Human Growth, Developmentally disabled, Flashcards
transference?
Transference: A set of expectations, beliefs, and emotional responses that a patient brings into the doctor patient relationship
CounterTransference: Physicians unconscious or unspoken expectations and feelings about a patient
categories of temperament
- Temperament Patterns of arousal and emotionality that represent consistent and enduring characteristics in an individual
- Temperament refers to how children behave, as opposed to what they do or why they do it.
- not fixed/unchangeable
Easy babies: Babies who have a positive disposition; their body functions operate regularly, and they are adaptable
Difficult babies: Babies who have negative moods and are slow to adapt to new situations; when confronted with a new situation, they tend to withdraw
Slow-to-warm babies: Babies who are inactive, showing relatively calm reactions to their environment; their moods are generally negative, and they withdraw from new situations, adapting slowly
attachment
- Attachment The positive emotional bond that develops between a child and a particular individual
When children experience attachment to a given person, they feel pleasure when they are with them and feel comforted by their presence at times of distress.
As children become more independent, they can progressively roam farther away from their secure base.
object permanence appears?
- The understanding that objects continue to exist when out of sight
- Usually partially complete by 8-12 months and established by 12-18 months
- Incomplete at first: Children will only look for the item where it was last seen instead of using inference to find where it has been moved
Reactive Attachment Disorder of Infancy/Childhood:
- child exposed to poor care/abuse
- Inhibited Type - Child is withdrawn or unresponsive
- Disinhibited Type - Child approaches and cuddles up to strangers
stranger anxiety?
- caution and wariness displayed by infants when encountering an unfamiliar person (usually seen at 8-10 months)
separation anxiety appears?
- Separation anxiety The distress displayed by infants when a customary care provider departs (usually first seen at 6-8 months and peaks at 14-18 months)
Eriksonian stages of psychosocial development?
- Trust vs. mistrust: birth-1 year
- trust develops when environment responds to stimuli, mistrust when experiences frustration and deprivation: depends on how well their needs are met by caregivers
- “hope”
- failure of this first phase can cause psychosis, depression and addictions later in life. - autonomy vs. shame and doubt: 1-3 years
- develop independence and autonomy if they are allowed the freedom to explore, or shame and self-doubt if they are restricted and overprotected
= “Will” phase
- failure can cause paranoia, OCD and obsessive personality disorder - initiative vs. guilt: 3-6 y/o
- goal-directed behavior, initiative, conflict when independent actions cause negative results
- “purpose”
- failure = phobias - industry vs. inferiority: 6-12 y/o
- learning to take pride in accomplishments, or can cause sense of failure and inferiority d/t interactions w/ other adults
- “competence” - Identity vs. Identity confusion: 12-21 y/o
- development of indepdent ego structure
- “fidelity” = faithfulness to sense of self
- failure = delinquency, gender identity disorders, psychosis - Intimacy vs. Isolation: 21-40 y/o
- must have solid sense of identity in order to form necessary relationships
“Love”
- failiure = schizoid personality, prejudice - Generativity vs. stagnation: mid adulthood (40-60 y/o)
- concern for future generations and society
“care”
- failure: substance abuse, marital infidelity, “mid-life crisis” - Integrity vs. Despair: 60+
- ability to accept one’s life as it had been and take responsibility for it
- coming to terms w/ possibility of death
“wisdom”
periods of cognitive theory of development
- Four factors influencing cognitive behavior
Maturation of the nervous system
Experience
Social transmission of information
Equilibration (innate tendency for mental growth to progress toward increasingly complexity and stability)
Piaget’s stages of cognitive development
- Sensorimotor stage (birth to 2 years)
- develop object permanence
- react to environment - Preoperational thought (2-6 y/o)- preschool
- ability to use symbols and language
- no deductive reasoning
- egocentric thought
- magical thinking (phenomenalistic causality)
- semiotic function
- centration (focusing on one obvious element of stimulus rather than considering all information) - Concrete operations (6-11 y/o)
- egocentric thought replaced by operational thought, able to reason, follow rules, have morals
- conservation (recognize objects are same even if change shape)
- reversibility (liquid to ice)
- social speech
- rigid interpretation of rules - Formal operations (11- late adolescence)
- ability to use deductive reasoning in abstract ways
- probability, philosophy, religion, politics
- higher mathematics
levels of intellectual disability
Mild IQ of 50 to 55-70
Moderate IQ of 35 to 40-50 to 55
Severe IQ of 20 to 25-35 to 40
Profound - Level below 20 to 25
down’s syndrome features
trisomy 21 - single palmar transverse crease, protruding tongue, flat facies, small ears, thick neck
fragile x syndrome
Xq27
Affects males more severely delayed cognitive abilities, behavior problems, hand flapping, large ears, elongated faces and enlarged testicles.
learning disorders
= Inability to achieve in a specific area of learning at a level consistent with the person’s overall IQ
asperger syndrome
- Relatively good verbal language
- Milder nonverbal language problems
- Restricted range of interests and relationships
- Often engage in repetitive routines
- struggle w/ peer relationships
autistic spectrum disorder
Impaired social interactions
Impaired ability to communicate
AND, a restricted range of activities and interests
onset:
- first three years of life
- boys 4x more likely
etiology:
- brain dysfunction with abnormalities in brain structure (including the cerebellum and cerebral cortex – frontal and temporal lobes),
- abnormalities in neurotransmitters such as serotonin and dopamine
- highly heritable disorder
Rett’s syndrome
mainly in girls
Normal development to age 4 then…
- decreased social, verbal and cognitive skills
- Hand wringing
- Ataxia
- Decreased IQ
feeding disorders of infancy…
- not related w/ GI or other medical/mental disorder
- failure to eat and gain weight over at least 1 mos
- onset before age 6
- May appear apathetic
- children develop to be smaller than peers
Parent-child interaction problems my contribute to or exacerbate the feeding problem
Factors may include:
Temperament
Intrauterine growth retardation
Preexisting developmental impairments
tourette’s disorder
= Involuntary Motor Movements & Vocal Tics (Dopamine in Caudate Nucleus)
- Median age of onset is 6-7 years, but can be seen as early as 2 years
- Seen more often in boys (3-5 X) than girls
- Duration may be lifelong or may resolve with adulthood
tx: antipsychotics
differentiate from transient tic disorder…
- presence of single/multiple motor/vocal tics for NO LONGER than 12 mos
major vs. mild NCD?
major NCD = significant cognitive decline which testing confirms
** Deficits interfere w/ADLs (not independent)
mild NCD = Modest cognitive decline documented by knowledgeable reporter
** Deficits do not interfere w/ADLs (is independent)
Characteristics of Neurocognitive Disorders:
- problems w/ planning, organizing, learning, language, social cognition
- signs: aphasia, agnosia, apraxia
- ** Progressive onset, steady course (dementia is stead, delerium comes on abruptly)
- No clouding of consciousness
which drug to avoid to tx NCD?
In all dementias, avoid anticholinergic meds!!!
**Cholinergic neurons are lost through toxic damage or cell death –> decreased acetylcholine transmission
Alzheimer’s disease
Epidemiology:
- Most common cause of dementia
- Diffuse atrophy, enlarged ventricles
- Risk factors: Down Syndrome (extra APP), female sex, hx head trauma, lower education level, ApoE alleles
- Apolipoprotein E: ε4 allele increases risk, ApoE ε2 is protective
Pathology:
- amyloid plaques: APP (amyloid precursor protein) cleaved improperly to amyloid β42 –> plaques (extracellular) –> cause cell death
- neurofibrillary tangles: Mostly phosphorylated tau protein folds and accumulates (intracellular)
- Both –> neuronal death directly and via inflammatory pathways
Behavioral disturbances common:
- psychosis, depression, agitation, sundowning (stay up all night, sleep all day)
Tx:
- AChE inhibitors! (Donzepizil, galantamine, Rivastigmine) - will help slow down progression
- memantine (protects against glutamate toxicity)
- anitpsychotics: black box warning of stroke!
- AVOID BENZOS - cause resp. depression, addiction, increased risk of falls
vascular NCD
- Deficit onset relates to a cerebrovascular event & decline prominent in complex attention & frontal/executive fxn
- More common in men
- More abrupt onset, step-wise decline
- Important to control risk factors (smoking, BP, glucose, aspirin, etc)
- Can try acetylcholinesterase inhibitors
Frontotemporal NCD
“Bad guys”
Insidious onset/gradual progression w/2 variants:
- Behavioral (disinhibited, apathetic, dramatic personality changes, ritualized bx, hyperoral, decline in social/executive fxn, overreaction)
- Language (production, naming, grammar, etc)
- MRI shows atrophy of frontal and temporal lobes
- more common in men
- earlier onset in 50s
NCD w/ Lewy Bodies
= AD + PD (visual hallucinations, tremor, dementia!)
Pathology: Lewy inclusion bodies (intraneuronal protein aggregates, mostly α-synuclein) –> cell death
Difficult to distinguish, overlap with other dementias especially PD
** Psychosis (esp visual hallucinations); parkinsonian features; occasional fluctuating mental function can mimic delirium and confound dx
tx: Paradoxical antipsychotic tx reaction (psychosis and ↑ side efx);
- consider acetylcholinesterase inhibitor
NCD d/t Prion disease
Rapid onset/course
Motor features of prion dz (clonus, ataxia, biomarker evidence)
Triphasic waves on EEG for CJD
HCD d/t Huntington’s disease
AD, 50% inheritance
- CAG trinucleotide repeat –> mutant protein –> neuronal death
sx:
- Abulia (lack of motivation), psychomotor slowing
- Complex tasks first, memory/language later
- Motor abnormalities (chorea)
- Mood disturbances and/or psychosis is common
Tx: antipsychotics, acetylcholinesterase inhibitors, mood stabilizers, SSRI
NCD d/t parkinson’s disease
- α-synuclein or tau protein in substantia nigra; Lewy Body involvement common
** Distinguish from NCD w/Lewy Body by time frame (NCD PD requires cognitive decline ≥1 yr dx of PD) - think LBD if dementia happens quicker
psychosis
= disruption in the experience of reality (includes delusions and hallucinations)
- this is a sx, never a ddx!
partial ddx for psychosis:
- SLE, acute intermittent porphyria, Major Depressive Disorder, Bipolar Disorder, seizures (esp TLE), Schizophrenia, Schizoaffective disorder, substance intoxication, Delirium, Dementia, adverse drug reaction, etc.
delusion
= misperception of existing stimuli
- fixed, false belief not consistent w/cultural or religious background. Can be bizarre or non-bizarre (thought broadcasting, ideas of reference, grandiose, alien chips, erotomanic, persecutory, partner cheating, etc)
hallucination
= responding to stimuli that doesn’t exist
false sensory perception not associated with real external stimuli (auditory, visual, tactile, gustatory, olfactory)
** note: personality disorders don’t have hallucinations (except for borderline)
schizophrenia
= NOT split personality
- est. 1% of population, men=women
- Typical onset: late teens to late 20s, men earlier than women
- Wide range of various mental disturbances
- Increased suicide risk; higher medical co-morbidities – some stats say up to 50% (15-20 year shortened life span…)
- More likely to be victim of violence
Typically have prodromal period:
- “first break” can be mild to severe
- often results in someone acting strange, messy, pulling away socially
DSM V Criteria for DDx:
- ≥2 of the following, each present for a significant portion of a 1-month period- prodrome (or less if successfully treated):
- delusions
- hallucinations
- disorganized speech (e.g., frequent derailment or incoherence)
- grossly disorganized or catatonic behavior
- negative symptoms
- social/occupational dysfunction
- signs persist for at least 6 months, including 1 mos of above sx
** The following must be ruled out: Schizoaffective, Mood Disorders, substances, general medical conditions, autism spectrum
Pathophysiology:
- ?? not sure: could be inflammatory, infectious, often genetic, d/t marjuana
- see ventricular enlargement of 3rd and lateral ventricles
- prefrontal cortex may be involved…
symptoms of schizophrenia
Positive symptoms:
- Hallucinations and delusions: Hallucinatory content varies greatly and usually auditory (AH) (visual hallucinations not as common)
- Disorganized speech/behavior
Negative symptoms:
- Lack of motivation
- Affective blunting – often blunted to flat
- Cognitive blunting
- Impaired social functioning and social withdrawal
NTs of schizophrenia
- “Dopamine hypothesis” – xs dopamine makes people psychotic!
- supported by efficacy of antipsychotics - Seratonin hypothesis:
- plays a role in negative sx!
LSD causes psychosis - Glutamate hypothesis:
- Hypo/hyperfunction at various receptors including NMDA
tx of schizphrenia
Major SE’s of antipsychotic tx:
- mvmt disorders (dystonia, akathisia, parkinsonism, tardive dyskinesia)
- neuroepileptic malignant syndrome (NMS): – total dopamine blockade, causing rigidity of mm. and VERY high fever (must tx w/ dopamine agonist, and control psychotic behavior w/ Benzos)
- anticholinergic SE’s
- sedation
- weight gain
- Clozapine: BEST drug, but BAD SE’s
- All of the above PLUS agranulocytosis (& others) –> restricted use
- Can ↓ suicidality
schizophreniform disorder
“Schizo lite”
- Similar to schizophrenia except symptom duration
** Symptoms of schizophrenia lasting >1 month but
schizoaffective disorder
Can be a difficult dx to make
** Features of both schizophrenia and depression or bipolar illness;
Requires 2 weeks of schizophrenia symptoms in the absence of mood symptoms AND the presence of mood symptoms for a substantial part of the lifetime illness course
Tx: psychosis with antipsychotics, mania with mood stabilizers, depression with antidepressants. Combine as necessary.
brief psychotic disorder
Psychosis >1 day but
Delusional Disorder
- ≥1 month of a delusion (erotomanic, persecutory, grandiose, jealous, somatic)
- *Does not meet basic schizophrenia criteria; behavior and function usu not affected
Women > men, usu mid-late life
R/O medical causes (eg, tumors, TLE, etc)
Tx: psychotherapy; poor response to antipsychotics
NOTE:
- erotomanic = thinks a celebrity is in love with them
- somatic = thinks something is growing out of body
bipolar disorder
= “a group of disorders in which a patient has sustained mood episodes in both directions (elevated or depressed)”
- total BAD is more common in women, age of onset 25 y/o (men have earlier onset)
** Manic Episode **
= Presence of abnormally elevated, expansive, or irritable mood for at least one week : “bigger, faster, better”
= + 3/7 characteristics
-Inflated self esteem or grandiosity
-Decreased need for sleep (more energy)
-More talkative or pressured
-Flight of ideas/subjective racing thoughts
-Distractibility
-Increased goal directed activity (more energy)
-Excessive involvement in pleasurable activities
Genetics:
- parent gives 10-25% risk in pt.
- family hx of MDD or BAD increases risk
- concordance rate b/w twins is 70-90%
differential ddx?
- stimulants: amphet, PCP, cocaine, antidepressants
- testosterone, hyperTH, pheo, FTD, schizo, ADHD, MDD
Bipolar type I
= a history of AT LEAST ONE MANIC EPISODE!
- ANY manic episode = severe = BAD I
- equal b/w genders
- characterized by recurrent depressed and manic episodes w/ good functioning in between
Bipolar type II
= Hypomanic episodes and major depressive episodes. (more depressive episodes seen in general)
- Symptoms do not meet full criteria for a manic episode
- relatives of Bipolar II patients have higher rates of Bipolar II disorder than either Bipolar I or MDD
** Also has a higher rate of comorbidity with substance abuse disorders
