7. SPECT SCAN
Neuroimaging in Psychiatry
Neuroimaging in psychiatry By Tripura Medical College , Slide 23
http://www.slideshare.net/shaan_47/neuroimaging-in-psychiatry
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14. ADOLESCENT CLINICAL PRESENTATION
•
Anger
•
Academic difficulties
•
Behavioral changes
• Reckless or hostile behavior
•
Social withdrawal
•
Giving away valued possessions
•
Frequent school absences
Source: Beat the Boards
15. OVERVIEW OF DEPRESSION IN ADOLESCENTS
•
Prevalence of Major Depressive Disorder:
• 2% in children
• 4%-8% in adolescents
• Lifetime prevalence by age of 18 is approximately 20%
• -----------------------------------------------------------------• 20% of teens seriously contemplate suicide
• 8% attempt suicide
More than 70% of children and adolescents with
depressive disorders or other serious mood disorders do
not get diagnosed or treated
Source: Beat the Boards
16. TREATMENT FOR DEPRESSION
•
Therapy
•
Medications
• SSRI’s
• Escitalopram: FDA approved treatment of adolescent depression (12-17 yrs)
• Fluoxetine: FDA approved treatment of child and adolescent depression (8-18
yrs)
•
Family Therapy
•
School / Learning Interventions
•
Community
Source: Beat the Boards
17. CONSEQUENCES OF FDA WARNING
•
FDA released a black box warning about suicidal thoughts and behaviors.
•
Positive correlation between SSRI use and decrease in adolescent and young adult
suicide rate
•
SSRI prescription rates have DECLINED by 25% since there was a warning introduced in
2004
•
CDC reported a 14% INCREASE in suicide rates in 5-19 year olds between 2003 and
2004
Source: Beat the Boards
24. GENERAL
•
Definition:
•
is loss of contact with reality that includes:
• False beliefs about what’s going on or who one is (delusion)
• Seeing/Hearing things that aren’t there (hallucinations)
•
It is less common than autistic disorder in children before 5 years of age
•
Between ages 5 – 7, diagnosis of psychosis can be difficult
•
Children’s delusions are less complex compared to adults, hallucinations are less
elaborated
•
Most children who report early hallucinations are not schizophrenic
25. DIFFERENTIAL DIAGNOSIS OF PSYCHOTIC
DISORDERS
•
Early Onset Schizophrenia (EOS)
• Onset before age 18
• 3% - 4% of schizophrenic pts present < age 15
• More common in males
•
Very Early Onset Schizophrenia (VEOS)
• Onset before age 13
• Predominant in males 2:1
• Predispositions:
• ADHD, speech disturbances, anxiety, substance abuse and OCD
•
Schizophrenia Dx
• Deterioration in social, occupational, and self-care functioning
26. ASSESMENT & TREATMENT
•
Assessment
•
Projective testing
• Rorschach ink plot test (3-adult)
• Perceptual accuracy and reality testing
• Integration of affective and intellectual functioning
• Thematic Apperception Test (TAT) (6-adult)
• Provides data regarding interpersonal funtioning
• Machover Draw a Person Test (DAT) (3-adult)
•
Treatment
•
Multimodal
• Includes; programs, case management services, psychopharmacology, psychotherapy,
vocational & rehabilitative mgt
• Supportive therapy – long term
• Support the child’s good reality testing and good sense of self and social skills training
27. TREATMENT
•
AACAP Guidelines of Pharmacotherapy
• Vital signs and weight/BMI: baseline & monthly
• Lipid profile and fasting blood sugar: baseline & quarterly
• Standardized rating scales and measurement such as AIMS and NRS
• EKG is not needed for all patients
• Pts with family Hx of sudden death, cardiac abnormalities or personal history of
syncope, EKG should be considered
28. ANTIPSYCHOTICS
•
Children and adolescents are more sensitive to EPS
•
Are more effective with negative symptoms
•
Varies
•
Withdrawal dyskinesia common in children
•
In children after remission of acute phase, medication free trial is recommended
•
FDA Approved Antipsychotics
•
Aripiprazole
•
Haloperidol and Chlorpromazine
•
Risperidone
• Schizophrenia in teenagers (13-17)
• Bipolar disorder for children (10-17)
• Autistic Disorder
29. ADVERSE EFFECTS
•
Increased lipids
•
Increased sugar
•
Photosensitivity
•
Hypersensitivity and rash
•
Weight gain
•
Cataract and Retinopathy
•
Increased Liver Enzymes
•
Sedation and Fatigue
•
Cardiac Rhythm Effects
• More common in young
• Highest in clozapine, lowest in risperidone, quetiapine and aripiprazole
32. ANXIETY DISORDER
Generalized anxiety disorder is characterized as excessive worrying,
that is uncontrollable and interferes with the individuals’ everyday life.
There are several anxiety disorders including: panic attacks, OCD,
PTSD, generalized anxiety disorder, social anxiety disorders and
Specific phobias.
Anxiety Disorder Prevalence
•
most common psychiatric diagnoses in childhood
•
6-15% of school aged children
•
through adolescences the ratio is girls: boys, 2:1
•
except for Obsessive Compulsive Disorder and social anxiety disorder
Prevalence Among Adolescences
•
social anxiety disorder
•
panic disorder
33. SOCIAL ANXIETY
DISORDER
Diagnosis:
•
Boys are equally as effected as girls
•
Duration of 6 months if <18 years old
•
Fear of one or more social performance
situations due to fear of scrutiny by others
and being humiliated or embarrassed
•
Exposure to feared situation provokes
anxiety
•
Avoiding social or performance situations
or endured with intense anxiety
Increased Risk of:
•
Social isolation
•
Depression in adulthood
•
Failure to reach potential
Panic Disorder
Diagnosis:
•Attack usually last 20-40 minutes
•With four or more of the following symptoms:
•Palpitations
•Shortness of breath
•Sweating
•Choking
•Cheat pain
•Nausea, abdominal distress
•Dizziness
•Paresthesias
•Chills
•Shaking, trembling
•Fear of dying
•Fear of going crazy
•Depersonalization or derealization
•Usually occurs in adolescents
Increased Risk of:
•Depression
34. TREATMENT
First line of Treatment:
Cognitive Behavioral Therapy
This consists of four components
1. Recognizing anxious feelings and physical reactions to anxiety
2. Understanding feelings in anxiety-provoking situations
3. Develop a coping plan
4. Administrating self-reinforcement
Medication:
Serotonin Reuptake Inhibitors (SSRI)
•
Paxil- Social phobia
•
Sertraline - GAD
•
Fluoxetine - GAD, social phobia,
•
Fluvoxamine - social phobia, SAD, GAD
Social:
School interventions
•
behavioral modification in school
•
social work at school
Community interventions
•
extracurricular activities
38. MANIA PRESENTATION
•
Elated mood – laughing hysterically without any reason
•
Grandiose behaviors – acting as if the rules do not pertain to them…so smart they can tell
the teacher what to teach
•
Flight of ideas – jump from topic to topic in rapid succession during a normal conversation
•
Decreased need for sleep – sleep only 4-6 hours and are not tired the next day
•
Hypersexuality – act flirtatious beyond their years, may try to touch the private areas of
adults (including teachers) and use explicit sexual language
Source: www.nami.org, National Alliance on Mental Illness
39. ACUTE MANIA
•
FDA Approved Psychiatric medications
• Lithium, risperidone, aripiprazole, quetiapine, olanzepine
• IF no psychosis evident:
• Mood stabilizer OR atypical
• Lithium, valproate, carbamazepine
• Olanzepine, risperidone, quetiapine, aripiprazole
• IF psychosis evident
• Mood stabilizer and atypical
40. Amrin Islam, 3 rd Year Medical Student
SUBSTANCE ABUSE IN ADOLESCENTS
41. OVERVIEW
•
Nearly 50% of students try illegal drugs by the time they graduate high school
•
Substance abuse is more common when another family member abuses the same
substances
•
Most adolescents experiment with alcohol and cigarettes
• Some advance to use of marijuana
• Small portion will further proceed to the use of illicit drugs
•
Monitoring the future survey by the National Institute on Drug Abuse Monitoring the Future
Survey 2010
• 27% of high school students have been drunk in the past 30 days
• Illicit substance abuse increased due to increases in marijuana use
42. LEGALLY AVAILABLE SUBSTANCES
•
Types
•
Prescription Drugs
•
Alcohol
•
Alcohol/Sedative Intoxication
•
•
Alcohol/Sedative Withdrawal
•
•
Slurred speech, lack of coordination, unsteady walking, unable to concentrate, impaired memory, coma, and
involuntary movements of the eye
Sweating, rapid heart beat, trembling of hands, sleeplessness, nausea or vomiting, hallucinations, and seizures
Inhalants
•
Fumes from glues, aerosols and solvents
•
Inhalant abuse risks
•
•
Inhalant Intoxication
•
•
Heart conditions including cardiac arrest, and can effect other vital organs including brain, heart, kidney, and
liver
Dizziness, involuntary movement of the eyes and blurred vision, slurred speech, lack of coordination, and slowed
reflexes
OTC medications
43. ILLEGAL DRUGS
•
Types
•
Marijuana
•
•
Intoxication- decrease motor performance, social with drawl, anxiety, red eyes, dry mouth, rapid heart beat, and
increased appetite.
Cocaine, Crack, Speed
•
•
•
Intoxication- euphoria, tachycardia, dilated pupils, anxiety, tension, anger, chills, weight loss
Withdrawal- fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite and
psychomotor retardation
Hallucinogens (LSD)
•
•
Intoxication- Dilated pupils, rapid heart rate, sweating, palpitations, blurred vision, tremors, and lack of
coordination
Opiates (Heroin)
•
•
•
Intoxication- Euphoria, constricted pupils, drowsiness, slurred speech, or impaired attention
Withdrawal- muscle aches, diarrhea, nausea, vomiting, dilated pupils
Designer Drugs(Ecstasy)
•
Intoxication- raised pulse and temperature, feeling of wellness, and “rush”, nausea, affection for others, teeth
grinding and jaw clenching, anxiety, and loss of appetite
44. TREATMENT STRATEGIES
•
Detoxification when indicated
•
Abstinence
• Family, individual, and group treatment
•
Use of Medication
•
Twelve Step Programs
•
Mutual help Groups
•
Relapse prevention/continuing recovery process
45. MEDICATIONS
•
Nicotine Dependence
• Bupropion SR (Zyban)
• Nicotine Patch
• Neither approved in adolescents
•
Opioid Dependence
• Buprenorphine/Naloxone (Suboxone)
• Now approved by FDA down to age 16
47. AUTISM
•
Aspergers is an Autism Spectrum Disorder
•
Autistic disorder
• Impaired social interaction
• Impaired communication
• Restricted repetitive and stereotyped patterns or behaviors, interests, and activities
•
Asperger’s disorder
• Impaired social interaction
• Normal communication/language development
• Restricted repetitive and stereotyped patterns or behaviors, interests, and activities
Source: Autism Spectrum Disorder
48. ASPERGER’S PRESENTATION
•
Naïve and gullible
•
Socially awkward and clumsy
•
Unaware of others feelings
•
Easily upset by changes
•
Unable to carry conversation
•
Repetitive and irrelevant comments
•
Literal in speech and understanding
•
Sensitive to loud sounds, lights, odors
•
Fixated on one subject or object
•
Physically awkward in sports
•
Accurate memory for details
•
Trouble understanding things they heard or read
•
Inappropriate body language & expression
Source: Aspergers by Alok Shukla
50. ETIOLOGY OF AUTISM
• We know little of the cause(s) of autism.
• In 1995, Dr Andrew Wakefield, British
academic gastroenterologist & surgeon with
special interest in inflammatory diseases (He
discovered that Crohn’s disease was caused
by decreased blood flow to the intestines),
was approached by group of parents claiming
that their children had become autistic
following the MMR vaccine.
• Wakefield was willing to look into this. His
theory was: measles vaccineintestinal
inflammation “leaky gut
syndrome”harmful proteins can affect brain
Autism.
52. DEFINITION
•
Attention Deficit Hyperactivity Disorder includes difficulty sustaining attention,
hyperactivity and impulsive behavior.
•
Three types:
• Inattentive (trouble focusing, following instructions, and finishing tasks)
• Hyperactive-impulsive (constantly on the go, talking excessively, and interrupting
others)
• Combined (symptoms of both inattention and hyperactivity-impulsivity)
53. STATISTICS
•
5-10% of children in the US ages 4-17 have been diagnosed with ADHD.
•
Boys are diagnosed at 3 times more often than girls.
•
More patients have been diagnosed in recent years due to increased awareness rather
than increased incidence.
54. FACTORS
•
Biochemical
• Dopamine deficiency (most medications target this area)
• Norepinephrine deficiency
• Some medications target both (Adderall)
•
Psychosocial
• Low arousal to stimuli- require more stimuli than average individuals to maintain
attention
55. MEDICATIONS
•
Stimulants
• Various forms of methylphenidate and amphetamine
•
Non-stimulants
• Strattera (atomoxetine), Intuniv (guanfacine), and Kapvay (clonidine)
•
Antidepressants
• Buproprion
• Tricyclic Antidepressants
• SSRIs
-Prescription abuse amongst adolescents is very common. Most commonly abused prescription drugs are Adderall and Oxycontin and Vicodin. 58% of the drugs abused by students in the 12th grade are prescribed drugs or OTC drugs.-About 71% of high school seniors drink alcohol and 23% had binge episode (which is 5 or more drinks at one time) in the past 2 weeks. Also, about 13% of adolescents has driven a car under the influence of alcohol and about 33% has been in a car with a driver who was drinking.About 50% of homicides/suicides/and injuries are associated with alcohol and alcohol accounts for 80% of teen deathInhalants- about 15% of 8th grades have used inhalants, so other then what's listed above what are other inhalants? Glues, nail polish remover, lighter fluid, hairspray, deodorants, and spray paintsInhalants decrease the oxygen binding capacity in the body which then damages vital organs OTC meds commonly abused are: Cough/cold syrups, Sleep medication, Diet pills
-decreased motor performance in intoxication of marijuana is due to slowed sense of time
- Unfortunately there are not many drugs approved by the FDA for substance abuse in adolescents. There are only drugs for opioid dependence mostly since only a few have been studied in adolescents
