Behavioral Aspects of Medicine - Exam 3
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Assessment of Any Psychiatric Disorder
- History of the Present Illness
- Past Psychiatric History
- Past Medical History
- Family History
- Mental Status Exam
- Collateral History
a biologically-based, psychosocially-influenced disorder of unclear pathogenesis and heterogeneous presentation, usually with a chronic, relapsing and remitting course, and profound biopsychosocial complications requiring a comprehensive treatment approach
Schizophrenia per DSM-IV - Characteristic Symptoms
- 2 or more of the following symptoms, ea. present for significant portion of time during a 1-month period:
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative Symptoms (ie - affective flattening, alogia (unable to speak), or avolition (lack of drive/motivation)
Schizophrenia per DSM-IV - Social/Occupational Dysfunction
For a significant portion of time since the onset of the disturbance, 1 or more major areas of functioning (such as: work, interpersonal relations, or self-care) are markedly below the level achieved prior to the onset
Schizophrenia per DSM-IV - Duration
- Continuous signs of the disturbance persist for at least 6 months.
- This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet criterion A and may include periods of prodromal or residual symptoms
- Perceptions without external stimuli
- auditory, visual, tactile, olfactory (smell), gustatory (taste)
An early symptom indicating the onset of an attack or a disease
Positive S&S of Schizophrenia
- appear to reflect an excess or distortion of normal functions.
- Disorganized thought
- Disorganized behavior
Fixed, false belief(s) held despite negative evidence, and not consistent with cultural norms
Delusions associated with Schizophrenia
- (positive S&S)
- grandiose (one’s power, importance, identity)
- erotomanic (someone is deeply in love w/ them)
- nihilistic (non-existence of everything)
- somatic (funx of one’s body)
- referential (about self)
- control (by external forces)
- thought interference (by other people / forces)
Disorganized thought associated with Schizophrenia
- (positive S&S)
- loose associations
- flight of ideas
- incoherence (word salad)
- blocking (abrupt interruption in train of thought before idea is finished)
- neologisms (new words or phrases whose derivation cannot be understood)
- clanging (spoken words associated only by their sound rather than their meaning)
Disorganized behavior associated with Schizophrenia
- (positive S&S)
- Catatonia - motoric immobility
- repetitive, purposeless movements
- extreme negativism or mutism
- abnormal voluntary movements
- echolalia (repeating of words/phrases of 1 person by another; tends to be repetitive/persistent)
- echopraxia (involuntary imitation of movements made by another)
Negative S&S of Schizophrenia
- appear to reflect a diminution or loss of normal functions.
- amotivation (apathy)
- alogia (inability to speak)
- flat affect
- social isolation
Cognitive S&S of Schizophrenia
- related to thought processes
- Poor attention
- Poor working memory
DDX for schizophrenia (other psychiatric conditions)
- Mood Disorders - bipolar, major depression
- Other Psychotic D/Os - schizoaffective d/o, delusional d/o
- Substance Use - THC, hallucinogens, amphetamines, etc
- Personality D/Os - borderline, schizotypal, paranoid
- Anxiety D/Os - OCD, PTSD
- Other - delirium/dementia, malingering/factitious
DDX for schizophrenia (general medical conditions)
- Neurological - stroke, seizures, brain tumor, Parkinson’s Disease
- Endocrine - thyroid / parathyroid
- Metabolic - B12, folate, thiamine
- Infectious - HIV, syphilis, herpes
- Other - lupus, Wilson’s Disease (Cu in LBK, et al)
- Medications, porphyria (excessive excretion of porphyrins), encephalopathy
Medications associated with psychosis
- (part of DDX for schizophrenia)
- Dopaminergic drugs (L-dopa, amantadine)
- Cardiovascular meds (antiarrhythmics, digitalis)
- Antimalarial meds
- Antituberculosis meds (ethambutol, isoniazid)
- Antibiotics (ciprofloxacin)
- Antivirals (HIV meds)
- Anticonvulsants (hi doses)
- Pain meds (Opioids, ie- meperidine), Indomethacin
- Undifferentiated (Criteria for Dx are met, but criteria for other subtypes are not met)
- Residual (Although there is absence of prominent delusions, hallucinations, disorganized speech, & grossly disorganized or catatonic behavior, there is continuing evidence of the disturbance).
Epidemiology of schizophrenia
- 1 - 1.5% lifetime prevalence
- 2 million patients in the US
- 100,000 new cases each year
- Onset at a young age - male (15-25 yo), female (20-35 yo)
- Black = White
- M = F
- City > Rural
- all cultures
- Slight low SEC
- late winter births
- Familial - twin concordance (MZ 45%; DZ 20%), 10% if first degree relative, 3% if second degree relative
Structural Abnormalities in Schizophrenia
- Ventriculomegaly (Lateral and Third ventricles)
- Diffuse gray matter loss
- Decreased Volume in Frontal & Temporal cortex
- Possible thalamic volume reductions
- Reduced Size of Corpus Callosum
Neurodevelopmental Model of Schizophrenia
Schizophrenia grows out of abnormal brain development beginning in utero, based on genetic susceptibility and in many cases environmental insults, with a delayed symptom activation following adolescence-related developmental changes in the central nervous system, and a fairly static picture thereafter.
Relapse triggers for Schizophrenia
- non-adherence to treatment
- inadequate life support
- inadequate socialization / recreation
- substance abuse
- high expressed emotion
Favorable Prognostic Signs of Schizophrenia
- acute onset
- good premorbid functioning
- few negative / cognitive symptoms
- supportive family
Suicide in Schizophrenia
- 20% attempt
- 10% complete
- 50% of the completes occur within 6 months of hospital discharge
- most common early in illness course
- improving insight
- higher premorbid functioning
- low dose of meds
- abrupt med d/c
- social isolation
Complications of Schizophrenia
- legal / violence
- family / interpersonal
Treatment Principles of Schizophrenia
- disease management
- rehabilitation / recovery
- continuum of care
- integration / coordination
- pharmacotherapy - essential, but insufficient by itself
Treatment Stages of Schizophrenia
- Acute Stage - 0-1 months, Develop tx plan, assess/work up,
- Stabilization Stage (continuation) - 1-6 months,
- Stable Stage (maintenance) - 6+ months,
Pharmacotherapy for Schizophrenia (meds)
- chlorpromazine (CPZ) (Thorazine)
- perphenazine (Trilafon)
- fluphenazine (Prolixin)
- other typicals:
- haloperidol (Haldol)
- loxapine (Loxitane)
- clozapine (Clozaril)
- risperidone (Risperdal)
- olanzapine (Zyprexa)
- quetiapine (Seroquel)
- ziprasidone (Geodon)
- aripiprazole (Abilify)
First Generation Antipsychotics
- Typical, Neuroleptic
- Post-synaptic D2 blockade
- Non-selective for DA
- Positive symptom efficacy
- Extrapyramidal/motor toxicity
Second Generation Antipsychotics
- 5HT/DA anatgonism, partial DA agonism
- Selective for DA
- Positive, negative, cognitive efficacy
- Metabolic toxicity
- all have 70% response at 2-8 wks (except clozapine – may take longer)
- atypicals as 1st-line:
- superior negative / cognitive syx improvement
- enhanced tolerability
- polypharmacy / augmentation strategy often required
- rapid initiation
- stay on meds
- minimum effective dose
- depot antipsychotics available (depot = long-acting injectable formulation)
Psychosocial Treatments for Schizophrenia
- supportive therapy
- milieu therapy
- syx management
- family psycho-ed
- crisis intervention
- social skills training
- cognitive remediation
- psychosocial rehab
- "personal therapy"
- supplemental therapies
- ?psychodynamic psychotherapy
Substance Use Disorder
- Drug use is NOT isolated, but it is intimately intertwined with a range of common, long-standing human issues and societal problems.
- Need integration of scientific knowledge and recommendations
Epidemiology of Substance Use Disorder
- High levels of illicit drug use
- 22.5 million (9.4%) Americans aged 12 and older classified with substance abuse or dependence
- Major causes of family dysfunction / both work-related and non-work-related accidents
- Associated with violent crimes
- Yearly costs to the US economy are $238 billion
- Of this, $34 billion are attributed to health care costs
- Shift in use to older adults aged 35 to 54 years
- Use of illegal drugs among adolescents continues to decline modestly but abuse of some prescription drugs (pain killers) is increasing
- Higher rates of use by blacks than by whites and Hispanics
- Ethnic differences
- Case of Native Americans
- Programs (treatment and prevention) should address the general needs of the community and the special needs of subgroups
Genetics and Neurobiology of Substance Use D/O
- Addictive disorders are complex genetic diseases
- Genetic factors interact with environmental factors to affect risk
- Variations in many different genes, acting together with variations in the environment
- Very much like type II diabetes or HTN in which genes, behaviors, and choices affect vulnerability
- Environmental factors - initiation and continuation of use beyond the experimental level
- Genetic factors - take precedence in individuals who move from use to dependence
- A family history of substance abuse is one of the strongest risk factors for development of a SUD
- Religious involvement remains the strongest protective factor in the prevention of substance use initiation among children, adolescents, and adults
- Drug use vulnerability factor that is shared across all drugs of abuse in addition to specific factors
Neurobiology of Substance Use D/O
- Not a disorder of self-control
- Cycle of addiction (reward and stress system)
- Positive reinforcement (drug euphoria) and negative reinforcement (withdrawal, craving, hedonic dysregulation)
- Drug-related cues and stress increase craving
- Brain disease - Prefrontal cortical dysfunction, Neurotransmitters involved
Results of Substance Use D/O
- Feel good - euphoria/reward
- Feel better - reduced negative feelings
- Develop craving, tolerance, withdrawal
Cognitive Deficits of Substance Use D/O
- Memory problems - short term loss
- Impaired abstraction
- Preservation using failed problem-solving practices
- Loss of impulse control
- Similar performance to those with brain damage
Screening and Assessment for Substance Use D/O
- Screening Tools using CAGE/S-MAST/AUDIT-C
- Screening means the use of procedures to identify individuals with alcohol or other substance abuse problems or those who are “at risk” for developing such problems - brief
- Assessment has the goal to gather more detailed information in order to make a diagnosis and develop a treatment plan
- Problem assessment stage uses DSM-IV-TR and other assessment tools / severity of use / Withdrawal
- Personal assessment stage - readiness to change; high-risk situations; self-efficacy; motivation; coping skills; spirituality and religion; craving and cue reactivity; twelve-step affiliation
- Laboratory screening
- Where do you go after screening?
Multidisciplinary Assessment Profile for Substance Use D/O
- Elements of assessment
- Assessing co-occurring disorders
- Neuropsychological deficits
- Placement criteria, clinically meaningful with 6 biopsychosocial assessment dimensions
Alcohol Use D/O
- Class of drug - Sedatives/Hypnotics
- The most common and potentially lethal SUD
- 13.8 million Americans have developed problems from drinking alcohol
- Complications of alcohol
- Alcohol withdrawal syndrome
- Pathophysiology of withdrawal
- Related issues - detoxification, fetal alchohol syndrome/effects, loss of judgement, suicide/homicide, DWI/DUI concerns, poly drug use, legality issues
Sedative-Hypnotics and Barbiturates
- Benzodiazepines, used for treatment of anxiety disorders, are also abused
- Most commonly comorbid with other SUDs
- Combined with alcohol is very risky
- Neuropsychiatric complications are the hallmark of their abuse
- Withdrawal is potentially dangerous and resembles alcohol withdrawal
- Barbiturate withdrawal could be very severe and is the most dangerous type of drug withdrawal
- Class of drug - stimulant
- Related issues - High relapse potential, high reward, euphoria, agitation, paranoia, "crash", sleeping, craving, obsessive rituals, risk of paranoia, no medications currently available
- Class of drug - stimulant
- Related issues - high energy levels, repetitive behavior patterns, incoherent thoughts and confusion, auditory hallucinations and paranoia, binge behavior, long-acting (up to 12 hours)
- Class of drug - opiate
- Related issues - detoxification, medications available, euphoria, cravings, intense withdrawal, physical pain
- Class of drug - prescription
- Popular with youth and young adults
- Significant health risk - Neuron destruction with Ecstasy
- Users believe they know how to reduce risks - WRONG
- Use increasing for Oxycontin, decreasing for esctasy
Other drugs of abuse
- Inhalants (“Huffing”)
- Anabolic-androgenic steroids
- Class of drug - Hallucinogen
- Related issues - amotivational, arrested development, memory/learning problems, long detecting time, legalization, medical use issues, health issues
- Found exclusively in tobacco
- Stimulant and depressant of the brain
- Smoking is a cause of CV disease and accounts for 18% of strokes
- Is a risk factor for CAD
- Accounts for 85% of all lung cancer deaths
- Association with some cancers (12+ anatomic sites)
- Nicotine withdrawal syndrome can be a hallmark of dependence
- Treatment works but what kind of treatments are effective??? Pharmacotherapies and psychosocial interventions
- Does assessment matter??? YES!
Treatment of Substance Use D/O
- General principles - therapeutic alliance and empathic style versus confrontational approaches
- How to integrate evidence-based practice with the humanitarian recovery-based model that values the patient’s personal experiences???
- Efficacy / cost-effectiveness / cost-benefit
- Different psychosocial modalities
Myths of Addiction Treatment
Myth of self-medication, myth of character weakness, myth of holding one's liquor, myth of detoxification, myth of brain reversibility
Myth of Brain reversibility in Substance Use D/O
- Addiction produces permanent neurotransmitter and chemical changes
- "Kindling" increases risk of permanent paranoia and hallucinations (from alcohol and stimulants)
"Kindling" WRT Substance Use D/O
Theory: episodes themselves may damage the brain in some way, making it more vulnerable; this may eventually lead to spontaneous (w/o the trigger of the substance, eg- alcohol) incidents of paranoia and hallucinations
Recovery from Substance Use D/O
regain: abstinence, sense of responsibility, range of emotions, intimacy
mentally impaired chemically addicted
Compounding Issues in Recovery from Substance Use D/O
- Single parent
- Domestic violence
- Living situation
- Extended family
Matching Treatment to Individual's Needs for Substance Use D/O
- No single treatment is appropriate for all individuals
- Effective treatment attends to multiple needs of the individual, not just his/her drug use
- Treatment must address medical, psychological, social, vocational, and legal problems
- Multi-systemic and Multi-modal
Co-occuring D/O with Substance Use D/O
- Very common clinical entity in all settings
- Comorbidity worsens the course of each disorder
- Bipolar disorder with the highest rate of SUDs
- Medical comorbidities complicate the picture
- Treatment should be integrated
- Difficulty getting to sleep or staying asleep
- Intermittent wakefulness during the night
- Early morning awakening
- or a combination of any of these
Common Factors of Dyssomnias
- Stress of Life
- Physical Discomfort
- Daytime Napping
- Early Bedtimes
- Shift Work w/ “chaotic scheduling”
- Psychiatric disorders
- Manic Disorders
- Abuse of Alcohol
- Heavy Smoking (> 1 ppd)
- Pain Syndromes
- Medication Side Effects
Medical Conditions and Dyssomnias
- Sleep Apnea (ie- obstructive, OSA; hypopnea syndrome) common problem
- Shift Work Sleep D/O (common problem)
- Excessive daytime fatigue (common problem)
- Narcolepsy, incl. sleep attacks that may occur during any type of activity
Evaluation for Dyssomnia
Treatment for Dyssomnia
- Psychological Strategies:
- Sleep Hygiene
- Medical Strategies:
- Continuous Positive Airway Pressure - (CPAP)
Medications for Dyssomnia
- Stimulants (class II):
- Dextroamphetamine (Dexedrine)
- Methylphenidate (Ritalin)
- OSA Hypopnea Syndrome, Narcolepsy, Shift Work Sleep D/O:
- Stimulants (class IV):
- Modafinil (Provigil)
- Armodafinil (Nuvigil)
- Establish regular to bed & wake up times
- Use the bedroom only for sex & sleep
- If still awake after 20 minutes, leave the bedroom & only return when sleepy
- Discontinue Caffeine & Nicotine, at least in the evening
- Avoid Alcohol as it may disrupt continuity of sleep
- Limit fluid intake in the evening
- Establish daily exercise regimen
- Relaxation techniques can help
Medications for Insomnia
- Best to limit use of medication to 1 – 2 weeks
- Hypnotics - Benzodiazepines & "Other"
- Antihistamines, ie- Diphenhydramine (Benadryl)
- Trazodone (Desyrel), an antidepressant, in low dose at bedtime (off-label use)
Hypnotics for Insomnia
- Benzodiazepines (Class IV):
- Flurazepam (Dalmane)
- Estazolam (ProSom)
- Temazepam (Restoril)
- Eszopiclone (Lunesta) (Class IV)
- Ramelteon (Rozerem)
- Zaleplon (Sonata) (Class IV)
- Zolpidem (Ambien) (Class IV)
- significant distress and impairment
- Encountered in medical settings more than in mental health settings
- Not based on the absence of identifiable medical explanation (except conversion disorder)
- Characterized by the way they present and interpret the somatic symptoms
Somatic symptoms contributing factors
- genetic and biological vulnerability
- early traumatic experiences
- cultural/social norms
Changes from DSM IV to DSM V
- No more "Pain disorder"
- No more "Hypochondriasis" now called Somatic symptom disorder or Illness anxiety disorder
- No more "Body Dysmorphic Disorder" now part of anxiety disorder category
- Malingering is not a psychiatric diagnosis in DSM V
Exaggerate or feign illness in order to escape duty or work
Diagnostic features of Somatic Symptom D/O
- Becomes center focus of their life
- Seeking medical care excessively, but doesn't alleviate concerns
- More extensive interventions → worsens sx
- Seek multiple doctors, very sensitive to medication side effects, feel their assessment and tx have been inadequate
Associated features of Somatic Symptom D/O
- Avoids physical activity
- repeatedly checks body
- Difficult to redirect
- Not receptive to assurance
- Referral to mental health may be met with refusal
Somatic Symptom D/O Associated with Depressive D/O
- Increased suicide risk
- Prevalence is 5-7%
- Females > males
- Risk factors:
- negative affectivity
- few yrs of education
- low socioeconomic status
- recent stressful event
Illness Anxiety D/O
- Preoccupied with medical illness
- Somatic symptoms less intense
- +/- medical condition
- More anxious about medical issue than focusing on actual physical pain
- High levels of worry about illness; think the worst about their health
- Excessive and disproportionate anxiety to condition
- Not alleviated by reassurance
- Excessive research, repeatedly seek reassurance from others, examines themselves incessantly
- Chronic, relapsing course.
- Onset early and middle adulthood
- Similar male to female ratio
- Risk factors:
- major life stress
- health problem
- childhood abuse
- childhood illness
- Various types:
- Motor - weakness, paralysis, tremor...
- Sensory - vision, hearing, skin sensation
- Nonepileptic seizures
- Dysphonia, dysarthria
- *Not simply diagnosis of exclusion
- *Perform exams to demonstrate incompatibility
- 2-5/100,000 per yr
- Onset in third or fourth decade usually
- Transient symptoms common > persistent
- Prognosis better for young children > adults
- Risk factors:
- Temperamental - maladaptive personality traits
- Environmental - childhood abuse or neglect, stressful life event
- Genetic and physiological - presence of neuro disease with similar sx
- Positive prognosis - short duration, acceptance of dx
- Negative prognosis - maladapative personality, comorbid physical disease, receipt of disability benefits
- Causes substantial disability
- Comorbidity - anxiety disorders, depressive disorders
- Tx - Attention to possible organic disease is critical
- Then treat underlying psychological condition
La belle indifference
lack of concern about the nature or implications of the symptom
- Factitious disorder imposed on another (previously "factitious disorder by proxy")
- Falsification of medical or physiological symptoms that are associated with the identified deception
- Need to demonstrate the surreptitious action that causes the illness
- Absence of obvious external rewards
- May be viewed as more ill or impaired. → leads to excessive clinical intervention
Eating D/O - Genetics
- 6-10 fold increase risk in women with 1° relative who have D/O
- Monozygotic twins - higher rate of concordance for eating D/O than dizygotic twins
Eating D/O - Family
Family distress of any kind can be a significant factor in the development of an eating disorder. Family characteristics associated with eating disorders may include high perceived parental expectations for achievement and appearance, families who have difficulties managing conflict, poor communication style (particularly related to feelings), and enmeshment and, less frequently, estrangement between family members, devaluation of the mother or the maternal role, and marital tension.
Eating D/O - CNS
- Decreased levels of the neurotransmitter nor epinephrine may partially account for the bradycardia and hypotension seen with starvation. Serotonin plays a role in the brain's appetite and satiety centers and may account for some neuropsychiatric changes and loss of appetite
- MRI studies have shown brain changes in patients with anorexia nervosa, including decreased volumes in the gray and white matter with increased CSF volume
- Refusal to maintain body weight at or above a minimally normal weight for age and height (eg, weight loss or failure to gain weight that leads to a body weight less than 85 percent of that expected for age and height).
- Intense fear of gaining weight or becoming fat, even though underweight
- Disturbed perception of one's body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
- In postmenarcheal females, amenorrhea, ie, absence of at least three consecutive menstrual cycles. Menstruation that occurs only after hormonal treatment, eg, estrogen, is considered amenorrhea.
Two subtypes of anorexia nervosa
- Restricting subtype
- characterized by dieting or excessive exercise, and the absence of regular binge-eating (eating an amount of food that is definitely larger than most people would eat under similar circumstances) or purging during the current episode of anorexia nervosa.
- Binge-eating/purging subtype
- characterized by episodes of binge-eating or purging at least once per week
Diagnosis of anorexia nervosa
- requires all of the following:
- Body weight is maintained at least 15% below that expected, or BMI ≤17
- Weight loss is self-induced by avoiding "fattening foods" and one or more of the following:
- Self-induced vomiting
- Self-induced purging with laxatives
- Misuse of diuretics
- Misuse of appetite suppressants
- Excessive exercise
- Distortion of body-image; a dread of fatness persists as an intrusive, overvalued idea; and patients impose a low weight threshold upon themselves
- An endocrine disorder involving the hypothalamic-pituitary-gonadal axis manifests in women as amenorrhoea and in men as a loss of sexual interest and potency. (An exception is the persistence of vaginal bleeds in anorexic women who are receiving replacement hormonal therapy.) There may also be elevated levels of growth hormone and cortisol, changes in the peripheral metabolism of the thyroid hormone, and abnormal insulin secretion.
Anorexia Nervosa vs. Unipolar major depression
Decreased weight often occurs in major depressive disorder However, the weight loss in major depression is due to loss of appetite and is not intentional, and reluctance to gain weight and distorted body image are not present. In addition, depressed patients are usually anergic; by contrast, anorexia nervosa patients often exercise excessively.
Anorexia Nervosa vs. Social phobia
Patients with either social phobia or anorexia nervosa may be embarrassed to eat in public. However, patients with social phobia recognize that the fear is excessive or unreasonable, and they are not emaciated.
Anorexia Nervosa vs. Obsessive-compulsive disorder
Obsessions and compulsions regarding food can occur in both anorexia nervosa and obsessive-compulsive disorder. However, patients with obsessive-compulsive disorder are not emaciated and recognize that the preoccupations and behaviors are excessive or unreasonable.
Anorexia Nervosa vs. Body dysmorphic disorder
Patients with anorexia nervosa may be excessively preoccupied with an imagined defect in body appearance, as occurs in body dysmorphic disorder. However, the preoccupation in anorexia nervosa concerns body weight ("fatness") or shape, whereas in body dysmorphic disorder the imagined defect typically involves the face or head. In addition, body dysmorphic disorder does not manifest with emaciation and a fear of becoming fat.
Anorexia Nervosa vs. Psychotic disorders
Psychotic patients may have delusions about food (eg, food is poisoned), refuse to eat, and lose weight. In contrast to anorexia nervosa, these psychotic disorders usually do not include fear of gaining weight or distorted body image.
Anorexia Nervosa vs. Attention-Deficit/Hyperactivity Disorder
Restlessness and impaired concentration are common to both ADD/ADHD and anorexia nervosa. However, in anorexia nervosa, these symptoms are typically due to low weight and improve with normalization of body weight.
Medical Complications of Anorexia Nervosa
- Constitution/whole body:
- Cachexia and low body mass index, Arrested growth
- Myocardial atrophy, Mitral valve prolapse, Pericardial effusion, Brachycardia, Arrhythmia, which may cause sudden death, ECG changes, Long QT syndrome, Increased PR interval, First-degree heart block, ST-T wave abnormalities, Hypotension, Acrocyanosis
- Amenorrhea, Infertility, Pregnancy and neonatal complications
- Osteoporosis and pathologic stress fractures, Euthyroid hypothyroxinemia, Hypercortisolemia, Hypoglycemia, Neurogenic diabetes insipidus
- Gastroparesis (delayed gastric emptying), Constipation, Gastric dilatation, Increased colonic transit time, Hepatitis, Superior mesenteric artery syndrome
- Renal and electrolytes:
- Decreased glomerular filtration rate, Renal calculi
- Impaired concentration of urine, Dehydration, Hypokalemia, Hypomagnesemia, Hypophosphatemia, Hypokalemic nephropathy, Hypovolemic nephropathy
- Pulmonary muscle wasting, Decreased pulmonary capacity, Respiratory failure, Spontaneous pneumothorax and pneumomediastinum
- Enlargement of peripheral lung units without alveolar septa destruction
- Anemia (normocytic, microcytic, or macrocytic), Leukopenia, Thrombycytopenia
- Cerebral atrophy (decreased gray and white matter), Enlarged ventricles, Cognitive impairment, Peripheral neuropathy, Seizures
- Xerosis (dry skin), Lanugo hair (fine, downy, dark hair), Telogen effluvium (hair loss), Carotenoderma (yellowing), Scars from self-injurious behavior (cuts and burns)
- Muscle wasting, Vitamin deficiencies
- Refeeding syndrome
Medical Evaluation of Pt with Anorexia Nervosa
- Should be evaluated for medical complications.
- Patients with medical complaints due to AN often attempt to mask their thinness and conceal their eating disorder from clinicians by wearing bulky clothes. In addition, patients may inflate their body weight by hiding objects in their clothes and drinking water.
- Findings from the medical evaluation help determine whether the patient requires hospitalization.
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating).
- Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.
- Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of anorexia nervosa.
- PURGING TYPE:
- Self induced vomiting or misuse of laxatives, diuretics or enema
- NON PURGING TYPE:
- Fasting or excessive exercise
Bulimia Nervosa Epidemiology
Prevalence rates of 1 to 1.5 percent of women have been reported .Rates for younger adolescents are generally lower than those for college students.
Bulimia Nervosa Evaluation
- Medical history — lethargy, irregular menses, abdominal pain and bloating, and constipation.
- Physical examination — Within the context of a complete physical examination, key portions include weight and height; vital signs including heart rate, blood pressure both supine and standing, and temperature; skin; oropharyngeal; abdominal and neurologic examination (to look for other causes of weight loss or vomiting, e.g., abdominal or central nervous system mass).
- Common physical signs :
- Hypotension (< 90 mm Hg systolic)
- Xerosis (dry skin)
- Parotid gland swelling
- Erosion of dental enamel
- Other signs that are often present include hair loss, edema, and scarring or calluses on the dorsum of the hand.
Medical Complications of Bulimia Nervosa
- Parotid and submandibular (salivary) gland hypertrophy, with puffy or swollen cheeks
- Loss of gag reflex
- Esophageal dysmotility
- Abdominal pain and bloating
- Heme-stained emesis
- Mallory-Weiss syndrome (esophageal tears)
- Esophageal rupture (Boerhaaves’ syndrome)
- Gastroesophageal reflux disease (GERD)
- Gastric dilation
- Diarrhea and malabsorption
- Protein-losing gastroenteropathy
- Hypokalemic ileus
- Colonic dysmotility
- Melanosis coli
- Cathartic colon
Eating D/O NOS
- This category includes patients with clearly aberrant eating patterns and weight management habits who do not meet the criteria for anorexia nervosa or bulimia nervosa. The most notable prototypes are binge eating disorder, night eating syndrome, sleep related eating disorder, and purging disorder.
- ED-NOS occurs in approximately 3 to 5 percent of women between the ages of 15 and 30 in Western countries
defined as eating an amount of food in a discrete period of time that is definitely larger than most people would eat in a similar period of time under similar circumstances without the inappropriate compensatory behaviors that are seen in bulimia nervosa
General criteria for personality disorder
- Enduring pattern of inner experience and behavior that deviate markedly from the expectations of the individual's culture.
- The pattern manifest in the following areas:
- Cognition - ways of perceiving self and other people.
- Affectivity - range, liability of emotional response
- Interpersonal functioning.
- Impulse control.
- Impairment in social and occupational functioning.
- Onset in adolescent or early adulthood.
- It is not account for other mental illness.
- Not due to direct physiological effect of substances.
Cluster A Personality D/O's
- Paranoid personality disorder.
- Schizoid personality Disorder.
- Schizotypal personality disorder
Paranoid personality disorder
- Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.
- Present in early adulthood and characterized by 3 criteria of :
- Excessive sensitivity to setbacks, persistent grudges, misconstruing others actions, recurrent suspicions without justification, conspiracy theories
- Psychotherapy - is the treatment of choice. Therapist must remember that trust and toleration of intimacy are troubled areas.
- Group psychotherapy - can be useful to improve social skills.
- Pharmacotherapy for agitation and anxiety:
- Diazepam, low dose of haldol
Schizoid personality disorder
- Detachment from social relationships and restricted range of expression of emotions in interpersonal setting.
- Neither desires nor enjoys closest relationship.
- Enjoys solitary activities
- Has little if any, interest in having sexual experiences with another person
- Takes pleasure in few, if any activities
- Lack of close friends or confidents.
- Appears indifferent to the praise or criticism of others
- Shows emotional coldness detachment, or flattened affectivity.
- Not that they want to avoid people, but the emotions of intimacy and self-disclosure
- Differential diagnoses:
- Avoidant personality disorder - avoidant patients avoid social situations due to anxiety or incompetence, but those with schizoid PD do so because they are genuinely indifferent to social relationships
- Asperger’s- SPD does not have difficulty in eye contact, repetitive behavior, or nonverbal communication
- Psychotherapists tend to encourage introspection - as trust develops pt may reveal a plethora of fantasies imaginary friends and fears of unbearable dependence.
- Group therapy - silent for long periods.
- Pharmacotherapy - antipsychotics like Risperdal or Olanzapine for negative symptoms of anhedonia and blunted affect
Schizotypal personality Disorder.
- Social and interpersonal deficits
- Need for social isolation, anxiety in social situations
- Eccentricity of behavior.
- Odd believes or magical thinking.
- Odd thinking and speech.
- Co-occurs with Major Depressive Disorder and generalized social phobia
- May develop schizophrenia, most do not
- Differential diagnoses - avoidant, paranoid, obsessive-compulsive, or borderline personality disorders.
- Psychotherapy - Therapists understand that patients have a peculiar way of thinking, cults, strange religious practices and occult.
- Pharmacotherapy - antipsychotic meds for ideas of reference, illusions and other symptoms. Antidepressants when necessary. SSRIs for obsessive-compulsive patients.
Cluster B Personality D/O's
- Antisocial Personality disorder
- Borderline personality disorder
- Histrionic Personality disorder
- Narcisistic personality disorder
Antisocial Personality disorder
- Disregard for and violation of the rights of others occurring since age 15 years. Three or more of the following:
- Failure to conform to social norms with respect to lawful behaviors. Repeatedly performing acts that are grounds or arrest.
- Repeated lying, use of aliases or conning others for personal profit.
- Failure to plan ahead.
- Irritability and aggressiveness as indicated by repeated physical fights or assaults.
- Reckless disregard for safety of self and others
- Repeated failure to sustain consistent work behavior or honor financial obligations.
- Lack of remorse as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
- The individual is at least 18 years.
- Evidence of conduct disorder before age 15 years.
- Psychotherapy - Self help groups have been ore useful than jails in alleviating the disorder. Before treatment can begin, firm limits are essential. Dealing with self-destructive behaviors.
- Pharmacotherapy - must used judiciously.
- If pt shows evidence of ADHD - Ritalin may be an option. Depakote and Carbamazepine are used to control impulse behavior.
Borderline personality disorder
- Pervasive pattern of instability of interpersonal relationships self image, and affects, and marked impulsivity beginning by early adulthood.
- Indicated by 5 of the following:
- Frantic efforts to avoid real or imagined abandonment.
- Pattern of instable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance - markedly and persistently unstable self image or sense of self.
- Impulsivity at least in 2 areas - spending, sex, substance abuse, reckless driving, binge eating
- Recurrent suicidal behavior, gesture, or threats, or self-mutilating behavior
- Affective instability due to marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger.
- Transient stress related paranoid ideation or dissociative symptoms.
- Causes of borderline personality D/O:
- Related to PTSD and childhood trauma
- 65% genetic heritability
- Brain abnormalities- smaller hippocampus (like PTSD), amygdala and more active (like OCD), less active prefrontal cortex, hyperactive HPA axis
- Pschycotherapy and pharmacotherapy for best results.
- Reality-oriented approach is more effective than in depth-interpretation of the unconscious. Projective identitification, splitting, act out impulses.
- Behavior therapy to control pt impulses and angry outbursts and to reduce sensitivity to criticism and rejection. Social skill training.
- Dialectic behavioral therapy
- Pharmacotherapy - antipsychotics, antidepressants, MAOI, Xanax, Carbamazepine, SSRI.
Histrionic Personality disorder
- Pervasive pattern of excessive emotionality and attention seeking beginning by early adulthood and present by 5 of the following:
- Uncomfortable in situations in which he or she is not the center of attention.
- Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
- Displays rapidly shifting and shallow expression of emotions.
- Consistently uses physical appearance to draw attention to self.
- Has a style of speech that is excessively impressionistic and lacking in detail.
- Show self dramatization, theatricality and exaggerated expression of emotions.
- Easily influenced by others or circumstances.
- Consider relationships to be more intimate than they actually are.
- Psychotherapy - clarification of their inner feelings is an important therapeutic process.
- Psychoanalytic oriented psychotherapy.
- Pharmacotherapy - Can be used when symptoms are target. Antidepressant, anti-anxiety and antipsychotics.
Narcisistic personality disorder
- Pursuit of gratification from vanity, self-focus in interpersonal relationships, difficulty with empathy, hypersensitivity to insults, flattery to people who admire them and detesting those who do not, bragging
- Grandiose sense of self importance. (exaggerate achievements and talents.)
- Preoccupied with fantasies of unlimited success. Power.
- Requires excessive admiration.
- Grandiose sense of self importance. (exaggerate achievements and talents.)
- Preoccupied with fantasies of unlimited success. Power.
- Requires excessive admiration.
- Sense of entitlement.
- Interpersonal exploitative, takes advantage of other to achieve his or her own ends.
- Lack of empathy - is unwilling to recognize or identify with the feelings and needs of others.
- Envious of others or believes that others are envious of him or her.
- Psychotherapy - difficult since they have to renounce their narcissism to make progress. Group therapy.
- Pharmacotherapy - lithium has used for mood swings. SSRIs.
Dialectical behavior therapy
- Change patterns of behavior such as self harm, suicidal thinking, and substance use.
- Increase awareness about triggers that lead to reactive states, encourage coping skills
- Assumes people are doing the best they can but are lacking skills or are influenced by positive or negative reinforcement in their environment
Cluster C Personality D/O's
- Avoidant personality disorder
- Dependent Personality disorder
- Obsessive compulsive personality disorder
Avoidant personality disorder
- Pervasive pattern of social inhibition, feeling of inadequacy, and hypersensitivity to negative evaluation
- Avoid occupational activities that involve significant interpersonal contact.
- Unwilling to get involved with people unless certain of being liked.
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
- Is preoccupied with being criticized or rejected in social situations.
- Views self as socially inept, personally unappealing, or inferior to others.
- Is unusually reluctant to take personal risk or to engage in any news activities because they may prove embarrassing.
- Psychotherapy - Depend of solidifying an alliance with patients. Therapist must convey an accepting attitude toward the patient fears.
- Failure can reinforce patient’s already poor self-esteem. Group therapy to understand how sensitivity to rejection affect themselves and others.
- Assertiveness training.
- Pharmacotherapy is used to manage anxiety and depression common in avoidant personality disorder.
- B-adrenergic antagonist - Atenolol for autonomic neuro-system hyperactivity which tends to be high.
Dependent Personality disorder
- Pervasive and excessive need to be take care of that leads to submissive and clinging behavior and fears of separation.
- 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.
- Difficulty initiating project or doing things on his or her own.
- 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.
- Unrealistically preoccupied with fears of being left to take care of himself or herself.
- Treatment - Psychotherapy insight-oriented therapy enable to understand the antecedent of their behavior.
- Pharmacotherapy - to target specific symptoms such as anxiety and depression.
Obsessive compulsive personality disorder
- Pervasive pattern of preoccupation with orderliness, perfectionism, and mental interpersonal control, at the expense of flexibility openness and efficiency.
- Preoccupied with details rules, lists, order organization or schedule to the extent that the major point of the activity is lost.
- Shows perfectionism that interferes with task completion. (unable to complete a project because his or her own overly strict standards are not met.)
- Is excessively devoted to work and productivity to the exclusion of leisure activities and friendship.
- Over conscientious scrupulous, and inflexible about matter of morality, ethics, or values.
- Unable to discard worn-out or worthless objects even when they have no sentimental value.
- Reluctant to delegate task or to work with others unless they submit to exactly his or her way of doing things.
- Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
- Shows rigidity and stubbornness.
- Psychotherapy - Group therapy and behavioral therapy can be helpful.
- Pharmacotherapy - clomipramine (Anafranil). Fluoxetina in high doses.
- Amnestic Disorder
- R/O Cognitive D/O's with MSE, onset recent or chronic, fluctuating course?
MSE with respect to Cognitive D/O's
- ADLs, Speech, thought process, mood
- AAO to self, location, time. (awake, alert, oriented)
- Short term memory (3 words in 3 minutes) without and with category prompt
- Visual or Auditory Hallucinations?
- Ability to abstract
- Include level of education
an important element of attention, shifts attention and behavioral readiness away from stimuli that do not possess high levels of intrinsic salience.
a process that opposes habituation and reflects an increase in orienting response.
- Although attention is often thought of as a process that prepares the individual for optimal sensory intake, it is also involved in response selection and control.
- We direct our behavior to obtain information that will allow us to select the most salient stimuli and optimal responses from available alternatives.
- Attention suppresses the probability of response to non-target stimuli (inhibition) and increase the probability of response to targets (enhancement).
dependent on the ability to efficiently shift from one response alternative to another in accordance with changing environmental demands.
sustained attention directed toward specific targets.
executive function, working memory.
The thalamus situated between the cerebral cortex and midbrain. Its function includes relaying sensory and motor signals to the cerebral cortex, along with the regulation of consciousness, sleep, and alertness.
Reticular Activating System
composed of several neuronal circuits connecting the brainstem to the cortex
on both sides of the thalamus, under the cerebral cortex includes the hippocampus, amygdala, includes emotion and long-term memory.
Bottom Up Modulation of Attention
- ARAS (Ascending Reticular Activating System) influences attentional modulation, without displaying any selectivity for sensory modality.
- Transition from relaxed wakefulness to intense attentiveness is associated with the activation of the midbrain reticular formation.
- Components of ARAS are the pacemaker of EEG rhythms. Desynchronized fast activity is associated with arousal, excitement, and REM sleep. High voltage slow waves are associated with drowsiness and stage 3 and 4 of sleep.
Top Down Modulation of Attention
Prefrontal and limbic system exert a top-down influence upon all types of attention modulation.
ARAS and Thalamic relay
- Brainstem sends acetylcholine to all nuclei of thalamus
- Reticular nucleus of thalamus sends GABA to other nucleus of thalamus and inhibit transferring of information to cortex.
- transmitter-specific extra thalamic pathways:
- Acetylcholine is necessary to maintain arousal-related low voltage fast activity in EEG. Anticholinegics interferes with numerous attention-related processes.
increases the postsynaptic evoked response relative to spontaneous activity, thus enhancing the signal-to-noise ratio in neural transmission.
can induce an arousal-related pattern of low-voltage fast activity in the cerebral cortex. Serotonergic agonists reduce distractibility in a two-choice runaway task, suggesting that serotonin may modulate the sensory gating of behaviorally relevant cues.
- (in Ventral Tegmental Area)
- are selectively responsive to motivationally relevant stimuli.
- (projection from hypothalamus to cortex)
- regulate cortical arousal
When less external stimuli interpersonal or light get confused, ataxic, fall.
- Reduced ability to focus, sustain or shift attention
- Change in cognition. Not dementia.
- Onset hours to days. Fluctuates
- Evidence from History, PE, or Labs of medical or substance intoxication/withdrawal etiology, multiple etiology or NOS
- Medical cause
- Fluctuating Course
- Recent onset
- Attention impairment
- Thinking/Cognition disturbance
Who gets delirium?
- 80% terminally ill
- 45% S/P Hip fracture
- 35% hospitalized with AIDS
- 30% in MICU
- 20% Severe Burns
- 10 to 30% of medically hospitalized.
- Stress, pain, insomnia, pain meds, electrolyte imbalance, infection, fever, blood loss, age, # of medications, prior brain damage, prior delirium, alcohol dependence, diabetes, cancer, sensory impairment, male
Delirium Etiology etc
- CNS, Systemic intoxication or withdrawal.
- Evaluate all medications!
- EEG usually overall slowing except alcohol/sedative withdrawal low voltage high frequency
- Reticular Activating System for attention and arousal.
- Delirium often too much anticholinergic medication
Treatment of Delirium
- If too much anticholinergic, treat with acetylcholinesterase inhibitor Physostigmine 1 to 2 mg IV or IM repeat in 15 to 30 minutes.
- Frequent orientation.
- For agitation - Haldol 2mg to 5mg po or IM repeat in an hour if necessary.
- Avoid phenothiazines (ex Thorazine) because has much anticholinergic effect.
- For Parkinson Pt , try Quetiapine or Clozapine if treatment resistant.
Prodrome to delirium
Gradual impairment in Cognitive function
- Subjective Memory Impairment (SMI)
- Mild Cognitive Impairment (MCI)
Subjective Memory Impairment (SMI)
In community Studies, majority do not have MCI or Dementia but some do. If younger Pt, SMI is likely depression or anxiety. Most Pts with objective memory impairment do not report SMI
Mild Cognitive Impairment (MCI)
Not normal for age. Cognitive decline. Not dementia. Essentially normal function. Cognitive decline.
Specifiers for Gradual Impairment in Cognitive Function
- Amnestic or NonAmnestic
- Single Domain or Multiple Domain
- No Tx but allows advanced planning and research.
- Multiple cognitive deficits:
- Memory + at least 1 of 4:
- -Executive function disturbance
- Social or occupational impairment and decline
- R/O other Disorders
- Memory Impairment PLUS 1 of 4
- Behavior disfunction/Apraxia
- Recognition disfunction/Agnosia
- Executive disfunction
- Word disfunction/Aphasia
- 30% over 85
- 5% over 65
- Disorganized behavior ex 3 step command
- Can the Pt dress himself?
- Does she cook for herself?
- Impaired recognition
- For objects vs Aphasia Word Finding. Ask about function
- For people - ask relatives
- Worsened work performance
- ex Clock drawing if High School at least
Montreal Cognitive Assessment
- Tool for assessing Dementia
- Disposing of litter
- Maintain hobby
- Find belongings
- Use home appliances
- Travel alone
- Use telephone
- Keep appointments
Types of Dementia
- Alzheimer's 55%
- Vascular 20%
- Lewy Body 10-15% (has visual hallucinations)
- Fronto-temporal 5-10%
- Alcohol 1-10%
- NPH, Metabolic ex Hypothyroid, Toxic, Anoxic, Infectuous ex AIDS death ¾ CNS affected, Cryptococcus, Trepanoma Pallidum Syphilis , Neoplastic, Head trauma related Dementia ex Boxing
- Most common form of dementia
- #7 in cause of death
- Death within 7-10 years
- Confusion, wandering, disruptive
- Death by fall, injury, infection, aspiration while eating
Symptoms of Alzheimer's
- -Volume reduction, early hippocampus
- -Bitemporal Hypoperfusion
- -Amyloid plaques
- -Neurofibrillary tangles
- -Oxidative damage
- -Inflammatory reactions
- -Synapse damage
- -Neuron death
- -Impaired neurotransmission
Comprehensive Treatment for Alzheimer's
- Educate patient, family, caregivers
- Support caregivers
- Home/Day Program/Long Term Care/Hospice
- Behavior - Safety, structure, stimulation
- FDA approved Medications:
- Cholinesterase Inhibitors - Early to late
- Donepezil(Aricept), Rivasigmine, Galantamine
- NMDA Antagonists - Middle to Late
- Memantine (Namenda) protect from excess glutamate
- NOT FDA for dementia but for noncognitive behavior symptoms - Antipsychotics, SSRI, Anticonvulsants
- Possible - Antioxidants
- (About 20%)
- Risk - HTN, cardiovascular risk
- M > F
- (Multi-infarct) Stepwise course
Lewy Body Dementia
- Loss of cholinergic neurons for cognition decline plus loss of dopaminergic neurons for motor decline (Risk with antipsychotic meds. Mainly Quetiapine.)
- Fluctuating cognition (before or within a year of Parkinsonian signs else Parkinsonian dementia)
- Parkinsonian signs. Can have orthostatic hypotension.
- Hallucinations of small people or animals
- REM sleep behavior disorder
- (includes Pick) (5 to 10 %)
- Atrophy FrontoTemporal
- Changes in Personality, impulsive, irritable,
General Dementia Features
- Personality changes
- 1/4 Hallucinations
- 1/3 Delusions ex paranoia
- Depression and Anxiety 15 to 45%
- Neurological abnormalities ex new Seizures Alzheimer 10% Vascular 20%, primitive reflexes
- Loss of abstraction, agitation when under stress
- Impaired creation of new memories due to:
- Medical condition ex Head Trauma
- Substance ex EtOH, CO
- Not Otherwise Specified
- L> R memory
- Memory involves Hippocampus(Temporal), Mamillary Bodies, Amygdala
- Thiamine deficiency, Hypoglycemia, hypoxia, HSV encephalitis, damage temporal lobes including hippocampus.
- Tumors, CVA, MS plaque, Surgery
- Sz, ECT, Head Trauma
Amnestic Disorders Criteria
- Memory Impairment - Inability to learn new or recall previously learned
- Marked social or occupational impairment and Decline.
- Not during delirium or dementia
- Evidence from History, PE, labs that due to medical or substance or NOS
- R/O Dementia and Delirium
- R/O Dissociation (Acute Stressor, more selective memory deficit ex lose orientation to self but can learn new info and recall selected past)
- R/O Factitious (Evidence of gain, no etiology and inconsistency in memory testing suggests conscious mimicking)
Transient Global Amnesia
- Abrupt Amnestic Disorder
- Lasts 6 to 24 hours
- 0.5 to 1 in 10 k people/year
- Likely ischemia of temporal lobe and diencephalon. Mostly Left.
Child vs Adult Psychopathology
- Disorders that occur or have onset primarily in childhood
- Disorders that can occur at all ages; kids have same symptoms but manifest in developmental context
- Disorders that occur in all ages but symptoms / presentation is different in kids
Disorders may appear differently in children
- Neurodevelopmental factors (certain neurocircuits not fully developed yet)
- Cognitive maturity
- Social Context
Issues in Making Psychiatric Diagnoses in Kids
- Must rely on parents/caretakers/teachers for much of the data – especially for externalizing disorders
- Though cognitive/language make interviewing kids more difficult, it is important to do – esp. for affective disorders, rule out abuse
- Need to evaluate whether symptoms are inappropriate for developmental level, and whether they cause functional impairment or clinically significant distress
- Make sure symptoms are contemporaneous
- Many symptoms are not specific to one diagnosis (e.g. irritability, distractibility)
- Often are seeing the initial or prodromal presentation of a disorder
- Prodromal presentations are often not specific to one disorder
- Comorbidity (more than one diagnosis) is very common
existing, occurring, or originating during the same time.
Major classes of childhood psychiatric disorders
- Developmental Disorders:
- Autism; Pervasive Developmental Disorders (PDD)
- Language and Learning Disorders
- Disruptive Behavior Disorders (“externalizing”):
- Attention Deficit Hyperactivity Disorder (ADHD)
- Oppositional Defiant Disorder (ODD); Conduct Disorder
- Affective Disorders (“internalizing”):
- Anxiety Disorders
- Depression; Bipolar Disorder
- Other disorders:
- Tic Disorders/Tourette’s Disorder; Eating Disorders; Substance Use D/Os; Schizophrenia
Epidemiology – Point Prevalence in Child Psychopathology
- Overall Prevalence (over 3-6 month period) of 15-20% of children & adolescents
- Comorbidity frequent (20 – 50%)
- Anxiety - 3 - 8% (child > adol.)
- Depression - 2 - 6% (adol. > child)
- Disruptive Disorders - 5 – 15%
Disorders more common in Girls
Affective, Anxiety, Depressive D/O's
Disorders more common in Boys
Behavioral, Conduct, Oppositional Defiant, ADD, Substance Abuse D/O's
- What is developmentally normal vs. pathological
- Generalized anxiety disorder, Post-traumatic stress disorder, Obsessive-compulsive disorder, social phobia, specific phobia can all occur
- Panic disorder – can occur, but rare in children
- Separation Anxiety Disorder – prototypical childhood anxiety disorder
- Kids frequently have multiple anxiety disorders
- Most kids improve; may develop depression when older
Separation Anxiety Disorder
- Prevalence of about 2%
- Children aged 5 to 8 most commonly report unrealistic worry about harm to parents or attachment figures and school refusal.
- Children aged 9 to 12 usually manifest excessive distress at times of separation, whereas adolescents most commonly manifest somatic complaints and school refusal.
- Boys and girls manifest similar symptoms of separation anxiety disorder.
- 75% of children with separation anxiety disorder manifest school refusal.
- Irritability is often the primary symptom
- Suicide attempts increase substantially after age 10 – depression is a primary risk factor
- Kids often brighten temporarily when in positive environment or with friends
- School performance often drops (amotivation, poor concentration)
How to ask about depression
- Have you felt sad, blue, moody, very unhappy, empty, depressed, like crying a lot? Is it a bad feeling?
- Cranky, irritable, angry about little things that usually would not bother you?
- Ever feel sad, angry, irritable and don’t know why?
- Ask about what the child likes to do – then ask about whether there was a time that they were bored all the time, or when the activities were not as fun as they used to be, or they lost interest in doing things they normally liked to do.
Asking kids about depression
- Always ask about whether there was a time where they felt really bad about themselves or life; when things seemed hopeless.
- Always ask about life not being worth living, wishing they were dead, wanting to kill themselves – if so, ask about plans, gestures, prior attempts.
- May occur in up to 1% of adolescents
- 10-20% of depressed youth develop bipolar disorder
- Can be present in young children as well
- Episodes may be less defined, brief or have rapid cycling from mania to depression
- High rates of comorbidity with other disorders (esp. ADHD, ODD, anxiety disorders and substance abuse in teens)
- Often difficult to differentiate from ADHD or irritable depression
How to ask about manic symptoms
- Was there a time where the child felt super happy, really good, more than just their normal happy? (Almost like they were high on drugs.)
- Very silly, everything was funny, everything was great and they didn’t know why? (find out context and duration).
- Would they get very angry at this time if something went wrong?
- Super energized, doing and thinking about many things at once.
- Not needing as much sleep because they had so much energy.
- Feeling like they could do anything. Doing things they normally would not do.
- Explosively angry while these symptoms were occurring.
- Delusions, Hallucinations, Disorganized Thinking
- Must remember what is developmentally appropriate (e.g. magical thinking, imagination)
- Most often associated with affective disorders (esp. eventually developing bipolar disorder)
- Can also be early-onset schizophrenia
- Need to rule out other medical etiologies
How to ask about psychotic symptoms
- Sometimes children when they are alone hear things or voices or see things and they don’t know where they came from – or they see/hear things that other people cannot.
- Find out specifically what they experienced.
- Assess context (sleep, medical illness).
- Assess whether child knows difference between imagination/pretend and real.
Asking about psychosis
- Sometimes does your imagination or your mind play tricks on you?
- Do you have secret thoughts or ideas that you don’t tell anyone else because they wouldn’t understand?
- Do you have special powers that other kids don’t have? Do things happen around you that only you can understand – on the TV or songs on the radio?
Attention-Deficit Hyperactivity Disorder
- Three cardinal diagnostic features ( > 6 mos.):
- Deficit in executive functioning:
- -Problems with learning/maintaining rule-governed behavior
- -Cannot hold behavior/consequence contingencies over time
- Core deficits in attention and inhibition are highly genetic (70%-90% genetic contribution)
ADHD - Epidemiology
- Prevalence rates vary among studies from 3–8% of school-age children
- Ratio of male to female generally ranges from 3-8:1
- Age of symptom onset:
- prior to age seven
Manifestations of Hyperactivity
- Unable to sit still in seat in the classroom -represents gross motor hyperactivity, particularly in pre-pubertal children.
- In post-pubertal children, usually more subtle fidgetiness
- Always on the go – “driven by a motor”
- Talks excessively
ADHD - Inattention
- Cannot sustain attention compared to peers, esp. at long, boring, or monotonous tasks
- Disorganized; often loses things
- Cannot follow through on instructions
- Doesn’t seem to be listening when spoken to
ADHD - Impulsivity
- Blurts out answers
- Interrupts others
- Intrudes on activities of others
- Difficulty waiting turn
- Can be verbal or physical
ADHD – Associated Symptoms
- Difficulty getting along with others
- Increase in behavioral problems due to impulsivity
- Difficulty learning due to inattention
- Poor self-esteem – can lead to depression
- Frequent Co-morbid Conditions (50-60%):
- Oppositional-Defiant Disorder (40%)
- Conduct Disorder (30%)
- Anxiety (15-20%) or Depression (15-20%)
ADHD - Complications
- Higher rates of accidental injuries & poisonings
- More likely to drop out of school, less likely to complete college
- Under perform at work
- Poor social relationships
- Higher rates of teen pregnancy and STDs
- Higher rates of automobile accidents
ADHD – Clinical Course
- About 30% improve substantially in adolescence
- 1/3 have some subthreshold symptoms as adults, but not substantial impairment
- 1/3 still very symptomatic into adulthood
- Sequelae include - substance use, school failure, antisocial behavior
Treatment of ADHD
- Amphetamines (Schedule II):
- Methylphenidate (Ritalin)
- Atomoxetine (Strattera), a SNRI (not a controlled substance, Selective Norepinephrine Reuptake Inhibitor)
Other disruptive behavior disorders
- More akin to syndromes or symptom clusters
- Oppositional Defiant Disorder
- Conduct Disorder (child vs. adolescent onset)
- Cruelty to animals
- Fighting; assaulting others (aggression)
- Stealing, Deceitfulness (conning)
- Property Destruction
Oppositional Defiant D/O
- Recurrent pattern of negativistic, defiant, hostile, and disobedient behavior towards authority figures
- Stubbornness, resistance to directions, unwilling to compromise
- Deliberate limit-testing, arguing, failing to accept blame
- Deliberately annoys others, verbal aggression
- Often comorbid with ADHD
- Often antecedent to Conduct Disorder
- Repetitive and persistent behavior that violates the basic rights of others and major age-appropriate societal norms
- Aggression to people and/or animals
- Deceitfulness or theft
- Property destruction
- Serious violations of rules (truancy, running away, repeatedly staying out all night beginning prior to age 13 )
Course of Conduct D/O
- High rates of substance abuse
- High rates of suicidal ideation and attempts
- Poor school performance
- Many progress to antisocial behavior as adults
Autistic Spectrum Disorders (ASD) / Pervasive Developmental Disorders (PDD)
- -Impairment in Language
- -Deficits in social functioning
- -Abnormally restricted activities and interests; repetitive unusual behaviors
- Likely a "spectrum" of PDDs / Autistic Spectrum Disorders
- Profound autism to milder PDD NOS or Asperger’s syndrome
Autistic Spectrum Disorders [ASD] - Epidemiology
- Prevalence is controversial
- -Best estimates - 1/160 – 1/300 for autistic spectrum d/o’s
- -More recent studies show higher prevalence
- -Likely related to broader criteria & better case finding
- Age of onset before age 3 in 94% cases
- Ratio of male to female = 4-5:1
- Evenly distributed across socioeconomic and ethnic groups
ASD – Impairment of Social Interactions
- Limited awareness of the existence of others or the feelings of others
- Absent or abnormal seeking of comfort at times of distress
- Absence of sharing experiences with others ("bring to show")
- Absent or abnormal social play
- Gross impairment in child’s ability to make peer friendships
ASD - Impairment of Communication/Language Abnormalities
- May have no mode of verbal communication
- Markedly abnormal non-verbal communication
- Absence of playacting, fantasy life, etc.
- Abnormalities in the production of speech
- Echolalia [idiosyncratic use of words or phrases, abnormal prosody (rhythm/melody) or articulation]
- Impairment in ability to sustain a conversation with others
ASD - Impaired Repertoire of Activities/Interests
- Stereotyped body movements
- Persistent preoccupation with parts of objects
- Marked distress over changes in trivial aspects of environment
- Unreasonable insistence on following routines in precise detail
- Markedly restricted range of interests
Autistic Spectrum Disorders – Associated Symptoms
- Difficulty in cognitive functioning, learning, attention, and sensory processing
- 50-75% have mental retardation
- Higher incidence of abnormal EEG and seizures
- Self-injurious behavior
- Unusual posturing and other motor behaviors (repetitive, non-functional movements)
Other Pervasive Developmental Disorders
- Asperger’s Disorder (or Syndrome)
- Normal early language development and intelligence (often still has subtle language abnormalities)
- Impairment in social functioning and restriction in interests like autism (usually milder)
- PDD NOS (Pervasive Developmental Disorders)
- Meets some but not all criteria for autism
- Milder and generally less impairing than autism
- Tourette’s / Tic Disorders
- Eating Disorders:
- Anorexia Nervosa, Bulimia, Eating Disorder Not Otherwise Specified (NOS)
- Family issues often important
- Substance Use Disorders:
- Abuse more common than dependence
Summary of Child Psychopathology
- Evaluate signs & symptoms in developmental context
- Know that many psychiatric disorders that occur in adults also occur in kids, but may have subtle differences in presentation
- Presentation may differ depending on the living environment / social context of the child
- Combine information from child and parent (and other sources such as teachers if possible)
- Many children / adolescents with significant psychopathology will not meet full DSM-IV diagnostic criteria for disorders – will be diagnosed as "Not Otherwise Specified" (NOS)
- High rates of comorbidity of psychiatric disorders - differential diagnosis may be more difficult than in adults
- May progress or change into other disorders as child matures – early manifestations of an illness may not be specific (e.g. irritability)
- A neuroleptic-induced movement d/o characterized by muscle spasms.
- Commonly involves musculature of the head & neck, but may also incl. extremities & trunk.
- Syx range from ↑ muscle tension to life-threatening syndrome of severe muscle tetany & laryngeal dystonia (laryngospasm) w/ airway compromise.
- Pharyngeal dystonia may produce impaired swallowing & drooling.
Risk factors of Dystonia
- Use of hi-potency antipsychotics, w/ Young men at ↑ risk.
- Usually develops early in drug therapy (w/in days).
Treatment of Dystonia
- Tx depends on severity of syx.
- (PO/IM) anticholinergic med [Benztropine (Cogentin); Diphenhydramine (Benadryl)].
- More severe cases / laryngospasm:
- same Tx given IV.
- If resp’y distress is severe, may require intubation.
- D/C of antipsychotic med may be necessary in some cases;
- In other cases, adding the anticholinergic med to regimen prevents recurrence of dystonia.
the inability to sit still because of uncontrollable movement caused by reaction to drugs
- Common S/E of antipsychotic meds.
- Also caused by serotonin reuptake inhibitors.
- Syx incl. a sensation of inner restlessness or strong desire to move one’s body.
- Pats. may appear anxious, agitated;
- Pace/move about; unable to sit still;
- Can produce severe dysphoria & anxiety – these may drive pat. to become assaultive or to attempt suicide.
- Important to accurately Dx – if mistaken for agitation or worsening psychosis, may ↑ dosage of antipsychotic med w/ resultant worsening of akathisia.
Risk factors of Akathisia
- recent onset of med use;
- recent ↑ of med dosing.
- Most cases occur w/in 1st month of starting medication; but can occur at any time during Tx.
Treatment of Akathisia
- decrease med dosage, if possible
- or administer one of following:
- beta-blockers [propranolol (Inderal) commonly used]
- benzodiazepines [ie- lorazepam (Ativan)]
- anticholinergics [diphenhydramine or benztropine]
- aka - neuroleptic-induced parkinsonism
- Common syx include:
- akinesia/bradykinesia (reduced spontaneous movement)
- may be accompanied by drooling and tremor in head & face muscles or limbs.
- Occur in up to 50% of pats. receiving long-term neuroleptic therapy
Risk factors of Extrapyramidal Symptoms
- use of hi-potency neuroleptics
- increasing age
- a prior episode of EPS
- EPS usually develops within first few weeks of initiation of med.
Treatment of Extrapyramidal Symptoms
- reduce dosage of antipsychotic if possible
- add anticholinergic meds to the regimen
Neuroleptic Malignant Syndrome
- Potentially life-threatening complication, most commonly associated with antipsychotic drug use.
- However, NMS may occur spontaneously in response to any med that blocks dopamine receptors, and in response to reductions/changes in dopamine agonist medications.
Symptoms of Neuroleptic Malignant Syndrome
- Syx may develop gradually over period of hours to days and can often overlap w/ syx of general medical illness.
- Many syx of NMS are non-specific & overlap w/ syx common to other psychiatric & medical conditions.
- Autonomic instability coupled w/ motor abnormalities is essential to the diagnosis of NMS.
- Tachycardia / other cardiac arrhythmias, Labile BP (hyper- and hypo- tension), Diaphoresis, Low Grade Fever progressing to Severe Hyperthermia, ↑ creatine kinase, ↑ LFTs, Leukocytosis, Rigidity/dystonia, dysphagia, mutism, Agitation, incontinence, delirium, Seizures, Coma
liable to change; easily altered
Risk factors for Neuroleptic Malignant Syndrome
- Use of high-dose antipsychotics,
- Rapid dose escalation,
- IM injex of antipsychotics,
- Prior h/o NMS.
- --Some Factors appear related to severity of psychiatric illness (rather than causative factors)
- such pats often have poor oral intake & become dehydrated, are more likely to be placed in restraints, & require IM injex of an antipsychotic.
Treatment of Neurleptic Malignant Syndrome
- Tx is largely supportive, incl. symptomatic mgt;
- Intensive care w/ cardiac monitoring;
- Intubation may be warranted;
- D/C antipsychotics;
- Dantrolene (muscle relaxant) [unapproved] to Tx rigidity and reduce myonecrosis;
- Bromocriptine (dopamine agonist) [unapproved] to reverse dopamine blocking effects of antipsychotics & other meds.
- Movement d/o that typically develops w/ long-term neuroleptic use;
- Especially in elderly pats, onset may not be as delayed.
- Constant, involuntary, stereotyped chroeoathetoid movements – most frequently confined to head & neck mucsulature.
- At times, extremities and respiratory & oropharyngeal musculature are also involved.
Risk Factors for Tardive Dyskinesia
- Risk Factors include:
- Long-term Tx w/ neuroleptics,
- Increasing age,
- Female gender,
- Presence of a Mood d/o.
- *Although TD is reversible in some cases, it tends to be permanent.
Treatment of Tardive Dyskinesia
- to reduce or eliminate the abnormal movements of TD:
- Change antipsychotics; or
- Lower the dosage; or
- Switch to Clozapine (Clozaril) – it appears to work by a different mechanism than other antipsychotics.
- Due to high synaptic concentrations of Serotonin.
- Can result from a single use of meds or illicit drugs that alter serotonergic function.
- Most commonly occurs when multiple meds that alter serotonin metabolism are used.
- Abrupt onset; Syx may include:
- Shivering, hyperreflexia, clonus;
- Prominent GI syx (N & D);
- Muscular rigidity may be seen in severe cases, mimicking NMS;
- * H/O MAOI and other med use can help in its identification.
Risk Factor for Serotonin Syndrome
combining an MAOI w/ other serotonin-altering meds.
Treatment of Serotonin Syndrome
- Tx is largely supportive;
- May require intensive care w/
- Cardiac monitoring & mechanical ventilation.
- D/C offending meds;
- Cyproheptadine (Periactin) [unapproved] serotonin 2A receptor antagonist -shows efficacy in treating this condition.
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