Lecture 1: DSM/MSE & ADHD Flashcards
Axis I contents
clinical disorders
other conditions that may be a focus of clinical attention
Axis II contents
Personality disorders
Mental retardation
Axis III contents
General Medical Conditions
Axis IV
Psychosocial & Environmental problems
Axis V
Global Assessment of functioning
GAF: scale, useful for what, takes into account what
0-100
-useful in planning treatment, predicting outcome and tracking clinical progress
-takes into account psychosocial functioning, social functioning, occupational functioning
NOT PHYSICAL LIMITATIONS!
Mental Status Examination (13 components)
[GAS, Motor, MA’AM, PIJ, Thought C & P]
- General description
- Alertness & orientation
- Speech
- Motor behavior
- Mood
- Affect
- Attention
- Memory
- Perception
- Insight
- Judgement
- Thought Content
- Thought Processes
General Description is what & 3 parts
Overall Appearance
posture
poise
grooming/clothing
Alertness and orientation consists of
Awareness of environment person time place level of consciousness: alertness or state of awareness of the environment
Speech: define this
system for expressing, receiving and comprehending words
When assessing Speech consider which 4 main components
Rate
Volume
Quantity
Type
9 types of speech
slurred mumbled emotional dramatic hesitant word salad clang associations neologisms aphasia
Motor Behavior (6 types)
Hyperactive Hypoactive (Psychomotor retardation) Rigid Restless/aasthisia Combative Tics
Mood definition
patient’s SUBJECTIVE DESCRIPTION OF HIS/HER EMOTIONAL STATE IN HIS/HER OWN WORDS
-sustained emotion that affects a person’s view of the world
Mood descriptors
depressed, irritable, anxious, angry, labile, euphoric, euthymic, dysphoric, apathetic, futile, frightened, guilty
Affect definition
- an observable feeling or tone expressed through voice, facial expression & demeanor
- emotional responsiveness
Affect descriptors
normal, BLUNTED, exaggerated, FLAT, constricted, labile
Attention definition
the ability to focus or concentrate over time on one task or activity
Memory definition
the process of registering or recording information
4 types of memory (& examples)
- Remote memory: childhood
- Recent remote memory: current events within the past few months
- Recent memory: what he or she had for breakfast
- Immediate retention & recall: 6 digit test
Perception definition
- sensory awareness of objects in the environment & their interrelationships
- also refers to internal stimuli
Hallucinations definition
false sensory perception NOT a/w a real external stimul
auditory, visual, olfactory, tactile, gustatory
Illusion definition
misperception or misinterpretation of a real external stimuli
Depersonalization definition
a person’s subjective sense of being unreal, strange or unfamiliar
Derealization definition
a subjective sense that the environment is strange or unreal
Formication definition
the feeling of bugs crawling on or under the skin
Insight definition
awareness that symptoms or disturbed behaviors are normal or abnormal
-patient’s awareness and understanding of his or her illness
Judgment definition
process of comparing and evaluating alternatives when deciding on a course of action
Thought Content Definition & 4 large categories
what the patient thinks about and the focus of their concerns
- delusions
- obsessions
- compulsions
- phobias
Delusions definition
- fixed, false, personal beliefs that are not shared by other members of the person’s culture
- cannot be corrected by reasoning
Types of Delusions (6)
- Paranoid
- Grandeur
- Nihilistic
- Ideas of Reference (ie. newscaster is speaking directly to me)
- Ideas of influence (ie. thought broadcast & ideas placed into you)
- Persecution
Obsession definition
recurrent, uncontrollable THOUGHTS, images or impulses
Compulsions definition
repetitive BEHAVIORS or mental acts that a person feels drive to perform
Phobias def
- persistent, irrational, exaggerated fear of a specific stimulus or situation
- accompanied by a compelling desire to avoid the stimulus
Social phobia
fear of public humiliation
Acrophobia
fear of heights
Agoraphobia
fear of open places
claustrophobia
fear of closed places
zoophobia
fear of animals
Thought Processes definition
the logic, coherence and relevance of the patient’s thought as it leads to selected goals (aka…how a patient thinks)
Thought processes (9 types)
Rapid Thinking Slow or hesitant thinking Goal-directed thinking Relevant responses Loose associations, flight of ideas Tangential Circumstantial Perseveration Blocking
ADHD definition
persistent pattern of INATTENTION and/or HYPERACTIVITY/IMPUSLIVITY that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development
-sxs affect cognitive, academic, behavioral, emotional and social functioning
Pathophysiology of ADHD
- not exactly known
- DECREASED DOPAMINE and/or NOREPINEPHERINE IN BRAIN appears to play primary role
- ?environmental factors
ADHD Inattention features (9)
- careless mistakes due to inattention
- difficulty sustaining attention
- does not listen
- does not follow through or finish work
- difficulty organizing tasks
- avoids tasks that require sustained mental effort
- loses things necessary for tasks
- easily distracted
- forgetful
ADHD Hyperactivity-Impulsivity features (9)
- fidgets
- leaves seat when sitting in seat is expected
- runs/climbs excessively in inappropriate situations
- difficulty playing/engaging in leisurely activities quietly
- “on the go”
- talks excessively
- blurts out answers prematurely
- difficulty awaiting turn
- interrupts or intrudes others
Types of ADHD
ADHD, combined type: meets inattentive & hyperactive-impulsive sxs (most common)
ADHD, Predominantly Inattentive type
ADHD, Predominantly Hyperactive-Impulsive Type
DSM-IV-TR Diagnostic Criteria
- at least 6 symptoms of inattention OR hyperactivity-impulsivity that have persisted for at least 6 mons to a degree that is maladaptive & inconsistent w/developmental level
- sxs present before age 7
- sxs with associated impairment present in at least 2 settings
- clinically significant impairment in social, academic or occupational functioning
- symptoms not better accounted for by another mental disorder
ADHD: age & dx
-dif to dx s childhood recall of ADHD)
ADHD ddx (11 listed here)
- age-appropriate behaviors in active kids
- intellectual disability
- learning disorder
- depression
- bipolar disorder
- anxiety
- post-traumatic stress disorder
- oppositional behavior
- substance abuse
- other medical conditions
- environmental factors
ADHD evaluation
comprehensive medical, developmental, educational & psychosocial eval to:
- confirm sxs, demonstrate fxnal complications, exclude other explanations for sxs, identify comorbid conditions
- review of medical, social & family histories
- interview patients & parents
- collect info from other caregivers & teachers
ADHD eval: what to ask parents
How is the kid doing in school?
Have you or teacher noticed any probs w/learning?
Is your child happy in school?
Does your child have any behavioral probs at school or home when playing with friends?
Does your kid have probs completing school assignments at school or home?
ADHD: what to ask teachers
how is the kids behavior in school? what interventions does the kid require? what are the kid's learning patterns? is there functional impairment? how does the kid get along with others? how is the kid's work? how are the kid's grades?
ADHD rating scales: who should complete these and when
should be completed by parents & teachers
-should be completed at time of dx, during med titration & at regular medication follow-up visits
[The slide points to NARROW-BAND ASSESSMENT: Vanderbilt Assessment Scales, so it must want us to use that, eh? whatevs.]
Treatment of ADHD (5 major components)
Therapy (psychotherapy & family) Behavior modification Educational intervention Environmental manipulation Pharmacologic agents
ADHD: Behavior Modification recommendations (9)
- maintain a daily schedule
- keep distractions to a minimum
- provide specific & logical places to keep schoolwork, toys & clothes
- set small, reachable goals
- reward positive behavior
- use charts and checklist to stay “on task”
- limit choices
- find activities in which the child can be successful
- use calm discipline
ADHD: Educational Intervention recommendations (9)
- tutoring
- individualized education programs (IEPs)
- write assignments on board
- smaller class size
- sit near the teacher
- frequent breaks
- extra time to complete tasks/tests
- signal from the teacher when he or she is “off-task”
- daily report to parents
Criteria for initiation of pharmacotherapy in kids w/ADHD
- dx assessment is complete and confirms dx of ADHD
- kid is 6 years or older
- parents accept meds as a contribution to management
- school will cooperate in admin & monitoring
- no previous sensitivity to chosen med
- kid has normal hrt rate & BP
- kid is seizure free
- kid DOES NOT have: tourettes, PDD or significant anxiety
- substance abuse among household members is not a concern (for kids who will be tx w/immediate release stimulants)
Stimulants: first line tx for what and how do they work?
considered FIRST-LINE TX for ADHD
- Affect the dopaminergic and noradrenergic systems, causing release of catecholamines
- ↑ dopamine and norepinepherine concentrations in brain are thought to be responsible for ↑ attention span and concentration
Which 2 stimulants are most commonly used
methylphenidate (trade names-Ritalin, Methylin, Concerta, Focalin, Metadate)
&
Dextroamphetamine (Dexedrine, Vyvanse)
What is another stimulant used in ADHD
Adderall, a mixed amphetamine salt
5 Short-acting formulations of stimulants used in ADHD & dosing intervals
- Ritalin, Methylin, Focalin, Dexedrine, Adderrall
- must be taken BID-TID
Long-acting formulations of stimulants used in ADHD
Methylphenidate-SR Ritalin-SR & LA, Metadate CD & ER Concerta Focalin XR Daytrana Adderall XR VYvanse -dosed Qday but side effects can extend longer -more expensive
Forms of ADHD stimulants
solution, pill, chewable tablet, patch
Efficacy of stimulants in ADHD
◦≈70% of patients with have ↓in hyperactivity and ↑ in attention
◦If patients do not have positive results or have significant side effects, try another agent.
Diversion and misuse of ADHD stimulants
◦Short-acting preparations tend to be preferred ◦Keep track of rx dates
◦Open discussion with patients and parents
ADHD stimulant SEs
Anorexia/appetite disturbance, Sleep disturbance,Weight loss, ↑ HR and BP, ? Sudden cardiac death, HA, Social withdrawal, Nervousness, Irritability, Stomach pain, Tics, Contact dermatitis (patch)
Atomoxetine (Straterra): use, MOA, pros, cons, SEs
selective norepinephrine reuptake inhibitor (NRI) used for ADHD
PRO:not a controlled substance, less potential for abuse
CON: more expensive than methylphenidate & dextroamphetamine
SEs: ◦Weight loss ◦Abdominal pain ◦↓ appetite ◦N/V ◦Dyspepsia ◦Sleep disturbances ◦Tics ◦Severe liver injury ◦↑ suicidal thinking ◦Cardiac risk
