Depressive, Anxiety and Attention Disorders and Treatment Flashcards

1
Q

What complex neuropsychiatric disorders that we know as mood disorders mess with emotion? Cognition? Visceral activity? Psychomotor activity?

A
  • emotion - mania, depression
    • Cognition - thought disorder, memory, concentration, focus, executive function
    • Visceral activity - appetite, bowel function, nausea
    • Psychomotor activity - sleep, insomnia, agitation, psychomotor retardation
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2
Q

Are mood disorders genetic?

A
  • 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
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3
Q

Are depression and bipolar disorder best thought of as chemical imbalances?

A
  • 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
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4
Q

Describe how depression is often associated with neuroendocrine dysfunction.

A

• 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

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5
Q

What are the DSM-V depressive disorders?

A
  • 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
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6
Q

What are the bipolar course and episode specifiers?

A
  • With anxious distress
    • With peripartum onset
    • With atypical features
    • With psychotic features
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7
Q

What are the depression course and episode specifiers?

A
  • With mixed features
    • With melancholic features
    • With seasonal pattern
    • With catatonia
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8
Q

What’s the time course for ddx of depression?

A
  • 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
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9
Q

What are the symptoms of depression?

A
  • SIGECAPS
    • Sleep
    • Interest
    • G - guilt
    • E - energy
    • C - concentration
    • A - anhedonia
    • P - psychomotoric changes
    • S - suicidal ideation
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10
Q

What course makes you think atypical depression?

A

• Mood reactivity
• Leaden paralysis
• Reverse neurovegetative symptoms
○ Increased appetite, weight gain, hypersomnia

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11
Q

What is melancholic depression?

A

Mood worse in morning, early morning awakening, anorexia, weight loss, guilt, psychomotor retardation

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12
Q

Describe bipolar disorder

A

• 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

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13
Q

How do you diagnose bipolar disorder?

A

• 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

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14
Q

What are the typical medical illnesses that can masquerade as a mental illness?

A
  • Endocrine - cushings, hyper/hypothyroidism, steroids
    • Infections - HIV, influenza, meningitis, CJD
    • CNS - stroke, tumor, MS, epilepsy
    • Metabolic - hypercalcemia
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15
Q

What substances of abuse can manifest as mood disorders either through toxicity or withdrawal?

A
  • Cocaine, alcohol, amphetamine/stimulants
    • Hallucinogens (LSD, PCP, mescaline)
    • Benzodiazepines
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16
Q

What are the prescribed medications that have side effects that can look like mood disorders?

A
  • Amantadine
    • Methyldopa withdrawal
    • Interferon
    • Steroids
    • Chemotherapy agents
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17
Q

What is considered optimal treatment of mood disorders?

A
  • For mood disorders, the optimal treatment is both behavioral AND medication therapy
    • Pharm and psychotherapy
    • Depression can be only psychotherapy, but bipolar needs meds
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18
Q

What are the three different phases of mood disorder treatment?

A
  • Acute - 0-3 months (50% may stop treatment here)
    • Continuation (4-9 months) - 65-75% may stop treatment
    • Maintenance (years)
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19
Q

What’s the treatment paradigm for depression?

A

• 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

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20
Q

Describe the different types of antidepressants

A

• 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

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21
Q

What are the important SNRIs?

A
  • Venlafaxine (vader)
    • Desnvenlafaxine (definately)
    • Duloxetine (defines)
    • Milnaciprin (mighty)
    • levomilnaciprin (levitation)
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22
Q

What are the important SSRIs?

A
  • Fluoxetine (Father)
    • Paroxetine (Priest)
    • Sertraline (says)
    • Citalopram (catholic)
    • Escitalopram (escatology)
    • Fluvoxamine (following)
    • vilazodone (valentine’s day)
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23
Q

What are the important MAOIs?

A
  • Phenelzine (poop)
    • Selegeline (transdermal) (stinks)
    • Tranylcypromine (taken)
    • isocarboxazid (internally)
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24
Q

What are the important “other” antidepressants?

A
  • Mirtazapine
    • Buproprion
    • Trazodone
    • Nefazodone (also an SSRI)
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25
Q

What are the important TCAs?

A
  • Amytriptyline (anybody)
    • Nortriptyline (never)
    • Desipramine (dancing)
    • Imipramine (impractically)
    • Doxepin (decides)
    • Trimipramine (to)
    • Protriptyline (practice)
    • amoxapine (anhedonia)
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26
Q

What are the benefits and risks for using TCAs?

A
• 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
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27
Q

What are the pros and cons of using MAOIs?

A
• 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)
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28
Q

What are the pros and cons of using SSRIs?

A
• 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
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29
Q

What are the pros and cons of using SNRIs?

A
• 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"
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30
Q

What are the pros and cons of mirtazapine

A
  • Pros - helpful with insomnia, rapid anti-anxiety effect, low incidence of sexual side effects
    • Cons - daytime somnolence, weight gain
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31
Q

What are the pros and cons of buproprion?

A

• 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

32
Q

What are other, non-pharm strategies for mood disorder treatment?

A

• 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

33
Q

Which is more simple to treat pharmacologically, unipolar depression or bipolar disorder?

A
  • 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
34
Q

Of all the bipolar medications listed in the table in the notes, which were the important ones listed out?

A
  • Lithium
    • Divalproex sodium
    • Atypical antipsychotics
35
Q

What is the treatment paradigm for mania?

A
  • 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
36
Q

What are the pros and cons to llitium treatment?

A
• 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
37
Q

What are the pros and cons of divalproex sodium?

A
• 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
38
Q

What are the pros and cons with atypical antipsychotic use?

A

• 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

39
Q

Should you use antidepressants in bipolar depression?

A

• 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)

40
Q

Besides lithium, what pharm treatments help prevent future bipolar episodes?

A
  • Aripiprazole
    • Olanzapine
    • lamotrigine
41
Q

Give a general definition/description of what a personality disorder is.

A
  • 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
42
Q

What are the 10 types of personality disorder?

A
  • Paranoid
    • Schizoid
    • Schizotypal
    • Antisocial
    • Borderline personality disorder
    • Histrionic
    • Narcissistic
    • Avoidant
    • Dependent
    • OCPD
43
Q

The hybrid methodology used in DSM-V criteria retain how many personality disorder types?

A
• 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
44
Q

What are the three cluster A personality disorders?

A

• Paranoid
• Schizoid
• schizotypal
*these are in the schizophrenia axis of diagnoses, along the spectrum of abnormal brain chemistry that is schizophrenia

45
Q

What are the cluster B personality disorders?

A
• Antisocial
	• Borderline
	• Histrionic
	• Narcissistic
		○ These are more similar to PTSD and bipolar than any of the other personality disorders
46
Q

What are the cluster C personality disorders?

A

• Avoidant
• Dependent
• Obsessive-compulsive
○ These all have traits from generalized anxiety disorder and depression

47
Q

What is the brief description of all the cluster A personality disorders?

A
• Paranoid
		○ Distrustful, suspicious
	• Schizoid
		○ Interpersonal detachment
	• Schizotypal
		○ Odd thoughts and behavior
		○ Interpersonal awkwardness
48
Q

What are the general description points for the cluster B personality disorders?

A
• antisocial
		○ disregard and violation of others rights
	• Borderline
		○ instability of relationships, self-image, affects
	• Histrionic
		○ emotionality, attention seeking
		• Narcissistic
			§ Grandiosity and lack of empathy
49
Q

What are the general description points for the cluster C personality disorders?

A
  • Avoidant
    * Worries of inadequacy and being negatively judged
    • Dependent
      • Need to be taken care of
    • Obsessive-compulsive
      • Orderliness, perfection, need to be in control
50
Q

Personality disorders are egosyntonic. What does that mean?

A

• 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

51
Q

Personality disorders manifest in 2 or more of what ways?

A

• 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

52
Q

What are the DSM-V criteria for the dx of a personality disorder?

A

• 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

53
Q

What symptoms have to be exhibited to warrant a paranoid personality disorder?

A

• 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

54
Q

What are the criteria for diagnosing schizoid personality disorder?

A

• 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

55
Q

What are the criteria for making the dx of schizotypal personality disorder?

A

• 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

56
Q

What are the criteria that need to be present to make the dx of antisocial personality disorder?

A

• 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

57
Q

What are the diagnostic criteria for borderline personality disorder?

A

• 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

58
Q

What are the diagnostic criteria for histrionic personality disorder?

A

• 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

59
Q

What are the diagnostic criteria for narcissisitic personality disorder?

A
  • 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
60
Q

What criteria are necessary for the dx of avoidant personality disorder?

A

• (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

61
Q

What constellation of behaviors makes you think dependent personality disorder?

A

• 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

62
Q

What are the 4 categories of drugs used in treatment of anxiety?

A
• 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
63
Q

Sedative and hypnotic drugs are separately classified from other CNS depressants how?

A
  • 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
64
Q

What, in general, is the problem in ADHD?

A

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

65
Q

What can be misdiagnosed as ADHD?

A

• 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

66
Q

What is the prevalance of ADHD?

A
  • Children of school-age - 3-8%

* Adults - 4%

67
Q

What does it mean to be inattentive?

A
  • 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
68
Q

What does it mean to be hyperactive/impulsive?

A
  • 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
69
Q

What are the types of ADHD?

A

• 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

70
Q

What are the common comorbidities with ADHD?

A
• 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
71
Q

What is the differential diagnosis for ADHD?

A
  • Anxiety
    • Sleep problems
    • PTSD (adult)
    • Sleep Apnea
    • Relational Problems
    • Learning Disorders
    • Depression
    • Abuse (adult or children)
    • Lack of food (children)
    • Psychosis
    • Mania
72
Q

What is the gold standard of treatment for ADHD?

A

• Stimulants are standard of care
• High efficacy and good tolerability in patients
• Hyperactivity
○ Atomoxetine
○ Bupropion
○ Alpha agonists (guanfacine, clonidine)

73
Q

What are the DSM V criteria for the dx of ADHD?

A
  • 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
74
Q

What are the two types of stimulants used for ADHD?

A
• Amphetamines
		○ Adderall
		○ Aderall XR
		○ Vyvanse (lisdexamphetamine)
	• Methylphenidates
		○ Ritalin
		○ Ritalin LA
		○ Concerta (methylphenidate ER)
75
Q

What’s the basic flow chart for treatment and dx of ADHD?

A

• 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