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Char: Communication difficulties with normal hearing, relationship problems, self-destructive behavior, IQ
Asperger Disorder
Char: Problems forming relationships, repetitive behavior, clumsy motor skills, no language delay, normal cognition
Age: 3-5
DDx: Autism, Childhood SCZ, Rett (girls), OCD, Schizoid Personality
Rett Syndrome
Char: Diminished social interest/skills after period normal functioning in girls, stereotyped body movements, mental retardation
DDx: Autism, Childhood disintegrative d/o, Asperger
Childhood Disintegrative D/O
Char: Regression in verbal, motor, social dev. after 2 years normal fxn, mental retardation
DDx: Autism, Rett (girls), Asperger
Age: 2-10 years
Prog: Chronic, lifelong
Char: Overactivity, self-control problems, limited attention, prone to impulsiveness, emotional lability, irritability, normal intelligence
DDx: Normal temperament, mood d/o, anxiety d/o, learning problems
Age: less than 7 years, lasts at least 6 months
Tx: methylphenidate (Ritalin; concerta (ER); 60 mg/day to children older than 6 years); Dextroamphetamine sulfate (Dexedrine, 40 mg/day in children older than 3 years); Amphetamine/ dextroamphetamine (Adderall and Adderral XR: 3 mg/day in childern older than 3 years)
Conduct d/o
Char: Behavior violates social norms, aggressive behavior, serious deviation from societal norms
Ddx: Mood d/o, ADHD
Oppositional Defiant d/o
Char: pattern defiant, negative behavior toward adults but does not violate social norms
Ddx: Normal oppositional behavior, conduct d/o, mood d/o
Tourette Disorder
Char: display of involunatry movements and vocalizations, many motor tics, at least 1 vocal tic; possibly involunaty use of profanity and obscene gestures
Chronic Motor or Vocal Tic Disorder
Char: Display of involuntary motor or vocal tics, but not both - otherwise same as tourette d/o
Char: Voiding of urine in inappropriate settings
Age: >5 years
Tx: 1. Nighttime enuresis: bed wetness alarm
2. Pharm: Imipramine (Tofranil) and Desmopressin Acetate (DDAVP)
3. Support/Reassurance
Char: Soiling in inappropriate settings
Age: >4 years
Tx: 1. Physiological Causes (laxatives/stool softeners)
2. Psych Causes: psychotherapy, family tx, behavioral tx
Selective Mutism
Char: child speaks in some social situations but not others, distinguish from normal shyness
Age: 5-6 years
Tx: 1. Family or behavioral tx
Separation Anxiety d/o
Char: overwhelming fear of loss of parents, child refusal to be alone
Age: 7-8 years
Tx: Family tx, gradual reintroduction to the school and ind. psychotherapy, antidepressants (primarily imipramine (150-200 mg/day)
Reactive Attachment Disorder of Infancy or Early Childhood
Char: Disturbed social relatedness: either nonresponsive (inhibited type) or forms indiscrimate attachments (disinhibited type). Developmental delays.
Age: First years
Tx: Improve family situation
Prog: Disinhib. better than inhibited
Char: Clouding of consciousness and difficulty with orientation due to central nervous system dysfx, illusions/hallucinations often visual, often worse at night
Causes: CNS diseases, systemic illnesses, drug abuse, withdrawal
Alzheimer Disease
Char: Normal consciousness, memory loss, language difficulties, changes in personality and mood, memory first followed by language and spatial ability, life expect. 8 years post diagnosis
Ddx: Depression, Delirium due to illness/medications
Anat: reduced choline acetyltransferase, abnormal amyloid precursor protein, chr 14 or 21, autosomal dominant
Tx: Acetylcholinesterase inhibitors: Tacrine (Cognex 40-160 mg/day), Donepezil (Aricept, 5-10 mg/day), Rivastigmine (Exelon, 6-12 mg/day), Galantamine (Reminyl, 16-32 mg/day),
structured environment, support groups for family, antianxiety/antidepressant/antipsychotic agents to relieve ass. sx
Vascular Dementias
Char: sudden onset cognitive dysfx, stepwise fxn detioration, better preservation patient's personality, focal neur. symptoms
Tx: Reduce risk factors associated with cerebrovascular disease
Amnestic Disorders
Char: d/o characterized by memory loss with little or no other cognitive impairment: both retrograde and anterograde amnesia occur, patient confabulates (fabricate forgotten information)
Etiology: Thiamine deficiency (Wernicke's encephalopathy) (acute delirium) followed by Korsakoff syndrome (chronic amnestic disorder); head injury, infection involoving temporal lobes (herpes simplex encephalitis), neurotoxins
Psychosis Secondary to Medication
Prominent Hallucinations or delusiong that do not occur only during an episode of delirium with evidence to support medication/substance related cause.  Also, disturbance not better accounted for by a psychotic disorder
3 phases: Prodromal (decline in function), psychotic, residual (between psychosis episodes-flat affect, odd thinking)
2+ must be present for 1 month: delusions (often bizarre), hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms.  Must cause significant social or occupational functional deterioration, duration at least 6 months
- presents between 15-45
- due to increased dopamine activity+elevated serotonin/norepinephrine
- CT: enlarged ventricles and cortical atrophy
- Tx: neuroleptics: typical better for positive symptoms, atypical better for negative symptoms
SCZ Paranoid Type
Highest functioning type, older age of onset - must have preoccupation with one or more delusions or frequent auditory hallucinations - no predominance of disorganized speech, catatonic behavior, or inappropriate affect
SCZ Disorganized type
Poor Functioning type, early onset, must have disorganized speech, disorganized behavior, flat/inappropriate affect
SCZ Catatonic Type
Rare, must have 2 of following: motor immobility, excessive purposeless motor activity, extreme negativism/mutism, peculiar voluntary movements/posturing, echolalia or echopraxia
SCZ Undifferentiated
SCZ Residual Type
Undif: characteristic of more than one subtype
Residual Type: Prominent negative symptoms with only minimal evidence of positive symptoms
Schizophreniform Disorder
Same as SCZ except lasts 1-6 months, 1/3 recover completely
- Tx: hospitalize, 3-6 month course of antipsychotics and psychotherapy
Schizoaffective Disorder
Must meet criteria for either major depressive episode, manic episode, or mixed episode (during which criteria for schizophrenia are also met) - must have had delusions or hallucinations for 2 weeks in the abscence of mood disorder symptoms, have mood symptoms for substantial portion of illness
- Tx: antipsychotics as needed for short-term psychosis control, mood stabilizers, antidepressants, or ECT
Brief Psychotic Disorder
Psychotic symptoms as defined for schizophrenia but symptoms 1 day to 1 month
- Tx: supportive psychotherapy and antipsychotics for psychosis and benzo for agitation
Delusional Disorder
Nonbizarre fixed delusions for at least 1 month, does not meet criteria for SCZ, functioning in life not significantly impaired
- Psychotherapy may be helpful
Shared Psychotic Disorder
Patient develops the same delusional symptoms as someone he or she is in a close relationship with.  Often a family member.  20-40% recover upon removal of inducing person
- Tx: reparate the people, psychotherapy, antipsychotics if no improvement in 2 weeks
Culture-Specific Psychoses
Koro: Patient believes that his penis is shrinking and will disappear, cuasing his death (Asia
Amok: Sudden unprovoked outbursts of violence of which the person has no recollection, often suicide afterwards (Malaysia, SE Asia)
Brain fag: Headache, fatigue, and visual disturbances in male students (Africa)
Schizotypal Personality Disorder
Pattern of social deficits marked by eccentric behavior, cognitive or perceptual distortions, and discomfort with close relationships in addition to 5 of the following
 - ideas of reference (excluding delusions of reference), odd beliefs or magical thinking inconsistent with cultural norms, unusual perceptual experiences, suspiciousness, inappropriate or restricted affect, odd or eccentric appearance or behavior, few close friends or confidants, odd thinking/speech (vague, stereotyped etc), excessive social anxiety
 - magical thinking may include belief in clairvoyance, bizarre fantasies/preoccupations, belief in superstitions
 - not frankly psychotic
 - Tx: psychotherapy + short low-dose antipsychotics if necessary for transient psychosis
Schizoid Personality Disorder
No desire for close relationships and prefer to be alone, lifelong pattern of social withdrawal
 - pattern of voluntary social withdrawal and restricted range of emotional expression, present in a variety of contexts in addition to at least 4 or following
 - neither enjoying nor desiring close relationships, generally choosing solitary activities, little interest in sexual activity, taking pleasure in few activities, few close friends or confidants, indifference to praise or cirticism, emotional coolness, detachment, or flattened affect
 - Tx: psychotherapy, low-dose short course antipsychotics if transiently psychotic
Major Depressive Episode
Must have at least 5 of the following for 2 week period: Depressed mood, anhedonia, change in appetite/weight, feelings of guilt/worthlessness, insomnia/hypersomnia, diminished concentration, psychomotor agitation/retardation, fatigue, recurrent thought death/suicide
- must cause social/occupational impairment
- 15% risk of suicide in patients who have been hospitalized for major depressive episode
Manic Episode
Period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week including 3 of following: distractibility, inflated self-esteem or grandiosity, increased goal-directed activity, decreased need for sleep, flight of ideas/racing thoughts, pressured speech, excessive involvement of in pleasurable activities
- 75% have psychotic symptoms
Mixed Episode
Criteria met for both manic episode and major depressive episode nearly every day for at least 1 week
- irritability is usually predominant mood state, poor response to lithium
Hypomanic Episode
Lasts at least 4 days, no marked impairment in social/occupational functioning, no requirement for hospitalization, no psychotic features
Major Depressive Disorder
At least one major depressive episode, no history of manic or hypomanic episode
- decreased serotonin in CSF, also need to check TSH levels
- Possible psychotic features
- Episodes self-limiting but usually last 6-13 months, risk of subsequent is 50% in 2 years, 15% eventually commit suicide
- 75% respond to therapy, usually takes 4-8 weeks to work
- Tx: SSRI's first line, TCA's (most lethal in overdose), MAOI's useful for treatment of refractory depression
- ECT indicated if patient unresponsive to pharmacotherapy, premedicate with atropine followed by muscle relaxant and then generalized seizure induced, 8 treatments over 2-3 weeks, SE of retrograde amnesia is common, usually disappears in 6 months
Unique Types of Depressive Disorders
Melancholic: 40-60%, anhedonia, early morning awakenings, psychomotor disturbance, excessive guilt, and anorexia, ECT helpful
Atypical: hypersomnia, hyperphagia, reactive mood, leaden paralysis, and hypersensitivity to interpersonal rejection
Catatonic: catalepsy (immobility), purposeless motor activity, extreme negativism/mutism, bizarre postures, echolalia - treat with antidepressants and antipsychotics concurrently
Psychotic: with presence of delusions or hallucinations
Bipolar I Disorder
Occurrence of one manic or mixed episode.  Between episodes there may be interspersed euthymia, major depressive episodes, dysthymia, or hypomanic episodes (not requird for diagnosis).
- Untreated manic episodes last average 3 months
- Tx: Lithium, anticonvulsants (carbamazepine or valproic acid (better for type II)), olanzapine, psychotherapy, ECT (need more treatments than for depression)
- Rapid Cycling: occurrence of four or more mood episodes in one year
Bipolar II Disorder
History of one or more major depressive episodes and at least one hypomanic episode
- Tx: same as Bipolar I Disorder
Dysthymic Disorder
Depressed mood for 2 years (children 1 year) in addition to at least 2 of following: poor concentration, feelings of hopelessness, poor appetite/overeating, insomnia/hypersomnia, low energy, low self-esteem (CHASES Acronym)
- never asymptomatic for greater than 2 months at a time, no major depressive episode, no psychotic features
- Tx: cognitive therapy/insight-oriented psychotherapy in addition to antidepressants (SSRI's, TCA's, MAOI's)
Cyclothymic Disorder
Numerous periods with hypomanic symptoms and periods with depressive symptoms for at least 2 years, never symptom free for greater than 2 months, no history major depressive episode or manic episode
- Tx: same as bipolar
Panic Attack
Discrete period (often peaks in several minutes and subsides in 25 minutes) of intense fear and discomfort that is accompanied by at least 4 of following: PANICS: Palpitations,Abdominal distress, Numbness/nausea, Intense fear of death, Choking/chills/chest pain, Sweating/shaking/SOB
- May be mistaken for MI
Panic Disorder
Spontaneous recurrent panic attack, at least one of the attacks followed by a minimum of 1 month of the following: persistent concern about additional attacks, worry about the implications of the attack, a significant change in behavior related to the attcks (avoid situations that may provoke attacks)
- specify with or without agoraphobia (fear of being alone in public places)
- attacks on average 2 times per week
- Precipitated by hyperventilation, inhalation of CO2, caffeine, nicotine
- Tx: Benzo's initially, then taper as SSRI instituted (especially paroxetine and sertraline) - 2-4 weeks to take effect and higher doses than for depression, also clomipramine/imipramine - treat for 8-12 months
Specific Phobia
Excessive persistent fear of specific situation or object, exposure brings immediate anxiety response, patient recognizes fear is excessive, , situation avoided when possible, if under 18 duration must be at least 6 months
- Tx: systematic desensitization
Social Phobia
Same criteria as specific phobia except that feared situation is related to social settings in which the patient might be embarrassed or humiliated in front of other people
- Tx: Paroxetine (SSRI), beta blockers frequently used to control sx of performance anxiety
Obsessive-Compulsive Disorder
Either obsessions or compulsions
- obsessions: recurrent and persistent intrusive thoughts or impulses that cause marked anxiety and are not simply excessive worries, person attempts to suppress the thoughts, person realizes thoughts are product of own mind
- Compulsions: repetitive behaviors that person feels driven to perform in response to obsession (aimed at reducing distress)
- Person aware that are unreasonable and excessive
- obsessions cause market distress, are time consuming, or significantly interfere with daily functioning
- Abnormal serotonin regulation
- Tx: SSRI's first line, higher than normal doses, TCA's (clomipramine) also effective, Behavioral Therapy
Having experienced/witnessed traumatic event, potentially harmful/fatal with reaction of fear/horror
- persistent reexperiencing of the event, avoidance of stimuli associated with the trauma, numbing of responsiveness (limited range of affect/detachment), persistent symptoms of increased arousal (i.e. hard to sleep, anger), symptoms present for at least 1 month
- Tx: TCA's (imipramine/doxepin), SSRI's, MAOI's, anticonvulsants (for flashbacks/nightmares), psychotherapy
Acute Stress Disorder
Presence of psychological symptoms after a stressful but non-life threatening event
- symptoms occur within 1 month of trauma and last for maximum of 1 month
Generalized Anxiety Disorder
Excessive anxiety and worry about daily events and activities (free floating, does not involve specific person/event/activity) for at least 6 months, difficult to control worry, must be associated with 3 of following (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance)
- onset usually before 20
- chronic, lifelong, fluctuating in 50%
- Tx: psychotherapy plus buspirone, benzodiazepines (short term, clonazepam or diazepam), SSRI's, venlafaxine ER
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