Diagnoses II Flashcards
Name 3 pervasive developmental disorders
Pervasive developmental disorders (axis I)
- Autism spectrum (includes old Asperger’s)
- Rett’s d/o
- Childhood disintegrative d/o
Autism
(a) Age of onset
(b) prevalence
(c) rate of comorbid MR
(d) gender difference
Autism (axis I pervasive developmental d/o)
(a) Almost always have symptoms before 3 years old
(b) 1/150 births (.6%)
(c) 70% have comorbid MR
(d) 3-4:1 boys:girls
Symptoms of Autism
-how many to qualify for dx
Autism: 6+ total symptoms
Social interaction impairment (2+)
- impairment of nonverbal behavior (poor eye contact)
- failure to develop peer relationships
- lack of spontaneous seeking to share enjoyment
Social Communication problems (1+)
- delay or lack of spoken language
- stereotyped use of language
- lack of varied or spontaneous play
Restrictive Behavior/Interests (1+)
- intense preoccupation w/ object
- inflexible adherence to rules
- repetitive motor mov’ts
What is Rett’s disorder?
(a) population
(b) age of onset
(c) main symptoms
(d) prognosis
Rett’s d/o = pervasive developmental d/o
(a) only in females: MCP2 gene on X chromosome
- thought to be lethal in utero for males
(b) Normal development in first 5 mo. 5-38 mo = deceleration causing lifelong impairment
(c) decrease in head circumference growth velocity during 5-38 months
- loss of previously acquired hand skills => stereotyped hand mov’t
- impaired language, psychomotor retardation, gait or trunk abnormal mov’ts
(d) cognitive development never progresses beyondt hat of first year of life
Childhood disintegrative d/o
(a) population
(b) age of onset
(c) symptoms
Childhood disintegrative d/o = pervasive developmental d/o
(a) Males 4:1
(b) Normal first 2 years, then onset before age 10
(c) Loss of previously acquired skill in 2+
1. language
2. social skills: bowel/bladder control, play, motor skills
2+ of the following
- impaired social interaction
- impaired use of language
- restricted, repetitive, and stereotyped behaviors and interests
What to rule out when assessing for developmental d/o
Rule out an organic cause!
- r/o vision problem, maternal health
- lab testing: chromosomal analysis, lead levels
Dx of MR
MR now called intellectual disability- have to have both:
subaverage intellectual functioning w/ IQ
Gender ratio of ID and possible explanation
- 5:1 M:F for ID
- Fragile X syndrome = most common inherited form of mental retardation (second overall) due to X chromosomal mutation
MR + obesity
Prader-Willi syndrome: MR, obesity, hypogonadism, almond-shaped eyes
-genetic cause of MR
Most common learning disorder
Reading disorder
4-10% of school-age children
Differentiate autism and asperger d/o
Both
- impairments in social interaction
- restricted or stereotyped interests and behaviors
Aspergers: no clinically sig delay in spoken or receptive language or cognitive development
-no delay in self-help skills or curiosity about environment
Contrast Rett d/o and Childhood disintegrative d/o
-both have high rates of EEG abnormality and seizure d/o
Rett d/o
-earlier onset (before 1st year)
Childhood disintegrative d/o
- head growth does not slow
- unusual hand movements are not present
Criteria for Tourette d/o
(a) more common in which gender
Tourette d/o = most severe tic d/o- multiple daily motor and 1+ vocal tics w/ onset before age 18
Describe types of
(a) motor tics
(b) vocal tics: coprolalia and echolalia
Tics
(a) motor tics- often involve face and head
ex: blinking eyes
(b) vocal tics often
- coprolalia = repetitive speaking of obscene words (uncommon in children)
- echolalia = exact repetition of words
Tourettes d/o
(a) more common in which gender
(b) peak age
(c) comorbidities
(d) neurochemial etiology
Tourettes d/o
(a) boys > girls
(b) peak in severity btwn 8-12, decreases w/ puberty
(c) high comorbidity w/ OCD (40%) and ADHD (50%)
(d) impaired regulate of dopamine in the caudate nucleus
Pharmacologic tx for tourettes
Atypical neuroleptics (risperidone)
Alpha-2 agonists = clonidine, guanfacine
What is selective mutism?
Girls > boys
Refusal to speak in certain situations for at least 1 month
ex: little girl will speak at home but not in school
Parents w/ anxiety d/o predispose their children to what?
Separation anxiety d/o
Differentiate the 3 anxiety disorders w/ identifiable stressor
Identifiable stressor of grave danger=> acute stress disorder vs. PTSD depending on timeline
- acute stress d/o: begins w/in 1 month of stressor, lasts less than 1 month
- PTSD begins anytime, lasts over 1 mo
Not life threatening identifiable stressor => adjustment d/o
-begins w/in 3 months, lasts less than 6 mo
Then free-floating anxiety, not fixed on a specific thing = GAD
Differentiate bereavement and grief
Bereavement- must be the loss of a loved one, while grief can be from anything (ex: divorce)
-pathological if > 1 yr or overtly psychotic
4 features of PTSD
PTSD: begins anytime, lasts > 1 mo
- re-experiencing (flashbacks, nightmares)
- avoidance of stimuli associated w/ trauma
- numbing of responsiveness (affect, detachment)
- increased arousal
Differentiate adjustment d/o and GAD
Adjustment d/o: due to non-life threatening stressor, begins w/in 3 month of and ends less than 6 months after stressor
- if it persists for 6 months after the stressor = GAD
- or can be chronic adjustment d/o if the stressor recurs or persists
Most effective tx for adjustment d/o
(a) gender disparity of adjustment d/o
Supportive therapy
(a) 2:1 F:M
GAD
(a) gender disparity
(b) comorbidity
(c) lifetime prevalence
(d) time requirement
(e) prognosis
Generalized anxiety d/o
(a) 2:1 F:M
(b) 50-90% have MDD, phobia, panic
(c) 45% lifetime prevalence
(d) lasts 6+ months
(e) 50% completely recover, 50% have chronic lifelong symptoms
Symptoms of GAD
GAD: excessive worry about daily events and activities
3+ associated symptoms
- restlessness, fatigue, irritability
- impaired concentration
- muscle tension, sleep disturbance
Treatment for GAD
(a) acute
(b) chronic
GAD tx
(a) acute = benzos
(b) chronic: psychotherapy + pharma: Buspirone, SSRI, Venlafaxine
Panic d/o
(a) prevalence
(b) most common comorbidity
(c) 2 requirements for diagnosis
Panic d/o
(a) 2-5%
(b) 40-80% comorbid MDD
(c) Spontaneous recurrent panic attacks w/ no obvious precipitant
- followed by 1 month of fear of panic attack, worry, change behavior
Tx for panic d/o
(a) acute- rule out what first?
(b) maintenance tx
Tx for panic d/o
(a) acute- rule out organic cause (ex: MI), then benzos
(b) maintenance- CBT + 8-12 months of SSRI (higher dose than for depression)
What are the most common mental disorders?
(a) time requirement
Specific phobias
(a) 6+ months if
Differentiate social phobia from agoraphobia
Agoraphobia = fear of being in a place where they can’t escape (ex: common w/ panic d/o)
=> avoidance of being in places or situations from which escape or help might be difficult
Social phobia = anxiety brought on by fear of embarassment
Tx for social phobia
SSRI- paroxetine
- beta blocker if performance anxiety
- CBT to correct autonomatic thoughts
Differentiate OCD and OCPD
OCD: ego dystonic (have insight)- know their obsessions/compulsions are excessive and wish they could stop
OCPD: ego dystonic- don’fat think anything is wrong
Tx for OCD
OCD:
- high dose SSRI
- CBT: exposure and response prevention
- TCA: Clomipramine
Define anxiety
subjective experience of fear and its physical manifestations
-pathologic when it is inappropriate (source not sufficient to the severity of symptoms) and symptoms interfere w/ daily functioning
Panic attacks
(a) peak, duration
(b) trigger
(c) symptoms
Panic attacks (a) Peak w/in 10 minutes and usually last under 25 minutes (b) can be provoked by triggers or come on spontaneously (c) PANICS P- palpitations A- abdominal stress N- numbness, nausea I- intense fear of death C- choking, chills, chest pain S- sweating, shaking, SOB
What type of breathing pattern can induce a panic attack?
Hyperventilation
What are the most common mental d/o in the US
Phobias
- 5-10% of the population
2: 1 W:M
What percent of OCD pts have both obsessions and compulsions?
75% of OCD pts have both obsessions and compulsions
-OCD, Tourette syndrome, and ADHD are frequently comorbid
Define dissociative d/o
(a) differentiate from amnestic d/o
Dissociative d/o = loss of memory, identity, or sense of self (not due to medical or substance use)
(a) if due to medical reason or substance use = amnestic d/o
Epidemiology of dissociative amnesia
Dissociative amnesia: pt not troubled by memory loss
- F > M
- young > old
- common in child abuse
- usually triggered by traumatic/stressful event
Symptoms of dissociative amnesia
Dissociative amnesia = inability to recall important personal info, usually involving a traumatic/stressful event
- amnesia as the only dissociative symptom (no loss of identity or sense of self)
- not troubled by the memory loss despite that it causes marked impairment or distress
- often reported as ‘gaps’ in recollection of a traumatic event (ex: rape)
What is dissociative fugue?
Dissociative fugue (‘fug’ = fugitive)
- sudden travel away from home w/ inability to remember parts of past or identity
- often assume new identity
- unaware of amnesia
Dissociative identity d/o
(a) prevalence
(b) gender
(c) why dangerous
Dissociative identity d/o (previously multiple personality d/o)
(a) prevalence = very rare
(b) 90% female
(c) 1/3 attempt suicide
In which dissociative d/o is the pt aware of his/her symptoms?
Dissociative d/o where pts are aware of his/her symptoms = depersonalization d/o: pts are aware and feel like they’re going crazy
While the other dissociative d/o, pts are unaware or not troubled by their symptoms:
- dissociative amnesia: not troubled by memory loss
- dissociative fugue: unaware of amnesia
- dissociative identity d/o: personalities unaware of each other
2 + 2 = 5
Ganser Syndrome = ‘prison psychosis’
= rare dissociative d/o, nonsensical or wrong answers or doing things incorrectly (previously considered a factitious d/o)
- approximate answers to questions
- can have somatic symptoms
- reaction to extreme stress
Dissociative identity d/o symptoms
2+ distinct personalities which alternate control of the person
-each are unaware of the other
Treatment for dissociative disorders
- Retrieve memory to prevent recurrence: hyponosis, amobarbital (truth serum), ativan
- psychotherapy
Sodium amobarbital
= barbiturate derivative, sedative hypnotic
-off label given slowly via IV as ‘truth serum’ b/c under its influence a person will divulge info they normally wouldnt
Diagnostic criteria for Depersonalization D/o
Depersonalization d/o = recurrent feelings of detachment from self, environment, social status
- feel like an outside observer
- aware of symptoms, feel like they’re going crazy
- however: reality testing remains intact during episode
-must be recurrent, not d/o if a single episode (single episode is a normal stress rxn)
Treatment for depersonalization d/o
Anti-anxiety and antidepressants PRN
Distinguish memory loss found in dissociative amnesia vs. dementia
Memory loss in
-dissociative amnesia: unable to recall common personal info but able to remember obscure details
-dementia: remember common personal info, can’t recall the obscure details
What kind of dissociative d/o may be triggered by a rape?
Dissociative amnesia- disruption in continuity of memory of an event (often a traumatic one)
What is abreaction?
Abreaction = the strong rxn pts often get when retrieving traumatic memories
-release of previously repressed emotion, achieved thru reliving the experience that caused it (ex: by hypnosis or suggestion)
Theories on the mechanism of anorexia
(a) hypothalamic
(b) thyroid
(c) CCK
Mechanism of anorexia
(a) hypothalamic- lack of leptin
(b) low t3
(c) low CCK- hunger suppressant hormone
Two prognostic indicators for anorexia
(a) Does anorexia or bulimia have a better prognosis?
Anorexia
-better prognosis: later age of onset, restricter (not binge/purge) subtype
(a) Bulimia has better prognosis than anorexia
Differentiate anorexia vs. bulimeia
Anorexia binge/purge subtype can look a lot like bulimia
Body weight
- anorexia: body weight below 85%
- bulimia: normal weight or overweight
Normal hormone levels in bulimia (not in anorexia)
Ego-dystonic (bulimic) vs. ego-systeonic (anorexia)
Russel’s sign
Russel’s sign- scaring on dorsum of hand, sign of forced vomiting
-anorexia binge-purge type or bulimia
Metabolic disturbances of anorexia nervosa
(a) pH distburance
(b) EKG changes
(c) Hormones
(d) BUN
(e) bone changes
Metabolic disturbances of anorexia nervosa
(a) hypochloremic hypokalemic metabolic acidosis
(b) Inverted or flattened T wave on EKG. arrhythmia (especially QTc prolongation)
(c) Hormones: euthyroid, increased cortisol and GD
(d) BUN elevated due to protein catabolism
(e) osteoporosis
Treatment for anorexia
Treating anorexia
- psychotherapy: CBT
- SSRI adjunct: helps gain weight and for comorbid depression
Reasons to hospitalize an anorexic pt
Hospitalize if
- under 80% ideal BMI (BMI under 18.5)
- bradycardia or other arrhythmia (1/2 of deaths are heart related)
- altered mental status
- suicidal ideation
- severe metabolic disturbance
- hypothermia
Psychological symptoms of anorexia
Anorexia
- intense fear of gaining weight
- disturbed perceptions of weight/image
Psychological symptoms of bulimia
Bulimia
- recurrent episodes of binge eating followed by compensatory behavior
- perception of self-worth excessively influenced by body weight
- ego-dystonic
Diagnostic criteria for bulimia nervosa
(a) differentiate the two types: purge vs. nonpurge
Binge 2+ times/week for 3+ months
(a) differ by type of compensatory behavior
- purge: vomiting, laxatives, diuretics
- nonpurge: excessive exercise or fast
Prognosis for bulimia
1/3 improve
1/3 stay the same
1/3 get worse
Diagnostic criteria for eating disorder NOS (binge-eating d/o)
Binge 2+ days/week for 6 months
- recurrent episodes of binge eating but binge not followed by compensatory behavior
- emotional distress over binge eating but don’t try to control weight by purging or restricting
- eat rapidly, a lot, alone
- feel uncomfortably full
- feel depressed, guilty, or disgusted after binge
Treatment for bulimia
Treating bulimia
- usually nonresponsive to psychotherapy/CBT
- SSRIs, TCAs: reduce by 50%
When to treat a bulimic pt
- suicidal
- severe metabolic disturbance
Diagnostic criteria for feeding disorder of infancy
1+ month, onset before 6 yoa
-persistent failure to eat w/ decreased weight
(not due to lack of available food)
Pica
= eating of non-nutritive substances for 1+ mo, onset btwn 1-2 years
- usually remits by adolescence
- 1/4 of institutionalized mentally retarded children
Rumination disorder
= repeated regurgitation
- possibly: pleasure, tension-relieving, learned attention-getting
- 1+ month
- rare
- most common in 3 mo-1 year and MR children/adults
Bimodal age of onset of anorexia
Bimodal age of onset
Age 13-14: hormonal influences
Age 17-18: environmental influences
Mortality rate of anorexia
Cumulative, about 10% due to starvation
-1/2 of cases are related to cardiac reason
Possible explanation for why SSRIs are ineffective in tx of anorexia
(a) why to refeed anorexic pts gradually
Inadequate dietary intake of tryptophan (serotonin precursor
(a) Avoid refeeding syndrome: too abrupt of a shift in metabolism from catabolism to anabolism => electrolyte abnormalities
Define binge eating episode
Excessive food intake w/in a 2 hour period accompanied by a sense of lack of control
Bulimia
(a) FDA approved medication
(b) Contraindicated medication
Bulimia
(a) FDA approved: Fluoxetine 60-80 mg/day
(b) Buproprion- or any med that could further lower seizure threshold
Why are eating d/o pts at an increased risk for developing arrhythmias
Anorexic and bulimic pts have increased risk of cardiac arrhythmias due to electrolyte disturbances
ex: hypokalemia, hypochloremia
Treatment for binge-eating disorder
(a) Stimulants
(b) Orlistat
(c) Sibutramine
Binge-eating d/o: psychotherapy, behavioral therapy w/ strict diet and exercise program
(a) Stimulants to suppress appetite
(b) Orlistat = inhibits pancreatic lipase => decreases fat absorption from GI tract
(c) Sibutramine inhibits NE, 5HT, and DA reuptake (by unique mechanism) = oral anorexiant
