Art education and art therapy.

Here the subject of discussion is the difference between the art education and art therapy. So what aspects of these two professional activities can usually be subjected to a comparison? Do they have any common ground and if so what and why is this? These differences, if any, arise because of the environment in which they are practised? I mean to say, teacher works in schools with normal children and therapists are in hospitals with sick people. But there are possibilities and circumstances, where teachers work in hospitals and the therapists in schools. Would they be doing the same thing, if they change their title in such circumstances?

Let us try to answer all these questions one by one. Let us understand this first, in any school is there are children, who for a variety of reasons require some form of remedial activities or therapy. They may need the attention of specialist teachers and/or therapists. They require special treatment. The educational mode of art therapy has been to address itself to the needs of our teachers who wish to orient themselves as therapists. This has proved both exciting and difficult. While such trainings are conducted it becomes clear where the similarities and differences in practice actually lie between art teaching and art therapy. In Britain they follow a child-centred approach in art education which puts emphasis on the child's personal expression through art. We could also refer to child-centred as person-centred and say art therapy are not confined to children but also to an adult.

So in order to tackle the task of comparison it is necessary to look at the historical account of art education. . At the end of 19th century and the rise of colourful postimpressionist work shortly afterwards made it possible for the first time a comparison between child and adult art is this. This child art, primitive art, tribal art and Western Asiatic art were no longer regarded as crude but rather as sensitive and expressive forms of art.

Now, we see the teacher's attitude towards the child is changing. Instead of impressing upon the child pre-conceived ideas of his own relating to technical attainment and adult standards, now the teacher encourage him to express fearlessly his own creative and imaginative impulses. Efforts are made by some to release the subconscious mind by letting that child draw and paint patterns and colours which he sees in his mind's eye. It is believed that morbid fears and fancies are thus released. Art therapy stresses the spontaneous expression of the patient and assumes that there is a stage when the artwork reaches a primitive or preverbal level which is somehow culture and value free.

Interest in art of mentally disturbed was apparent at the turn of 19th century is under the same impetus as the interest in child's art. Jung, who was an artist himself, was a great influence on the art educator and philosopher Herbert Read, and truly had a strong influence on the movement in art education from child art. There is evidence that Jung had begun to use the artwork of his patients therapeutically before 1920 at his clinic in Zürich.

The small girl who was not completing her class works

Case Description

A 7-year-old girl Rita is brought to her pediatrician on the suggestion of her second-grade teacher. The patient has been back in school following a summer break. According to the teacher, the patient has found it very difficult to complete her classroom tasks since returning to school. The child does not disturb other students but cannot finish her assignments in the allotted time although her classmates do so without difficulty.

She is also known to make careless mistakes in her work. Although she is still passing her classes, her grades dropped, and she seems to daydream a great deal in class as well. The teacher reports that it takes several repetitions of the instructions for the patient to complete a task (eg, in an art class).

The patient enjoys physical education and does well in that class. The child indicates that when it appears to others that she is not paying attention she is thinking about other things. Teachers report that her attention wanders constantly and they have to call her name or wave to get her immediate attention. There have been no episodes where she stares blankly and the teacher cannot get her attention for a few seconds.

Although her parents have noticed some of the same behaviors at home, they have not been particularly concerned because they have found ways to work around them. If they monitor the child and her work directly, she can complete her homework, but they must continually check her work for careless mistakes.  She does seem to know the right answer when it is pointed out.

The parents also report that the patient does not get ready for school in the mornings without moment-by-moment monitoring.  Her bedroom is in shambles, and she loses things all the time. The parents describe their daughter as a happy child who enjoys playing with her siblings and friends. They note that she does not like school, except for the physical education classes.

Analysis

Most likely diagnosis: Attention-deficit/hyperactivity disorder (ADHD)

Signs and symptoms of  ADHD

Attention deficit :

• Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
• Often has trouble keeping attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace
• Often has trouble organizing activities.
• Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
• Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
• Is often easily distracted.
• Often forgetful in daily activities.
• Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level

Hyperactivity:

• Often fidgets with hands or feet or squirms in seat.
• Often gets up from seat when remaining in seat is expected.
• Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
• Often has trouble playing or enjoying leisure activities quietly.
• Is often "on the go" or often acts as if "driven by a motor".
• Often talks excessively.

Impulsiveness:

• Often blurts out answers before questions have been finished.
• Often has trouble waiting one's turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games).

Other general characteristics to remember

• Some symptoms that cause impairment were present before age 7 year
• There must be clear evidence of significant impairment in social, school, or work functioning
• The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Differential Diagnosis

• The presence of oppositional defiant disorder (ODD) or conduct disorder in a child or youth with ADHD is relatively common.
• Patients with ADHD often have learning disabilities, and a thorough evaluation of this problem should be conducted for every child suspected of having this disorder.
• Lead intoxication can lead to hyperactivity, and the presence of this disorder should be ruled out by determining the lead level in the blood at the initial evaluation.
• Patients with petite mal seizures may report poor attention. However, with careful questioning, clinicians can usually get a history of brief periods where the patient is unaware of what is happening around them, often describing brief periods when they have lost time(absences).
• Parents and teacher should be asked about staring spells when the child is unresponsive even when directly spoken to face-to-face, suggesting petit mal seizures.
• ADHD, especially if occurring with oppositional defiant disorder, may be mistaken for childhood bipolar disorder.

Treatment Approach

• Approximately 70% to 80% of all children with ADHD will respond to stimulant medications, either methylphenidate or amphetamine preparations.
• Occasionally, the stimulants are associated with the development of tics or worsening of tics in those with tic disorders. Stimulants have, as a group, a very rapid onset of action, and typically, their therapeutic effects wear off by the end of the day.
• Adverse effects typically include decreased appetite (sometimes with subsequent slowed growth rate), initial insomnia, irritability, dysphoria, and headache.

Summary

There are three primary subtypes of ADHD (inattentive type, hyperactive-impulsive type, and combined type), all of which have different presentations.

Use of a stimulant medication or atomoxetine is probably the best medication for these children. Pemoline is effective in ADHD, but its association with a rare hepatotoxic reaction has resulted in recommendations that a baseline ALT be obtained and that it be remonitored every 2 weeks while the patient is on the medication.

References

DSM IV Handbook for differential Diagnosis for PDA
Case Files Psychiatry
A Quick reference to APA practice guidelines

The man who never grew up and remained under the care of his mother

Case description

One day a 33 years old man reports to a psychologist with a complaint of feeling depressed because he broke up with his girl friend 2 years back.
While describing the incident he said that he loved his girl friend dearly but he broke up because his mother did not wanted him to get married with her. His mother has a strong influence in his life. He cannot go against his mother to marry that girl and stay separately with her.  He further narrated that her mother has been sincere and always taken care of him right from his childhood till now. He says that he cannot imagine himself to be away from his mother. She knows about him from childhood, she has supported him  this way till now and she knows the best about him what to do in future.

In his education  years he has lived at home entirely except for one semester away at college.  He returned home at the end of the semester because he was homesick, and did not go back.

He reports of no loss of appetite, normal concentration or energy.  He claims that he performs “adequately” at work and has no job-related problems. He works for an accounting firm in an entry-level position even though he has been there for several years.  He says that he has turned down promotions in the past because he knows that he “couldn’t possibly supervise anyone or make decisions for them.”

This man has two childhood friends whom he has to talk every day several times. They are great support for him and without them he feels empty and lost.

The results of his mental status examination are normal except for revealing a depressed mood (although affect is full range).

Analysis

The traits indicate Dependent Personality Disorder

General characteristics of a dependent personality.

• Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
• Needs others to assume responsibility for most major areas of his or her life.
• Has difficulty expressing disagreement with others because of fear of loss of support or approval (this does not include realistic fears of retribution)
• Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
• Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself .
• Urgently seeks another relationship as a source of care and support when a close relationship ends
• Is unrealistically preoccupied with fears of being left to take care of himself or herself

Treatment Approach

• Insight-oriented therapies can often be helpful. Behavioral therapy, assertiveness training, family therapy, and group therapy have all proven useful with selected patients as well.
• Pharmacotherapy can be used to treat specific symptoms such as anxiety and depression as they arise.
• Dependent personality disorder, like all personality disorders, is difficult to treat.
• Patients can respond to psychosocial support groups in the face of loss of their usual support systems.
• Long-term psychodynamic psychotherapy might eventually help, but many patients do not have either the motivation or the insight needed to successfully undergo treatment.

Differential Diagnosis

Patients with agoraphobia can be dependent, but the dependent behavior usually does not start until the panic attacks or anxiety do—thus there is no pervasive, lifelong pattern of dependency.

Some information about Dependent Personality Disorder

Patients with dependent personality disorder have a pervasive need to be taken care of by others. They are dependent and submissive and are uncomfortable when alone because they do not believe they can take care of themselves.

Physicians should reassure these patients of their availability but set limits as to how often the patient can contact them. If feeling “burned out” by the patient’s extreme dependence, they should be careful not to reject the patient.

Dependence is a prominent factor in several personality disorders, including histrionic and borderline disorders. Patients with dependent personality disorder tend to stick to one caregiver, such as a parent or spouse, for the long term and tend to be less manipulative.

References

DSM IV Handbook for differential Diagnosis for PDA
Case Files Psychiatry
A Quick reference to APA practice guidelines

He was afraid speaking before a crowd

Case History

Vijay was 30 years old.  He has been a good and sincere team worker.  He was well known for his honesty and serious attitude towards his duty. But now the time has come when he has to work with a team and he is expected to take bigger responsibility. But he has had a long-standing difficulty speaking in public. He believes he will look stupid or otherwise embarrass himself. He usually handles this fear by avoiding speaking if possible or by speaking only before a small audience.

Since his job promotion, he has been terrified by the thought of speaking to an audience of 100, although it is a necessary requirement of the new position. He has been unable to sleep because of his anxiety. He knows that this level of anxiety about public speaking is abnormal but is unable to quell his fears. His fear of speaking in public is consistent with social phobia.


Diagnostic Criteria for social phobia.

• A marked, persistent fear of at least one social or performance situation in which exposure to unfamiliar people or possible scrutiny of others occurs.
• The person fears that he or she will act in a way or show anxiety symptoms that will be humiliating or embarrassing.
• Exposure to the feared situation(s) invariably provokes anxiety that can take the form of a panic attack.
• The person recognizes that the fear is unreasonable.
• The avoidance of, anxious anticipation of, or distress in the feared situation(s) interferes with the person’s normal routine, or there is marked anxiety about having the phobia.
• The fear or avoidance is not related to a substance or a general medical condition.
• a general medical condition is present, the fear in criterion 1 is not related to it

Other general information about this phobia

• Phobias are the single most common mental disorder affecting 5% to 10% of the population everywhere.
• Genetics can have a role in predisposing individuals to these disorders.
• Phobias are often treated by exposure therapy, a type of cognitive behavioral therapy in which the individual is slowly desensitized with controlled “doses” of the feared stimulus..
• Functional neuroimaging studies show more activity in the amygdale and insula in patients with social phobia

Treatment and management

Psychotherapy is helpful in treating social phobia and usually involves a combination of behavioral and cognitive therapy using desensitization to the feared situation, rehearsal during sessions, and homework assignments in which patients are asked to place themselves in public situations in a graded fashion.

Psychopharmacotherapy for severe social phobia has succeeded with the use of selective serotonin uptake inhibitors (SSRIs), benzodiazepines, venlafaxine, and buspirone.

Treating the anxiety associated with performance situations involves the use of beta-adrenergic receptor antagonists just before the feared situation. Atenolol and propranolol have been shown to be helpful in these instances and are the most commonly used.

Some helpful information about social phobia

• Social phobia is one of the most common anxiety disorders, affecting approximately 3% of the general population. Onset usually occurs in late childhood or early adulthood, and the course is often chronic.
• Anxiety disorders have a high degree of comorbidity.
• Cognitive behavioral therapy, a form of psychotherapy, is the treatment of choice for social phobia.
• Beta-blockers such as propranolol and atenolol are the agents of choice for treatment of the anxiety provoked by performance situations. SSRIs may also be useful.
• Panic attacks can be part of the presentation of social phobia but this does not mean they have panic disorder.

References

DSM IV Handbook for differential Diagnosis for PDA
Case Files Psychiatry
A Quick reference to APA practice guidelines

The story of a chronically upset person.

Case History

A 42-year-old man visits a doctor with complaints about his disturbed sleeps for last 3-4 months. It happened almost every day in last few weeks .. He had dull headaches in the evening time which was not very painful but upsetting.  For last few months he has lost interest on things which used to be his favourite.

Two years back he visited a psychiatrist with similar symptoms. That doctor suggested him to take some anti-depressant medicines. When he started taking, after a month he improved to a great extent. Then when things were alright the doctor helped him to withdraw the medicines by gradually tapering down.

But for last three months his symptoms have re-appeared. He gain feels overly dis-interested with every aspect of his life. His appetite have markedly reduced. He does not feel like working any more.

On further questioning about his family life and past episodes. He said that he is a self employed person for last 10 years. His profession involved transportation. He was initially helped by his uncle to start the business. He was very hard working so gradually he started earning well. later he owned few trucks. Two years back one of his truck met with an accident on the main road and two persons were killed on the spot.  His other truck was burnt down by the local public. Then he has to pay huge compensation to the victim's family. That incident affected the financial balance. Which might have been a reason for the episodes of depression he initially want through and treated by the doctor.  However it was well managed. But last three months he has similar repeated and continuous experiences of previous episodes of depression again.

He has his own family with a wife and two sons.  Both of them are young and still studying in school.  His current condition may affect his business and profession. During this time he did not feel like talking to people while in office. He had chronically empty feelings. 

Doctor further questioned him about his outlook towards his future life. He did not appear hopeful about his life and lost interest in everything in his day to day life. But he did not show any sign of suicidal ideation. But he feels no energy .. always feel lack of initiative and energy leading to continuous craiving for good sleep .. he continuously feel like resting in bed but his sleep is never a sound sleep and when he wakes up in the morning,  he does not feel freshened up.

Analysis

Above case indicates Major Depression.

Following are the presentation of Major Depressive Disorder

• Depressed mood
• Anhedonia (Inability to experience pleasure)
• Significant weight change or change in appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Decreased ability to concentrate or indecisiveness
• Thoughts of death or suicidal ideation
• Symptoms cause significant distress or impairment in functioning.
• There has never been a manic, hypomanic, or mixed episode.
• Symptoms are not caused by a substance of abuse, medication, or a medical condition.

Possible treatment options

In the above case the suggested treament mode is ...

• Medication with anti-depressants (SSRIs)
• Parallel sittings on Psychotherapy or Cognitive behavioral Therapy

Some general observations about the this disorder.

• It is important to rule out an underlying substance (eg, alcohol and cocaine withdrawal), medication (eg, antihypertensives, steroids), or medical condition causing depression (eg, hypothyroidism, multiple sclerosis), especially if the patient does not have a prior history of depression.
• More than 50% of patients who have had one episode of major depression will have recurrent episodes.
• The risk of further episodes of major depression increases with the number of prior episodes, the occurrence of residual symptoms of depression between episodes, and any comorbid psychiatric or chronic medical illnesses.
• The treatment that was successful for prior episodes of major depression has a higher likelihood of achieving remission in future episodes.
• Selective serotonin reuptake inhibitors, as well as bupropion, venlafaxine, mirtazapine, and duloxetine, are all first-line treatment options for major depressive disorder.

References

APA Guidelines : Treatment of Patients With Major Depressive Disorder, Second Edition
DSM IV Handbook for differential Diagnosis for PDA
Case Files Psychiatry