Depressive, Anxiety and Attention Disorders and Treatment Flashcards
What complex neuropsychiatric disorders that we know as mood disorders mess with emotion? Cognition? Visceral activity? Psychomotor activity?
- emotion - mania, depression
- Cognition - thought disorder, memory, concentration, focus, executive function
- Visceral activity - appetite, bowel function, nausea
- Psychomotor activity - sleep, insomnia, agitation, psychomotor retardation
Are mood disorders genetic?
- They can be inherited, so yes
- Bipolar disorder tends to be the more heritable of them all
- However, no clear etiology has emerged for any psychiatric illness
Are depression and bipolar disorder best thought of as chemical imbalances?
- No, the long-standing chronic disease state is better described as a full disruption in neural circuitry
- Involves the amygdala, prefrontal cortex, cingulated, striatum, thalamus, hippocampus
- Serotonin, NE and DA play an important role in modulating these circuits
Describe how depression is often associated with neuroendocrine dysfunction.
• Activation of HPA axis to stress is well-known
• Neurons in paraventricular nucleus of the hypothalamus secrete corticotropin-releasing factor (DRF)
• Stimulates the synthesis and release of ACTH (adrenocorticotropin) from the anterior pituitary
• ACTH then stimulates synthesis and release of glucocorticoids (cortisol) from the adrenal cortex
• These exert profound effects on general metabolism and affect behavior
• The activity of the HPA is controlled by several brain pathways including the hippocampus and the amygdala
○ Hippocampus is inhibitory, amygdala excitatory
• Sustained elevations of glucocorticoids, like under severe and prolonged stress, may damage hippocampal neurons
• This may involve a reduction of dendritic branching and loss of dendrites and loss of glutamatergic synaptic inputs
• The inhibitory control that the hippocampus exerts on the Hpa axis is thus diminished and that results in a further increase in circulating glucocorticoid levels
○ Hippocampal atrophy may be observed
What are the DSM-V depressive disorders?
- Disruptive mood dysregulation disorder
- MDD (major depressive disorder)
- Depressive disorder due to a medical condition
- Persistent depressive disorder (dysthymia)
- Substance/medication-induced depressive and related disorder
- Premenstrual dysphoric disorder
- Unspecified and other specified depressive disorder
What are the bipolar course and episode specifiers?
- With anxious distress
- With peripartum onset
- With atypical features
- With psychotic features
What are the depression course and episode specifiers?
- With mixed features
- With melancholic features
- With seasonal pattern
- With catatonia
What’s the time course for ddx of depression?
- Must experience 5 or more of the symptoms
- Must persist for 2 weeks or more
- Must experience sad mood or anhedonia
- Must be a change from baseline
What are the symptoms of depression?
- SIGECAPS
- Sleep
- Interest
- G - guilt
- E - energy
- C - concentration
- A - anhedonia
- P - psychomotoric changes
- S - suicidal ideation
What course makes you think atypical depression?
• Mood reactivity
• Leaden paralysis
• Reverse neurovegetative symptoms
○ Increased appetite, weight gain, hypersomnia
What is melancholic depression?
Mood worse in morning, early morning awakening, anorexia, weight loss, guilt, psychomotor retardation
Describe bipolar disorder
• Best considered on a spectrum
• Ranging from extreme mood swings to cyclothymia to hypomanias and major depression
• Can range to frank (real) manias (bipolar I)
• Manias can be induced by medications (antidepressants or steroids are more common) or brain injuries
○ If induced by these events they are called secondary manias
• Bipolar disorder symptoms can be divided into 4 domains
○ Manic mood and behavior
§ Euphoria, grandiosity, pressured speech, impulsivity, excessive libido, recklessness, social intrusiveness, diminished need for sleep
○ Dysphoric mood and behavior
§ Depression, anxiety, irritability, hostility, violence or suicide
○ Psychosis
§ Delusions and halllucinations
○ Cognitive symptoms
§ Racing thoughts, distractability, disorganization, inattentiveness
• No clear etiology. More inherited than other psych conditions
How do you diagnose bipolar disorder?
• Need mania or hypomania. With full mania that bumps the dx to bipolar I
• Mania - particular symptoms and particular rules for course of disease
○ Distinct period of abnormally and persistently elevated, expansive or irritable mood
○ Persistently increased goal-directed activity or energy, present most of the day nearly every day lasting at least 1 week
○ Or any duration if hospitilization is necessary
○ PLUS 3 or more symptoms (euphoric)
○ OR 4 or more symptoms (if irritable)
• Symptoms - DIGFAST
• Distractibility, insomnia, grandiosity, flight of ideas, activity, speech, thoughtlessness
• The symptoms have to co-occur and cause significant problems in daily life
What are the typical medical illnesses that can masquerade as a mental illness?
- Endocrine - cushings, hyper/hypothyroidism, steroids
- Infections - HIV, influenza, meningitis, CJD
- CNS - stroke, tumor, MS, epilepsy
- Metabolic - hypercalcemia
What substances of abuse can manifest as mood disorders either through toxicity or withdrawal?
- Cocaine, alcohol, amphetamine/stimulants
- Hallucinogens (LSD, PCP, mescaline)
- Benzodiazepines
What are the prescribed medications that have side effects that can look like mood disorders?
- Amantadine
- Methyldopa withdrawal
- Interferon
- Steroids
- Chemotherapy agents
What is considered optimal treatment of mood disorders?
- For mood disorders, the optimal treatment is both behavioral AND medication therapy
- Pharm and psychotherapy
- Depression can be only psychotherapy, but bipolar needs meds
What are the three different phases of mood disorder treatment?
- Acute - 0-3 months (50% may stop treatment here)
- Continuation (4-9 months) - 65-75% may stop treatment
- Maintenance (years)
What’s the treatment paradigm for depression?
• Ssri and snri almost immediately block the reuptake of serotonin and NE, antidepressant effects take weeks to work
○ Likely b/c downstream changes that are caused by the blockade of NT
• The exact mechanism of antidepressant efficacy is currenlty unclear
○ May ultimately alter the expression of brain-derived neurotrophic factor (BDNF)
○ This increases neuronal growth (specifically hippocampal volume)
• ALL current FDA-approved pharm treatments target NT systems and boost synaptic actions
○ NE, 5HT, DA
• ALL current treatments have a 4-16 week delay before achieving antidepressant effect
• ECT = electroconvulsive therapy - the only approved treatment for depression that produces more rapid response
• Overall response rate to antidepressants in first 8 weeks is 67%
○ Only about 1/3 will achieve remission with SSRI initial therapy regimen
• All approved meds appear to have the same efficacy
Describe the different types of antidepressants
• Generally broken into 5 broad categories (there is no right antidepressant. Consider individual risks and benefits)
○ SSRIs - selective serotonin reuptake inhibitors
§ Block 5HT pre-synaptic reuptake pump
○ SNRIs - selective norepinephrine reuptake inhibitors
§ Block both NE and 5HT reuptake pumps
○ (TCA’s)- Tricyclic antidepressants
§ Block reuptake of 5HT and NE (also DA but not as much) and also blocks H1, muscarinic cholinergic receptors and alpha1 receptors
○ MAOIs - monoamine oxidase inhibitors
§ Irreversibly inhibit MAO-A and MAO-B, increasing levels of 5HT and NE
○ Other (mixed)
• Mirtazapine
○ Blocks several 5HT receptors AND alpha 2 receptors
• Buproprion
○ Increases whole body NE, weakly blocks reuptake of DA
• Trazodone and nefazodone
○ Most potent action is blockade of post-synaptic 5HT2
○ Block reuptake of 5HT and NE
• Vilazodone (newer guy)
○ SSRI + 5HT1a partial agonist
What are the important SNRIs?
- Venlafaxine (vader)
- Desnvenlafaxine (definately)
- Duloxetine (defines)
- Milnaciprin (mighty)
- levomilnaciprin (levitation)
What are the important SSRIs?
- Fluoxetine (Father)
- Paroxetine (Priest)
- Sertraline (says)
- Citalopram (catholic)
- Escitalopram (escatology)
- Fluvoxamine (following)
- vilazodone (valentine’s day)
What are the important MAOIs?
- Phenelzine (poop)
- Selegeline (transdermal) (stinks)
- Tranylcypromine (taken)
- isocarboxazid (internally)
What are the important “other” antidepressants?
- Mirtazapine
- Buproprion
- Trazodone
- Nefazodone (also an SSRI)
What are the important TCAs?
- Amytriptyline (anybody)
- Nortriptyline (never)
- Desipramine (dancing)
- Imipramine (impractically)
- Doxepin (decides)
- Trimipramine (to)
- Protriptyline (practice)
- amoxapine (anhedonia)
What are the benefits and risks for using TCAs?
• Benefits ○ Time-tested ○ Very effective ○ Great in severe depression ○ Newer ones have fewer side effects • Risks ○ Hypotenstion ○ Orthostasis ○ Anticholinergic side effects ○ Weight gain ○ Sexual side effects ○ Dangerous in overdose
What are the pros and cons of using MAOIs?
• Pros ○ Can be very effective in non-responsive patients, especially atypical depression ○ Time-tested • Cons ○ Hypotension, orthostasis ○ Dry mouth ○ Constipation ○ Urinary retention ○ Sexual side effects ○ Weight gain ○ Hypertensive crisis (tyramine reaction)
What are the pros and cons of using SSRIs?
• Safe, effective • Multiple indications for use ○ Generalized anxiety disorder ○ Social anxiety ○ Panic ○ OCD ○ PTSD ○ Premenstrual dysphoric disorder • Cons ○ Diarrhea ○ Nausea ○ Jitteriness/anxiety ○ (MAJOR) Sexual side effects (huge here) ○ (MAJOR) Drug interactions b/c of P450 inhibition
What are the pros and cons of using SNRIs?
• Pros ○ Some evidence says these are more effective than SSRIs ○ Safe ○ Better tolerated than TCAs ○ Also used for multiple indications • Cons ○ Sexual side effects ○ Sweating ○ Increased diastolic blood pressure ○ Withdrawal syndrome (flu-like) § "electric shocks"
What are the pros and cons of mirtazapine
- Pros - helpful with insomnia, rapid anti-anxiety effect, low incidence of sexual side effects
- Cons - daytime somnolence, weight gain
What are the pros and cons of buproprion?
• PROS - No sexual side effects, weight neutral, activating
• CONS - Increased anxiety, jitteriness, ineffective in panic disorder
• Insomnia
• (MAJOR) Higher seizure risk
○ Contraindicated in eating disorder patients
○ Contraindicated in seizure disorder
What are other, non-pharm strategies for mood disorder treatment?
• Electrical/magnetic strategies
○ Vagal nerve stimulators
○ Deep brain stimulation
○ Transcranial magnetic stimulation
§ Rely on altering monoamines as their primary mechanism of action and their efficacy and cost-benefit ratio are unclear
• Ketamine - increasing interest in this as a treaatment
○ Novel mechanism of action and rapid antidepressant response
○ Very little data, no long-term use data
Which is more simple to treat pharmacologically, unipolar depression or bipolar disorder?
- Unipolar depression is far more simple to treat
- Bipolar treatment is different depending on the phase of the disorder
- An ideal drug would be anti-manic, anti-depressive and prevent future episodes. But nothing works in all three phases
Of all the bipolar medications listed in the table in the notes, which were the important ones listed out?
- Lithium
- Divalproex sodium
- Atypical antipsychotics
What is the treatment paradigm for mania?
- Important to realize treatment is effective
- Numerous FDA approved pharm treatments
- Bipolar II though, and particularly bipolar depression is very difficult to treat
- 2 FDA treatments - quetiapine and Olanzapine + fluoxetine (symbyax)
- All atypical antipsychotics, lithium, divalproex and carbamazepine are anti-manic agents
What are the pros and cons to llitium treatment?
• Pros ○ Very well studied, best proven drug ○ Effective anti-manic ○ Reasonable protection from events ○ Some antidepressant effect ○ Anti-suicidal properties ○ Neuro-regenerative effects ○ Inexpensive • Cons ○ (MAJOR) narrow therapeutic window § Toxic and lethal in overdose ○ (MAJOR) - diabetes insipidus risk ○ (MAJOR) - hypothyroidism ○ Tremor ○ Nausea, diarrhea ○ Taste ○ Thirst ○ Cognitive dulling ○ Renal effects, decreased urine concentration
What are the pros and cons of divalproex sodium?
• Bipolar treatment • Pros ○ (MAJOR) - rapid loading ○ Individualized treatment ○ Safe and effective • Cons ○ Not proven as preventative agent ○ Weight gain ○ Sedation ○ Not effective in bipolar depression
What are the pros and cons with atypical antipsychotic use?
• All are anti-manic and reasonably safe and effective
• There are different routes of admin available (oral, injection)
• Less extrapyramidal effects
• Cons
○ Weight gain, risk of metabolic effects, diabetes, increased cholesterol
○ expensive
Should you use antidepressants in bipolar depression?
• There is really no great, large RCT evidence suggesting that antidepressants are effective in the treatment of bipolar depression
○ There is evidence though that use can make it worse
• Best treatments for bipolar depression are
○ Quetiapine
○ Lamotrigine
○ Olanzapine/fluoxetine combo
○ Lithium (really better as a protection from future episodes)
Besides lithium, what pharm treatments help prevent future bipolar episodes?
- Aripiprazole
- Olanzapine
- lamotrigine
Give a general definition/description of what a personality disorder is.
- Associated with ways of thinking and feeling about oneself and others
- Significantly and adversely affect how an individual functions in many aspects of life
- 10 distinct types
What are the 10 types of personality disorder?
- Paranoid
- Schizoid
- Schizotypal
- Antisocial
- Borderline personality disorder
- Histrionic
- Narcissistic
- Avoidant
- Dependent
- OCPD
The hybrid methodology used in DSM-V criteria retain how many personality disorder types?
• 6, Instead of the 10 traditional ones • Borderline • OCPD • Avoidant • Schizotypal • Antisocial • Narcissistic ○ Each type is defined by a specific pattern of impairments and traits ○ This approach also includes a diagnosis of personality disorder-trait specified (PD-TS) ○ Rating severity of different traits
What are the three cluster A personality disorders?
• Paranoid
• Schizoid
• schizotypal
*these are in the schizophrenia axis of diagnoses, along the spectrum of abnormal brain chemistry that is schizophrenia
What are the cluster B personality disorders?
• Antisocial • Borderline • Histrionic • Narcissistic ○ These are more similar to PTSD and bipolar than any of the other personality disorders
What are the cluster C personality disorders?
• Avoidant
• Dependent
• Obsessive-compulsive
○ These all have traits from generalized anxiety disorder and depression
What is the brief description of all the cluster A personality disorders?
• Paranoid ○ Distrustful, suspicious • Schizoid ○ Interpersonal detachment • Schizotypal ○ Odd thoughts and behavior ○ Interpersonal awkwardness
What are the general description points for the cluster B personality disorders?
• antisocial ○ disregard and violation of others rights • Borderline ○ instability of relationships, self-image, affects • Histrionic ○ emotionality, attention seeking • Narcissistic § Grandiosity and lack of empathy
What are the general description points for the cluster C personality disorders?
- Avoidant
* Worries of inadequacy and being negatively judged- Dependent
- Need to be taken care of
- Obsessive-compulsive
- Orderliness, perfection, need to be in control
- Dependent
Personality disorders are egosyntonic. What does that mean?
• An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture
• The syntonic part comes from the fact that they believe their behavior RIGHT.
○ Example - OCPD person thinks everybody should be perfectionists. It’s wrong to NOT desire perfection out of everybody
Personality disorders manifest in 2 or more of what ways?
• 4 ways personality disorders manifest
○ Cognition
§ Ways of perceiving and interpreting self, other people, and events
○ Affectivity
§ Range, intensity, lability, appropriateness of emotional response
○ Interpersonal functioning
○ Impulse control
What are the DSM-V criteria for the dx of a personality disorder?
• There has to be:
○ An enduring pattern of inner experience and behavior
§ This must be markedly deviant from individual’s cultural expectation
○ The enduring pattern is inflexible and pervasive across a broad range of personal and social situations
○ The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning
○ The pattern is stable and of long duration, and onset can be traced back at least to adolescence or early adulthood
○ The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder
○ The enduring pattern is not due to the direct physiological effects of a substance/medication
What symptoms have to be exhibited to warrant a paranoid personality disorder?
• Pervasive distrust and suspiciousness of others
○ Others’ motives are seen as malevolent
• They suspect without sufficient evidence that others are exploiting, harming, or deceiving them
• They are preoccupied with unjustified doubts about the loyalty or trustworthiness of friends
• They are reluctant to confide because they think that info can be used against them
• Interprets hidden demeaning or threatening meanings to benign remarks/events
• They bear grudges and are unforgiving of insults injuries or slights
• They perceive others as attacking their character or reputation and are very defensive or quickly counterattack
*frequent and recurrent suspicions about fidelity of sexual partner
What are the criteria for diagnosing schizoid personality disorder?
• Pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
○ Must begin in early adulthood and present in a variety of contexts
• Neither desires nor enjoys close relationships, including being a part of a family
○ Egosyntonic here
• Always chooses solitary activities
• Has little, if any, interest in having sexual experiences with another person
• Takes pleasure in few, if any, activities
• Lacks close friends or confidants other than first-degree relatives
• Appears indifferent to the praise or criticism of others
• Shows emotional coldness, detachment or flattened affect
What are the criteria for making the dx of schizotypal personality disorder?
• General - has the discomfort for close relationships similarity with schizophrenia, AND cognitive or perceptual distortions and eccentriciites of behavior
○ But is not schizophrenia. If these behaviors happen in the context of schizophrenia this dx is null
• They have ideas of reference (excluding delusions of reference)
• Odd beliefs or magical thinking that influences behavior and is inconsistent with subcurltural norms
○ Highly superstitious, believe in magic, telepathy, sixth sense
• Unusual perceptural experiences including bodily illusions
• Odd thinking and speech (vague, circumstantial, metaphorical, overelaborate, sterotyped)
• Suspiciousness or paranoid ideation
• Inappropriate or constricted affect
• Behavior or appearance that is odd, eccentric or peculiar
• Lack of close friends or confidants other than first degree relatives
• Excessive social anxiety that does not diminish with familarity and tends to be associated with paranoid fears rather than negative judements about self
What are the criteria that need to be present to make the dx of antisocial personality disorder?
• Pervasive pattern of disregard for and violation of the rights of others occuring since 15 y/o
○ Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
○ Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
○ Impulsivity or failure to plan ahead
○ Irritability and aggressiveness, as indicated by repeated physical fights or assaults
○ Reckless disregard for safety of self or others
○ Consistent irresponsibility, as indicated by 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
• They must be at least 18
• They have evidence of conduct disorder (juvenile version before 15y/o)
• Not part of a manic episode
What are the diagnostic criteria for borderline personality disorder?
• Pervasive pattern of INSTABILITY of interpersonal relationships, self-image, affects. Marked impulsivity beginning by early adulthood and present in a variety of contexts
○ Frantic efforts to avoid real or imagined abandonment
○ Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
○ Identidy disturbance - mardely and persistenly unstable self-image or sense of self
○ Impulsivity in at least two areas that are potentially self-damaging (substance abuse, reckless driving, binge eating)
○ Recurrent suicidal behavior, gestures, threates, self-mutilating behavior
○ Affective instabliity due to a marked reactivity of mood
○ Chronic feelings of emptiness
○ Inappropriate, intense anger or difficulty controlling anger
○ Transient, stress-related paranoid ideation or severe dissociative symptoms
What are the diagnostic criteria for histrionic personality disorder?
• Excessive emotionality and attention seeking
○ 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
○ Shows self-dramatization, theatricality, exaggerated expression of emotion
○ Suggestible
○ Considers relationships to be more intimate than they actually are
What are the diagnostic criteria for narcissisitic personality disorder?
- Grandiosity (fantasy or behavior), need for admiration, lack of empathy
- Grandiose sense of self-importance
- Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
- Believes he or she is special and unique and can only be understood by high status people
- Requires excessive admiration
- Has a sense of entitlement
- Interpersonally exploitive
- Lacks empathy
- Often envious of others or believes that others are envious of him or her
- Arrogant, haughty attitudes and behaviors
What criteria are necessary for the dx of avoidant personality disorder?
• (pattern) - Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation
• (manifestations) - avoids occupational activites that involve significant interpersonal contact
○ Fears of criticism or rejection
• Unwilling to et involved with people for fear of being liked
• Restraint within intimate relationships for fear of shame or ridicule
• Preoccupied with being criticized or rejected in social situations
• Inhibited in new interpersonal situations due to feeling inadequate
• Views self as socially inept or unappealing
What constellation of behaviors makes you think dependent personality disorder?
• Excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation
○ Difficulty making everyday decisions without advice
○ Needs others to assume responsibility for major life areas
○ Difficulty expressing disagreement with others for fear of loss of approval
○ Difficulty initiating projects on their own
○ Exessive effort to obtain nurturance and support
○ Uncomfortable or helpless when alone for fear of unable to care for themselves
○ REBOUND relationships
○ Preoccupied with fears of needing to take care of themselves
What are the 4 categories of drugs used in treatment of anxiety?
• Antidepressants ○ SSRIs and SNRIs are most commonly used • Benzodiazepines ○ Useful in acute or situational anxiety • Buspirone ○ Weaker, but fewer side effects • Barbituates ○ Try not to use these
Sedative and hypnotic drugs are separately classified from other CNS depressants how?
- Graded, dose-dependent depressant effects
- Augment GABA neuronal inhibition and/or inhibit glutamate neuronal excitation
- Sedative - decreasing activity, moderating excitement, calming
- Hypontic - drowsiness, facilitate onset and maintenance of sleep that resembles natural sleep and from which recipient can be easily aroused
What, in general, is the problem in ADHD?
What, in general, is the problem in ADHD?
• This is a DISORDER, therefore reflects brain pathology, or such a different pattern of behavior as to be socially limiting and interfering with normal life activities
• Excessive inattention
• Hyperactivity
• Impulsivity
○ Any combination of these
What can be misdiagnosed as ADHD?
• Oppositional behavior patterns
• Intellectual disability
• Specific learning disorders
• It’s also not the only reason for poor focus or hyperactivity
○ It can’t be blamed for all attention problems
What is the prevalance of ADHD?
- Children of school-age - 3-8%
* Adults - 4%
What does it mean to be inattentive?
- Symptoms of inattention
- Fails to give close attention to details or makes careless mistakes
- Difficulty sustaining attention
- Does not appear to listen
- Struggles to follow through on instructions
- Has difficulty with organization
- Avoids or dislikes tasks requiring a lot of thinking
- Loses things
- Easily distracted
- Forgetful in daily activities
What does it mean to be hyperactive/impulsive?
- Fidgets with hands or feet or squirms in chair
- Difficulty remaining seated
- Runs about or climbs excessivly in children
- Just really restless in adults
- Difficulty engating in activities quietly
- Acts or feels as if driven by a motor
- Talks excessivly
- Blurts out answers before questions have been completed
- Difficulty waiting or taking turns
- Interrupts for intrudes upon others
What are the types of ADHD?
• Inattentive type
○ The more undiagnosed
○ More common in girls
• Hyperactive type
○ Diagnosed earlier b/c is more bothersome to others
○ Frequently confused with oppositionality
• Combined type
○ Meets criteria for both of the others
○ 6 symptoms in each category
What are the common comorbidities with ADHD?
• Substance Abuse • Anxiety disorders • Depression • Learning disorders • Oppositional behavior ○ These are adjuncts, and do not need to be present for the disorder to be dx
What is the differential diagnosis for ADHD?
- Anxiety
- Sleep problems
- PTSD (adult)
- Sleep Apnea
- Relational Problems
- Learning Disorders
- Depression
- Abuse (adult or children)
- Lack of food (children)
- Psychosis
- Mania
What is the gold standard of treatment for ADHD?
• Stimulants are standard of care
• High efficacy and good tolerability in patients
• Hyperactivity
○ Atomoxetine
○ Bupropion
○ Alpha agonists (guanfacine, clonidine)
What are the DSM V criteria for the dx of ADHD?
- Need 6 or more symptoms in either categories (combined if there are 6 in each)
- Several symptoms need to be present before age 12
- Several symptoms present in two or more settings (home, school, work, church, friends, parties)
- There needs to be clear evidence that the symptoms interfere with or reduce the quality of functioning
- Not better explained by a medical condition or other dx
What are the two types of stimulants used for ADHD?
• Amphetamines ○ Adderall ○ Aderall XR ○ Vyvanse (lisdexamphetamine) • Methylphenidates ○ Ritalin ○ Ritalin LA ○ Concerta (methylphenidate ER)
What’s the basic flow chart for treatment and dx of ADHD?
• Concern
• Diagnostic interview
• Confirmed diagnosis in more than one setting?
○ No - further discuss differential with family and ask to observe more
• First trial of stimulant
• Toleration check
○ No - change class of stimulant then re-check for toleration and efficacy
• Tolerated but not effective - increase dose
• If no toleration after changing class then consult psychiatry
• If you are playing with the high end of the range of dose then consult psychiatry
