Psych AND Adolescent Flashcards
Female athlete triad
Low energy availability (+/- disordered eating)
Menstrual irregularity
Low bone mineral density
ASD DSM 5 diagnostic criteria
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history
- Deficits in social-emotional reciprocity,
range: from abnormal social approach and failure of normal back- and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. - Deficits in nonverbal communicative behaviors for social interaction,
range: from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. - Deficits in developing, maintaining, and understanding relationships,
range: from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history
1. Stereotyped or repetitive motor movements, use of objects, speech (e.g., simple motor stereotypies, lining up toys or flipping objects,
echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
(e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
3. Highly restricted, fixated interests abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects,
excessively circumscribed or perseverative interests).
4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment
(e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)
C. Symptoms must be present in the early developmental period (although may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.
Intellectual disability and autism spectrum disorder frequently co- occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
ASD incidence
M:F ratio
Risk in sibling
Best predictors of outcome
Incidence approx 1/150 M:F - 4:1 Average age diagnosis 6-7years Risk in sibling is 5-10% (60% in MZ twin) ; 2+ children (30-50% risk) Syndrome Assoc: TS, Fragile X
Best predictor of outcome are IQ and speech by 5 years
ASD associations / complications
25% develop seizures (11-14years) 10% lose speech in adolesence Low IQ (30% have IQ<70) Psych: ADHD, Anxiety, depression OCD Sleep problems OCD Sensory processing difficulties Aggression (consider low dose antipsychotic - risperidone)
Oppositional defiant disorder
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms of the following categories, and exhibited during interaction with at least one individual who is not a sibling:
Angry/Irritable Mood
- Often loses temper
- Is often touchy or easily annoyed
- Is often angry and resentful
Argumentative/Defiant Behavior
- Often argues with authority figures or, for children and adolescents, with adults
- Often actively defies or refuses to comply with requests from authority figures or with rules
- Often deliberately annoys others
- Often blames others for his or her mistakes or misbehavior
Vindictiveness
8.Has been spiteful or vindictive at least twice within the past 6 months.
B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues) or it impacts negatively on social, educational, occupational, or other important areas of functioning
C. The behavior does not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also the criteria are not met for disruptive mood dysregulation disorder.
Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).
Moderate: Some symptoms are present in at least two settings
Severe: Some symptoms are present in three or more settings.
Rx
Behaviour management
Parent management training - incredible years programme (3-12 year olds)
Conduct disorder DSM 5
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age- appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:
Aggression to People and Animals
- Often bullies, threatens, or intimidates others.
- Often initiates physical fights.
- Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
- Has been physically cruel to people.
- Has been physically cruel to animals.
- Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
- Has forced someone into sexual activity.
Destruction of Property
- Has deliberately engaged in fire setting with the intention of causing serious damage.
- Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or Theft
- Has broken into someone else’s house, building, or car.
- Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
- Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).
Serious Violations of Rules
- Often stays out at night despite parental prohibitions, beginning before age 13 years.
- Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
- Is often truant from school, beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.
Conduct disorder
- Cruelty to people and animals
- Destruction of property
- Deceitfulness or theft
- Serious violations of rules
• Diagnostic criteria present for 12 months
• Causes clinically significant impairment
• Childhood or adolescent onset
• Repetitive & persistent pattern
Childhood Onset
– one symptom present before 10 years old
– More likely male, aggressive, disturbed peer relationships – likely have ODD, ADHD
– likely develop Antisocial Personality Disorder (ASPD)
Adolescent Onset
– no symptoms before10
– F=M, less aggression, peer relationships, less likely to develop ASPD
Prevalence
3-5% children, increased prevalence >12years
M:F 2:1
Improves young adulthood
30-50% develop ASPD
Increase risk substance abuse, mood disorders and suicide later in life ;
ADHD/learning issues/PTSD
Separation anxiety
Separation anxiety is developmentally inappropriate and excessive anxiety concerning separation from parents and home
– Fears of things that could threaten integrity of family
– School Refusal common
– Often demanding, intrusive and in need of constant attention, especially when anxious
– Often have somatic complaints especially on school days or when facing separation eg bed‐time
• Prevalence–4% of children/ young adolescents
• Onset usually early–by 6years
• Clinic samples:f=m; population samples f>m
• Increased symptoms after a stress
– e.g.death of pet, move to new school, etc.
• LongTerm
– most children with Sep. Anxiety do not have impairing anxiety disorders at extended follow‐up
• Family History o fanxiety, mood disorders and alcohol abuse common
Rx behavioural and cognitive strategies
- graduated exposure to things child afraid of (school)
- Rx comorbid depression in adolescents
COPING CATS
PTSD
- the person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury or threat to the physical integrity of self or others
- the person’s response involved intense fear helplessness or horror
- Re‐experiencing–flashbacks, dreams, repetitive play
- Avoidance–places,activities,people,thoughts
- Hyper‐arousal–hypervigilance, poor concentration, poor sleep
Rx trauma focused CBT
OCD
The diagnosis of obsessive-compulsive disorder (OCD) is based on DSM-5 diagnostic criteria:
A. Presence of obsessions, compulsions, or both.
B. The obsessions or compulsions are time-consuming (e.g. take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder
• Obsessions
– persistent ideas, thoughts, images or impulses that are experienced as intrusive and inappropriate and that cause marked anxiety and distress
• Compulsions
– repetitive behaviours (hand washing) or mental acts (praying, counting), the goal of which is to prevent or reduce the symptoms of anxiety
General onset in adolescence / early adulthood, sometimes childhood
– Prevalence 1%
– Generally gradual onset/ progression
– Most have waxing/ waning course
– 15% have progressive deterioration
- 5% episodic course with minimal inter episode symptoms
Ddx PANDAS (more acute onset)
High incidence of comorbidities (80%) • 80% have another comorbid disorder – ADHD 35-50% – Depression 33% – Tics 25% – ODD 20-50% – Developmental concerns 25% – Other anxiety 16%
Rx
CBT - exposure and response prevention
Medications: SSRIs (high doses, fluoxetine 60mg/day), TCA(clomipramine)
Tourette’s
• Multiple motor tics, and one or more vocal tics
• Occur multiple times per day, through a period of more than one year
• Onset before 18 years old
• Simple tics–repetitive muscle twitch like eye
blinking
• Complex tics–touching,throwing movement, retracing steps
• Vocal tics– grunts, yelps, snorts, clearing throat
• Coprolalia–uttering obscenities in10%
• Often comorbid with ADHD and OCD
• Can be mild and have little impairment on social/school functioning
• Can be severe and impair function at school, leading to isolation from peers
• M:F = 3:1
• Prevalence – Children 5‐30 / 10 000 Adults 1‐2/ 10 000
• Illness may be lifelong, though there may be long
remissions
• Suggestion of genetic inheritance
Rx
Psychoeducation
CBT - habit reversal therapy
Meds - Low dose haloperidol/risperidone, clonidine
Nocturnal enuresis incidence
15% of 5 year olds ; resolves by 15% each year 13% of 6 year olds 10% of 7 year olds 7% of 8 year olds 5% of 10 year olds 2-3% of 12-14 year olds 1-2% >15 years
Boys are more commonly affected than girls (2:1) and there is a strong family predisposition (both parents = 77%, single parent = 43%)
Depression
• Persistent sad or irritable mood (2 weeks+)
• Loss of interest or enjoyment in activities
• and 4 of the following
– Difficulty sleeping or oversleeping
– Substantial change in appetite or body wt.
– Difficulty concentrating
– Loss of energy
– Psychomotor agitation or retardation
– Feeling worthless or inappropriate guilt
– Recurrent thoughts of suicide or death
In depressed children and adolescents
• Irritability often more prominent
• Symptoms more unstable–may have a ‘good’day, or retain some isolated interest
• Somatic symptoms prominent in children and in those with co‐morbid anxiety as well as depression
• Hopelessness an important prognostic sign for suicidal ideation and attempts
Epidemiology depression and treatment
• Children low rates ,m=f
• Rates rise through adolescence
• Rates in girls rises disproportionately to adult rates – by age 15 years f:m = 2:1
• 12month prevalence
– 3.1% aged 15 years,
– 16.7% aged 18 years.
• 20‐24% have had depressive illness (MDD or Dysthymic disorder) by age 18 years.
Treatment
• CBT in milder depression and for relapse prevention
• Main components include
– Activity scheduling
• Keeping busy
• Programming in positive activities
– Early detection of triggers for mood dips
• Avoiding negative spiral
– Positive self talk, challenging negative attributions
• Selective serotonin reuptake inhibitors SSRIs for moderate to severe MDD
– Fluoxetine only one with RCT evidence and approved for adolescents
• Must warn about early increase in anxiety/agitation and in suicidal ideation. Family and GP monitoring important
• No evidence of increased suicide with fluoxetine
– Start at low dose (5‐10 mg) and increase to 20mg
– No evidence that tricyclics (TCAs) work
– Recent concerns re Citalopram and QTc prolongation
– In severe MDD no additional benefit from CBT initially
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Diagnosis od serotonin syndrome
- Symptoms within mins‐hours
- At least 3 of the following signs or symptoms:
– Agitation or restlessness – Diarrhoea – Heavy sweating not due to activity – Fever – Mental status changes such as confusion or hypomania – Muscle spasms (myoclonus) – Overactive reflexes (hyper‐reflexia) – Shivering – Tremor – Uncoordinated movements (ataxia)
Management
• Rule out other causes for symptoms
• Benzodiazepines to decrease agitation, seizure‐like
movements, and muscle stiffness
• Cyproheptadine (Periactin), a drug that blocks serotonin production
• Fluids by IV
• Withdrawal of medicines that caused the syndrome
