• Listed as mild, moderate, or severe
• Pscyosocial and environmental stressors
• Divorce
• Death of a spouse, etc

• Global assessment of functioning (GAF)- do not worry about specific numbers
• Composite of social, occupational, and psychological functioning
• 100 point scale- a continuum of mental health to illness
• 100= normally functioning person; 1=very sick, depressed, suicidal patient, danger to themselves= hospitalize immediately
• be sensitive and recognize that the brain gets sick too

• Observed, objective expression/signs of emotional experience
• Appropriate- consistent emotional tone w/ idea, thought or speech

•                         i.     Inappropriate—inconsistency b/t emotional tone and idea, thought, or speech

                          Seen with psychotic disease

                         ii.     Constricted—reduction in intensity of feeling tone, but less severe than blunted

  o   Often able to only experience one set of emotions (e.g. depression)

                       iii.     Blunted—severe reduction in intensity of externalized feeling tone

                        iv.     Flat—(near) absence of any signs of affect

  o   Monotonous voice, immobile face

                         v.     Labile—rapid, abrupt changes in emotional tone

  o   Changes unrelated to external stimuli

a.      Echopraxia

                        i.     Pathological imitation of movements of one person by another

b.     Catatonia

                        i.     Motor abnormalities characterized by the absence of spontaneous movements OR rigidity, stupor, posturing, or purposeless agitated behavior

                       ii.     Catalepsy—immobile position

                     iii.     Waxy flexibility—person can be molded into a position which is then maintained

o   Tx is electroconvulsive therapy (ECT)

c.      Negativism

                        i.     Motiveless resistance to all attempts to be moved

                       ii.     Resistance to following instructions

d.     Mutism

                        i.     Voicelessness without structural abnormalities

e.      Psychomotor Agitation

                        i.     6yExcessive motor and cognitive overactivity

                       ii.     Often nonproductive and responding to inner tension

f.       Psychomotor Retardation

                        i.     Decreased motor and cognitive activity with visible slowing of thought, speech, or movements

g.     Akathisia

                        i.     Subjective feeling of muscular tension secondary to antipsychotic medication particularly older drugs

                       ii.     Manifests as restlessness, pacing, repeated sitting and standing

                     iii.     Feeling of psychomotor tension and restlessness

                      iv.     May be indication to stop or change med

                       v.     Might be mistaken for psychotic agitation

h.     Compulsion

                        i.     Uncontrolled impulse to perform repetitive act

                       ii.     Handwashing is MC

a.      How thoughts are developed and assembled

b.     Psychosis—inability to distinguish reality from fantasy with impaired reality testing

                        i.     Reality testing—objective evaluation of ability to accurately perceive the external world

c.      Autistic thinking—preoccupation with inner, private world

d.     Magical thinking—belief that thoughts or words assume power (over events)

e.      Neologism—new word created has special meaning not apparent to others

f.      Circumstantiality—indirect speech that is delayed in reaching the point, but eventually gets there

                        i.     Over-inclusion of details and parenthetical remarks

                       ii.     Too much information in irrelevant details

g.     Tangentiality—inability to have goal-directed associations of thought

                        i.     Never gets to the point of speech—rambling and purposeless

h.     Perseveration—persisting response to a prior stimulus after a new stimulus has been presented

                        i.     Repeats same answer to multiple questions

i.      Verbigeration—meaningless repetition of specific words/phrases

                        i.     Similar to word salad

j.      Echolalia—pathological repeating of another’s words or phrases

                        i.     Often spoken in mocking or staccato intonation

k.     Looseness of Associations—flow of thought in which ideas shift from one subject to another in a completely unrelated way; can be incoherent

                        Almost diagnostic of schizophrenia

l.      Flight of Ideas—markedly accelerated thought processes

                        i.     Ideas are verbalized rapidly and are difficult to understand

                       ii.     Extremely rapid thought process

                     iii.     If you slow down thoughts make sense

                      iv.     Sx of mania

m.    Clang Associations—association of words similar in sound but not meaning

n.     Thought Blocking—abrupt cessation of thought before an idea is finished

                        i.     No recollection of idea after pause

a.     Pressured Speech—rapid speech increased in rate and amount

                        i.     Difficult to understand

                       ii.     Associated with flight of ideas

b.     Volubility—copious, coherent, logical speech (logorrhea)

a.     Hallucinations

                        i.     False sensory perception not associated with real external stimuli

                       ii.     +/- Delusional interpretation of the hallucinatory experience

                     iii.     Auditory, visual, olfactory, gustatory, tactile

                      iv.     Hypnagogic—transition to sleep

                       v.     Hypnopompic—transition to wakefulness

b.     Illusions—misperceptions or misinterpretations of real external sensory stimuli

                        False perception

                        Background noise

                        Illusion is real stimulus that is just being misperceived

                                    Air condioning goes on and you think it is someone talking

c.      Depersonalization—subjective sense of being unreal, strange, or unfamiliar to oneself

d.     Derealization—subjective sense that environment is strange, unreal, changed

e.      Fugue

                        i.     Taking on a new identity with amnesia for the old personality

                       ii.     Often involves travel or wandering to new environments

1. What are the 4 major psychodynamic theories?

Classical Psychoanalytical Theory

Ego Psychology

Object Relations Theory

Self Psychology

1. What is meant by the term “psychodynamics?

The mind is a fluid & dynamic entity.  Multiple forces influence behavior & emotion & these factors are constantly changing.  Psychodynamics is the study of those forces to understand what influences thought, emotion, & behavior. 

Unconscious mental processes

Past experiences

Current life situation

Quality of interpersonal relationships

Ego strength (helps us cope)

Personality structure

Ego defenses

• It said that past influences current feelings & behavior via psychic determinism & unconscious mental processes.  Unconscious impulses influence feelings & behavior from birth forward.  These are instincts (drives) that evolve & mature throughout the life cycle.  Different drives are expressed at various points in the life cycle & the relative strength of the drives is determined by the amount of psychic energy (libido) they possess.  Freud said there were 2 basic drives: sexual (affection, belonging, acceptance, intimacy, & adult sexuality—NOT NECESSARILY SEXUAL AS WE THINK OF IT) & aggression (self preservation, etc).  This is the Instinct theory of “Id” psychology.  The Economic theory is the study of psychic energy & its distribution in the mind.  Psychic energy is the amount of force that the instincts have on you.  Narcissism is related to too much immature energy as you grow up-lack self assurance later

• is a group of psychoanalytic theories dealing with various ego functions.  The ego has 2 primary functions: defense against the unconscious (Id) & adaptation to reality.  Freud’s daughter defined the defense mechanisms we have.  Hartmann said certain ego functions are outside the influence of unconscious impulses (Autonomous ego functions).  The autonomous ego functions include perception, learning, intelligence, language, conscious thought, & motility.  Ego is supposed to suppress the bad things from the unconscious & express the good.  It is our personality. Superego is conscious—sense of right & wrong.  It has 2 components: conscience & ego-ideal.  The Ego & Superego try to regulate the Id & censor it. 
• EGO PSYCHOLOGY: HELPS DEAL WITH WORLD AROUND YOU THROUGH MEMORY, PERCEPTION, LANGUAGE AND VOLUNTARY BEHAVIOR. LOOKS INWARD AND OUTWARD. DIFFERENT FROM FREUD WHO ONLY LOOKED INWARD AND WASN’T AWARE OF AROUND HIM.
•             DEFENSE AND ADAPTATION ARE 2 MAJOR THINGS

A group of loosely related theories examining the importance of relationships in                      ego/personality development.  The basic premise is that the ego can’t develop properly without healthy                           interpersonal relationships. This is really important to understand personality disorders.  During personality                       development mental representations, called introjects, of significant people are formed.  The nature of the                                introject             determines how a person perceives & reacts to others.  The object relations theory basically says                                   that people learn to form relationships from the relationships they see & experience. KNOW                                             INTROJECTS: mental representation of person in our life. Process of internalization.People in our life                                  affect us psychologically and mentally, we internalize characteristics from them and create a mental r                                epresentation.

                        PERSONALITY MATURES IF ENVIRONMENTS ARE SUPPORTIVE (NON-ABUSIVE, NON-TRAUMATIC).

Examined development of normal & pathological narcissism (sense of self esteem).  It                                     focuses on self esteem & self-cohesion.  It stressed the importance of empathy in development & therapy.                                    In simple words-give them what they need as they need it so that when they grow up they can take care of                          themselves, make own decisions, etc.  This psychology says that psychopathology results from defects in                           the self & is useful in understanding personality disorders. Stressed importance of empathy in development                              and therapy

                                    Theory emphasizes defects or deficits in personality unlike Freud’s conflict focus

1.     Attachment and Stress

a.      Pervasive pattern of disturbed and developmentally inappropriate social relatedness specific to children

b.     Onset before 5 yo

                        i.     Not due to pervasive developmental disorder (PDD), MR

c.      Inhibited subtype—do not seek or respond to adult care

                        i.     Limited affective range and ability

                       ii.     Emotional dysregulation, especially if physically abused

                     iii.     Failure of learned trust and dependability

d.     Disinhibited subtype—indiscriminate and superficial seeking out of others for closeness, comfort

                        i.     Increased risk of victimization

                       ii.     Lack of personal boundaries

                     iii.     Pseudo-attachment—seemingly bonded with a caregiver with no specificity and will detach and leave for another without anxiety

e.      Etiology

                        i.     Failure in bonding, nurturing process

o   NICU, dysmorphic features, lack/loss of 1^o caregiver, parental mental or physical illness, neglect and failure to thrive, physical abuse

o   Adult risk factors are immaturity, impulsivity, lack of support or information, substance abuse

f.       Epidemiology

                        i.     Rare, but high in maltreated groups—foster kids > homeless children > Head Start Children

                       ii.     Resilience keeps up to 70% of children from developing RAD

                     iii.     20-50% of special population children will have criteria for RAD

g.     Treatment

                        i.     Infant-parent or child-parent psychotherapy

                       ii.     Circle of security—family therapy based on attachment theory (COS.org)

                     iii.     Tx of Comorbidities—ADHD, major depression, PTSD, anxiety

  PTSD in Children and Teens

a.      Exposure to traumatic event with possible severe injury or death, with severe fear, horror, and helplessness

b.     Dissociative Sx—numbing, detachment, lack of normal emotional response, cognitive impairment, derealization, depersonalization, amnesia

c.      Re-experiencing, recurring memories, dreams, and flashbacks

d.     Avoidance of events that remind child

e.      Marked, excessive arousal and anxiety

                        i.     Problems sleeping, irritability, problems concentrating, memory impairment and academic deterioration

                       ii.     Hyper-vigilance, motor agitation, hyperactive startle response

f.       Acute Stress Disorder

                        i.     Occurring within 4 weeks of event, lasting b/t 2 and 30 days

g.     PTSD—Sx lasting longer than 30 days

                        i.     Increased nightmares, repetitive play reenactment of events

                       ii.     Hallucinations/illusions that are trauma-specific and not psychotic

                     iii.     Domestic violence/physical abuse is MC cause

                      iv.     Children at risk for PTSD have statistically significantly elevated cortisol and catecholamine urine levels within hours of the event

o   Used in research

                       v.     High lifetime comorbidity with major depression, generalized anxiety disorder, panic attacks, and possibly agoraphobia

h.     Tx of PTSD in kids

                        i.     Cognitive behavioral therapy (CBT)

                       ii.     Propranolol given in ER to decrease ANS stimulation

                     iii.     SSRIs, SNRIs etc to modulate HPA axis, increased BDNF in hippocampus, and modulate glutamate release

                      iv.     Clonidine, guanfacine (a2-agonists) to modulate excessive SNS activity

                       v.     BDZs are avoided!

o   Increase risk of PTSD

1.     Autism (defect in dev of communication and socialization in children), Asperger’s (normal communication but inadequate socialization skills), and Social Communication

a.      Autism

                        i.     Presence of markedly abnormal development of social interaction and communication

                       ii.     Markedly restricted repertoire of activity and interests, tendency to fixate on a certain kind of factual information

                     iii.     Current prevalence of about 1 in 100

                      iv.     4-6:1 male to female ratio

                       v.     Half of affected children may develop normally until age 1 then regress

                      vi.     Half of affected children do not develop language and have IQs less than 70

                    vii.     Higher prevalence in families where parents were older at time of conception

                   viii.     Genetic component likely—runs in families

                      ix.     Environmental link being sought in research.  Vaccines do not cause Autism.

a.      —high functioning Autism

                        i.     No clinically significant delays in language development

                       ii.     No clinically significant delays in cognitive development or in development of age-appropriate self-help skills and adaptive behavior

                     iii.     Normal IQ

                      iv.     Significant deficits in social communication skills

a.      Rett’s Disease (barely mentioned in class this year)

                        i.     Small hands, feet, and deceleration in head growth rate

                       ii.     Regression of language and hand use, developmental delay

                     iii.     Repetitive stereotypies—hand wringing or putting hands in mouth

                      iv.     Genetic disease, X-linked, affected males stillborn, affected females often misdiagnosed as Autistic, MeCP2 gene mutation

a.      Domains of social communication (impaired mastery in Autism)

                        i.     Facial expressions

                       ii.     Prosody—melody of speech

                     iii.     Gestures—instrumental, social, emotional

                      iv.     Pragmatics--knowledge of social rules of communication and Theory of Mind--implicit ability to deduce thoughts and motives of others

                        i.     Week 1

o   Recognize mother’s voice, face

o   Mimics facial movements

o   Looks at complex visual stimuli like faces preferentially

o   Tabula rosa or blank slate theory of child development is false—infants are primed to respond to human caregivers

                       ii.     Months 0-6

o   Eye contact, social smile

o   Driven to interact intersubjectively, especially when caretaker uses ‘motherese’ (exaggerated tone of voice, gestures, and facial expressions) a cross-cultural phenomenon

§  Affective reciprocity (child responds to caregiver with facial expressions and gestures of his own)

                     iii.     Months 9-12

o   Triadic exchange involves coordination of child and caregiver’s attention with respect to some third object

§  Proto-imperatives—requesting behaviors

§  Proto-declaratives—pointing to indicate interest

§  By 15 months children should follow their caregivers’ points and should try to point things out to others

                      iv.     Months 12-24

o   Pragmatics (rules for communication and conversations) and theory of mind (awareness that others have thoughts and feelings different from our own which can be used to enhance our interpersonal relationship)

§  Pretend play skills=early indicator of theory of mind skills development, usually mimicry of familiar adults

§  Later Theory of Mind skills include empathizing with others and systemizing (working through a problem using intellect)

                       v.     Single words at 16 months

                      vi.     Two word phrases at 24 months

                        i.     Language development

                       ii.     Intellectual capacity

                     iii.     Sensory hypersensitivities

                      iv.     Fine and gross motor development

                       v.     Comorbid conditions—anxiety, depression, OCD

                      vi.     Must distinguish from Rett’s, Fragile X, and Disintegrative Disorder among other causes of pervasive developmental delay

                    vii.     Autism and Asperger’s likely to be merged into a single diagnosis—Autism Spectrum Disorder—in the DSM-V

a.      Functions of Play

·       Improve fine and gross motor skills

·       Seek mastery of social games

·       Re-enact traumatic events

·       Pretend social roles and interactions

a.      Pediatric Autism Screening

·       Autism Diagnostic Interview—ADI-R, ask parents

·       Autism Diagnostic Observation Scales—ADOS, observe child

·       Social Communication Screening Questionnaire—SCSQ

a.      Key questions to ask caregivers in the ADI

·       Does the child recognize her name?

·       Smile?

·       Make eye contact and appropriate facial expressions?

·       Initiate gestures?

·       Point to objects?

·       Engage in pretend play with peers

·       Vocalize to be social

·       Engage in reciprocal conversation

·       Have friendships

·       Comfort others in distress

·       Spontaneously share food, toys, activities

·       Any loss of milestones

BEHAVIORAL DISORDERS OCCUR IN CHILDREN WHO ARE DEPRESSED

a.      Presents with 2+ weeks of persistently depressed or irritable mood

                        i.     Anhedonia, suicidal behavior, changes in appetite, sleep, energy level, self-worth

                       ii.     Significant fxnal impairment

                     iii.     Children have more mood lability, behavioral problems, anger, social withdrawal

                      iv.     Children have fewer melancholic Sx, psychosis, and suicidal attempts

                       v.     Straight ? and A from the “Study Guide “

o   What is the main difference between depression in children and adults?

o   Answer – Depression in children is often characterized by behavior/school problems rather than sadness.  Children tend to act-out feelings rather than verbalize them.

b.     Epidemiology

                        i.     Equal gender prevalence before puberty

                       ii.     Affects females more after puberty

                     iii.     40-90% have comorbid psychiatric illnesses

c.      Median duration of 8 months

                        i.     20% have depression for 2+ yrs

                       ii.     70% recur after 5 yrs

                     iii.     30% attempt suicide

o   Risk factors include previous history of suicide attempts, impulsivity, and exposure to fire arms

                      iv.     20-40% develop bipolar disorder

o   Risks include rapid onset (of depression), psychomotor retardation, psychosis, family Hx of bipolar disorder

o   Hx of mania or hypomania after antidepressant Tx

                       v.     Prepubertal depression associates with familial adversity (e.g. divorce)

d.     Genetics and Environment

                        i.     5-HTTLPR transporter gene

o   Kids with two short alleles have more depression and suicidal ideation

                       ii.     Higher risk of severe depression with more affected 1^st-degree relatives

                     iii.     Parental Hx of sexual abuse associated with increased risk of offspring depression

e.      Treatment

                        i.     CBT focuses on negative thoughts

                       ii.     Interpersonal therapy examines relationship roles

                     iii.     SSRIs

o   Fluoxetine for kids 8 and older

o   Escitalopram for kids 12 and older

                      iv.     Best is combination therapy

1.     Child and Adolescent Anxiety

a.      Anxiety is fear without overt threat and a preoccupation with the future

                        i.     Normal developmental process

o   Stranger anxiety at 8-9 months

o   Separation anxiety at 18-24 months

                       ii.     Child anxiety disorders present more commonly with somatic, not psychological, Sx

b.     Epidemiology

                        i.     More common in girls

                       ii.     2-3x risk of adult anxiety, depression

                     iii.     Increased rates of drug dependence and academic dysfunction

                      iv.     3-5x risk of anxiety among affected 1^st degree relatives

                       v.     1/3 present with comorbid ADHD

a.      —pediatric autoimmune neuro-psychiatric disorder after (group A) strep

                        i.     Abrupt onset of OCD Sx, tics, choreiform movements

o   Obsessions-contamination, harm to self or others, scrupulosity, reassurance, sexual thoughts

o   Compulsions-washing, repeating, checking, counting, touching, arranging, hoarding

o   OCD etiology is in the basal ganglia

                       ii.     ASO titer rises 3-6 weeks after infxn

                     iii.     DNase B titer rises 6-8 weeks after infxn

                      iv.     Tx with CBT (exposure and response therapy) and SSRIs or Clomipramine

a.      Separation Anxiety

                        i.     Intense fear of separation from caregiver 4+ weeks in duration causing impaired fxning

o   Sx include somatic complaints (e.g. stomach ache)

o   ANS arousal

o   Refusal to leave home, go to school, fear of sleeping alone/in the dark, nightmares

o   Anticipatory anxiety

                       ii.     Peak age of onset at 8yo

o   Predicts later adult anxiety disorders

o   Precursor to panic disorder and agoraphobia

a.      Generalized Anxiety Disorder (GAD)

                        i.     Worriers with 6+ months of Sx including ANS arousal, headache, stomach ache, sleep dysfxn, muscle aches, appetite changes

                       ii.     Average age of onset at 11yo

                        i.     Average age of onset at 17yo

                       ii.     Severe ANS arousal

                     iii.     Children have more physiological Sx than cognitive Sx

                      iv.     High comorbidity with other psychiatric disorders

                       v.     Chronic Course-3.5 yrs

                      vi.     Etiology: Biologic disposition- respiratory and environmental events

                    vii.     Treatment: CBT and relaxation behavioral treatment

o   No trials of medication in children and adolescents-suggest SSRI first

a.      Phobias

1.     Attention Deficit/Hyperactivity Disorder (ADHD) (HYPERACTIVE)

a.      Sx present before 7yo with impairment in 2+ settings for 6+ months with developmentally inappropriate areas of:

                        i.     Inattention

o   Doesn’t give attention to details, makes careless mistakes

o   Fails to follow instructions, etc

o   Avoids, dislikes, doesn’t try activities that require lots of mental effort

o   Loses things, easily distracted, forgetful

o   Trouble keeping attention on tasks of play

o   Doesn’t seem to listen when spoken to

o   Has trouble organizing activities

                       ii.     Hyperactivity

o   Fidgets, squirms, runs about and climbs at inappropriate times

o   Gets out of seat prematurely

o   Trouble playing or participating quietly

o   Talks excessively

o   On the go, acts as if “driven by a motor”

                     iii.     Impulsivity

o   Interrupt/intrude others, blurts out answers before question is finished

o   Trouble waiting one’s turn

                      iv.     Requirements for diagnosis

o   Clear Evidence of social, school, or work impairment

o   Not better accounted for by other disorders

o   Symptoms present before age 7

o   Impairment present in 2 or more settings

o   Symptoms do not happen during a course of Pervasive Developmental Disorder, Schizophrenia, or other psychotic disorder

b.     Epidemiology

                        i.     4-5x more common in males

                       ii.     >90% will continue to have Sx as adults will have 5 symptoms with a Global Assessment of Functioning score (GAF) score less than 60

                     iii.     50-84% comorbid oppositional defiant disorder or conduct disorder

                      iv.     15-20% will smoke

                       v.     Increased risk of substance abuse, especially Cannabis

                      vi.     40-50% with learning or language problems

                    vii.     30% have an anxiety disorder

                   viii.     10-30% have a mood disorder (controversial)

                      ix.     Higher incidence of tic disorders (5-8% vs general pop. Incidence of 2%)

                       x.     8% of children meet strict criteria

                      xi.     only 4% receive treatment

                    xii.     60-85% continue to meet criteria into adolescence, young adulthood

c.      Etiology

                        i.     High genetic heritability—76%

o   Many chromosomal gene markers (4, 5, 6, 8, 11, 16, and 17)

                       ii.     Abnormalities in D4 and D5 receptors, DA transporter, DA-b-hydroxylase, 5-HT transporter, 5-HT_1B receptor

                     iii.     Decreased grey and white matter throughout CNS

o   Decreased glucose and O₂ metabolism in caudate, anterior cingulate gyrus, and frontal lobe

                      iv.     Impairment in Executive Functioning:

o   Vigilance

o   Response prevention

o   Working memory

o   Planning

d.     Diagnosis:

                        i.     Use of screening instruments, such as Conners and Vanderbilt

                       ii.     Good history and physical exam

                     iii.     Chronic symptoms, not episodic

                      iv.     6/9 criteria for Inattention

                       v.     6/9 criteria for Hyeractivity/Impulsivity

                      vi.     Childhood onset

                    vii.     Screen for:

o   Learning problems/academic problems

o   Substance abuse

o   Sexual activity

o   Antisocial behaviors

o   Similar problems in relatives

o   Family functioning

e.      Treatment

                        i.     Stimulant therapy is best- Long acting formulations will improve compliance and tolerability

o   Methylphenidate or amphetamine(can also facilitate increased DA release)

§  DA reuptake inhibitors

o   Atomoxetine—SNRI with longer T_1/2 can improve insomnia and anxiety

§  Suicidal ideation black box warning

§  Sig GI issues

§  No increased seizure or tic incidence vs placebo

o   General Side FX of Tx

§  Anorexia, irritability, insomnia, tics, aggression

§  Cardiovascular toxicity

                       ii.     2^nd line agents

o   Bupropion—NE and DA reuptake inhibitor

§  Lowers seizure threshold

o   Clonidine, guanfacine—a2-agonists- not as good for inattentiveness

§  For aggression, insomnia, impulsivity, hyperactivity

§  Lowers BP and HR

§  Close monitoring when used in conjunction with stimulants (ECG)

o   TCAs have limited use

1.     Oppositional Defiant Disorder

a.     Transient disorder. Constantly test limits and boundaries. Behaviour is not nearly as destructive as conduct disorder.

b.     Pattern of negative, hostile, and defiant behaviors for 6+ months with at least 4 of the following:

                        i.     Often loses temper, argues with adults

                       ii.     Actives defies or refuses to comply

                     iii.     Deliberately annoys/teases others

                      iv.     Blames others for own mistakes, misbehaviors

                       v.     Easily annoyed, irritable, angry, resentful, spiteful, vindictive (very touchy!)

                      vi.     Willful misbehavior

                    vii.     Obscene language use

                   viii.     Low self-esteem

                      ix.     Does NOT violate basic rules and rights of others (stealing, bullying)

                       x.     Not due to psychiatric disorder or developmental periods of increased defiance (e.g. terrible twos) and early adolescence

                      xi.     Does not occur primarily in course of PDD, schizophrenia, or psychotic disorder

c.      Epidemiology

                        i.     3x more common in males before puberty

o   Equal sex prevalence after puberty

                       ii.     Dx by age 8 60% will not meet criteria 3 years later, but early onset is more severe w/

                     iii.     Up to 80% will develop conduct disorder and 40% graduating to antisocial personality disorder

                      iv.     ~10% will become criminals as adults

                       v.     Comorbid ADHD or other anxiety disorders ~14%

d.     Etiology

                        i.     Domestic violence

                       ii.     Frequent moving (of homes)

                     iii.     Increased family Hx of psychiatric illness or substance abuse

                      iv.     Temperament and family’s response to same

                       v.     Unspecified heritability

                      vi.     Marital discord/ domestic violence

                    vii.     Frequent of multiple moves

                   viii.     Rarely Neurological injury

                      ix.     Multifactoral

e.      Treatment

                        i.     No medications!

                       ii.     Intensive interventional therapies (in-home)

                     iii.     Parent training—reduce parental validation, encouraging of negative behaviors

                      iv.     First steps

                       v.     Head start

                      vi.     School-based therapy

                    vii.     All require direct family involvement

b.     Treatment—comprehensive systemic therapy most effective

                        i.     Unified behavioral therapy approach in all arenas of child’s life—over a long period of time

1.     Infancy—0-12 Months

a.      Developmental Milestones (establish social bond: attachment, establish sense of trust and security)

                        i.     3 months—social smile

                       ii.     6 months—differential response to a specific person

                     iii.     8 months—stranger and separation anxiety; crawling

                      iv.     12 months—walking and speech

b.     Play

                        i.     Solitary, sensory motor

c.      Developmental Tasks

                        i.     Establish social bond—attachment

                       ii.     Sense of basic trust and security

d.     Regulating Task Mastery (Goodness of Fit)

                        i.     Stimulating interaction with warm, loving, sensitive and response parenting

e.      Key Question

                        i.     Will there be someone there?

1.     Sense of Autonomy and Object constancy (the awareness that when Mom leaves the room she doesn’t just disappear. She will come back. Before this is attained child has no awareness that person continues to exist), self control

a.      Developmental Milestones

                        i.     Self-feeding, toilet-training

                       ii.     Limits and self-control

                     iii.     Self-assertion, physical independence

                      iv.     Can walk

b.     Play

                        i.     Parallel mastery

c.      Developmental Tasks

                        i.     Sense of autonomy

                       ii.     Object constancy

                     iii.     Self-control of aggression and impulses

d.     Regulating Task Mastery

                        i.     Consistent limit-setting and structure of environment—idealization

                       ii.     Encouraging self-control

e.      Key Question

                        i.     Can I be me?

a.      Developmental Milestones

                        i.     Social and sex role

                       ii.     social values and belief

                     iii.     religion/culture

b.     Play

                        i.     Cooperative, socio-dramatic, rough-tumble

c.      Developmental Tasks

                        i.     Socialization, role-learning, enculturation: learning and appreciating your background

d.     Regulating Task Mastery

                        i.     Exposure to various social roles and cultural values

                       ii.     Appropriate sex-role modeling

e.      Key Question

                        i.     Where do I fit in?

1.     School—7-12 Years

a.     Developmental Milestones

                        i.     “gang” formation

                       ii.     Peer and group identification

                     iii.     Family can still play an important role

                      iv.     Sense of productivity membership (become productive member of society)

b.     Play

                        i.     Competitive and intellectual games

                       ii.     Rough-tumble play

c.      Developmental Tasks

                        i.     Sense of productivity membership

d.     Regulating Task Mastery

                        i.     Experience of success

                       ii.     Intellectual stimulation and school education

                     iii.     Peer and peer group interactions

e.      Key Question

                        i.     Can I do it?

1.     Adolescence—13-19 Years

a.      Developmental Milestones

                        i.     Body changes, sexual activities

                       ii.     Sense of identity

                     iii.     Sex role

                      iv.     Independence from Family

b.     Play

                        i.     Social

c.      Developmental Tasks

                        i.     Sense of identity, sex role, independence from family

d.     Regulating Task Mastery

                        i.     Consistent expectations with flexibility

                       ii.     Tolerance of regression

                     iii.     Respect and encouragement of individual, autonomy, and separation

e.      Key Question

                        i.     Who am I?

Developmental Deviations and Psychopathology not on study guide, but included below

1.     Developmental Deviations

a.      Development proceeds “naturally” unless interrupted

b.     Psychological interruptions include lack of trust or inability to accept limits (eg. Conduct disorder)

c.      Biological interruptions include genetic vulnerabilities (eg. Autism)

2.     Psychopathology

a.      Key issues

                        i.     Consideration of healthy functioning and adjustment

                       ii.     Developmental pathways

                     iii.     Developmental discontinuities

                      iv.     Developmental pathways

                       v.     Risk and resilience

o   Protective and vulnerability factors

                      vi.     Roles of contextual influences

b.     Theories

                        i.     Disorder specific

                       ii.     Biopsychosocial

                     iii.     Attachment and interpersonal relationships

                      iv.     Behavioral and learning theories

                       v.     Cognitive and emotion models

                      vi.     Family systems

c.      Developmental psychopathology

                        i.     The study of origins and course of individual patterns of behavioral maladaptation

                       ii.     Historical context

o   Other contributing disciplines such as embryology, genetics, etc.

o   Pathology as distortion, disturbance, or degeneration of normal functioning

                     iii.     Guiding principles

o   Interplay between normality and pathology

o   Importance of multiple levels of analysis and multidomain approach

o   Utilization of developmental framework for comprehending adaptation and maladaptation across the life course

                      iv.     Assumptions

o   Child is active participant in development

o   Self-regulation and self-organization occurs at multiple levels

o   Dialectic between canalization and ongoing changes

o   Outcomes best predicted through consideration of prior experience coupled with concurrent adaptations

o   Importance of individual choice and self-organization

o   Significance of transitional turning points or sensitive periods

                       v.     Common dimensions

o   Withdrawn

o   Somatic complaints

o   Anxious/depressed

o   Social problems

o   Thought problems

o   Attention problems

o   Delinquent behavior

o   Aggressive behavior

SOMATOFORM IN KIDS: FOCUS ON CHARACTERISTICS

A.    Characteristics of Somatiform Disorders

-        Physical symptom that suggests an underlying medical condition but the medical condition is either not found or does not fully account for the level of functional impairment.

-        Somatization (definition): “the tendency to experience and communicate somatic distress and symptoms unaccounted for bypathological findings, to attribute them to physical illness, and to seek medical help for them” (Lipowski, 1988).

B.    DSM IV Somatiform Diagnoses

1.     Somatization Disorder

2.     Conversion Disorder

3.     Pain Disorder

4.     Hypochondriasis

5.     Body Dysmorphic Disorder

6.     Related Conditions:

a.      Vocal Cord Dysfunction

b.     Reflex Sympathetic Dystrophy

c.      Recurrent Abdominal Pain (RAP)

*Problem - No separate criteria for children - 8 of 35 symptoms would only occur after puberty (e.g., pain during Intercourse, painful menstruation, etc.)

C. Some Epidemiology

1.     Recurrent somatic complaints are common in children of all ages:

-3% of three-year-olds have headaches

            -9% of three-year-olds have recurrent stomach aches

            -10% of school-age children have RAP or headaches

            -10% of 8 to 12-year-olds report frequent limb pain(growing pains)

2.     Recurrent somatic complaints are common in children of all ages:

a.      10% of adolescents report chest pain, headaches and fatigue.

b.     Headaches are common in community samples of youth, ranging from 10 to 30%.

                        -Sore muscles reported in 20-25%.

                        -Pseudoneurological symptoms are more rare.

Psychogenic Factors in the Child:

a.      Propensity towards affective disorder (anxiety/depression)             

b.     Tendency to respond in the extreme

c.      Behavioral problems (6 and under)

4. Family Factors:

     a. Parental psychopathology (alcoholism, sociopathy, somatic complaints, pain) leading to possible modeling learned illness behavior, dysfunctional family environment.  (Not always found or evident in eval.)

              --model present in 44-66% of conversion cases

              --conversion kids more likely to have ill parent than other psych patients

     b. Health Beliefs

     c. Parental tendency toward “overprotection”

     d. Separation problems

     e. Alexythymia/repressive defensive style

5.     Social Environment Factors:

     a. Daily stress and hassles

            --90% conversion d/o kids have significant stressor

     b. Trauma - sexual abuse

            --associated with pseudoneurological, GI and GU symptoms

     c. School functioning

            --teasing by peers

            --academic achievement concerns

     d. Social relationships

     e. Family functioning

            --parental discord, divorce, abuse, psych sx

D. Family dynamics that may have preceded and/or evolved around the patient’s symptoms, and may impede patient independence and optimal functioning in the course of treatment.

1.     Overprotection – This reflects the tendency of family to restrict the patient’s activities in the service of recovery, which may in fact reinforce inactivity and contribute to deconditioning.

2.     Misguided support – In their efforts to support the recovering teen, family members may actually engage in behaviors that undermine the teen’s confidence and sense of independence.  This may involve either lowering expectations or applying excessive pressure for rapid change and improvement in function.

3.     Communication pattern and style – Look for family communication patterns that involve poor conflict resolution, difficulty communicating affect and discussing emotionally charged issues.

4.     Attributions – Patient and family may tend to attribute both illness and recovery to factors outside themselves and often beyond their control (Locus of Control).

5.     Perceptions/attitudes regarding health care providers – Adopting a perspective (at times based on actual experience) that depicts traditional medicine alone as generally ineffective in providing symptomatic relief or improved functioning. It may also involve an endorsement of non-traditional and complimentary/alternative treatment approaches.

6.     Level of patient independence in managing illness – Patient self-confidence is often undermined via their emersion in the ill role, whereby family members increasingly take over their responsibilities and provide assistance that may not necessarily be needed (closely related to Overprotection and Misguided Support). 

7.     Social/peer dynamics – Teens with these conditions can become avoidant (and phobic) of normal peer situations after long periods of isolation away from school and social events.  Look for patterns of social avoidance.

E. Cognitive Style

1.     Patients with chronic pain have been observed to report greater pain behavior if they exhibit a cognitive pattern of “Catastrophizing,” e.g., “What if…..?”

2.     Catastrophizing cognitive style is associated with increased pain severity, lower pain tolerance, greater functional disability, more anxiety and depression, and increased use of analgesics (Crombez et al., 2003; Vervoort et al., 2006).

3.     Patient focuses on pain and makes exaggerated and fearful appraisals of pain symptoms and their consequences, while regarding themselves as lacking the capacity to successfully cope.

4.     Child disability and family disruption are conceptualized as a function of the child and family interpretation of pain symptoms, type of coping employed (problem-focused or emotion- focused) and parent attempts to support their child’s efforts to cope with the pain (Folkman et al, 1986; Lipani & Walker, 2005; Zeltzer et al, 2006).

5.     Children with chronic pain appear to have few and inadequate coping strategies and feel that they lack any control over their symptoms (Branson & Craig, 1988; Dunn-Geier et al., 1986)

6.     Pain and functional disability are more strongly related in adolescents with lower perceived competence in academic, social and athletic endeavors (Claar et al., 1999), and/or tendency towards perfectionism and setting exceedingly high expectations.

7.     Pain-related disability may be reinforced if it allows the individual to avoid activities at which s/he is (or believes him/herself to be) ineffective or unsuccessful. 

8.     More active coping strategies are associated with a greater sense of control, less pain behavior, social withdrawal and functional disability (Flor et al., 1990; Siegel & Smith, 1989). 

F. Formulations:

1.     stressful/emotionally-demanding situation leads to internal distress

2.     learning history where there is a model for illness behavior and reinforncement for the illness role

3.     predisposition to reacting to stress via somatic expression (combination of genetics, temperament, learning leads to the child responsing to stress in a hyper-aroused physiological state)

4.     Family system that may be characterized by:

a.      Rigid, moralistic rules of conduct

b.     High standards of performance

c.      Dysfunctional marital relationship

d.     Other family pathology (ex. Substance abuse, physical or sexual abuse, inappropriateness in personal boundaries, etc.)

G. Treatment of Pediatric Somatization Disorders

1.     Flexible use of a variety of treatment approaches and modalities:

a.      Cognitive behavioral therapy

b.     Psychoeducaiton

c.      Family intervention

d.     Psychotropic medications

2.     Clinician often functions in the role of being a consultant to the primary care physician, who manages and maintans active follow up.

3.     Treatment plan has the following characteristics:

a.      Deemphasizes the final diagnosis

b.     Focuses on reducing dysfunction

c.      May employ benign, face saving remedies during the acute phase

d.     Avoids making physician contact contingent on escalting sick-role behavior

Four things to be familiar with: Characteristics of dysfunctional family (emotional uninvolvement, overinvolvement, rigid family structure and harsh limit-setting (interferes with autonomy and mastery), chaotic family structure and no limit setting (don’t acquire the understanding that in life there are rules to follow and limits on what you can do. Have problems with impulsive behavior) All of these interfere with personality development and maturation.

1.     Families and Individual Development

a.      Healthy families aid development while dysfunctional families impair development

b.     Definitions of family are in flux—may be defined by genetic relatedness, marriage, emotional bonds, cooperative child rearing, etc. 

c.      Healthy families are diverse, there is no single right way to raise kids

d.     Divorce breaks a fundamental bond in a child’s worldview and threatens their sense of safety, child may become enraged with the leaving parent and hyper-protective of the remaining parent

e.      Parental authority is more important for small children while discussion and reasoning become increasingly important for adolescents

f.       A family is a system, greater than the sum of its parts, and each family goes through a lifecycle  (marriageàyoung children at homeàadolescent childrenàempty nestersàold age)

g.     Historically families were blamed for disorders now known to have biological roots like schizophrenia

h.     But, now families are often not held accountable for the problems they do create, like lack of effective boundary setting causing behavioral problems

1.     Characteristics of a Healthy Family

1.     Dysfunctional Family Patterns

a.      Emotional over-involvement

                        i.     Symbiosis, enmeshment, overprotectiveness

b.     Emotional under-involvement

                        i.     Neglect, rejecting, unavailable

c.      Rigid family structure and harsh limit setting

                        i.     Inflexible, uncompromising

d.     Chaotic family structure and no limit setting

                        i.     Unclear boundaries, directionless

1.     Goodness of Fit And the Biopsychosocial Model of Family Functioning

a.      “the properties of the environment and its expectations and demands are in accord with the organism’s own capacities and motivations”

b.     Ideally parents of a hyperactive kid would be very patient and frequently reiterate boundaries while parents of a timid child would constructively encourage her

c.      Families have to modulate their behavior to suit kids’ needs

1.     The Family Observational Interview

FIRST LINE TX is SSRI

1.     Basics of Depression and Mood Disorders

a.      Annual cost of depression is $44 billion

                        i.     Majority of which is due to lost productivity

b.     Mood disorders like bipolar disorder affect all facets of life (work, social, family)

c.      Native health effects

                        i.     Increased M&M post-MI

                       ii.     3x mortality rate in 1^st six months post-MI

                     iii.     Increased morbidity post-stroke

                      iv.     Worsens outcome of cancer, DM, AIDS, etc.

d.     Depression is MC in women

                        i.     In any given year, 1 in 10 depressed persons attempt suicide

e.      Genetics of mood disorders is multifactorial

                        i.     Risk increases with more first-line family members affected

1.     (SEVERE AND INTENSE DEPRESSION. MORE THAN A FEW DAYS)

a.      Epidemiology—MC in women

b.     Clinical Features

                        i.     Minimum 2-week period of depression and/or loss of interest or pleasure in most activities

                       ii.     Accompanied by 5+ of following Sx:

o   Depressed mood

o   Anhedonia  (defined as the inability to experience pleasure from activities usually found enjoyable)

o   Significant changes in appetite and/or weight

o   Sleep disturbances

o   Psychomotor agitation or retardation

o   Fatigue, loss of energy

o   Feelings of worthlessness or guilt

o   Decreased concentration or ability to think clearly

o   Suicidal ideation

2.     In severe cases, psychotic symptoms may accompany major depression.  Delusions usually involve themes of guilt.

a.      Treatment

                        i.     SSRIs—1^st line

o   Fluoxetine, paroxetine, sertraline, citalopram

o   For depression and anxiety

o   Sexual side FX

o   Discontinuation syndrome—headache, sweating

                       ii.     Tricyclic Antidepressants

o   Imipramine, amitriptyline

o   Efficacious but slow and with significant anti-cholinergic side FX and risk of cardiotoxicity

                     iii.     MAOIs (phenelzine)

o   Effective but significant dietary restrictions (tyramine)

                      iv.     Atypical Antidepressants

o   Trazodone, bupropion, mirtazapine, nefazodone

§  Mirtazapine good for depression and insomnia

o   Effective with rapid action onset and Anxiolytic FX

o   Frequent weight gain—bad for depression

o   Self-injury problems

                       v.     SNRI (duloxetine)

o   Effective on Tx-resistant depression

                      vi.     CBT—aim is to correct automatic negative thoughts prominent in depression

1.           Duration longer than major depression but shorter than dysthymia                                                

Intensity of symptoms is mild                                                                                          

There is a clear psychosocial stressor

1.     -The most important aspect of dysthemia is to recognize it is chronic low grade depression of at least 2 years duration and NO psychotic symptoms AT LEAST 2 YEARS OF CONTINOUS DEPRESSION defines Dysthimia

a.      Epidemiology—MC in women

b.     Clinical Features

                        i.     Chronic depression of mild-to-moderate severity for at least two years

                       ii.     Accompanied by 2+ Sx

o   Poor appetite or overeating

o   Insomnia or hypersomnia

o   Low energy, fatigue

o   Poor concentration or difficulty making decisions

o   Feelings of hopelessness

o   Low Self-esteem

o   CAN BE SUICIDAL BUT WON’T BE PSYCHOTIC

c.      Treatment is same for major depression

1.     Seasonal Affective Disorder

a.      Depression occurring seasonally with onset in late fall and most severe in winter

                        i.     MC in northern latitudes

                       ii.     Decreased sunlight decreases melatonin, causing NT abnormalities

b.     Treatment—antidepressants and light therapy

1.     Bipolar Disorder

MAY INITIALLY PRESENT AS DEPRESSION. WHEN THEY COME BACK WITH MANIA CHANGE FROM MAJOR DEPRESSION TO BIPOLAR I. ANY ANTIDEPRESSANT CAN THROW PERSON INTO MANIC EPISODE.

a.      Epidemiology

                        i.     Lifetime prevalence is ~2%

                       ii.     Equal in men and women

                     iii.     Rates higher in MZ twins than DZ twins

b.     Clinical Features of Mania BE ABLE TO DISTINGUISH BETWEEN MANIA AND HYPOMANIA

                        i.     Manic episode—distinct period of consistently elevated, expansive, or irritable mood lasting at least one week

                       ii.     Associated with 3+ Sx: (4 if the mood is only irritable)

o   Inflated self-esteem or grandiosity

o   Decreased need for sleep

o   More talkative than usual or pressure to keep talking

o   Racing thoughts, flight of ideas

o   Distractibility

o   Increase in goal-directed activity or psychomotor agitation

o   Excessive involvement in pleasurable activities with high risk potential (promiscuous sex, spending sprees)

c.      Clinical Features of Hypomania

                        i.     Hypomanic episode—distinct period of consistently elevated, expansive, or irritable mood lasting at least 4 days

                       ii.     Accompanied with 3+ Sx as above                                                                                                    1.         inflated self-esteem or grandiosity                                                                                                2.   decreased need for sleep                                                                                                                 3.            more talkative than usual or pressure to keep talking                                                                                       4.        flight of ideas or subjective feeling that thoughts are racing                                                                               5.            Distractibility                                                                                                                                                     6.            increase in goal-directed activity (either socially, at work, or at school) or psychomotor agitation                            7.        excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., excessive sexual activity, spending sprees, etc.)

LESS INTENSE THAN MANIA

                     iii.     Episode is not severe enough to cause marked impairment in social or occupational fxn or to necessitate hospitalization due to absent psychotic features

d.     Clinical Features of Mixed Episode

                        i.     Criteria for manic and hypomanic episodes are met nearly every day in a one-week period

e.      Bipolar Disorder I (AT LEAST ONE MANIC)

                        i.     Presence or Hx of 1+ manic episodes-diagnosis is not made until this is seen

o   Many alternate b/t manic and depressive episodes

f.       Bipolar Disorder II (ONE HYPOMANIC AND ONE MAJOR DEPRESSION)

                        i.     Presence or Hx of 1+ major depressive episode(s)

                       ii.     Presence or Hx of 1+ hypomanic episode(s)

                     iii.     Never had a manic episode

g.     Treatment of Bipolar Disorder—remember we do not have to know this b/c they want us to learn it the way that pharm teaches it

                        i.     Traditional mood stabilizers