RDA; Lecture 4, 5 and 6 - Adolescent psychological development, Depression, Anorexia and Conduct Disorder; Ageing Flashcards
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What are the developmental stages of adolescence?
Early = 11-14; middle = 14-17; late = 18-21
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What are the gender differences of development in adolescents?
Girls grow taller earlier than boys
Girls start puberty earlier than boys
Girls are physically mature in general 2 years earlier
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What are the pubertal changes in different sexes during adolescence?
x
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What are the clinical implications of the different ages of maturation between the sexes?
Early maturing girls and late maturing boys are at higher risk of: Depression Substance abuse Disruptive behaviour/Delinquency Eating Disorder Bullying
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What are the changes in the brain that occur during puberty?
- Grey matter volumes decrease from 6 years-adolescence
- Linear increase in white matter - 20 years
- Developmental curves peak at ~12years: frontal and parietal lobes ~16 years: temporal lobes
- NB: Brain develops from back to the front, with higher thinking developing at around 13 as prefrontal cortex is mainly involved.
- Synapses are selected , with the ones important for development kept and the ones that aren’t necessary are removed = called pruning
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What cellular processes occur in brain development during puberty?
Synaptogenesis followed by pruning (synapse elimination) Axonal myelination [speeds up nerve conduction] Fine tune prefrontal cortex and other cortical regions Cortical function becomes fine-tuned with development. Brain regions associated with more basic functions such as sensory and motor processes mature first, followed by association areas involved in top-down control of behaviour
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What are Piaget’s 4 stages of cognitive development?
Symbolic thinking = imagine a bottle is a plane and play with it like a plane
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What is Kohlberg’s theory of moral development?
Moral reasoning (basis for ethical behaviour), has 6 developmental stages, each > adequate at responding to moral dilemmas than its predecessor.
Sequence is fixed
Many people never obtain highest level [some adults continue to think in immature terms]
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When do you acquire postconventional moral reasoning in adolescence (Kohlberg’s stages)?
x
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What is self concept?
Intellectual development = more complex self-concept Pubertal & social changes = self concept Adolescence struggle to understand self Different ways conceptualising self –concept Most common described dimensions of self-concept
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What are the 8 dimensions of self-concept (Harter)?
Scholastic competence Job competence Athletic competence Physical appearance Social acceptance Close friendships Romantic appeal Conduct
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What are the clinical implications of emotional development (self concept)?
x
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When is identity formed and what are Erikson’s 8 life-span stages?
Search for identity important at this stage
Coincides with physical growth
Need for important life decisions
Resolution may be through “crisis”
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What is Marcia’s view on identity formation?
- ID status develops over time;
- only moratorium is necessary for ID development;
- extent of crisis is debated/unnecessary.
- ID associated with highest:
- Achievement
- Moral reasoning
- Career maturity
- Social skills
- Lower anxiety
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How is ethnic identity in cultural minorities carried out?
x
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What are the clinical implications of ethnic identities?
Varied parental expectations (duties etc.) Gender differences May generate conflict
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How do family relationships affect development?
Development of autonomy and continuation close relationships Social domains - adolescents and parents may have different views about who has final say depending on “Domain”: friendships, clothes, career etc. Mid-adolescence: most intense negotiations
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What kind of conflicts occur with parents during social development?
Most adolescents report good relationships parents Get on well with mother 86% father 80% High confiding to mothers Disagreements around dress, music choice, leisure activities, time of coming home, tidying bedrooms.
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How does family connectedness manifest and what are the benefits?
x
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How do peers affect development in primary school 7-11y?
Friends shared activities Main goal: acceptance by same gender group Stable preference for same gender friends Loyalty built on earlier interactions
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How do peers affect development from 11-18y?
- Variations in friendships (popularity <=> rejection)
- Rejected children less satisfying friendships
- Gender differences:
- Girls: close relationships, more confiding, more brittle
- Boys: less intimate, less disclosing, friendships more embedded in larger circle
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What is the difference between parental and peer influence?
x
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What are the opportunities and risks of online generation?
x
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How does the school and classroom affect development?
A study showed that there are higher chances to achieve 5+ GCSE’s A*-C, girls achieve better than boys, can be ethnic variations
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What is anorexia nervosa (ICD10 criteria)?
ICD10 criteria = Body wt at least 15% below expected (<17.5 BMI) Avoidance of “fattening” foods (may also be self-induced vomiting, purgative abuse, alternating periods of starvation, drugs eg appetite suppressants, laxatives) Psychopathology-morbid dread of fatness, aims for wt lower than premorbid or healthy Endocrine disturbance (amenorrhea in women and men lose sexual interest) May also be other wt loss behaviours.
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What is anorexia nervosa (DSM5 criteria)?
x
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What is bulimia nervosa (ICD10)?
Persistent preoccupation with eating, and an irresistible craving for food, succumbs to episodes of eating large amounts of food in short periods of time binges Wt losing behaviours: Purging: by vomiting, taking a laxative, diuretic, or stimulant, &/or excessive exercise Psychopathology- morbid dread of fatness, aims for wt lower than premorbid or healthy
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What is bulimia nervosa (Dsm 5)?
x
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What pubertal development occurs in boys?
x
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What pubertal development occurs in girls?
x
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What are the influences of fashion and media on girl development?
Influence of media/fashion Hard to prove direction of causality Models/mannequins getting slimmer last 50 years Slimmer body shapes attractive
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How can you predict eating problems in girls?
Earlier pubertal maturation and higher body fat; concurrent psychological problem. Dieting (severe level) can lead to 16x more probability to have eating difficulties
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What is the epidemiology of anorexia nervosa?
x
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What is the trend in puberty in girls?
Puberty starting earlier
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What is the aetiology of anorexia nervosa - what are the causes?
MULTIFACTORIAL!!!! Traumatic event; genetic predisposition, perfectionist temperament, specific subcultures, childhood abuse and adversities, perhaps higher social class
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What are the corresponding neuropsychological mechanisms of anorexia nervosa?
Association anorexia nervosa and ASD
Weak central coherence in ED’s Global processing difficulties [review]
Poorer global processing -> Weak central coherence (limited ability to understand context or to “see the big picture”)
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How does anorexia nervosa present?
x
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How do you assess for anorexia nervosa?
Family interview, individual interview with child/adolescnet, physical exam and investigations and data on growth
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What are the probable differential diagnoses for anorexia nervosa?
*Physical Gastro-intestinal disorder e.g.. Crohns disease Metabolic e.g. diabetes Pituitary *Psychiatric Bulimia nervosa Depression Psychosis Obsessive compulsive disorder (OCD)
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What treatment options exist for anorexia nervosa?
Admission for weight restoration in a minority of cases - Family therapy - Nutritional counselling - Cognitive behaviour therapy (CBT) - Treatment of persistent depression etc.
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What are the 3 stages of family therapy for anorexia nervosa?
TREATMENT OF CHOICE 1) Initial focus of adolescents need to eat Parents/carers to take charge/supervise 2) Adolescent gradually assumes more control of eating Graded improvement in social function 3) Address other developmental/ relationship/life cycle issues
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How does cognitive behavioural therapy work in anorexia nervosa?
x
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What is the prognosis of anorexia nervosa?
Mortality at 20y follow up is 15-20%
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What developmental features characterise adolescence?
Cognitive/emotional changes, family, peers and biology
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What defines anti-social behaviour, delinquency/offending and conduct disorder?
x
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What is a conduct disorder?
x
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What are the behaviours of conduct disorders?
x
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What are the types of conduct disorder?
x
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What is cyberbullying and how does that affect adolescent aggression?
x
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What is the epidemiology of conduct disorder?
x
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What is the ecological framework for aetiology of conduct disorder?
x
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What are the factors and causes of conduct disorder?
x
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How does the familial relationship affect conduct disorder?
x
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How does the social and neighbourhood relationship affect conduct disorder?
x
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What is the impact of conduct disorder?
x
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What interventions can be used in conduct disorder?
- Best treatment: **prevention**
- Cognitive problem solving skills:
- Adolescents with CD may have distorted attributions of aggressive intentions in other people.
- Techniques to develop more accurate perceptions.
- Teaching of problem-solving skills including range of options and their consequences.
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What are the key aspects of parenting programmes?
i) Play and good times together ii) Praise and recognition for good behaviour iii) Clearly expressed expectations iv) Consistent & calm consequences for misbehaviour v) planning ahead to avoid trouble
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What are other interventions for conduct disorder?
x
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What is the prognosis of conduct disorder?
x
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What are the symptoms of depression disorder?
Increase of symptoms -> increase of impairment.
Degree of depression determined by:
- not depressed (< 4 symptoms)
- mild depression (4 symptoms)
- moderate depression (5 to 6 symptoms)
- severe depression (7 or > symptoms, with or without psychotic symptoms).
Symptoms are pervasive, impairing and present for at least 2wks -> affective (sadness, loss of enjoyment, irritability), biological (disturbed sleep, reduced appetite), cognitive (self blame, hopelessness, guilt)
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What are the associated problems with depression?
Increased risk of self-harm Association with anxiety disorders; eating disorders [females]; conduct problems Familial aggregation (genetic and learning);
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How does childhood depression present clinically?
Persistent and pervasive; Relatively unresponsive to pleasurable activities, interactions and attention from other people Functional impairment is an important distinguishing factor from the normal mood fluctuations of childhood
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What are the 2 main types of pre-pubertal depression?
x
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What is the difference between normal adolescent angst vs psychiatric disorders?
‘Normal adolescent angst’: Mastering the tasks of development physical, cognitive, social, emotional, moral Psychiatric disorder: Symptoms -> Serious suffering/impairment personal, family, peers, education/work
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What is adolescent depressive disorder?
Irritability instead of sadness/low mood
Especially in boys
Somatic complaints and social withdrawal are common
Psychotic symptoms rare before mid-adolescence
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What is the epidemiology of depression?
FHx of major affective disorders usually depression exist
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What is the amine hypothesis of depression?
Suggests that depression results from hypo-activity of monoamine NT reward systems
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What are the developmental changes that occur during puberty which can lead to depression?
Endocrine changes, changes in family relationships, peers, responsibility and hassles
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What are the cognitive and emotional changes that occur during puberty which can lead to depression?
x
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What are the social and relationship changes that occur during puberty which can lead to depression?
x
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What are the developmental changes and vulnerability to depression?
x
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What are the treatments for depression?
x
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How is cognitive behavioural therapy used in depression?
x
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What is interpersonal psychotherapy in treatment of depression?
Conceptualises depression as occurring within an interpersonal matrix and targets resolution of interpersonal stress that seem to be associated with it.
Starts by taking an interpersonal inventory of important relationships.
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What medication can be given for depression?
No difference between TCA (Tricyclic AD) and placebo Several studies have demonstrated efficacy with selective serotonin reuptake inhibitors (SSRI) Esp. using fluoxetine This may be reflective of an overall developmental difference in so far as adolescents and younger adults may respond better to serotonergic agents
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What is a key feature of depression in adolescence?
Higher levels of irritability
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What is ageing?
Process of growing older -> biological, psychological/cognitive and social
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What is life expectancy?
Statistical measure of how long a person can expect to live -> increasing, with popn getting older overall, led by falling fertility rates and people living longer overall
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Why do people age?
Programmed ageing - genetic, Hayflick limit (cells appear to be able to count, reaching a certain number of divisions and then stopping - thought to be enough to allow organism to reach maturity and reproduce, reducing risk of Cancer); damage/error theories ->Free radical-oxidative stess due to reactive oxygen species exceeding antioxidant capacity - mitochondria remain source of radicals, but also come from macrophages, peroxisomes, cytochrome P450, supported by people with chronic inflammation/infections clinically age more rapidly; DNA damage -> frequent damage to DNA whilst it is being transcribed, which DNA polymerase can’t always repair, leading to damage accumulation and contributing to eventual cell death
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What are the challenges society faces as a result of an ageing popn?
Outdated and ageist beliefs/assumptions
Working life/retirement balance
Medical system designed for single acute diseases
Extending healthy old age not just life expectancy Inadequate or absent services
Lack of accessibility for people with disabilities
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What decides if we are healthy in old age or not?
- Small proportion due to genetic inheritance, most due to ongoing interactions between broader characteristics of individuals and environment (home, enighbourhood and community). sex and ethnicity, occupation, educational attainment, wealth, contributing to social position and ability to access resources
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What are the benefits that the ageing popn give?
Older people make +ve contributions to society, so health and social care expenditures for them are an investment not a cost
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What is social care in England like?
Councils are reducing/freezing the amount they pay care agencies and homes, despite ageing popn
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What is frailty?
- Loss of biological reserve across multiple organ systems, leading to vulnerability to physiological decompensation and functional decline after a stressor event.
- When we have a ‘stressor’ event its fine, we bounce back.
- When old frail people have a ‘stressor’ event end up with less functional, in hospital and can’t bounce back fast enough.
- Much longer to get back up to a good level, which may not even be the same level that they were previously at
- Loss of biological reserve
- Cumulative damage
- STRESSOR EVENT
- Falls and delirium
- Functional decline
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What is the cycle of frailty?
x
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What is frailty associated with?
Increased risk of falls, worsening disability, care home admission, death
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How can we treat frailty?
Exercise, nutrition and drugs (possibly) -> prevention better than cure
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What are the 5 giants of Geriatrics?
Instability Immobility Incontinence Intellectual impairment Iatrogenic harm
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What is the problem with non-specific presentations in frailty?
Older people are less likely to have common, “textbook” symptoms of disease ACS - Less likely to have chest pain PE - Less likely to have pleuritic chest pain Less likely to have haemoptysis More likely to have other symptoms ACS - More likely to have shortness of breath PE - More likely to have syncope
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What is multimorbidity?
2 or more chronic conditions.
Conditions impact on one another
Treatment for one condition may impact on another
Negative impacts:
- Worse QoL, more likely to be depressed
- Increased functional impairment
- Burden of treatment
- Polypharmacy
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Why is polypharmacy affecting the ageing popn?
Comorbidities Guidelines/QOF/NICE
Undetected non adherence
Infrequent review
Poor communication.
Up to 405 of prescriptions are inappropriate, associated with bad outcomes -> falls, increased length of stay, delirium and mortality
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What iatrogenic harm can occur to older frail popn?
Adverse reactions to medications -Nosocomial conditions: Infections Pressure sores Constipation Deconditioning Delirium Malnutrition Incontinence -Falls Pyschological/cognitive damage 2-36% of inpatients, with half probably avoidable
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How do adverse drug reactions affect older popn?
Up to 17% of hospital admissions due to drug reactions -> more meds taken = greater risk. Drugs most likely to cause hospital admission: NSAID 30% Opioid 6% Warfarin 10% Digoxin 3% Antidepressant 7%
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What is the comprehensive geriatric assessment?
CGA in the community1 Reduce admissions to institutional care Reduce falls Most benefit in mild or moderate frailty CGA for frail inpatients2 Reduces inpatient mortality Reduces functional and cognitive decline Reduces admission to institutional care. Multidisciplinary assessment -> medical, functional, social, psychological/psychiatric; problem list, plan
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What is the aim of rehab?
To restore/improve funcitonaity, multidisciplinary, rehab alongside acute illness (prevent deconditioning), rehabilitation
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What are the changes in the ageing brain?
White matter reduction; grey matter reduction -> mainly in size and number of connections between neurones not in neuron number.
CSF increases as well, with larger size in ventricles and gaps between major gyr widen
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What are the normal cognitive changes in older people?
Reduciton in inductive reasoning from 45y, reduction in mental flexibility, ability to generate novel soln to problems and response inhibition from 70y
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What is dementia?
Decline in all cognitive functions, not just memory
Impairment of function
Progressive
Degenerative
Irreversible, chronic
West London diagnosis rate is 76%
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What are the types and causes of dementia?
x
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What is the difference between demetia and delirium?
x
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What cognitive assessments are carried out for dementia?
AMT, MOCA, MMSE, CAM and 4AT
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What is the abbreviated mental test and what are the problems with it?
Very orientation focused
Orientation can be well preserved in some forms of dementia
Assumes cultural knowledge/interest (WW2, PM)
Assumes numeracy
Monarch or PM could give different results
No time limit on 20-1
Person recognition can be difficult in hospital
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What are the problems with cognitive assessments?
Most assumes some basic cultural knowledge Most assume numeracy and literacy Depression can masquerade as dementia Ceiling effects in highly educated/intelligent Interpret them in context
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What is the role of Kisspeptin in puberty?
Initiates secretion of GnRH at puberty, which triggers release of LH/FSH; encoded by KISS1 gene; it’s a G-protein coupled receptor ligand for GPR54
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What are the causes of depression?
Familial aggregation, effects of family interaction and life events/adversities
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Summarise depression in adolescents - symptoms, epidemiology, prognosis, causes and interventions
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Summarise conduct disorder - clinical features, epidemiology, developmental considerations, causes, outcome and interventions
x
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Summarise anorexia nervosa - cardnal features, epidemiology, causes, outcome and treatment
x
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What is delirium?
Delirium is an acute episode of confusion, usually with clear precipitant such as infection/medication changes; usually resolves but can leave residual problems
