuals who do not eat enough/show little interest in feeding or eating; individuals who accept only a limited diet in relation to sensory features; and, individuals whose food refusal is related to aversive experience.
The current criteria for Feeding Disorder of Infancy or Early Childhood have been criticized for failing to capture many very young children presenting with feeding difficulties. The alternative system DC:0-3R has sometimes been used. This system includes six subtypes of feeding behavior disorder. The proposed DSM-5 criteria with accompanying text map onto three of the DC:0-3R subtypes. The three excluded are: feeding disorder secondary to a medical condition (such a disturbance would not fulfill criteria for a mental disorder); feeding disorder of state regulation (a disturbance in infant regulation, similar to disturbances in sleep or crying); and feeding disorder of parent-infant reciprocity (currently classifiable under a V code).
Level of change: Moderate.

References: Literature review (Bryant-Waugh et al., in press).

Criterion A:

This criterion has been modified to take account of the fact that many young children fail to meet current criteria because of the primary focus on failure to gain weight or weight loss, as well as the fact that certain features of presentation are also commonly seen in older individuals. ‘Feeding disturbance’ has been replaced by ‘Eating or feeding disturbance’ to take account of the wider age range. ‘Eat adequately’ has been replaced by wording better describing the nature of the disturbance; previously this was only referred to as resulting in weight loss/failure to gain weight. The phrase ‘over at least 1 month’ has been removed as the features specified as resulting from food avoidance or restriction, in themselves, imply persistence of the disturbance. Faltering growth, nutritional deficiency, dependency on enteral feeding, and interference with psychosocial functioning have been added as these are common clinically significant consequences of such eating or feeding disturbances.

Level of change: Moderate.

References: Literature review (Bryant-Waugh et al., in press).

Criterion B:

Reworded from DSM-IV Criterion B to reflect evidence suggesting it can be impractical and difficult to separate out ‘organic’ and ‘non-organic’ components. The phrase “not due to lack of available food” DSM-IV Criterion C has been added here, and the statement that there should be no evidence that a culturally sanctioned practice might account alone for the disorder has been added, to clarify that the criteria are not, for example, intended to include weight loss resulting from religious fasting.

Level of change: Clarification.

References: Literature review (Bryant-Waugh et al., in press).

Criterion C:

Added as proposed criteria are intended across the age range, and it is necessary to make a distinction between restricted food intake in the context of eating disorders where there are weight/shape concerns and restricted food intake in the absence of such concerns.

Level of change: Clarification.

References: Literature review (Bryant-Waugh et al., in press).

Criterion D:

Amended to retain consistency with criteria for other eating and feeding disorders.

Level of change: Clarification.

References: (none – based on Work Group expert consensus)

Criterion E:

The requirement that onset should occur before the age of 6 years has been removed, consistent with the discussion above.

Level of change: Moderate.

References: Literature review (Bryant-Waugh et al., in press)

Severity Criteria:

Severity of medical or psychosocial problems associated or potentially associated with the disorder.

0 No symptoms of the disorder

1 Subthreshold: Some symptoms of the disorder are present, but diagnostic criteria for the disorder are not fully met.

The individual presents with one or more of the following:

• Some weight loss (or failure to achieve expected weight gain in children)

• Sub-optimal dietary intake in terms of nutritional content but not resutling in medical complications

• Dependence on oral nutritional supplements

• Some interference with psycholosocial functioning

2 Diagnostic criteria are fully met, and the disorder is mild.

The individual presents with no more than ONE of the following:

• Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)

• Significant nutritional deficiency

• Dependence on enteral feeding (to address weight loss and/or nutritional deficiency)

• Marked interference with some aspects of psychosocial functioning

3 Diagnostic criteria are fully met, and the disorder is moderate.

The individual presents with either of the following:

• Significant weight loss OR nutritionally inadequate oral intake associated with significant medical complications OR dependence on enteral feeding

• Marked interference with psychosocial functioning in several areas

4 Diagnostic criteria are fully met, and the disorder is severe.

The individual presents with both the following:

• Significant weight loss AND nutritionally inadequate oral intake associated with significant medical complications OR dependence on enteral feeding

• Marked interference with psychosocial functioning in most areas

Day 11 - Oppositional Defiant Disorder (ODD)

2011-02-11T06:27:00.000-08:00

"[N]egativistic and defiant behaviors [associated with oppositional defiant disorder] are expressed by persistent stubbornness, resistance two directions, and unwillingness to compromise, giving in, or negotiate with adults or peers. Defiance may also include deliberate or persistent testing of limits, usually by ignoring others, arguing, and failing to accept blame for misdeeds. Hostility can be directed at adults or peers in a shown by deliberately annoying others or by verbal aggression (usually without the more serious physical aggression seen and conduct disorder). Manifestations of the disorder are almost invariably present in the home setting, but may not be evident at school or in the community. Symptoms of the disorder are typically more evident in interactions with adults or peers whom the individual knows well, and thus may not be apparent during clinical examination. Usually individuals with this disorder do not regard themselves as oppositional or defiant, but justify their behavior as a response to unreasonable demands or circumstances." (American Psychiatric Association [DSM-IV-TR], 2000, p. 100)
Diagnostic criteria for 313.81 Oppositional Defiant Disorder
A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
(1) often loses temper

(2) often argues with adults

(3) often actively defies or refuses to comply with adults' requests or rules

(4) often deliberately annoys people

(5) often blames others for his or her mistakes or misbehavior

(6) is often touchy or easily annoyed by others

(7) is often angry and resentful

(8) is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
DSM-V
In reviewing the DSM-V's revision board's rationale for changes they indicate after reviewing the published literature from 1995-2008 "it appeared that the DSM-IV criteria had been fairly successful for designating a group of children who were impaired and who were at risk for future problems in adjustment, even controlling for common co-morbid conditions. Further, its presence added to the predictive utility of other diagnoses." (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=106#)
Revision team is currently recommending removing the exclusion criteria for conduct disorder, organizing the diagnostic criteria into emotional and behavioral clusters because distinguishing between the two is helpful in diagnosis and treatment. They are also recommending the development of a severity index and they are considering criteria that will replace the DSM-IV-TR's they "often " with objective and standard definitions of frequency for ODD symptoms threshold.
“I. Initial Literature Review
To guide decisions on the degree and types of changes that may be needed for the diagnostic criteria for Oppositional Defiant Disorder in the DSM-V, a comprehensive literature review was conducted by Dr. Deborah Drabick of Temple University, a advisor to the ADHD and Disruptive Behavior Disorders Workgroup, to evaluate the utility of the DSM-IV definition of the disorder. The review included published manuscripts from 1995-2008 that used DSM-IV definitions of ODD. However, given the importance of considering prospective and epidemiological studies, articles that used DSM-III-R criteria were included, if these studies were prospective investigations (most were epidemiological studies). The results of this review were presented to the workgroup on November 3rd, 2008. The main questions addressed by the review and the main findings are summarized here.
a. Does the diagnosis of ODD have independent predictive validity when comorbid disorders are controlled?
34 studies reviewed suggested that the DSM-IV definition of ODD predicted numerous important clinical outcomes controlling for ADHD, Conduct Disorder, anxiety disorders, depressive disorders, and substance abuse disorders
b. Does the diagnosis of ODD add to the predictive validity of other comorbid disorders?
38 studies reviewed suggested that the DSM-IV criteria for ODD added to the prediction of numerous important clinical outcomes in youths with ADHD, Conduct Disorder, anxiety disorders, depressive disorders, and substance abuse disorders.
c. Would requiring a pervasiveness criterion improve the predictive validity of ODD?
The available research did not directly address this question. That is, most studies compared different informants (e.g., parent and teacher) and did not directly assess whether the ODD symptoms were situational (e.g., at home or home or school only) or pervasive. 7 studies reviewed suggested that even when ODD symptoms are reported by parents only, they are associated with significant impairment. However, when they are reported by multiple informants, the impairment is greater.
d. Do the emotional (e.g., spiteful, angry) vs. behavioral (e.g., argues, defies) symptoms of ODD show different predictive associations with important outcomes?
5 studies were reviewed suggesting that the emotional and behavioral symptoms were highly intercorrelated and both symptom domains predicted disruptive behavior disorders outcomes (e.g., ADHD, Conduct Disorder). However, the emotional symptoms independently predicted mood and anxiety disorders.
II. Recommendation 1. Do not make major changes to the symptoms or structure of the ODD criteria.
Based on the results of this review, it appeared that the DSM-IV criteria had been fairly successful for designating a group of children who were impaired and who were at risk for future problems in adjustment, even controlling for common co-morbid conditions. Further, its presence added to the predictive utility of other diagnoses.
III. Recommendation 2. Remove exclusionary criteria for Conduct Disorder.
The DSM-IV criteria for ODD allowed for the diagnosis only if the criteria for Conduct Disorder are not met. In the review of the literature, ODD predicted the following outcomes, controlling for Conduct Disorder (either alone or with other comorbidities):
a. Concurrent studies: injuries/maltreatment (n=1); anxiety/depression (n= 2); substance use (n=4); ADHD (n=1); delinquency or greater symptom severity of Conduct Disorder (n=2); family impairment (n=2); peer difficulties (n=1); treatment utilization (n=1)
b. Longitudinal studies: anxiety/depression (n= 1); delinquency or Conduct Disorder at subsequent time points (n=3); truancy (n=1); impairment (n=1).
IV. Recommendation 3. Organize symptoms in the criteria for ODD to distinguish emotional and behavioral symptoms.
The review suggested that the symptoms of ODD were highly intercorrelated and that all of them contributed to the prediction of disruptive behavior disorders outcomes. However, the emotional symptoms also contributed uniquely to the prediction of emotional disorders. Also, the workgroup viewed it important to highlight the fact that, although the emotional symptoms of the disorder are not reflected in the name of the disorder, the criteria consist of both emotional and behavioral indicators. Finally, one additional study that emerged after this review supported the importance of separating the behavioral and emotional symptoms but also supported separating the spiteful/vindictive symptom from the other behavioral symptoms
Stringaris, A. & Goodman, R. (2009). Longitudinal outcome of youth oppositionality: Irritable, headstrong, and hurtful behaviors have distinctive predictions. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 404-412.
V. Recommendation 4. Develop a severity index based on the cross-situation pervasiveness of the symptoms.
The review suggested that youth reported as meeting ODD criteria by parents only were impaired and likely warrant a diagnosis; however, those reported as meeting criteria by both parents and teachers seemed to show even greater impairment. These results were suggestive that cross-situationality should not be a criteria for the disorder but may be a useful index of severity.
To test this possibility more directly, Dr. Eric Youngstrom of the University of North Carolina Chapel Hill, conducted secondary data analyses on 802 youths, ages 5 to 18, seeking outpatient mental health services. A comprehensive summary of these analyses are provided in Appendix B. To summarize the main findings supporting the proposed severity index:
a. The KSADS interview was used to separate youth with an ODD diagnosis into those impaired in three different contexts – with peers, at home, with the family, and at school.
b. Of the cases meeting DSM-IV criteria for ODD (n=311), 96% reported impairment at home, 85% reported impairment at school, 67% reported impairment with peers. When looking at cross-setting impairment, 11% of ODD cases had impairment only at home, 27% had impairment in at least one other setting besides home, and 62% had impairment reported in all three settings. The number of cases with single-setting impairment that was not in the home was negligible.
c. Those youth showing impairment due to ODD symptoms only at home did show significant levels of externalizing behaviors and other signs of disability but less so than those who showed impairment in one other setting. Further, those who were impaired in two settings showed lower levels of externalizing behaviors and lower scores on other indices of disability than those who were impaired by ODD symptoms in more than two settings.
d. Regression analyses indicated that impairment across settings explained significant variance in the various measures of impairment and functioning, even after controlling for the number of ODD symptoms.
VI. Under consideration: Provide objective and standard definitions of frequency for ODD symptom threshold.
The DSM-IV criteria for ODD define each symptom as occurring “often” (e.g., often loses temper). In the text, the frequency threshold is defined as follows:
“the behaviors must occur more frequently than is typically observed in individuals of comparable age and developmental level and must lead to significant impairment in social, academic, or occupational functioning” (p. 100).
The workgroup is currently reviewing secondary data analyses from various clinic and community samples of children and adolescents of various age groups to determine if a more objective frequency criteria can be used to define symptom thresholds.
a. Advantages - such objective criteria could provide clinician with guidance from research as to what level of these behaviors, which occur to some degree in non-disordered individuals, is indicative of a more pathological condition.
a. Disadvantages - such objective criteria change the wording of symptoms that have been evaluated extensively by research and have proven indicative of an impairing condition; further, it may be impossible to find objective thresholds that generalize across age, gender, and cultural groups and such decisions may be best left to clinicians.”
The criteria under the DSM-V as currently proposed are as follows:

A. A persistent pattern of angry and irritable mood along with defiant and vindictive behavior as evidenced by four (or more) of the following symptoms being displayed with one or more persons other than siblings.

Angry/Irritable Mood
1. Loses temper
2. Is touchy or easily annoyed by others.
3. Is angry and resentful
Defiant/Headstrong Behavior
4. Argues with adults
5. Actively defies or refuses to comply with adults’ request or rules
6. Deliberately annoys people
7. Blames others for his or her mistakes or misbehavior
Vindictiveness
8. Has been spiteful or vindictive at least twice within the past six months
B. (NOTE: UNDER CONSIDERATION) The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic to determine if they should be considered a symptom of the disorder. For children under 5 years of age, the behavior must occur on most days for a period of at least six months unless otherwise noted (see symptom #8). For individuals 5 years or older, the behavior must occur at least once per week for at least six months, unless otherwise noted (see symptom #8). While these frequency criteria provide a minimal level of frequency to define symptoms, other factors should also be considered such as whether the frequency and intensity of the behaviors are non-normative given the person’s developmental level, gender, and culture.
C. The disturbance in behavior causes clinically significant impairment in social, educational, or vocational activities.
D. The behaviors may be confined to only one setting or in more severe cases present in multiple settings.

Day 10 - Conduct Disorder

2011-02-10T06:55:00.000-08:00

This mental disorder may be diagnosed when a child seriously misbehaves with aggressive or nonaggressive behaviors against people, animals or property that may be characterized as belligerent, destructive, threatening, physically cruel, deceitful, disobedient, or dishonest. This may include stealing, intentional injury, and forced sexual activity.
Diagnostic criteria for 312.8 Conduct Disorder (new code as of 10/01/96: 312.xx)
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
Aggression to people and animals
(1) often bullies, threatens, or intimidates others

(2) often initiates physical fights

(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)

(4) has been physically cruel to people

(5) has been physically cruel to animals

(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)

(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in fire setting with the intention of causing serious damage

(9) has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
(10) has broken into someone else's house, building, or car

(11) often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)

(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before age 13 years

(14) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)

(15) is often truant from school, beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
Specify type based on age at onset:
Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years (new code as of 10/01/96: 312.81)
Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years (new code as of 10/01/96: 312.82)
(new code as of 10/01/96: 312.89 Unspecified Onset)
Specify severity:
Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between "mild" and "severe"
Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others.
Note: Neuro-psycho-biological research indicates that the etiology behind the development of the sociopath is similar to the predominate theory for most other mental disorders at this time: “the result of a heritable neurodevelopmental difference that can be either slightly compensated for, or made much worse, by child-rearing or cultural factors.” (Stout, Martha. Sociopath Next Door : The Ruthless Versus the Rest of Us.
Westminster, MD, USA: Broadway, 2005. p 125).
Stout’s take on the sociopath is really enlightening. She points out that the sociopath’s lack of conscience is tragic enough, however, the real issue goes to the person’s lack of “the ability to have and to appreciate real (noncalculated) emotional experience, and therefore to connect with other people within real (noncalculated) relationships. To state the situation concisely, and maybe a little too clearly for comfort: Not to have a moral sense flags an even more profound condition, as does the possession of conscience, because conscience never exists without the ability to love, and sociopathy is ultimately based in lovelessness. A sociopath is someone who “fails to conform to social norms,” or who is “never monogamous,” or who “fails to honor financial obligations,” for the straightforward reason that an obligation of any kind is something one feels toward beings, or toward a group of beings, who matter emotionally. And to a sociopath, we simply do not matter.” (Ibid, p. R26).
DSM-V
The DSM-V recommends no changes to the DSM-IV-TR does recommend adding a specifier: "Callous and Unemotional Traits in Conduct Disorder".
The criteria for the callous and unemotional traits and conduct disorder specifier are as follows:
1. Meets full criteria for Conduct Disorder.
2. Shows 2 or more of the following characteristics persistently over at least 12 months and in more than one relationship or setting. The clinician should consider multiple sources of information to determine the presence of these traits, such as whether the person self-reports them as being characteristic of him or herself and if they are reported by others (e.g., parents, other family members, teachers, peers) who have known the person for significant periods of time.
1. Lack of Remorse or Guilt: Does not feel bad or guilty when he/she does something wrong (except if expressing remorse when caught and/or facing punishment).
2. Callous-Lack of Empathy: Disregards and is unconcerned about the feelings of others.
3. Unconcerned about Performance: Does not show concern about poor/problematic performance at school, work, or in other important activities.
4. Shallow or Deficient Affect: Does not express feelings or show emotions to others, except in ways that seem shallow or superficial (e.g., emotions are not consistent with actions; can turn emotions “on” or “off” quickly) or when they are used for gain (e.g., to manipulate or intimidate others).

Day 9 - Attention-Deficit/Hyperactivity Disorder (ADHD)

2011-02-09T05:57:00.000-08:00

DSM-IV-TR
When problems with attention, hyperactivity, and impulsiveness develop in childhood and persist, in some cases into adulthood, this mental disorder may be diagnosed.
Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder
A. Either (1) or (2):
(1) inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively

Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder).
Code based on type:
314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months
314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.
DSM-V
One of the first things that jumps out at ya in reading the following proposed language for ADHD in the DSM-V is the official importance placed upon “teachers” in diagnosis. The DSM-V addresses this issue in a pdf found at

http://www.dsm5.org/Proposed%20Revision%20Attachments/APA%20Options%20for%20ADHD.pdf
which reads as follows:
“F. Ascertainment of Cross-situationality
Option 1. Existing, i.e., requires cross-situationality, and does not specify ascertainment procedures for un-witnessed behavior.
PRO
Ensures that the diagnosis is not based on situation-specific behavior, which might not
differentiate between normality and abnormality.
CON
Parental report of school-based behaviors is not always accurate and can be based on
hearsay or supposition.
Option 2. Require that cross-situationality be based on direct report from teacher, employer, orsignificant other to the current informant or clinician.
PRO

Improves quality of information on which diagnosis is based and against which to measure treatment effect.

CONS

a. Situations in which non-caretaker third-party information is not available are likely to

exist.
b. Might be very difficult for adult ADHD.”
The DSM-V criteria for diagnosing ADHD is as follows:
The disorder consists of a characteristic pattern of behavior and cognitive functioning that is present in different settings where it gives rise to social and educational or work performance difficulties. The manifestations of the disorder and the difficulties that they cause are subject to gradual change being typically more marked during times when the person is studying or working and lessening during vacation.
Superimposed on these short-term changes are trends that may signal some deterioration or improvement with many symptoms becoming less common in adolescence. Although irritable outbursts are common, abrupt changes in mood lasting for days or longer are not characteristic of ADHD and will usually be a manifestation of some other distinct disorder.
In children and young adolescents, the diagnosis should be based on information obtained from parents and teachers. When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child’s behavior and performance at school. Examination of the patient in the clinician’s office may or may not be informative. For older adolescents and adults, confirmatory observations by third parties should be obtained whenever possible.
A. Either (1) and/or (2).
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: for older adolescents and adults (ages 17 and older), only 4 symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.
(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (for example, overlooks or misses details, work is inaccurate).
(b) Often has difficulty sustaining attention in tasks or play activities (for example, has difficulty remaining focused during lectures, conversations, or reading lengthy writings).
(c) Often does not seem to listen when spoken to directly (mind seems elsewhere, even in the absence of any obvious distraction).
(d) Frequently does not follow through on instructions (starts tasks but quickly loses focus and is easily sidetracked, fails to finish schoolwork, household chores, or tasks in the workplace).
(e) Often has difficulty organizing tasks and activities. (Has difficulty managing sequential tasks and keeping materials and belongings in order. Work is messy and disorganized. Has poor time management and tends to fail to meet deadlines.)
(f) Characteristically avoids, seems to dislike, and is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework or, for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers).
(g) Frequently loses objects necessary for tasks or activities (e.g., school assignments, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones).
(h) Is often easily distracted by extraneous stimuli. (for older adolescents and adults may include unrelated thoughts.).
(i) Is often forgetful in daily activities, chores, and running errands (for older adolescents and adults, returning calls, paying bills, and keeping appointments).
2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: for older adolescents and adults (ages 17 and older), only 4 symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.
(a) Often fidgets or taps hands or feet or squirms in seat.
(b) Is often restless during activities when others are seated (may leave his or her place in the classroom, office or other workplace, or in other situations that require remaining seated).
(c) Often runs about or climbs on furniture and moves excessively in inappropriate situations. In adolescents or adults, may be limited to feeling restless or confined.
(d) Is often excessively loud or noisy during play, leisure, or social activities.
(e) Is often “on the go,” acting as if “driven by a motor.” Is uncomfortable being still for an extended time, as in restaurants, meetings, etc. Seen by others as being restless and difficult to keep up with.
(f) Often talks excessively.
(g) Often blurts out an answer before a question has been completed. Older adolescents or adults may complete people’s sentences and “jump the gun” in conversations.
(h) Has difficulty waiting his or her turn or waiting in line.
(i) Often interrupts or intrudes on others (frequently butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing.
(j) Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.
(k) Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.
(l) Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.
(m) Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).
B. Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12.
C. The symptoms are apparent in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities).
D. There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Specify Based on Current Presentation
Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for the past 6 months.
Predominately Inattentive Presentation: If Criterion A1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met and 3 or more symptoms from Criterion A2 have been present for the past 6 months.
Predominately Hyperactive/Impulsive Presentation: If Criterion A2 (Hyperactivity-Impulsivity) is met and Criterion A1 (Inattention) is not met for the past 6 months.
Inattentive Presentation (Restrictive): If Criterion A1 (Inattention) is met but no more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have been present for the past 6 months.

Day 8 - Rett's Disorder

2011-02-08T06:40:00.000-08:00

Rett's Disorder, DSM-IV-TR
Children with this pervasive developmental disorder appear to develop normally at first, but their head growth slows, they lose social "engagement" and hand skills, and they develop stereotyped movements of the hands and poorly coordinated gait or trunk movements. There is also psychomotor retardation and impairment of language development.
Diagnostic criteria for 299.80 Rett's Disorder
A. All of the following:
(1) apparently normal prenatal and perinatal development
(2) apparently normal psychomotor development through the first 5 months after birth
(3) normal head circumference at birth
B. Onset of all of the following after the period of normal development:
(1) deceleration of head growth between ages 5 and 48 months
(2) loss of previously acquired purposeful hand skills between ages 5 and 30 months with the subsequent development of stereotyped hand movements (e.g., hand-wringing or hand washing)
(3) loss of social engagement early in the course (although often social interaction develops later)
(4) appearance of poorly coordinated gait or trunk movements
(5) severely impaired expressive and receptive language development with severe psychomotor retardation

DSM-V

The DSM-V proposes removing Rett’s Disorder from DSM. The rationale for removal is as follows:

“Rett's Disorder patients often have autistic symptoms for only a brief period during early childhood, so inclusion in the autism spectrum is not appropriate for most individuals. Like other disorders in the DSM, Autism Spectrum Disorder (ASD) is defined by specific sets of behaviors and not by etiology (at present) so inclusion of a specific etiologic entity, such as Rett's Disorder is inappropriate. To ensure that etiology is indicated, where known, clinicians will be encouraged to utilize the specifier: “Associated with Known Medical Disorder or Genetic Condition.” In this way, it will be possible to indicate that a child with ASD has Fragile X syndrome, Tuberous Sclerosis, 22q deletion, etc.”

Day 7 - Childhood Disintegrative Disorder

2011-02-07T06:42:00.000-08:00

Children with this pervasive developmental disorder appear to develop normally for the first two years of life, but then lose skills in areas such as language, play, and bowel control and manifest impaired social interaction and communication associated with "restrictive, repetitive, stereotyped" behaviors.
Diagnostic criteria for 299.10 Childhood Disintegrative Disorder
A. Apparently normal development for at least the first 2 years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior.
B. Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following areas:
(1) expressive or receptive language
(2) social skills or adaptive behavior
(3) bowel or bladder control

(4) play
(5) motor skills
C. Abnormalities of functioning in at least two of the following areas:
(1) qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity)
(2) qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make-believe play)
(3) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, including motor stereotypies and mannerisms
D. The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by Schizophrenia.
DSM-V
The DSM-V proposed subsuming this disorder into the newly proposed autistic spectrum disorder and be viewed as regressive autistic spectrum disorder. The reasons for this boil down to the fact that CDD is extremely rare 2 in 100,000 children and their has been no demonstrable prognostic benefit afforded by leaving it as its own diagnostic. “The possibility that this diagnosis is being used in the face of what could represent treatable neurological conditions is especially concerning.”

Day 6 - Autistic Spectrum Disorder (ASD)

2011-02-06T08:48:00.000-08:00

In children with this Pervasive Developmental Disorder there is substantial delay in communication and social interaction associated with development of "restricted, repetitive and stereotyped" behavior, interests, and activities.
Diagnostic criteria for 299.00 Autistic Disorder
A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
(1) qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(2) qualitative impairments in communication as manifested by at least one of the following:
(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
(3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

(b) apparently inflexible adherence to specific, nonfunctional routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
(d) persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
C. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.
DSM-V
The DSM-V as currently proposed relates the following rationale for changing the DSM-IV-TR on this and other disorders in the pervasive developmental disorders section of the manual:
“New name for category, autism spectrum disorder, which includes autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.
Differentiation of autism spectrum disorder from typical development and other "nonspectrum" disorders is done reliably and with validity; while distinctions among disorders have been found to be inconsistent over time, variable across sites and often associated with severity, language level or intelligence rather than features of the disorder.
Because autism is defined by a common set of behaviors, it is best represented as a single diagnostic category that is adapted to the individual’s clinical presentation by inclusion of clinical specifiers (e.g., severity, verbal abilities and others) and associated features (e.g., known genetic disorders, epilepsy, intellectual disability and others.) A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation; previously, the criteria were equivalent to trying to “cleave meatloaf at the joints”.
Three domains become two:

1) Social/communication deficits

2) Fixated interests and repetitive behaviors
Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities.
Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis.
Requiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivity.
Providing examples for subdomains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domains.
Decisions based on literature review, expert consultations, and workgroup discussions confirmed by the results of secondary analyses of data from CPEA and STAART,
University of Michigan, Simons Simplex Collection databases.
Several social/communication criteria were merged and streamlined to clarify diagnostic requirements.
In DSM-IV, multiple criteria assess same symptom and therefore carry excessive weight in making diagnosis.
Merging social and communication domains requires new approaches to criteria.
Secondary data analyses were conducted on social/communication symptoms to determine most sensitive and specific clusters of symptoms and criteria descriptions for a range of ages and language levels.
Requiring two symptom manifestations for repetitive behavior and fixated interests improves specificity of the criterion without significant decrements in sensitivity. The necessity for multiple sources of information including skilled clinical observation and reports from parents/caregivers/teachers is highlighted by the need to meet a higher proportion of criteria.
The presence, via clinical observation and caregiver report, of a history of fixated interests, routines or rituals and repetitive behaviors considerably increases the stability of autism spectrum diagnoses over time and the differentiation between ASD and other disorders.
Reorganization of subdomains increases clarity and continues to provide adequate sensitivity while improving specificity through provision of examples from different age ranges and language levels.
Unusual sensory behaviors are explicitly included within a sudomain of stereotyped motor and verbal behaviors, expanding the specfication of different behaviors that can be coded within this domain, with examples particularly relevant for younger children

Autism spectrum disorder is a neurodevelopmental disorder and must be present from infancy or early childhood, but may not be detected until later because of minimal social demands and support from parents or caregivers in early years.
This last point that ASD “is a neurodevelopmental disorder” is very interesting. “Many studies have linked autism with amygdala dysfunction. The lack of empathy often shown by autistic individuals has associated with amygdala (Blair, 2008). Neural activity in the amygdala has also been strongly linked to depression (Northoff, 2007) and bipolar disorder (Phillips & Vieta, 2007). There is very strong evidence linking post-dramatic stress disorder with amygdala responses (Brewin, 2008)”. (From Ipad App, the 3d Brain, http://www.dnalc.org/)
Autism Spectrum Disorder
Must meet criteria A, B, C, and D:
A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:
1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,
2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.
3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people
B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:
1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).

Social and Emotional Reciprocity

2011-02-06T08:17:00.000-08:00

This morning I read about autistic disorders in the DSM. One of the most striking symptom of one who has this disorder is a lack of "social and emotional reciprocity".

When studying the mental disorders I cannot help but to think about my own life. The importance of social and emotional reciprocity in a healthy person's life (read in my own life) can hardly be overestimated. Reciprocity simply means give and take of life. It is important to give oneself socially and emotionally to others and at the same time it is equally important to receive the social and emotional gifts or extensions of other people.

Recently I read chapter 2 of Irvin Yalom's insightful book, "Theory and Practice of Group Psychotherapy, 5th Ed." Describing the importance of interpersonal relationships, Yalom draws upon the work of Harry Stack Sullivan for the proposition that one's identity is inextricably intertwined with the total matrix of one's relationships with other people. Quoting Sullivan, Yalom recounts:

"The self may be said to be made up of reflected appraisals. If these were chiefly derogatory as in the case of an unwanted child was never loved, of a child who is fallen into the hands of foster parents with no real interest in him as a child; as they say, if the self-dynamism is made up of experience which is chiefly derogatory, it will facilitate hostile, disparaging appraisals of other people and it will entertain disparaging and hostile appraisals of itself." (Kindle Version, Location 446-455).

Daniel Goleman (1995) illustrates this point in his book Emotional Intelligence where he compellingly describes an infant infant's experience with his caretaker which then internalized into the child's schemas about self, others and the world into later life:
“Say a two-month-old baby wakes up at 3 A.M. and starts crying. Her mother comes in and, for the next half hour, the baby contentedly nurses in her mother’s arms while her mother gazes at her affectionately, telling her that she’s happy to see her, even in the middle of the night. The baby, content in her mother’s love, drifts back to sleep. [If this basic pattern of interaction happened throughout the child's infancy and beyond at an age appropriate level, it is not hard to see how the child would internalize a world which is generally safe and hospitable where he is loved and can appropriately expect that his needs will be met]

Now say another two-month-old baby, who also awoke crying in the wee hours, is met instead by a mother who is tense and irritable, having fallen asleep just an hour before after a fight with her husband. The baby starts to tense up the moment his mother abruptly picks him up, telling him, “Just be quiet—I can’t stand one more thing! Come on, let’s get it over with.” As the baby nurses his mother stares stonily ahead, not looking at him, reviewing her fight with his father, getting more agitated herself as she mulls it over. The baby, sensing her tension, squirms, stiffens, and stops nursing. “That’s all you want?” his mother says. “Then don’t eat.” With the same abruptness she puts him back in his crib and stalks out, letting him cry until he falls back to sleep exhausted.

The two scenarios are presented by the report from the National Center for Clinical Infant Programs as examples of the kinds of interaction that, if repeated over and over instill very different feelings in a toddler about himself and his closest relationship? The first baby is learning that people can be trusted to notice her needs and counted on to help, and that she can be effective in getting help; the second is finding that no one really cares, that people can’t be counted on and that his efforts to get solace will meet with failure ….” (pp. 194-195, emphasis added)

Now it may be that you were a child that was treated to some degree like the latter in these two scenarios. This simply means that your schemas (the way you view yourself, others and the world large will be contaminated with a negative bias repeatedly and incessantly drilled and instilled within you from a very young age. Unlearning or better yet replacing and transforming these schemas with more realistic and adaptive ones is an important journey that can begin right now.

For me, that journey truly began on the day that I gave my life to Jesus Christ and committed myself to being his disciple. Since that time in January 1980 I have grown in the ability to see myself as "beloved" of God, and as a valued and permanent member of "the body of Christ"--the church and family of God. I have grown in my ability to see that God does provide for my needs and that I do not have to fear that I will be crushed by an uncaring world. I have grown since that day to experience the truth of these things but nevertheless struggle with negativity.

Having said all that, it is important for me to interject that I do not believe that our negative schemas only come from parental abuse and neglect. Albert Ellis points out that negative schemas are ubiquitous and universal. So much that he describes them as "Two Fundamental Human Disturbances": [1.] Ego disturbances which "relate[] to the demands that we make about ourselves and the consequent negative self ratings that we make what we fail to live up to our self-imposed demands. Furthermore, ego-disturbance issues may underpin what at first glance appear to be demands made of others or of life conditions...[; and] [2.] Discomfort disturbance, on the other hand, is more related to the domain of human comfort and occurs when we make dogmatic demands that comfort and comfortable life conditions must exist." (The Basic Principles of Rational Emotive Behavioral Counseling, Windy Dryden & Michael Neenan, (2004), p. 5).

Moreover, when it comes to autism, the latest research indicates that the disorder Autism spectrum disorder is a neurodevelopmental disorder. (DSM-V website at http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94#)
“Many studies have linked autism with amygdala dysfunction. The lack of empathy often shown by autistic individuals has associated with amygdala (Blair, 2008). Neural activity in the amygdala has also been strongly linked to depression (Northoff, 2007) and bipolar disorder (Phillips & Vieta, 2007). There is very strong evidence linking post-traumatic stress disorder with amygdala responses (Brewin, 2008)”. (From Ipad App, the 3d Brain, www.dnalc.org)

Bottom Line? Assuming you do not have autism, if you see that your life is filled with schemas about yourself, others, or your environment that are unbiblical / not in keeping with reality, begin the journey now by marinating your heart and mind with the thoughts of God about yourself, others and his provision for you. Eventually you will begin to experience it and feel it and know from the heart what it is to be born again into the loving family of God himself.

Day 5 -- Pervasive Development Disorders (Asperger's Disorder)

2011-02-05T06:51:00.000-08:00

Severe impairment pervades broad areas of social and psychological development in children with these mental disorders.

These include the following specific disorders:
Asperger's Disorder, Autistic Disorder, Childhood Disintegrative Disorder, and Rett's Disorder
Asperger's Disorder

In children with this pervasive developmental disorder language, curiosity, and cognitive development proceed normally while there is substantial delay in social interaction and "development of restricted, repetitive patterns of behavior, interests, and activities.”

Diagnostic criteria for 299.80 Asperger's Disorder:
A. Qualitative impairment in social interaction, as manifested by at least two of the following:
(1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(2) failure to develop peer relationships appropriate to developmental level
(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
(4) lack of social or emotional reciprocity
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
(1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(2) apparently inflexible adherence to specific, nonfunctional routines or rituals
(3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
(4) persistent preoccupation with parts of objects
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).
E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.
F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
DSM-V
The revisers of the DMS-V propose subsuming Asperger’s Disorder into a proposed new disorder, namely, Autism Spectrum Disorder.

Day 4 - Communication Disorders

2011-02-04T06:55:00.000-08:00

According to the DSM-IV-TR, Communication Disorders are mental disorders of childhood affect listening, language and speech.

These include the following specific disorders:

Expressive Language Disorder, Phonological Disorder, Receptive-Expressive Language Disorder, Stuttering.

Expressive Language Disorder

Individuals with this Communication Disorder of childhood test substantially below their expected level in the development of ability to express themselves in language.

Diagnostic criteria for 315.31 Expressive Language Disorder:

A. The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.

B. The difficulties with expressive language interfere with academic or occupational achievement or with social communication.

C. Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorders.

D. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.

Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

Phonological Disorder

Individuals with this Communication Disorder of childhood demonstrate impairment in their ability to produce sounds as expected for their developmental level.

Diagnostic criteria for 315.39 Phonological Disorder:

A. Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or organization such as, but not limited to, substitutions of one sound for another [use of /t/ for target /k/ sound] or omissions of sounds such as final consonants).

B. The difficulties in speech sound production interfere with academic or occupational achievement or with social communication.

C. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the speech difficulties are in excess of those usually associated with these problems.

Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

Mixed Receptive-Expressive Language Disorder

Impairment in ability to both understand and express language afflict individuals with this Communication Disorder with onset in childhood.

Diagnostic criteria for 315.32 Mixed Receptive-Expressive Language Disorder

A. The scores obtained from a battery of standardized individually administered measures of both receptive and expressive language development are substantially below those obtained from standardized measures of nonverbal intellectual capacity. Symptoms include those for Expressive Language Disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.

B. The difficulties with receptive and expressive language significantly interfere with academic or occupational achievement or with social communication.

C. Criteria are not met for a Pervasive Developmental Disorder.

D. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.

Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

Stuttering

Stuttering is a communication disorder characterized by excessive involuntary disruptions in the smooth and rhythmic flow of speech, particularly when such disruptions consist of repetitions or prolongations of a sound or syllable, and when they are accompanied by emotions such as fear and anxiety, and behaviors such as avoidance and struggle.

Diagnostic criteria for 307.0 Stuttering

A. Disturbance in the normal fluency and time patterning of speech (inappropriate for the individual's age), characterized by frequent occurrences of one or more of the following:

(1) sound and syllable repetitions

(2) sound prolongations

(3) interjections

(4) broken words (e.g., pauses within a word)

(5) audible or silent blocking (filled or unfilled pauses in speech)

(6) circumlocutions (word substitutions to avoid problematic words)

(7) words produced with an excess of physical tension

(8) monosyllabic whole-word repetitions (e.g., "I-I-I-I see him")

B. The disturbance in fluency interferes with academic or occupational achievement or with social communication.

C. If a speech-motor or sensory deficit is present, the speech difficulties are in excess of those usually associated with these problems.

Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

DSM-V

The DSM-V proposes a major revision in this area of the DSM-IV-TR mainly because the research has no born out a distinction between expressive and receptive language disorders.

“What has been removed from the DSM-IV and why? Subgroups 315.31, Expressive Language Disorder, and 315.32, Mixed Receptive-Expressive Language Disorder, were removed based on research documenting there are no measures of receptive versus expressive language disorder with demonstrated validity for making that distinction. For example, Tomblin and Zhang (1999) found that language measures loaded on only one general factor on 1,929 kindergarten children in their epidemiological study of children with Language Impairment (LI), and language expression and reception were not separate factors, as subtest names imply. Reviews of commonly used diagnostic language tests (e.g., Langlois, 2005) also indicate that separate receptive and expressive language scores are not supported by factor analysis that shows language subtests loading on one “general language” factor. Thus, the revision adds a more general or umbrella classification for Language Impairment (LI) and four new diagnostic classifications under LI. Having LI as a more general classification also signifies that LI may appear as the only (i.e., primary) developmental disorder or it may be co-existing with other developmental disorders.

Recommendations for severity criteria for this disorder are forthcoming. We encourage you to check our Web site regularly for updates.”

Expressive Language Disorder

A. The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.

B. The difficulties with expressive language interfere with academic or occupational achievement or with social communication.

C. Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorder.

D. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.

Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

Note: I am reminded of what was said yesterday with Developmental Coordination Disorders: "You may be wondering as I have just why what seems to be a general medical condition would be diagnosed by psychiatrists as a mental disorder? Spitzer et al. (2002) in DSM-IV-TR, Casebook, point out “it seems reasonable to classify it [Developmental Coordination Disorder] with the other developmental disorders of childhood because of the absence of a specific known etiology and because the behavioral consequences of the disorder (e.g., irritability and avoidance behavior) are treated by mental health professionals.”" (p. 363).

Day 3 -- Developmental Coordination Disorder

2011-02-03T06:56:00.000-08:00

When a child's motor coordination falls substantially below that which would be expected, and this cannot be accounted for by a known physical illness or injury, this mental disorder may be diagnosed.

DSM-IV-TR

Diagnostic criteria for 315.4 Developmental Coordination Disorder:

A. Performance in daily activities that require motor coordination is substantially below that expected given the person's chronological age and measured intelligence. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling, sitting), dropping things, "clumsiness," poor performance in sports, or poor handwriting.

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living.

C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet criteria for a Pervasive Developmental Disorder.

D. If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Note

You may be wondering as I am just why what seems to be a general medical condition would be diagnosed by psychiatrists as a mental disorder? Spitzer et al. (2002) in DSM-IV-TR, Casebook, point out “it seems reasonable to classify it [Developmental Coordination Disorder] with the other developmental disorders of childhood because of the absence of a specific known etiology and because the behavioral consequences of the disorder (e.g., irritability and avoidance behavior) are treated by mental health professionals.” (p. 363).

DSM-V

Under the DSM-V, as currently proposed, the diagnostic criteria are similar to those in the DSM-IV-TR except that subsection D is dropped:

A. Motor performance that is substantially below expected levels, given the person's chronologic age and previous opportunities for skill acquisition. The poor motor performance may manifest as coordination problems, poor balance, clumsiness, dropping or bumping into things; marked delays in achieving developmental motor milestones (e.g., walking, crawling, sitting) or in the acquisition of basic motor skills (e.g., catching, throwing, kicking, running, jumping, hopping, cutting, coloring, printing, writing)

B. The disturbance in Criterion A, without accommodations, significantly interferes with activities of daily living or academic achievement.

C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy).

Day 2 -- Learning Disabilities

2011-02-02T07:37:00.000-08:00

According to the DSM-IV-TR:

When individuals demonstrate abilities below the level that would be expected given their age and grade level in school based upon an arbitrary gap, they may be diagnosed with this mental disorder which should be further specified according to the particular academic function affected: Mathematics Disorder, Reading Disorder, Disorder of Written Expression.

Mathematics Disorder

A. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability.

C. If a sensory deficit is present, the difficulties in mathematical ability are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Reading Disorder

A. Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require reading skills.

C. If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

[Note: dyslexia is a reading disorder]

Disorder of Written Expression
A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).

C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

"Learning disabilities" are distinct from "emotional disturbances" and "social maladjustment" in the laws relating to the education of our children.

DSM-V

The DSM-V proposes a less rigorous test for determining whether a child has a learning disability in keeping with “IDEA regulations (2004) which state that: ‘the criteria adopted by the State must not require the use of a severe discrepancy between intellectual ability and achievement for determining whether a child has a specific learning disability, as defined in 34 CFR 300.8(c)(10).’”
Thus, according the DSM-V learning disabilities will be defined, for clinical purposes, as follows:

A. A group of disorders characterized by difficulties in learning basic academic skills (currently or by history), that are not consistent with the person's chronological age, educational opportunities, or intellectual abilities. Basic academic skills refer to accurate and fluent reading, writing, and arithmetic.
Multiple sources of information are to be used to assess learning, one of which must be an individually administered, culturally appropriate, and psychometrically sound standardized measure of academic achievement.

B. The disturbance in criterion A, without accommodations, significantly interferes with academic achievement or activities of daily living that require these academic skills.
34 CFR 300.8(c)(10) states as follows:

“Specific learning disability (i) General. Specific learning disability means a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia.

(ii) Disorders not included. Specific learning disability does not include learning problems that are primarily the result of visual, hearing, or motor disabilities, of mental retardation, of emotional disturbance, or of environmental, cultural, or economic disadvantage.”

Day 1 -- Through the DSM in a Year -- Intellectual Disability

2011-02-01T08:51:00.000-08:00

Day 1 - Mental Retardation / Intellectual Disability

I have heard it said that there are 365 mental disorders in the Diagnostics and Statistical Manual, 4th Edition, Text Revision. I really don't know if that's true or not but in any event thought the correspondence of 365 mental disorders with 365 days is a helpful one. Given the fact that the DSM is such a huge book with so many facts and diagnoses in it (all of which I am required to know a s a therapist), I thought it would be good to take the diagnoses one day at a time, reviewed the criteria and perhaps offer an interesting comment on my blog.

Mental retardation is defined in the DSM as follows:

A. Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning).

B. Concurrent deficits or impairments in present adaptive functioning (i.e., the person's effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety.

C. The onset is before age 18 years.

Code based on degree of severity reflecting level of intellectual impairment:

317 Mild Mental Retardation: IQ level 50-55 to approximately 70

318.0 Moderate Mental Retardation: IQ level 35-40 to 50-55

318.1 Severe Mental Retardation: IQ level 20-25 to 35-40

318.2 Profound Mental Retardation: IQ level below 20 or 25

319 Mental Retardation, Severity Unspecified: when there is strong presumption of Mental Retardation but the person's intelligence is untestable by standard tests.

The term “mental retardation” is being phased out and the new term “mental
disability should be used. According to an AP article dated September 23, 2010 “"Changing how we talk about people with disabilities is a critical step in promoting and protecting their basic civil and human rights," said Peter Berns, CEO of The Arc, an organization promoting the human rights of people with intellectual and developmental disabilities.” (http://www.nola.com/politics/index.ssf/2010/09/congress_eliminates
_term_menta.html)

The DSM-V which is expected to be released/published in May 2013 proposes the following diagnostic criteria for "intellectual disability":

Intellectual Disability is a disorder that includes both a current intellectual deficit and a deficit in adaptive functioning with onset during the developmental period. All three of the following criteria must be met.

A. Intellectual Disability is characterized by deficits in general mental abilities such as reasoning, problem-solving, planning, abstract thinking, judgment, academic learning and learning from experience. Intellectual Disability requires a current intellectual deficit of approximately 2 or more standard deviations in Intellectual Quotient (IQ) below the population mean for a person’s age and cultural group, which is typically an IQ score of approximately 70 or below, measured on an individualized, standardized, culturally appropriate, psychometrically sound test.

AND

B. The deficits in general mental abilities impair functioning in comparison to a person’s age and cultural group by limiting and restricting participation and performance in one or more aspects of daily life activities, such as communication, social participation, functioning at school or at work, or personal independence at home or in community settings. The limitations result in the need for ongoing support at school, work, or independent life. Thus, Intellectual Disability also requires a significant impairment in adaptive functioning. Typically, adaptive behavior is measured using individualized, standardized, culturally appropriate, psychometrically sound tests.

AND

C. Onset during the developmental period.

Interesting On Divorce from Bill Gothard

2011-01-17T06:55:00.000-08:00

As a young Christian in 1981 I attended a Bill Gothard seminar Institute of Youth Conflicts and my life was transformed by the experience.

I have reread my textbook from that seminar from time to time since then to my great spiritual profit.

Today, I read a section called "Our Responsibility to "Heal" Offenders" where Mr. Gothard draws upon 1 Peters 2:19-24 and shares this passage with a lady who had told him in reply to his inquiry as to how she is doing "Horrible! I'm getting a divorce. I can't stand to live with that man any longer!"

Gothard points out "I asked her if I could give her a three minute message. She agreed. I asked her if she could visualize the abuse and beatings and rejection and agony which Jesus Christ suffered in His life. she said she could. I emphasized that His response to those who did it to Him was one of love and forgiveness, and by His stripes we were healed according to 1 Peter 2:19-24."

"Then I asked her if she knew what the very next verse was following this section. She didn't and was startled to hear it--"Likewise, ye wives be in subjection to your own husbands; that if any obey not the word, they also may be won by the conduct of the wives." (1 Peter 3:1) (Six verses later it also states, "Likewise, ye husbands...")

Christ's passion and crucifixion upon the cross is the ultimate example for us when considering reconciliation and the healing of broken relationships.

God Loves the Church

2010-12-25T09:38:00.000-08:00

“The Lord loveth the gates of Zion more than all the dwellings of Jacob.” (Verse 2)

There is certainly a tendency to look only at the negative aspects of the church as an institution in the world. However, as put by Brooks (1919) in the Summarized Bible:
“Zion may be taken as a type of the Gospel church of which even more glorious things are spoken than of Jerusalem. It is the Bride of Christ, a peculiar people, a royal priesthood, and the gates of hell shall not prevail against it. We need never be ashamed of the church, even in its meanest condition.”

A Call to Developing a Biblical Truly Christian Self Image

2010-12-17T06:34:00.000-08:00

/
“Preserve my soul; for I [am] holy….” (Psalm 86:2)

Notice the Psalmist’s definition of his relationship to the Lord. He says that he is holy. By this he means that he is totally dedicated to God.

This image of himself as being totally dedicated to God brings with it a certain confidence in God. Notice the Psalmist prays that God would save him because or “for” he is holy (totally dedicated to God)

What is your image of yourself? Is your image of yourself accurate or true according to the scriptures?
Note the parallel ideas expressed in Romans 12:1-2 “I beseech you therefore, brethren, by the mercies of God, that ye present your bodies a living sacrifice, holy, acceptable unto God, which is your reasonable service. And be not conformed to this world: but be ye transformed by the renewing of your mind, that ye may prove what is that good, and acceptable, and perfect, will of God.”

Truly Loved by God

2010-11-30T04:55:00.000-08:00

"Can a woman forget her sucking child, that she should not have compassion on the son of her womb? yea, they may forget, yet will I not forget thee. Behold, I have graven thee upon the palms of my hands; thy walls are continually before me." (Isaiah 49:15, 16)

Keil & Delitzsch point out that God’s love for us as seen in the sacrifice of our Lord Jesus Christ upon the cross is even more “inalienable” than “maternal love”. Note the prophetic reference in Isaiah written some 700 to 800 years before the death of our Lord Jesus Christ the Messiah whose hands were sacrificially graven with nail spikes for us. In this portion of the crucifixion procedure, Jesus engraved each of us upon the palms of his hands as prophesied by Isaiah at 49:16. In verse 16, the Messiah then tells us that he guards and protects us—”thy walls”, Jesus says to us, “are continually before me.” “Behold, he that keepeth Israel shall neither slumber nor sleep. The Lord is thy keeper: the Lord is thy shade …. (Psalm 127:4). Listen to the words of Christ to you by brother and my sister in the faith: “My sheep hear my voice, and I know them, and they follow me: And I give unto them eternal life; and they shall never perish, neither shall any man pluck them out of my hand. My Father, which gave them me, is greater than all; and no man is able to pluck them out of my Father's hand. I and my Father are one.” (John 10:27-29)

The Comfort of Love and Compassion

2010-09-22T06:26:00.000-07:00

"Praise be to the God and Father of our Lord Jesus Christ, the Father of compassion and the God of all comfort, who comforts us in all our troubles, so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow over into our lives, so also through Christ our comfort overflows." (2 Corinthians 1:3-5)

Those outside the faith think the Christian life is some sort of really negative existence characterized by futile attempts at denying oneself the pleasures of life where trudge through a tasteless life of bland and mindless obedience to other people's rules and regulations.

Nothing could be further from the truth. The Christian life is a vibrant interaction with God and other people as we live real lives with real people facing real troubles as well as joys. In this life we experience the love, comfort and compassion of God both directly by his Holy Spirit in our hearts and indirectly through the intimacy of sharing our lives with others.

Live Entirely for Christ Today

2010-09-21T05:28:00.001-07:00

Today I commit myself to loving you Lord my God with all my heart, and with all my soul, and with all my strength, and with all my mind; and my neighbor as myself. (Luke 10:27)

Therefore, my dear brothers, stand firm. Let nothing move you. Always give yourselves fully to the work of the Lord, because you know that your labor in the Lord is not in vain. (1 Cor. 15:58)

The Christian Life is Empowered by the Spirit of God

2010-09-12T05:40:00.000-07:00

“The kingdom of God is not a matter of talk but of power.” (1 Corinthians 4:20, NIV)
John Calvin says of this passage “As to our gospel, of which we are proud, where is it in most persons except in the tongue? Where is newness of life? Where is spiritual efficacy? Nor is it so among the people merely. On the contrary, how many there are, who, while endeavoring to procure favor and applause from the gospel, as though it were some profane science, aim at nothing else than to speak with elegance and refinement! I do not approve of restricting the term power to miracles, for from the contrast we may readily gather that it has a more extensive import.”

O Lord, please let us experience your reality and presence in our lives today.

It is God's Will That We Understand What He Has Freely Given Us

2010-09-04T20:32:00.000-07:00

"We have not received the spirit of the world but the Spirit who is from God, that we may understand what God has freely given us." (1 Corinthians 2:12)
Of this passage Robertson’s Word Pictures points out that the original language of this passage conveys the idea that “God expects us to understand “the things that are freely given us by God”.
God’s chosen stumble in many ways (James 3:2) and one of them is failing to see the thing that are freely given us by God. Jacob you may remember was astounded by his own stupor of faith when he woke up after his dream about the ladder (Jacob’s Ladder) and said “Surely the Lord is in this place, and I was not aware of it.” (Genesis 28:16)
O Lord, help us to walk in faith being aware of the things you freely give us for this is your will for us have believed and been saved in Christ Jesus our Lord.

Bearing Each Other's Crises and Backpacks Gal. 6:2

2010-08-30T06:27:00.000-07:00

Last night my son and I got into a little argument over waking him up for school at 6:00 a.m. in the morning. I should note that he is 17 years old.

"Dad, would you wake me up at 6:00 a.m. tomorrow for school?"

"Don't you have an alarm?"

"No, I don't. Mom hasn't bought me one."

"What about the alarm on your cell phone? I know cell phones have alarms because that's what I use to make sure I wake [parenthetically, I can't remember the last time I actually needed an alarm to wake up. As I get older I wake up all the time and almost always before the alarm goes off].

"I've tried that" he says "but it doesn't wake me up."

"You just need to train yourself to wake up to it" I tell him.

"Jeez, why don't you just do me a favor and wake me up?" he says, exasperated.

"Because I don't think I'm doing my 17 year old son a favor by letting him rely on my to wake himself up in the morning for school. I'm actually doing you a disfavor by not forcing you to be responsible for getting yourself out of bed in the morning for school."

He didn't have much to say after that because it's true. Some people, like my son in this exchange think that asking for favors equates to little tests of love and a failure to comply with their request involves a betrayal of one's love. However, Cloud and Townsend point out with regard to bearing one another's burden's and so fulfilling the law of Christ (Galatians 6:2):

"“Denying ourselves to do for others what they cannot do for themselves is showing the sacrificial love of Christ. This is what Christ did for us. He did what we could not do for ourselves; he saved us. This is being responsible to. On the other hand, verse 5 [of Galatians 6] says that “each one should carry his own load. Everyone has responsibilities that only he or she can carry. These things are our own particular “load” that we need to take daily responsibility for and work out. No one can do certain things for us. We have to take ownership of certain aspects of our life that are our own load.”

Cloud & Townsend go on to say that the word translated burden in verse 2 means boulder and the word translated burden in verse 5 is cargo. Thus, we are expected to help one another in crisis and with big things of life that require cooperation to overcome; whereas, when it comes to the cargo or daily burdens of life, we are each individually expected to work that out ourselves.

An Exhortation to Passionate Engagement With Your Calling

2010-08-29T08:33:00.000-07:00

When you were called by God to fellowship with Christ Jesus our Lord, quite likely you felt a passion for life and fullfilling your calling in Christ. As time and troubles come and go, that passion can wane and weaken. I want to encourage you to remind yourself of you calling in Christ today and reawaken to a life of passionate engagement with God in fulfillment of your calling to fellowship with Jesus Christ.

See the following song from Matthew West called the motions. The refrain in the song is as follows:

I don't wanna go through the motions

I don't wanna go one more day

without Your all consuming passion inside of me

I don't wanna spend my whole life asking,

"What if I had given everything,

instead of going through the motions?"

GOD BLESS YOU!

God is Faithful

2010-08-22T20:08:00.000-07:00

"God, who has called you into fellowship with his son Jesus Christ our Lord, is faithful." (1 Corinthians 1:9)

The Scripture tells you here that God has called you into fellowship with his son Jesus Christ our Lord.

What does it mean to be called by God into fellowship with his son Jesus Christ our Lord? I think it means to a number of things. First, it involves bringing Jesus Christ our Lord into every aspect of your life. Doing so necessarily means making changes. There is an old gospel tract called "My Heart, Christ Home" Take a minute to read this little tract. It's a classic with a really good message about what it means to fulfill your calling to fellowship with Jesus Christ our Lord.

Every Day is a New Day

2010-03-28T10:21:00.000-07:00

Dear reader,

Are you down about how things have been going for you? Are you pesimistic about the future? Has your spouse left you? Are you bankrupt? Have you been charged with a serious crime? Are you depressed, frustrated, dissapointed or angry?

Let me encourage you to take a moment and pray to God about it. I mean to pray to God from your heart to his heart and ask him to help you. Ask him to teach and guide you into his will in the midst of your perils and plight.

See Jeremiah 29:11-13 "For I know the plans I have for you,” says the Lord. “They are plans for good and not for disaster, to give you a future and a hope. In those days when you pray, I will listen. If you look for me wholeheartedly, you will find me." (NLT)

Post for me and other how God answered your prayer.

Jim

Overcoming Depression. How to Live a Joyful Life

2009-11-10T02:44:00.000-08:00

“I will say unto God my rock, Why hast thou forgotten me? why go I mourning because of the oppression of the enemy? As with a sword in my bones, mine enemies reproach me; while they say daily unto me, Where is thy God? Why art thou cast down, O my soul? and why art thou disquieted within me? hope thou in God: for I shall yet praise him, who is the health of my countenance, and my God.” (Psalm 42:9-11)

Cognitive Behavioral Therapy is premised on the fact that feelings come from thought. Here, the Psalmist is asking himself why he is cast down and disquieted. He also recognizes the source of his depression, if you want to call it that. He has been thinking about and indoctrinating himself with such thoughts as God has forgotten me (verse 9); I am oppressed by my enemy (verse 9); I am a reproach to my enemies (verse 10).

These sorts of thoughts naturally lead to feelings of depression. However, thoughts such as my hope is in God (verse 11); and God is the health of my countenance (verse 11); and, I belong to God who protects me, loves me and really does care about me (verse 11) produce feelings of courage, happiness and joy. D. Martyn Lloyd-Jones in his book Spiritual Depression (1965) points out that “the main trouble in this whole matter of spiritual depression in a sense is that, that we allow our self to talk to us instead of talking to ourself” (p. 20). He further points out that “the main art in the matter of spiritual living is to know how to handle yourself. You have to take yourself in hand, you have to address yourself, preach to yourself, question yourself… exhort yourself and say to yourself: ‘Hope thou in God’ instead of muttering in this depressed, unhappy way” (p. 21).

What Motivated God to Send His Son to Die For Us?

2009-09-28T05:54:00.000-07:00

"For when we were yet without strength, in due time Christ died for the ungodly. For scarcely for a righteous man will one die: yet peradventure for a good man some would even dare to die. But God commendeth his love toward us, in that, while we were yet sinners, Christ died for us" (Romans 5:6-8).

What does this passage tell us about God’s motivation in sending his son, Jesus Christ to die for us?

"For God so loved the world, that he gave his only begotten Son, that whosoever believeth in him should not perish, but have everlasting life" (John 3:16). God's love for us is the source and foundation of death of Christ on the cross. His resurrection from the dead and ascension into heaven where he sits at the right hand of God is the victory and power of God's love over sin and death.

Our Father who art in heaven, hallowed, holy and awesome is your name. Thank you for loving us. Thank you for loving me so much that your sent your son to make the ultimate sacrifice of love for us.

In Jesus' Name. Amen.

Trust, Delight and Commit = Contentment in the Will of God

2009-09-17T06:47:00.000-07:00

Psa 37:3 Trust in the LORD, and do good; so shalt thou dwell in the land, and verily thou shalt be fed.

Psa 37:4 Delight thyself also in the LORD; and he shall give thee the desires of thine heart.

Psa 37:5 Commit thy way unto the LORD; trust also in him; and he shall bring it to pass.

What three things are we told to do in this passage?

1. Trust in the Lord and do good; 2. Delight yourself in God; and , 3. Commit your way to the Lord and trust in him.

You will have a place to stay and you will be fed. You will be satisfied with life, that is, you will have contentment; and, God will bring your way or destiny to pass.

Call for Collaboration on this Question: When do you know you are a man or woman?

2009-09-16T08:52:00.000-07:00

Please follow the following link to read and collaborate with me on the question of when do you know you are a man or woman?

Please link to the following, read, write or upload. Thanks, Jim

https://jimhusen.box.net/shared/uojkdsz48u

We Trust God Because He is Loving, Kind and Righteous

2009-09-07T06:27:00.000-07:00

“Thy mercy, O LORD, is in the heavens; and thy faithfulness reacheth unto the clouds.Thy righteousness is like the great mountains; thy judgments are a great deep: O LORD, thou preservest man and beast. How excellent is thy lovingkindness, O God! therefore the children of men put their trust under the shadow of thy wings” (Psalm 36:5-7)

What characteristics of God are mentioned in this passage?

Why should someone trust in the Lord?

O Lord, I pray for my readers and clients. Preserve them. Strengthen and Encourage them. In Jesus' Name. Amen.

The Salvation of God is His Gift. It Cannot be Earned. It is a Cause for Humility Not Self Righteous Pride

2009-09-01T05:12:00.000-07:00

In studying Romans, Chapter 2 begins with a discussion of self righteousness and how it is very much in the same camp as the worst sins committed. The the self righteous, the Apostle Paul wrote "And thinkest thou this, O man, that judgest them which do such things, and doest the same, that thou shalt escape the judgment of God?" (Romans 2:3).

And yet, it is the goodness of God that leads us to repentance. It is the love of God that brought us Jesus Christ to die on the cross for our sins that we might be forgiven and delivered from our sin before God. There is no room for boasting in this.

“And he spake this parable unto certain which trusted in themselves that they were righteous, and despised others: Two men went up into the temple to pray; the one a Pharisee, and the other a publican.The Pharisee stood and prayed thus with himself, God, I thank thee, that I am not as other men are, extortioners, unjust, adulterers, or even as this publican. I fast twice in the week, I give tithes of all that I possess. And the publican, standing afar off, would not lift up so much as his eyes unto heaven, but smote upon his breast, saying, God be merciful to me a sinner. I tell you, this man went down to his house justified rather than the other: for every one that exalteth himself shall be abased; and he that humbleth himself shall be exalted” (Luke 18:9-14).

Lord God Almighty, protect us from self righteousness. Remind us that forgiveness and repentance are gifts given us from you the Father of light who sent your son, Jesus Christ to die on the cross and to be raised from the dead and who now sits at your side.

In Jesus' Name. Amen.

THE LORD WILL COME TO YOU IF YOU HUMBLY TURN TO HIM IN YOUR NEED

2009-08-30T06:49:00.000-07:00

“The LORD is nigh unto them that are of a broken heart; and saveth such as be of a contrite spirit” (Psalm 34:18).

What does the Psalmist assert as fact in this verse? See also Isaiah 55:17 which says “For thus saith the high and lofty One that inhabiteth eternity, whose name is Holy; I dwell in the high and holy place, with him also that is of a contrite and humble spirit, to revive the spirit of the humble, and to revive the heart of the contrite ones.”

Is this true? Have you ever tried turning to the Lord and spending time with him in prayer and study of the Bible when you are down? James 4:8 says “Draw nigh to God, and he will draw nigh to you. Cleanse your hands, ye sinners; and purify your hearts, ye double minded.” I have on more times than I can count and the result has always been encouragement perspective as I have felt the Lord’s presence in my life.

What destructive things do people turn to instead of the Lord when they are broken hearted or feeling pulverized and/or overwhelmed?

If you are down right now, I remind you of the importance of turning to the Lord instead of alcohol, drugs or any of the other destructive things people turn to instead of God when they are upset, depressed or confused.

Seek the Lord and Look to Him

2009-08-27T06:35:00.000-07:00

"I sought the LORD, and he heard me, and delivered me from all my fears. They looked unto him, and were lightened: and their faces were not ashamed" (Psalm 34:4,5)

How does one go about seeking the Lord?
What happened for the Psalmist when he sought the Lord as expressed here at Psalm 34:4? What promise does this passage give to those who look to God? What does it mean to be lightened and have a face free from shame?

We Are Chosen

2009-08-26T04:50:00.000-07:00

"Among whom are ye also the called of Jesus Christ" (Romans 1:6)

"Ye have not chosen me, but I have chosen you, and ordained you, that ye should go and bring forth fruit, and that your fruit should remain: that whatsoever ye shall ask of the Father in my name, he may give it you." (John 15:16)

One of my friends told me that the idea expressed here when Jesus says that he chose us and ordained us to go and bear fruit is that he chose us and strategically placed us where we would bring God’s fruit to others.

Will you allow God to bless others through you today? He has strategically placed you among others so that you could bless them and be blessed.

WHAT DOES IT MEAN TO BE ESTABLISHED IN THE FAITH?

2009-08-25T06:33:00.000-07:00

(Rom 1:11) For I long to see you, that I may impart unto you some spiritual gift, to the end ye may be established; (Rom 1:12) That is, that I may be comforted together with you by the mutual faith both of you and me.

Here, the scripture highlights Paul’s deep relationship with others the people at the church in Ephesus. He sought to deepen and establish them in their spiritual lives with God. The synergistic result was one of mutual comfort.

So too for us. There is great mutual comfort that comes with using our gifts to strengthen and establish one another. The word establish used in the original Greek of the Bible is στηρίζω (stērízō) and the time it was employed by the Apostle Paul when he wrote the Book of Ephesians carried the idea of fixing and supporting in place as where a stake supports a vine or a cane helps support an aging person as he or she walks, (Kittel & Friedrich,1971, Vol. VII, p. 653).

However, the idea of being established also carried the connotation as it does today being committed, secure and steadfast as with the stars that are fixed in the sky, (Ibid, p. 654).

The teachings of Scripture we apply to our lives, comfort us, hold us up. They also help us stay on course and bring security, stability, endurance and growth into our lives.

I would recommend studying the Bible a little every day. Trust me. Your life will be transformed by the enterprise and God will bless you for your effort.

What does it mean to be “established” in the faith?

Note from Robertson’s Word Pictures in the New Testament where he comments on 1 Thess 3:3 “That no man should be moved by these afflictions: for yourselves know that we are appointed thereunto” as follows: “We Christians are set hereunto (eis touto) to be beguiled by tribulations. We must resist.”

In The TDNT the writer says of the Greek word for establish (στηρίζω) that “It presupposes that the Christians who are to be strengthened are under assault and in danger of becoming uncertain or slothful in their faith or walk…. The effect or aim of strengthening is the impregnability of [the] Christian faith in spite of the troubles which have to be endured.” (Vol. VII, P. 656).

“(1Pe 5:10) But the God of all grace, who hath called us unto his eternal glory by Christ Jesus, after that ye have suffered a while, make you perfect, establish, strengthen, settle you.”

The Liberating Power of the Gospel of Jesus Christ

2009-08-24T06:35:00.000-07:00

(Rom 1:5) By whom we have received grace and apostleship, for obedience to the faith among all nations, for his name:

The purpose of the God’s grace in our lives is to transform our lives into beautiful works of creative cooperative art in the eyes of God. Obedience to the Christian faith liberates the soul from the bondage of lust and sin into the freedom of love and righteous living.

Issue: Can one be a Christian and please God as a Lawyer at the same time?

Can one be a Christian and do any job at all (other than being a pastor or missionary) and please God?

How about in your line of work or carreer or calling?

What do you think?

JESUS CHRIST LIBERATES US FROM SIN AND DEATH

2009-08-22T22:20:00.000-07:00

Rom 8:1 With the arrival of Jesus, the Messiah, that fateful dilemma is resolved. Those who enter into Christ's being-here-for-us no longer have to live under a continuous, low-lying black cloud. Rom 8:2 A new power is in operation. The Spirit of life in Christ, like a strong wind, has magnificently cleared the air, freeing you from a fated lifetime of brutal tyranny at the hands of sin and death. (Message Bible)

Rom 8:1 There is therefore now no condemnation to them which are in Christ Jesus, who walk not after the flesh, but after the Spirit. Rom 8:2 For the law of the Spirit of life in Christ Jesus hath made me free from the law of sin and death. (King James Version)

Jim Downing in his book Meditation gives a wonderful practical exposition on the meaning of this passage.

And so it is that we are no longer condemned. We are heaven bound and our lives are set free from the bondage of the law in Jesus Christ.