1-5 Flashcards
role of psyD in treating individuals with intellectual disabilities
- complete eval (karyotype)
- make sure appropriate interventions occur
- ensure other dx are found as 35-40% have another psych disorder
- provide adequate tx
- coordinate care
psychological assessments for intellectual capacities
Wechsler scales (the Wechsler Preschool and Primary Scale of Intelligence, the Wechsler Intelligence Scale for Children, and the Wechsler Adult Intelligence Scale) and the Stanford-Binet Scale
prevalence of intellectual disability is approximately ? of the population
1%
males being more affected than females
Two pieces of information are needed to make a diagnosis of intellectual disability:
Evidence of deficits in intellectual functioning both clinically and via standardized testing AND evidence of deficits in adaptive functioning
typical symptoms of ASD
difficulty with social reciprocity, poor peer interaction, poor language development, and repetitive and odd play
Asperger’s disorder
old terminology for a type of ASD that describes individuals who display social impairment and restricted interests and behavior (stereotyped behavior) but have normal language and cognitive skills.
Rett disorder
old term for a type of ASD that describes individuals who show a type of childhood developmental disorder of unknown etiology in which the patient develops progressive encephalopathy, loss of speech capacity, gait problems, stereotyped movements, microcephaly, and poor social interaction skills. The child must have shown normal development in early infancy, and only females are affected.
ASD findings:
MRI
fMRI
others
increased cortical thickness that may relate to abnormalities in cortical connectivity
less activation of the prefrontal regions indicating a dysfunction of the frontostriatal networks
abnormalities in glutamate/glutamine physiology, particularly in the limbic areas
ASD characteristics
failure to develop relationships
lack of social reciprocity
impairment in nonverbal behaviors
impairments in communication: delay/failure in learning spoken language
exhibit repetitive behaviors and strict adherence to mannerisms
preoccupation with specific objects
what previous diagnoses have been consolidated into the term autistic spectrum disorder (ASD)?
autistic disorder Rett disorder childhood disintegrative disorder Asperger disorder pervasive developmental disorder NOS
ASD vs schizophrenia
the onset of childhood schizophrenia usually occurs later, there is a family history of schizophrenia, and the child is less impaired in the area of intellectual functioning
approach to managing ASD
family education, behavior shaping, speech therapy, occupational therapy, and educational planning
recent studies indicate a role for ? in the etiology and treatment of ASD
oxytocin (the neuropeptide)
shown a likely benefit in improving nonverbal communication behaviors
other medications used in ASD
low-dose Risperdal (risperidone)
aripiprazole may also be of benefit with the irritability symptoms of ASD
look for these comorbid disorders in ASD
ADHD), OCD, behavior disorders, and psychotic disorders
the best predictor of future outcome in autistic disorder
Language development
symptoms seen in ADHD inattentive type
Making careless mistakes
Having difficulty focusing one’s attention
Often seeming not to listen
Often failing to follow directions
Having difficulty in organizing tasks
Avoiding tasks requiring sustained mental effort
Often losing things
Often becoming distracted by other stimuli
Being forgetful
girls > boys
first line treatment of ADHD inattentive
stimulants: Adderall (dextroamphetamine and amphetamine), Ritalin (methylphenidate) (Concerta is XR), Focalin (dexmethylphenidate)
or Strattera (Atomoxetine) (NE reuptake inhibitor-NRI)
what ADHD patients should use Strattera over stimulants?
individuals/families with substance abuse problems, individuals with tics (does not cause or worsen tics as stimulants do), or patients with comorbid anxiety disorders
second-line choices for ADHD
clonidine (Kapvay) 0.1 mg at bedtime max 0.4
and guanfacine (Intuniv) 1 mg per day max 4
a2 antagonists
(low-dose often used to help with sleep disturbances/agitated behavior after on a stable dose of stimulant)
diagnostic criteria of ADHD
6+ symptoms of inattention or hyperactivity/impulsivity before 12 in more than one setting and there is clinically significant impairment
ADHD hyperactive symptoms
Fidgeting or squirming Often leaving one's seat Running or climbing excessively and inappropriately Difficulty playing quietly Often being "on the go" Talking excessively
ADHD impulsive symptoms
Often blurting out on answer before a question is completed
Difficulty waiting for one’s turn
Often interrupting others
third-line choices for ADHD
Bupropion (Wellbutrin)
-may worsen tics (Dopamine)
Imipramine (Tofranil)
-blood levels and EKG should be followed because of QT prolongation
ADHD etiology may involve
decreased DA and NE tracts in several areas of the prefrontal cortex
- dorsal anterior cingulate gyrus is involved in selecting what an individual focuses
- dorsolateral prefrontal cortex is involved with sustaining attention and various executive functions
Impairment in the ? appears to account for the hyperactivity
Decreased activity in the ? is involved with impulsive actions
prefrontal motor cortex
orbitofrontal cortex
common comorbid disorders with ADHD
oppositional defiant disorder (ODD) or conduct disorder
failing to recognize leads some physicians to attempt to medicate away purposeful disruptive behavior
medications for ADHD can only
(1) help the child sit still-if the child wants to sit still
(2) help the child to focus his or her attention-if the child wants to pay attention
(3) help the child to think before he or she acts-but will not affect whether the child makes a good decision or not
ddx ADHD
ODD/conduct: but intentional
learning disabilities
bipolar: may be restless/distractible but +affective
Lead intoxication can lead to hyperactivity
petit mal seizures (Absence)
How many kids with ADHD will respond to stimulant medications?
adverse effects
70% to 80%, rapid, wear off by end of day decreased appetite (sometimes with subsequent slowed growth rate), initial insomnia, irritability, dysphoria, and headache, development or worsening of tics
Strattera (Atomoxetine)
potent selective inhibitor of the presynaptic norepinephrine transporter
not a stimulant or a controlled substance
gradual onset of action: 2-3 weeks with 24-hour length of action
may cause decreased appetite, sedation, does not worsen tics
the only medications with FDA approval to treat Tourette’s
but why not utilized?
haloperidol (EPS) and pimozide (prolonged QT)
instead a2 antagonists and atypical antipsychotics are used
symptoms consistent with Tourette disorder
combination of multiple motor and vocal tics occurring for at least 1 year
strong relationship between Tourette disorder and ?
OCD and ADHD, and these disorders run in families
imbalances in Tourettes
decreased GABA and increased dopamine in the caudate nucleus
tic disorder ddx
Huntington chorea, Wilson disease, and stroke, tardive dyskinesia, stimulant use, PANDAS (strep, worse in winter/spring), OCD compulsions, schizophrenia
Transient tic disorders timeframe
Patients with a chronic motor or vocal tic disorder can have it for more than ? but there is an absence of ?
4 weeks but for no longer than 1 year
1 year
multiple motor tics and/or motor and vocal tics occurring simultaneously (as the combo would be Tourette’s)
first line pharmacotherapy for Tourettes
a2 agonists: Clonidine, Guanfacine
also good for ADHD symptoms in kids who have tics
MOA for Clonidine in Tourettes
Clonidine: alpha-adrenergic agonist that is believed to activate presynaptic autoreceptors in the locus ceruleus to reduce norepinephrine release that may reduce tics
MOA for Guanfacine in Tourettes
Guanfacine binds to postsynaptic prefrontal alpha-adrenergic cortical receptors to enhance functioning in the prefrontal cortex
In practice most clinicians utilize ? for Tourettes/tics
MOA?
most common one used?
atypical antipsychotics
block dopamine and serotonin receptors, decreasing input from the substantia nigra and ventral tegmentum to the basal ganglia
Risperdal: 1 to 3.5 mg/d with weight gain, lipid abnormalities, and sedation as the most common side effects
(next: haloperidol or pimozide)
psychotherapy with the strongest empirical evidence for effectiveness in Tourettes/tic
Habit reversal training:
teaching awareness of the aversive sensation or buildup of tension called a premonitory urge that is relieved by the tics, then helped build a competing response to that urge without engaging in tic behavior (+social support)
depression that responds to antidepressant but evidence of paranoia after mood symptoms resolved think?
schizoaffective disorder
treatment for schizoaffective
atypical antipsychotic: risperidone first,
if bipolar type, treat with mood stabilizer i.e. lithium, carbamazepine, and valproic acid
if depressive type, add antidepressant (SSRI) ONLY if antipsychotic alone not affective
Schizoaffective d/o
> 2 weeks of hallucinations or delusions without major mood episode (major depression or mania), plus periods of concurrent major mood episode with schizophrenic symptoms
**psychotic episodes occur during the mood episodes, but the mood symptoms do not always occur during the psychotic episodes
always ask about ? if considering schizoaffective
manic symptoms, as schizoaffective may be depressive type or bipolar type
brain matter abnormalities in schizophrenia/schizoaffective d/o
white matter pathology hypotheses of frontotemporal dysfunction and abnormalities in left-hemisphere lateralization in the pathophysiology of these illnesses
schizoaffective ddx
substance-induced mood disorder: cocaine or amphetamine intoxication (manic symptoms), cocaine withdrawal (depressive symptoms), and prescribed meds including steroids and antiparkinsonian medications
schizoaffective vs schizophrenia
symptoms can appear similar, but the mood symptoms in schizophrenia if present are generally brief in relation to the total length of the illness while in schizoaffective mood symptoms occur during significant portions of their illness
schizoaffective vs mood disorders
(*mood first then +/- psychosis)
bipolar disorder, mania, generally have had mood symptoms (euphoria, irritability) before development of the psychoses, as have patients with major depression with psychotic features (a depressed mood predating the onset of psychosis)
other treatment for schizoaffective (correlates with schizophrenia as well)
hospitalization (if suicidal or unable to care for self/psychotic)
social support
TMS: transcranial magnetic stimulation
What age group with schizoaffective disorder may exhibit more severe symptomatology
Younger patients
DSM V for schizoaffective
Patients must exhibit psychotic symptoms consistent with the acute phase of schizophrenia.
Psychotic symptoms are accompanied by prominent mood symptoms (mania or depression) during part of the illness.
At other points in the illness, the psychotic symptoms are unopposed; that is, no mood symptoms are present. Periods of illness in which there are only psychotic symptoms, and no mood symptoms, must last for at least 2 wk.
The disorder cannot be caused by a substance or by another medical condition.
