NRNP 6665 Midterm & Final Exam (5 Versions Q &A , Latest 2022-2023) 100% Verified Q&A, Exams of Pharmacology

Download NRNP 6665 Midterm & Final Exam (5 Versions Q &A , Latest 2022-2023) 100% Verified Q&A and more Exams Pharmacology in PDF only on Docsity! NRNP 6665 Midterm&Final Exam (5 Versions Q & A, Latest-2022/2023) 100% Verified Q & A NRNP 6665 Final Exam (2 Versions, 134 Q & A, Latest-2022/2023) / NRNP 6665N Final Exam / NRNP-6665N Final Exam: Walden University | 100% Verified Q & A Final Questions 1) Question: An illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors in known as which of the following? A. functional neurological symptom disorder 2) Question: A condition characterized by the person giving approximate answers, with clouding of consciousness, frequently accompanied by hallucinations or other dissociative, somatoform or conversion symptoms is A. Ganser Syndrome 3) Question: Which of the following can cause delirium? Check all that apply. A. Polypharmacy B. Sleep deprivation 4) Question: Acute withdrawal from alcohol represents which type of clinical problem in psychosomatic medicine? A. Medical complications of psychiatric conditions or treatments 5) Question: The principal theoretician to bring psyche and soma together was which of the following? A. Sigmund Freud 6) Question: Which of the following would not be included in the treatment plan for a patient with illness anxiety disorder? A. Exploratory invasive procedures to obtain diagnosis 7) Question: Which of the following is consistent with current literature about the relationship between obstetrical complications and autism spectrum disorders (ASD)? A. Research proves there is a positive correlation between obstetrical complications and ASD 8) Question: The epidemiology related to kleptomania includes which of the following? A. Kleptomania is reported to occur in fewer than 5 percent of identified shoplifters. 9) Question: A frontotemporal dementia with onset in the fifth to sixth decade of life, more common in men, marked by personality change and cognitive decline, is known as which of the following? A. Pick’s Disease 10) Question: Which of the following demographics are consistent with autism spectrum disorder (ASD) A. Four times more common in boys than girls. 11) Question: The ARNP is working with the family of a patient with Alzheimer’s Disease who keeps stating the family is plotting against her, trying to have her “snuffed out.” The family is distraught because they state they are doing their best to make sure their family member is safe. The ARNP explains which of the following in educating the patient about the patient’s A. The patient is delusional. An estimated 30 to 40 percent of patients with dementia have delusions 12) Question: Which of the following persons hypothesized that the symptoms of conversion disorder reflect unconscious conflict? A. Sigmund Freud 13) Question: Which of the following is consistent within normal range developmental milestones in adaptive skills for a 4-year-old? A. Toilets self alone; uses fork 14) Question: A temporary marked alteration in the state of consciousness or by the customary sense of personal identity without the replacement by an alternate sense of identity is known as which of the following? A. Dissociative trance disorder 15) Question: Differential diagnoses to be considered when diagnosing Ganser syndrome include which of the following? A. All the above (organic dementia, depressive pseudodementia, Korsakoff’s syndrome) 16) Question: A patient who has been raped, presents with the inability to recall important personal information and any information about the rape, does recall events prior and since. There does not appear to be any physiological reason for this. This presentation is consistent with which of the following diagnoses? A. Disruptive, impulse-control disorders 41) Question: A person reveals to the ARNP that they steal to get the things they want and cannot afford. The person says they just can’t help themselves because they have kleptomania. The ARNP realizes the following: A. The person likely does not have kleptomania because a person with kleptomania is more concerned with the act of stealing rather than the obtaining the object which has been stolen. 42) Question: Which of the following would demonstrate the normal achievement of gross motor developmental milestone for a 6-month-old? A. BRIEFLY SITS ALONE: PIVOTS IN PRONE 43) Question: According to a psychodynamic perspective, depersonalization and derealization are understood as which of the following? A. Traumatic stress response 44) Question: Which of the following is consistent with brain-imaging findings related to autism spectrum disorder (ASD)? A. Increased head size and brain volume 45) Question: Which of the following biological factors have been associated with kleptomania? Check all that apply. A. Cortical atrophy, brain diseases, mental retardation and enlarged lateral ventricles 46) Question: The symptom of giving approximate answers is known as which of the following? A. Paralogia 47) Question: An acute onset, short-term confusion, with changes in cognition and level of awareness due to a physiological cause is known as which of the following? A. Delirium 48) Question: A dissociative disorder described as an identity disturbance due to prolonged and intense coercive persuasion is known as which of the following? A. Brainwashing 49) Question: The ARNP in working with a parent of a 6-month-old would offer which of the following in anticipatory guidance? A. All of the above (give baby much attention, attune to baby’s need for hunger, fatigue, diaper change and provide supervised time for cawing, sitting and rolling) 50) Question: Which of the following are behavioral red flags for a 6–12-yearold? A. None of the above 51) Question: Neuropsychiatric testing is defined as which of the following? A. Standardized quantitative reproducible evaluation of patient’s cognitive abilities 52) Question: The term psychosomatic literally refers to which of the following? A. How the mind effects the body 53) Question: Which of the following questions are recommended to assess sexual identity in a male adolescent? A. Do you have, or have you had romantic feelings toward anyone? 54) Question: A tension state that can exist without an action is known as which of the following? A. An obsession 55) Question: Which of the following diagnostic instruments for autism spectrum disorder is recommended for universal clinical practice? A. Autism Diagnostic Interview – revised (ADI-R) 56) Question: A new diagnosis in the DSM-5 characterized by persons preoccupied with being sick or developing a disease of some kind is known as which of the following? A. Illness anxiety disorder 57) Question: A disorder characterized by 6 or more months of general and no delusional preoccupations with fears of having a serious disease based on a person’s misinterpretation of bodily symptoms that causes significant distress and impairment in one’s life is A. Somatic symptom disorder 58) Question: A precipitous onset prion disease, with rapid decline, progressing to death within 6 months of onset is known as which of the following? A. Creutzfeldt-Jackob disease 59) Question: A term use to describe a neuro developmental disorder characterized by impairments in reciprocal social communication and a tendency to engage in repetitive stereotyped patterns of behaviors, interests and activities is A. Autism Spectrum Disorder 60) Question: Which of the following is an example of a medical complication of psychiatric conditions or treatment? A. Neuroleptic Malignant Syndrome 61) Question: Experiences of depersonalization and derealization are common in which of the following patients? A. All of the above (Patients with seizures, migraines or use marijuana) 62) Question: Which of the following shows normal developmental visual motor skill for an 18- monthold? A. Scribbles on own; makes 3-cube tower 63) Question: Deficits in attention and the ability to complete multi-step commands are associated with impairment in which of the following regions of the brain? A. Prefrontal Cortex 64) Question: Which of the following is not consistent with what is known about depersonalization and derealization? A. Derealization is two to four times more often in men than in women. 65) Question: The second-most common type of dementia caused by cardiovascular and cerebrovascular disease with progressive cognitive decline in stepwise fashion is known as which of the following? A. Vascular Dementia 66) Question: Which of the following would be a developmental red flag that would trigger further assessment for a 2-year-old? A. Cannot use a meaningful two-word phase; lack of empathy (looking sad if a child cries) 67) Question: Which of the following are included in the clinical features of anxiety illness disorder? Check all that apply. A. Persons maintain they have a particular disease or as time progresses their belief may transfer to another disease. Preoccupation with illness may or may not interfere with their interaction with family, friends, and co-workers. They are often addicted to internet search about their feared illness, inferring the worst from the information. 68) Question: A dementia which usually occurs in the sixth decade of life, characterized by gradual onset and progressive decline without focal neurological deficits is known as which of the following? A. Alzheimer’s Disease 69) Question: Which of the following is true about impulses? Check all that apply. A. Impulses are usually ego-dystonic, Impulsive behaviors are characterized by their repetitive nature, The repeated acting out of impulses leads to psychological impairment 70) Question: Which of the following is consistent with dementia in HIV? A. the individual's decline is progressive in nature with motoric and behavioral abnormalities. 71) Question: Somatoform disorders represent which type of clinical problem in psychosomatic Medicine? A. Psychological factors precipitating medical symptoms 72) Question: A type of delirium characterized by psychomotor retardation and apathy is known as which of the following? A. Hypoactive delirium 73) Question: A child 0–3 months would be expected to be able to do which of the following? A. All the above (Develop social smile, React, and turn toward sounds. Watch faces, follows objects) 74) Question: The ARNP is meeting with a person who reports a fascination with fire, along with recurrent deliberate and purposeful setting of fires. The ARNP realizes that these behaviors are consistent with which of the following disorders? A. Pyromania 75) Question: Which of the following supports a good prognosis for a person with a conversion disorder? A. Tremors and aphonia 76) Question: Which of the following medications are FDA-approved medications for the treatment of delirium? A. None of the above 77) Question: Depression secondary to interferon treatments represents which of the following clinical problems in psychosomatic medicine? A. Psychiatric complications of medical conditions or treatment 78) Question: Which of the following is a common visceral symptom of conversion disorder? A. Diarrhea 79) Question: Which of the following are common disorders that must be differentiated from dissociative identity disorder? Check all that apply. A. Amnesic disorders, PTSD, acute stress disorders, malingering and factitious amnesia 80) Question: In treating a patient with dementia and a co-occurring depression, which of the following symptoms should be treated first? A. Loss of appetite 81) Question: Which of the following is consistent with normal range gross motor developmental milestones for a 4-year-old? A. Walks downstairs one step to a tread, stands on one foot for 5 to 8 seconds 82) Question: Which of the following social interactions indicates progression into the normal range, meeting developmental milestones for a 5-year-old? A. Engages in imaginative play A. Impulses are acted upon with the expectation of receiving pleasure B. Impulses are usually egodystonic. C. Impulsive behaviors are characterized by their repetitive nature.D. The repeated acting out of impulses leads to psychological impairment. 5) Which of the following is consistent with dementia in HIV? A. The individual's decline is very slow and may take years to progress.B. The individual's decline is progressive in nature with motoric and behavioral abnormalities. C. The individual's decline is in a stepwise fashion with motoric and behavioral abnormalities. D. The individual's decline has marked variability and fluctuating motoric and behavioral abnormalities. 6) Somatoform disorders represent which type of clinical problem in psychosomatic Medicine? A. Co-occurring medical and psychiatric conditions. B. Psychiatric complications of medical conditions and treatments. C. Psychiatric symptoms secondary to a medical condition. D. Psychological factors precipitating medical symptoms. 7) A type of delirium characterized by psychomotor retardation and apathy is known as which of the following? A. Mixed delirium B. Medical delirium C. Hypoactive delirium D. Hyperactive delirium 8) A child 0-3 months would be expected to be able to do which of the following? A. Develop social smile B. React and turn toward sounds C. Watch faces, follows objects D. All the above 9) The ARNP is meeting with a person who reports a fascination with fire, along with recurrent deliberate and purposeful setting of fires. The ARNP realizes that these behaviors are consistent with which of the following disorders? A. Pyromania B Obsessive-compulsive disorder C. Intermittent explosive disorder D. Pyrophobia 10) Which of the following supports a good prognosis for a person with a conversion disorder? A. Insidious onset B. Clearly identifiable stressors at time of onset C. Average intelligence D. B and C 11) Which of the following medications are FDA-approved medications for the treatment of delirium? A. Donepezil B. Galantamine C. Rivastigmine D. None of the above 12) Depression secondary to interferon treatments represents which of the following clinical problems in psychosomatic medicine? A. Psychiatric complications of medical conditions and treatments. B. Psychiatric symptoms secondary to a medical condition. C. Psychological factors precipitating medical symptoms. D. Psychiatric symptoms as a reaction to medical condition or treatments. 13) Which of the following is a common visceral symptom of conversion disorder? A. Seizures B. Diarrhea C. Paralysis D. Mid-line anesthesia 14) Which of the following are common disorders that must be differentiated from dissociative identity disorder? Check all that apply. A. Perimenstrual disorders B. Posttraumatic stress disorder C. Obsessive-compulsive disorder D. B and C only 15) In treating a patient with dementia and a co-occurring depression, which of the following symptoms should be treated first? A. Insomnia B. Irritability C. Loss of appetite D. Depressed mood 16) Which of the following is consistent with normal range gross motor developmental milestones for a 4-year-old? A. Walks downstairs, jumps backwards B. Balances on one foot for 4 seconds, can broad jump 1 foot C. Writes part of name; copies a square. D. Eats independently, unbuttons items 17) Which of the following social interactions indicates progression into the normal range, meeting developmental milestones for a 5-year-old? A. Shares on own B. Engages in imaginative play C. Group play; has a preferred friend D. Has a group of friends, apologizes for errors 18) Visual hallucinations are associated with impairment in which of the following regions of the brain? A. Occipital B. Temporal C. Left parietal D. Frontal, prefrontal 19) The ARNP is doing a physical exam on a patient that has a paralyzed hand of unknown etiology in which the patient's hand is raised and dropped into the patient's face. Which of the following patient responses support the finding of a conversion disorder? A. The patient's hand drops onto the patient's face. B. The patient's hand falls next to the patient's face. C. The patient's hand stays in the air when dropped. D. This would not be an appropriate test for conversion disorder. 20) Which of the following are included in the five different milestone skill areas that should be evaluated? A. Social/emotional skills B. Gross/fine motor skills C. Speech and language skills D. All the above 21) Which of the following approaches/treatments are recommended in working with patients with a conversion disorder? A. After a very thorough evaluation to r/o any medical cause, tell the patient that the symptoms are imaginary. B. Recommend psychotherapy to focus on issues of stress and coping. C. Recommend psychoanalysis to explore intrapsychic conflicts. D. B and C only 22) Which of the following adaptive skills are consist with normal range developmental milestone of an 18-month-old? A. Bite, chews cookie; looks for fallen item B. Finger feeds items; takes off a hat. C. Gets onto a chair; removes garment D. Opens doorknobs; pulls off pants. 23) N-Methyl D-aspartate glutamate receptor antagonists are used to treat dementia by doing which of the following? A. Stall the neurodegenerative processes B. Promotes synaptic plasticity C. Prevent over excitation of glutamate receptors D. All of the above 24) Which of the following is NOT consistent with what is known about intermittent explosive disorder across the lifespan? A. Intermittent explosive disorder may appear at any stage of life. development has occurred improves diagnostic accuracy because DSM-5 specifically requires consideration of developmental stages • Five different milestone skill areas should be evaluated: gross/fine motor, visual motor problem solving, speech and language, social/emotional, and adaptive skills • Gross motor skills are the most obvious to recognize because they involve crawling, walking, running, and throwing • Visual motor problem solving describes a child’s physical interactions with the world. Fine motor skills (using one’s hands and fingers) rely on visual input and generally progress at a slower pace than gross motor skills. If the development of these milestones is delayed, it may be because of impairments in cognitive, sensory, or motor abilities. • To be able to communicate, a person first must be able to receive input (process what is seen and heard), understand the meaning of that input, then generate an expression of his thoughts (translate thoughts into words, then express fluently). Delays in expressive language milestones may be more apparent than receptive language delays, which may be more subtle but when present may worsen an expressive language impairment • Social/emotional skills are the core elements of psychiatric functioning. Social skill development is interactive and thus reliant on the presence of a responsive caregiver. A child’s temperamental traits influence how he responds to routine activities, which influences how his caregivers respond. Developing shared joint attention with another person by approximately age 1 year is a key social milestone. Normal social and emotional development is most closely linked with speech and language skills. • When you evaluate for the presence of an intellectual disability, adaptive milestones need to be investigated. Standardized intelligence testing is no longer considered the sole basis for diagnosing intellectual disability. Adaptive skills include infants learning to feed themselves or dress themselves. For older kids, it involves self-protection and self-direction. • A child may acquire all his skills in the usual sequence but at a slower rate (a delay), may acquire his skills at differential rates in different areas (a dissociation), or may achieve milestones out of the usual order of acquisition (a deviation). Growth and development will follow recognizable patterns, but it is not an exact script. It is our task to consider what would constitute normalrange development. • Table 12-2 in the book shows normal-range developmental milestones and developmental red flags that should trigger specialized assessments • ***************************************************************************** RUTTER’S CHILD AND ADOLESCENT PSYCHIATRY CHAPTER 51 AUTISM SPECTRUM DISORDER • ASD is characterized by impairments in reciprocal social communication and a tendency to engage in repetitive stereotyped patterns of behaviors, interests, and activities. It arises from atypical brain development. The etiology is likely multifactorial. • The clinical presentation can change over time, often in response to the demands of the environment or in the presence of co-occurring conditions. • Many individuals with ASD have an early history of regression or a period of lack of progress of language, of cognition more generally, or social behavior in the early preschool period • The clinical presentation of ASD is remarkably diverse usually with a combination of some delayed/immature behaviors together with the emergence of more unusual behavioral profiles. Some of the earliest social communication symptoms represent difficulties in joint attention, eye contact, lack of social intention to communicate with others, lack of social imitative play and fascination with sensory stimuli. Some symptoms of ASD are an exaggeration of delays observed in typical development (lack of useful speech, limited symbolic, and imaginative play skills) whereas other symptoms are quite distinct and are rarely (or only very transiently) observed in the development of typical children (delayed echolalia and neologisms). • Cognitive difficulties are very common in individuals with ASD but with the broadening of the diagnostic criteria for ASD, the proportion of individuals with intellectual disability has declined • “Hyperlexia,” a remarkable ability to read but with little comprehension of content, is sometimes observed in severely disabled individuals • Children with moderate to severe cognitive impairment at earlier developmental stages in the preschool years often present with little or no speech and poor nonverbal communication. They also tend to engage in repetitive play with sensory stimuli and can become quite upset by stimuli from the environment such as the texture of certain clothes, some everyday noises, and particular foods • With higher functioning or older individuals, speech and language are often present, grammar and vocabulary may be age appropriate, but there remain difficulties in the social use of communication. In addition to the sensory interests, higher functioning children and adolescents with ASD often develop intense circumscribed interests that are observed in typically developing children but are pursued in a solitary, non-social, manner • AS referred to individuals with characteristics of autism but without clinically significant cognitive or language delay. PDDNOS referred to individuals with characteristics of autism but not enough to qualify for a diagnosis of either autism or AS. Rett syndrome was a type of PDD that was characterized by a period of normal development and then a very specific set of signs and symptoms (e.g., hand wringing) with developmental regression. Disintegrative disorder was a subtype of PDD characterized by normal development past 36 months of age at which point the clinical presentation of autism would emerge • DSM-5 has revised the diagnostic criteria for ASD replacing a triad of impairments with two behavioral domains—social communication and repetitive stereotyped behaviors. • Although delays in language acquisition are common in ASD, they are nonspecific and so have been removed from the diagnostic criteria. Each domain includes different groups of symptoms or sub-domains and can be represented dimensionally depending on the need for intervention and support. • DSM-5 includes stereotyped and repetitive speech within the restricted/repetitive behaviors domain and for the first-time sensory reactivity to aspects of the individual’s environment has also been included • For an individual to meet criteria for a DSM-5 diagnosis of ASD, evidence of symptoms in all three of the social-communication sub-domains and any two (or more) of the four restricted and repetitive behavior sub-domains is required. For individuals who meet criteria for impaired Social Communication in the absence of restricted and repetitive behaviors, a new diagnostic category of Social Communication Disorder has been included in DSM-5. Impaired Social Communication- non-verbal communication, developing and maintaining relationships, and social-emotional reciprocity. Repetitive/Restrictive patterns of behavior- restricted and fixated interests, excessive adherence to routine, stereotyped repetitive speech/motor/use of object, hyper or hypo-reactivity to sensory input. • In the USA, a rapid increase in the number of children receiving a diagnosis occurred once legislation for special schooling was introduced for autistic children • Parents often become concerned about the development of their children at 12–18 months of age but children most commonly do not receive a diagnosis until 4 or 5 years of age. the American Academy of Pediatrics (AAP) and the UK National Screening Committee do not recommend universal screening. The AAP does suggest that surveillance for ASD should take place at well baby visits at 6, 12, 18, and 24 months • No screening instrument currently available has sufficient sensitivity and specificity to be used as a diagnostic instrument • Among all mental disorders, health care spending in the United States is the highest for individuals with ASD, who had higher physician and outpatient visits as well as greater prescribed medication use when compared to the non ASD pediatric population • Zaroff and Uhm (2012) have reported higher rates of ASD among white Americans compared to Hispanic individuals. Likewise, according to Bernier et al. (2010), white Americans receive a diagnosis approximately a year and a half before African American children and two and a half years before Latino children • The ToM (Theory of Mind) deficit may help our understanding of some of the behavioral features of ASD including a lack of ability to generalize learned responses across settings and the presence of repetitive and stereotyped behaviors. The “ToM” deficit focuses on aspects of the social communication impairments and the inability to impute mental states either to oneself or to others. • The WCC (Weak Central Coherence) Theory was formulated by Frith arguing that individuals with autism demonstrated a local processing bias (and thus a WCC). The weak central coherence theory attempts to explain how some people diagnosed with autism can show remarkable • The core components of an ASD diagnostic assessment include: o an ASD specific developmental history using the framework of published internationally agreed diagnostic criteria o medical history including a prenatal and perinatal history, identification of any relevant past and/or current health conditions and risk factors such as a history of possible epilepsy, and family history to identify genetic disorders, recognized medical and mental health conditions o physical examination including an assessment for congenital anomalies, any evidence of skin conditions, evaluation of growth, and measurement of head circumference. o individual ASD specific assessments (through direct interaction and observation usually in more than one setting). Observational assessment may include the use of an ASD- specific tool such as the Autism Diagnostic Observation Schedule (ADOS) or the Childhood Autism Rating Scale (CARS) o other individual assessments depending on the clinical presentation o individual assessments such as vision or hearing, cognitive, sensory, perceptual, motor co-ordination, and psychological investigations to complete a skill- and need-based profile • The four most commonly used diagnostic instruments for ASD include three semi-structured instruments for obtaining a developmental history (Autism Diagnostic Interview-Revised (ADI-R); Diagnostic Interview for Social and Communication Disorders (DISCO) and Development, Dimensional and Diagnostic Interview (3di) and one observational measure (the ADOS) • In some parts of the world, comparative genomic hybridization arrays are now recommended within professional clinical best practice guidelines to be used as first line investigations especially in the presence of intellectual disability or dysmorphology • Assessment of family strengths and needs and the social and cultural context for the child or young person is important as part of a skill- and need-based assessment. • Over time, intervention plans will change in response to the child’s developmental profile, their circumstances and the onset of any additional physical and mental health disorders. Management and support are likely to include a number of different agencies and professionals working collaboratively • The goals of interventions include: Reduce the core symptoms and behaviors of ASD o Enable an individual to achieve their own potential o Treat any co-occurring problems or symptoms that impair developmental progress or cause significant distress for the affected individual and other family members or carers o Treat any co-occurring problems or symptoms that impair developmental progress or cause significant distress for the affected individual and other family members or carers • National and professional organizations have published practice guidelines which provide general and specific recommendations usually based on the best clinical practice • Early intensive behavioral intervention (EIBI) is the most frequently evaluated intervention in preschool children with ASD. These interventions are largely based on the model of Applied Behavioral Analysis (ABA) principles and other comprehensive behaviorally and developmentally based programmes for young children with ASD • There is evidence that augmentative forms of communication such as the Picture Exchange Communication System (PECS) can improve the communication skills of young children with ASD and should be part of the comprehensive treatment plan • Interventions such as sensory integration therapy (SIT) and auditory integration training (AIT) have been proposed to alleviate hyper- or hyposensitivity to certain stimuli and to frequencies and sounds • Visual therapies, music therapy and use of restricted diets and dietary supplementation such as omega- 3 fatty acids, have also been used by families to treat both core ASD symptoms and associated problems such as ADHD-like behaviors, gastrointestinal problems, and sensory disturbance. The gluten free, casein free diet (GFCFD) is the most frequently implemented restrictive dietary intervention for individuals with ASD. • There is some evidence that vocational programs may increase employment success for some individuals with ASD • Systematic reviews have also demonstrated some evidence that the use of antipsychotic medications (such as risperidone) can reduce repetitive behaviors in children and adolescents. Considering the evidence for statistically significant adverse effects associated with antipsychotics (see NICE CG 170, 2013 for an updated review) the NICE clinical guideline development group did not recommend antipsychotic medications for the treatment of core symptoms of ASD. There is now sufficient evidence to recommend that certain interventions should not be used to treat core features of ASD. These include long-term chelation therapy, hyperbaric oxygen, and secretin • It is now widely recognized that children and young people with ASD have higher rates of cooccurring mental health disorders than individuals in the general population and children with other disabilities. These include ADHD, Oppositional Defiant Disorder, anxiety, mood disturbance, and obsessive- compulsive disorder • There is evidence that a group or individual-based intervention adjusted to the needs of children with ASD can be effective • For the treatment of co-occurring ADHD, a combination of family and school-based behavioral interventions could be instigated and later, if required, supported by a trial of medication. However, the use of stimulants and other recommended second line medications for the treatment of ADHD-like symptoms show that the response rate is lower than for children and adolescents without ASD and with a higher rate of adverse side effects • Antipsychotic medication has been used to ameliorate associated symptoms such as aggression and irritability. The evidence appears to be consistent in demonstrating a positive impact on these symptoms. The starting dose should be low, aiming for the minimum effective dose and carefully monitoring for adverse effects with a plan for regular review and eventual discontinuation ************************************************************************************* CERTIFICATION REVIEW MANUAL CHAPTER 8 DELIRIUM AND NEUROCOGNITIVE DISORDERS • The primary symptom associated with cognitive deficits involves either short term or remote memory • Rule out delirium before diagnosing dementia • Neurocognitive evaluation- evaluates the relationship between the functional integrity of the brain and human behavior. The process distinguishes behavioral changes resulting from central nervous system disease or injury. The evaluation consists of psychometrically validated tests and clinical interview (neuropsychological testing). The PMHNP combines this formalized testing procedure with a comprehensive history and physical exam to rule out delirium and diagnose dementia o Comprehensive history: general medical conditions that can cause delirium include sepsis, toxicity, nutritional deficiency, electrolyte disturbance, over/under stimulation. Substance induced disorders, primary sleep disorder, primary mood or psychotic disorder • Delirium- a constellation of symptoms marked by an acute onset causing short term decline in cognition with a disturbance in consciousness and inattention. Treatment should be supportive in nature and target the underlying cause. Symptoms may take up to 6 months to resolve. o Hypoactive- characterized by psychomotor retardation, apathy o Hyperactive- characterized by psychomotor agitation, restlessness, hypervigilance o Mixed- characterized by cycling through psychomotor agitation and retardation, from apathy to hypervigilance. o Risk factors- sensory impairment, polypharmacy, substance use disorder, pain acute illness o Often confused with dementia or depression o Often assumed to be a worsening of psychotic symptoms o Standardized assessment tool is the Confusion Assessment Methods Instrument • Dementia- a constellation of signs and symptoms characterized by a gradual onset of multiple cognitive impairments in executive function, intellect, impaired problem-solving, and alteration in memory with preservation of level of consciousness. The signs and symptoms of the dementias are similar, the etiology can be variable. o Alzheimer’s type (DAT) usually occurs in the sixth decade of life and is the most prevalent type. It is characterized by a gradual onset and progressive decline, without • Medical foods- believe to provide essential nutrients by introducing high concentrations of ketones to cross the blood brain barrier o Axona 40g packet contains 20grams of medium chain triglycerides to be mixed into 4-8 oz. water, drink immediately. Adverse reactions include bloating, nausea, and diarrhea during acclimation.  Metabolized into ketone bodies for energy with impaired glucose metabolism • Depression can occur with dementia. Treat depressive symptoms targeting insomnia first, followed by loss of appetite, irritability, and depressed mood. • Traumatic brain injury- impairment can be lifelong including limitations in emotional regulation, cognition, and behavioral regulation. o Symptoms include photosensitivity, memory impairment, headaches, vertigo, irritability, and circadian rhythm disturbances. Increased risk for suicide o Neuropsych testing can help distinguish depression, anxiety, dementia or ptsd o Pharmacology is symptom focused. Avoid CNS suppressants ********************************************************************************** CERTIFICATION REVIEW MANUAL CHAPTER 13 CHILD/ADOLESCENT NEURODEVELOPMENTAL DISORDERS • It is important to consider antepartum and peripartum factors when evaluating the child for the achievement of normal growth and development milestones. Children who are born prematurely may demonstrate developmental incongruence with their chronological age during their normal trajectory of growth and development. The neurodevelopment must be assessed according to the corrected or adjusted age rather than the chronological age • Adjusted age is used until the age of 24 months • Behavioral red flags: o 2months: doesn’t respond to loud sounds, doesn’t track faces or lights around the room, doesn’t reciprocate smiling, doesn’t bring hands to mouth, unable to hold head while on tummy o 4-6months: eyes don’t move symmetrically in all directions, doesn’t push down legs when placed on a hard surface, shows no affection for caregivers, difficulty bringing things to mouth, no ability to roll over in either direction, no laughter or squealing sounds o 6-8months: no attempt to get things in reach, no interest in exploring, no babbles o 9months-1year: unable to bear weight on legs, unable to sit with help, doesn’t babble, doesn’t respond to name, doesn’t recognize familiar people, doesn’t look where pointing, doesn’t transfer toys from one hand to another, doesn’t crawl, can’t stand when supported, losing skills previously acquired o 18mos-3years: unable to walk, doesn’t point to show things, doesn’t know what familiar things are for, doesn’t copy others, has no interest in caregiver leaving or entering room, trouble with stairs, drools, unclear speech, no pretend play, poor eye contact o 4-5 years: can’t jump in place, trouble scribbling, no interest in interactive games, ignores other children, resists dressing, sleeping, using the toilet, unable to follow a three-step command, restricted range of emotions, withdrawn, poor attention span, can’t brush teeth, wash hands, or get dressed without help o 6-12 years: fearful or timid behavior, extreme aggression, easily distracted, unable to concentrate for more than 5 minutes, little interest in other kids, restricted emotions, trouble dressing or undressing, poor impulse control, doesn’t respond to positive attention, ignored by other children, can’t adapt behavior to different social settings o 13-21 years: lacking secondary sex characteristics, poor motor coordination, lack of peer relationships, doesn’t consider consequences, can’t empathize, doesn’t question, or reject parental standards, emotional or behavioral problems, lack of concentration, drug use • Intellectual disability can be like many conditions but are distinguished by: o Autism: defined by the presence of persistent deficits in social interactions with restricted and repetitive patterns of behavior. The social impairment in intellectual disability is on par with deficits in other intellectual abilities rather than the primary feature as in autism o Communication disorders: impairment is confined to speech and language without deficits in intellectual and adaptive functions o Specific learning disorders: impairment is confined to a specific area of academic achievement without deficits in intellectual and adaptive behaviors o Major neurocognitive disorder: a decline in relation to previously mastered skills in one or more areas of cognition. If the decline is during the developmental period, then intellectual disability is comorbid • Rett syndrome: a congenital neurodevelopmental disorder primarily occurring in females, characterized by specific deficits following a period of normal function, growth, and development o Genetic mutation of MECP2, which codes for methyl-CpG binding protein-2, suggesting a metabolically mediated disorder o Progression: 6-18 months developmental arrest, followed by rapid deterioration (1-4 years), then a pseudo-stationary period (2-10years) and finally motor deterioration (>10 years) o Stage 1: 6-18 months- gross development delay, loss of eye contact, placidity, and poor motor tone, breath holding spells o Stage 2: 1-4 years- stereotypic hand movements while awake, irregular breathing pattern, absence seizures, sleep disorders and increased irritability o Stage 3: 2-10 years- increased rigidity, bruxism, abnormal involuntary movements extrapyramidal symptoms of the head, neck, poor feeding, weight loss, increased seizure activity o Stage 4: >10 years- unable to walk, worsening trunk control, deterioration plateau and reduced seizure activity • Eating disorders: disordered eating pattern combined with a persistent preoccupation of a distorted self-perception relating to body shape and size o Males may suffer from body dysmorphia in which they don’t perceive their muscles big enough or may engage in avoidant/restrictive eating behaviors o Diagnostic criteria for anorexia include FADE: Fear of gaining weight, amenorrhea, delusion related to body weight, expected body weight o Diagnostic criteria for bulimia include BASTE: binge eating, anorexia excluded, selfworth based on weight, twice weekly for 3 months purging, excessive exercise, emesis, enemas o Binge eating disorder: characterized by recurrent episodes of binge eating associated with significant distress without compensatory measures to prevent weight gain or enhance weight loss despite over-valuation of body weight and shape. Sufferers often have comorbid obesity o Physical exam findings: NRNP6665 Final Study Guide Rutter’s Chapter 65 (pages 913- 927) by Krista Hobson Oppositional Defiant and Conduct Disorders 1. Introduction a. ODD/CDs are characterized by antisocial behaviors outside of socially acceptable norms that violate others’ expectations or rights i. Behaviors include: 1. Excessive verbal and physical aggression 2. Temper tantrums 3. Lying and stealing 4. Disobedience 5. Rule Breaking 6. Violence b. Considered by others not to be true psychiatric disorders but rather character flaws c. Now we know that ODD/CDs have: i. Biological component involving genetic and brain differences ii. Different subtypes of antisocial behavior are better understood iii. Considerable advances in developing effective treatments for children and adolescents 2. Classification a. ODD requires 4 of the following 8 symptoms to be present for a least 6 months i. Angry & Irritable Mood (children with angry and irritable mood symptoms of ODD are most likely to develop mood disorders later in life) 1. (1) Unusual and frequent temper tantrums 2. (2) Often touchy or easily annoyed 3. (3) Often Angry or resentful ii. Argumentative and Defiant Behavior 1. (4) Often argues with adults 2. (5) Often actively refuses to comply with adults requires or defies rules 3. (6) Often deliberately does things to annoy other people 4. (7) Often blames others iii. Vindictiveness 1. (8) Often spiteful or resentful b. CD requires 3 of the following 15 criteria to have been manifest in the past 12 months i. Aggression to People and Animals 1. (1) Frequently bullies others 2. (2) Frequently initiates physical fights 3. (3) Has used a weapon that can cause serious physical harm to others 4. (4) Exhibits physical cruelty to other people 5. (5) Exhibits physical cruelty to animals 6. (6) Commits a crime involving confrontation with the victim 7. (7) Forces another person into sexual activity ii. Destruction to Property 1. (8) Deliberately sets fires with a risk of causing serious damage 2. (9) Deliberately destroys the property of others iii. Deceitfulness or Theft 1. (10) Has broken into someone else’s house, building or car 2. (11) Often lies to obtain goods or favors or to avoid obligations 3. (12) Has stolen objects of value without confronting the victim iv. Serious Violations of Rules 1. (13) Often stays out at night despite parental prohibitions, beginning before age 13 2. (14) Has run away from home at least twice 3. (15) Is Frequently truant from school beginning before age 13 c. Differences in ODD and CD i. In ICD-10 1. In ICD-10 ODD is a subtype of CD 2. ICD-10 has clinical guidelines that are broader descriptions for everyday diagnostic practice 3. ICD-10 requires distress and impairment only for ODD 4. In ICD-10 ODD and CD appear in disorders that usually occur in childhood – suggesting less applicable in adults 5. ICD-10 prefers one diagnosis to be paramount ii. In DSM-5 1. ODD and CD are separate entities 2. Requires distress or impairment for ODD and CD 3. Has 2 other disorders that may overlap - Intermittent Explosive Disorder 1. diagnosed before age 6 - Disruptive Mood Dysregulation Disorder (DMDD) 1. Introduced to stop overdiagnosis of pediatric bipolar disorder and over medication 2. Considerable overlap with ODD 3. Validity of DMDD has NOT been established 4. DSM-5 allows ODD and CD to be diagnosed in adults 5. DSM-5 allows multiple diagnoses 3. Epidemiology a. Overall Prevalence i. ODD more common in younger children ii. CD more common in adolescents iii. ODD/CD make up about half of all child and adolescent psychopathology and is the commonest condition b. Variations in Prevalence i. Gender 1. Gender and parenting is the strongest predictor of antisocial behavior 2. Boys outnumber Girls by about 2:1 in ODD in younger children 3. CD in adolescents boys outnumber girls between 3:1 to 7:1 ii. Socioeconomic Status (SES) & Geographical Area 1. 5 x more common in lower SES 2. Rates 2-3 x higher in Inner City areas iii. Worldwide Prevalence & Minority Ethnic Groups 1. High rates in Bangladesh, Yemen and Brazil 2. Medium rates in Britain 3. Low rates in Italy 4. Very low rates in Goa, India 5. In developed countries - High rates in African Caribbean/African American v. Brain Function 1. Lower Amygdala Volume in ODD/CD in both child and adolescent onset 2. Reduced Right Insula Volume in Adolescent Onset Group 3. Associated with abnormalities of the “hot” paralimbic system that regulates motivation and affect vi. Language, IQ and Educational Attainment Deficits 1. Low IQ and low school achievement are important predictors of ODD/CD and delinquency 2. Poor verbal ability 3. Performance scores are lower 4. Low language ability/verbal IQ 5. Lower abilities to recall oral instructions and to use language to think through consequences of actions 6. Children who cannot reason verbally may attempt to use aggression 7. Low IQ can contribute to academic difficulties vii. Executive Dysfunction 1. Poor Executive Dysfunction 2. Largely associated with frontal lobe function 3. ODD/CD (not ADHD) related to HOT executive function indicating risky decision making 4. Also related to COOL executive functioning namely slower sleeps of inhibitory responding viii. Autonomic Reactivity and the Hypothalamus-PituitaryAdrenal Axis 1. Low heart rate associated with antisocial behavior 2. Low Heart Rate BEST replicated biological correlate of antisocial behavior 3. Slow Autonomic Activity linked to antisocial behavior ix. Information Processing and Social Cognition 1. More likely to favor aggressive solution to social challenges b. Family Level Influences i. Child Rearing Practices 1. ODD/CD associated with harsh inconsistent discipline, low warmth, low involvement, and high criticism 2. Patents of antisocial children - More inconsistent on rules - Less likely to monitor child’s whereabouts - Unresponsive to children’s prosocial behavior 3. Mechanisms - Positive overtures and behaviors by children are ignored - Negative behavior attracts parental attention - Negative Reinforcement Trap 1. Parent responds to mild oppositional behavior to which the child responds by escalating his behavior and mutual escalation continues until the parent backs off 2. Thus, teaching child if he gets more aggressive the parents will back off and he will get his way 4. Possible Alternative Explanations - Associations reflect familial genetic liability toward children’s psychopathology and parents’ coercive discipline 1. Common genetic liability 2. Strong association between parent to child hostility and child antisocial behavior - They represent children’s behaviors on parents 1. Evidence that children’s difficult behaviors do evoke parental negativity - That coercive parenting may be a correlate of other features of the parent/child relationship ii. Attachment Insecurity 1. Insecure attachment patterns are strongly associated with antisocial behavior iii. Exposure to Interparental Conflict and Violence 1. Children exposed to domestic violence between adults are subsequently more likely to themselves become aggressive 2. More studies needed to see extent to which interparental conflict adds to child antisocial behavior iv. Maltreatment 1. Physical punishment is widely used and parents resort to it out of desperation 2. The “child effect” in which children’s bad conduct provokes their parents to use more corporal punishment rather than the reverse c. Influences Beyond the Family i. Overview of Peer Effects 1. Children with ODD/CD have more negative interchanges with other children 2. Tend to be rejected by nondeviant peers ii. Peer Rejection 1. Peer rejection shown to contribute to declines in academic achievement and increases in aggression 2. Aggressive antisocial children tend to associate with other deviant children iii. Impact of Deviant Peers on Antisocial Behavior 1. Deviant youths reinforce each other’s antisocial behaviors and attitudes 2. Evidence that peer influences do increase antisocial behaviors primarily with adolescents 3. Antisocial young people who have deviant peers offend more 4. Increased rates of antisocial acts and offending after joining a gang 5. Argues for Individual Treatment Approaches 5. School Effects a. Children with ODD/CD are more likely to attend schools with high delinquency rates b. These schools have high rates of distrust between students and teachers c. Low pupil commitment to the school d. Unclear and inconsistent rules e. Schools with clear, fair and consistently enforced rules tend to have low rates of student misbehavior 6. Poverty a. Antisocial children come in disproportionate numbers from poor families b. Reduced poverty can reduce antisocial behaviors as seen in the “natural experiment” c. Poor circumstances can also affect parenting quality, which in turn affects child antisocial behaviors - Impulsively, inattention and motor overactivity can be misconstrued as antisocial - Careful history of ability to attend and be still both at home and school will usually reveal ADHD if present - In contrast antisocial behavior is NOT a feature of pure ADHD 2. Mood Disorders - Depression can be present with irritability but, unlike ODD/CD, mood is clearly low and often vegetative features - If irritability is marked, then DMDD should be considered – although disobedience is not a core feature - Intermittent Explosive Disorder shares features, but aggression is not premeditated or committed to achieve a tangible object - DO NOT diagnose early bipolar without clear evidence of manic symptoms 3. Adjustment Reaction - Can be diagnosed after exposre to a stressor like divorce, trauma, abuse etc. But onset is one (1) month after stressor for ICD-10 and 3 months for DSM-5 - Symptoms do not persist for more than 6 months after the cessation of the stress 4. Autistic Spectrum Disorders - Often accompanied by marked tantrums or destructiveness - As with ODD/CD a lack of friendship may be present - Children with ODD/CD have callous unemotional traits - Children with ASD fail to understand social situations and judge accurately the emotions of others. 5. Antisocial/Dyssocial Personality Disorder (ASPD - In DSM-5 ASPD cannot be diagnosed under 18 years of age – although requires the evidence of CD before the age of 15 - ICD-10 does not mention an age limit but criteria does not appear in section on childhood disorders 6. Subcultural Deviance - Some youths are antisocial and commit crimes but are not particularly aggressive or defiant - Just in a deviant peer culture that approves drug use, shoplifting and so on. - Always ask about drug and alcohol use but often will fall short of dependent syndrome ii. Multiaxial System - ICD-10 has scheme for multiaxial assessment for children and adolescents 1. Axis 1 = clinical syndromes 2. Axis 2 = specific learning disabilities 3. Axis 3 = general learning disabilities 4. Axis 4 = medical conditions 5. Axis 5 = psychosocial and environnemental problems 6. Axis 6 = global level of functioning iii. Formulation 1. The formulation should synthesize all that has been learned from the assessment about the child’s predisposing, precipitating, perpetuating and protective factors in an individualized narrative way 2. First assessment session crucial for engaging the family and identifying strengths that can bring about therapeutic change 9. Intervention – covers treatment of children ages 2-12 a. Principles i. Personalizing the Treatment Plan 1. Personalized to fit the needs of the child and family 2. Intervention needs to be tailored to the needs and strengths of the family ii. Engaging the Family 1. Drop out rates are high often 60 percent 2. Practical measures like assisting with transportations, providing childcare, and holding sessions in the evening are likely to facilitate retention 3. Form a good alliance with the family 4. The quality of the alliance with the therapist and the family affects treatment success iii. Choosing which treatment modality to use 1. Improvements in home arise from successful parent training program but will not lead to antisocial behavior at school 2. Therefore, cases with difficulty at home = first line treatment is parent training 3. If classroom behavior is a problem and a school visit shows that the teacher is not using effective methods, then advice to the teacher and staff can be effective 4. Pervasive problems like fights with peers then anger management and social sills training - Note anger management on its own is unlikely to be successful as when combined with other approaches 5. Medication is controversial and generally best avoided iv. Encouraging strengths 1. Encouragement of abilities and prosocial activities increases achievements and self-esteem and hope for the future v. Treating Comorbid Conditions 1. Comorbidity is the Rule rather than the Exception 2. Common accompaniments are depression and ADHD vi. Promoting Social and Learning Sills 1. Treatment involves more than the reduction of antisocial behavior 2. Positive behaviors need to be taught too 3. Learning disabilities need treatment 4. And planning homework vii. Following Guidelines 1. The American Academy of Child and Adolescent Psychiatry published parameters for the assessment and treatment of CD in 1997 – guidelines for ODD published in 2007 viii. Treating the Child in a Natural Environment 1. Psychiatric hospitalization is rarely necessary 2. No evidence that inpatient leads to gains b. Great deal has been discovered including what leads to the condition and what treatments are likely to work to make it better Much further research needs to be done ********************************************************************************** Kaplan and Sadock Chapter 19 Disruptive, Impulse-Control, and Conduct Disorder Five conditions comprise this category: 1) Oppositional Defiant Disorder 2) Conduct Disorder (childhood disorders) 3) Intermittent Explosive Disorder 4) Kleptomania 5) Pyromania. Characterized: Inability to resist an intense impulse, drive, or temptation to perform a particular act that is harmful to self or others or both. Mounting tension builds and arousal, with conscious anticipatory pleasure. Completion = gratification, relief. Then later: remorse, guilt, self-reproach and dread. Shameful secretiveness expands and pervades the individual’s entire life, delaying treatment. Etiology: Psychodynamic, psychosocial, and biological factors all play an important role in impulsecontrol disorders; however, the primary causal factor remains unknown. Some impulse-control disorders may have common underlying neurobiological mechanisms. Fatigue, incessant stimulation, and psychic trauma can lower a person's resistance to control impulses. Psychodynamic factors: Otto Fenichel linked impulsive behavior to attempts to master anxiety, guilt, depression, and other pain by means of action. He thought that such actions defend against internal danger and that they produce a distorted aggressive or sexual gratification. To observers, impulsive behaviors may appear irrational and motivated by greed, but they may actually be endeavors to find relief from pain. Heinz Kohut considered many forms of impulse-control problems, including gambling, kleptomania, and some paraphilic behaviors, to be related to an incomplete sense of self. He observed that when patients do not receive the validating and affirming responses that they seek from persons in significant relationships with them, the self might fragment. As a way of dealing with this fragmentation and regaining a sense of wholeness or cohesion in the self, persons may engage in impulsive behaviors that to others appear self-destructive. Kohut's formulation has some similarities to Donald Winnicott's view that impulsive or deviant behavior in children is a way for them to try to recapture a primitive maternal relationship. Winnicott saw such behavior as hopeful in that the child searches for affirmation and love from the mother rather than abandoning any attempt to win her affection. Patients attempt to master anxiety, guilt, depression, and other painful affects by means of actions, but such actions aimed at obtaining relief seldom succeed even temporarily Biological: Experiments have shown that impulsive and violent activity is associated with specific brain regions, such as the limbic system, and that the inhibition of such behaviors is associated with other brain regions. A relation has been found between low cerebrospinal fluid (CSF) levels of 5hydroxyindoleacetic acid (5-HIAA) and impulsive aggression. Certain hormones, especially testosterone, have also been associated with violent and aggressive behavior. Some reports have described a relation between temporal lobe epilepsy and certain impulsive violent behaviors, as well as an association of aggressive behavior in patients who have histories of head trauma with increased numbers of emergency room visits and other potential organic antecedents . A high incidence of mixed cerebral dominance may be found in some violent populations. Considerable evidence indicates that the serotonin neurotransmitter system mediates symptoms evident in impulsecontrol disorders. Brainstem and CSF levels of 5-HIAA are decreased, and serotonin-binding sites are increased in persons who have committed suicide. The dopaminergic and noradrenergic systems have also been implicated in impulsivity. Impulse-control disorder symptoms can continue into adulthood in persons whose disorder has been diagnosed as childhood ADHD) Lifelong or acquired mental deficiency, epilepsy, and even reversible brain syndromes have long been implicated in lapses in impulse control. Intermittent Explosive Disorder: Discrete episodes of losing control of aggressive impulses; these episodes can result in serious assault or the destruction of property. The aggressiveness expressed is grossly out of proportion to any stressors that may have helped elicit the episodes. The symptoms, which patients may describe as spells or attacks, appear within minutes or hours and, regardless of duration, remit spontaneously and quickly. Signs of generalized impulsivity or aggressiveness are absent between episodes. The diagnosis of intermittent explosive disorder should not be made if the loss of control can be accounted for by schizophrenia, antisocial or borderline personality disorder, ADHD, conduct disorder, or substance intoxication. The term epileptoid personality has been used to convey the seizure-like quality of the characteristic outbursts, which are not typical of the patient's usual behavior, and to convey the suspicion of an organic disease process, for example, damage to the central nervous system. Several associated features suggest the possibility of an epileptoid state: the presence of auras; postictal-like changes in the sensorium, including partial or spotty amnesia; and hypersensitivity to photic, aural, or auditory stimuli. Epidemiology: Intermittent explosive disorder is underreported. The disorder appears to be more common in men than in women. The men are likely to be found in correctional institutions and the women in psychiatric facilities. In one study, about 2 percent of all persons admitted to a university hospital psychiatric service had disorders that were diagnosed as intermittent explosive disorder; 80 percent were men. Evidence indicates that intermittent explosive disorder is more common in first-degree biological relatives of persons with the disorder than in the general population. Many factors other than a simple genetic explanation may be responsible. Comorbidity: High rates of fire setting in patients with intermittent explosive disorder have been reported. Other disorders of impulse control and substance use and mood, anxiety, and eating disorders have also been associated with intermittent explosive disorder. Psychodynamic Factors: Psychoanalysts have suggested that explosive outbursts occur as a defense against narcissistic injurious events. Rage outbursts serve as interpersonal distance and protect against any further narcissistic injury. Psychosocial Factors: Typical patients have been described as physically large, but dependent, men whose sense of masculine identity is poor. A sense of being useless and impotent or of being unable to change the environment often precedes an episode of physical violence, and a high level of anxiety, guilt, and depression usually follows an episode. An unfavorable childhood environment often filled with alcohol dependence, beatings, and threats to life is usual in these patients. Predisposing factors in infancy and childhood include perinatal trauma, infantile seizures, head trauma, encephalitis, minimal brain dysfunction, and hyperactivity. Investigators who have concentrated on psychogenesis as causing episodic explosiveness have stressed identification with assaultive parental figures as symbols of the target for violence. Early frustration, oppression, and hostility have been noted as predisposing factors. Situations that are directly or symbolically reminiscent of early deprivations (e.g., persons who directly or indirectly evoke the image of the frustrating parent) become targets for destructive hostility. Biological: Some investigators suggest that disordered brain physiology, particularly in the limbic system, is involved in most cases of episodic violence. Compelling evidence indicates that serotonergic neurons mediate behavioral inhibition. Decreased serotonergic transmission, which can be induced by inhibiting serotonin synthesis or by antagonizing its effects, decreases the effect of punishment as a deterrent to behavior. The restoration of serotonin activity, by administering serotonin precursors such as L- tryptophan or drugs that increase synaptic serotonin levels, restores the behavioral effect of punishment. Restoring serotonergic activity by administration of L-tryptophan or drugs that increase synaptic serotonergic levels appears to restore control of episodic violent tendencies. Genetics First-degree relatives of patients with intermittent explosive disorder have higher rates of impulsecontrol disorders, depressive disorders, and substance use disorders. Biological relatives of patients with the disorder were more likely to have histories of temper or explosive outbursts than the general population. Diagnosis: Neurological examination sometimes reveals soft neurological signs, such as left–right ambivalence and perceptual reversal. Electroencephalography (EEG) findings are frequently normal or show nonspecific changes. History-taking that reveals several episodes of loss of control associated with aggressive outbursts One discrete episode does not justify the diagnosis. 2x weekly for 3 months-- Verbal or Behavioral Physical Findings and Labs: being apprehended and may manifest signs of depression and anxiety. Patients feel guilty, ashamed, and embarrassed about their behavior. They often have serious problems with interpersonal relationships and often show signs of personality disturbance. In one study of patients with kleptomania, the frequency of stealing ranged from less than 1 to 120 episodes a month. Most patients with kleptomania steal from retail stores, but they may also steal from family members in their own households. Differential Diagnosis Episodes of theft occasionally occur during psychotic illness, for example, acute mania, major depression with psychotic features, or schizophrenia. Psychotic stealing is obviously a product of pathological elevation or depression of mood or command hallucinations or delusions. Course and Prognosis The onset of the disorder generally is late adolescence. Women are more likely than men to present for psychiatric evaluation or treatment. Men are more likely to be sent to prison. Men tend to present with the disorder at about 50 years of age; women present at about 35 years of age. In quiescent cases, new bouts of the disorder may be precipitated by loss or disappointment. The course of the disorder waxes and wanes, but tends to be chronic. Persons sometimes have bouts of being unable to resist the impulse to steal, followed by free periods that last for weeks or months. The spontaneous recovery rate of kleptomania is unknown. Treatment Because true kleptomania is rare, reports of treatment tend to be individual case descriptions or a short series of cases. Insight-oriented psychotherapy and psychoanalysis have been successful, but depend on patients’ motivations. Those who feel guilt and shame may be helped by insight-oriented psychotherapy because of their increased motivation to change their behavior. Behavior therapy, including systematic desensitization, aversive conditioning, and a combination of aversive conditioning and altered social contingencies, has been reported successful, even when motivation was lacking. The reports cite followup studies of up to 2 years. SSRIs, such as Prozac and (Luvox), appear to be effective in some patients with kleptomania. Case reports indicated successful treatment with tricyclic drugs, trazodone, lithium, valproate, naltrexone, and electroconvulsive therapy. PYROMANIA Pyromania is the recurrent, deliberate, and purposeful setting of fires. Associated features include tension or arousal before setting the fire, fascination with, interest in, curiosity about, or attraction to the activities and equipment associated with firefighting; and pleasure, gratification, or relief when setting fire or when witnessing or participating in their aftermath. Patients may make considerable advance preparations before starting a fire. Pyromania differs from arson in that the latter is done for financial gain, revenge, or other reasons and is planned beforehand. Epidemiology No information is available on the prevalence of pyromania, but only a small percentage of adults who set fires can be classified as having pyromania. The disorder is found far more often in men than in women, with a male-to-female ratio of approximately 8:1. More than 40 percent of arrested arsonists are younger than 18 years of age. Comorbidity Pyromania is significantly associated with substance abuse disorder (especially alcoholism); affective disorders, depressive or bipolar; other impulse control disorders, such as kleptomania in female Ore setters; and various personality disturbances, such as inadequate and borderline personality disorders. Attention-deficit/hyperactivity disorder and learning disabilities may be conspicuously associated with childhood pyromania; this constellation frequently persists into adulthood. Persons who set fires are more likely to be mildly retarded than are those in the general population. Some studies have noted an increased incidence of alcohol use disorders in persons who set fires. Fire setters also tend to have a history of antisocial traits, such as truancy, running away from home, and delinquency. Enuresis has been considered a common finding in the history of fire setters, although controlled studies have failed to confirm this. Studies, however, have found an association between cruelty to animals and fire setting. Childhood and adolescent fire setting is often associated with ADHD or adjustment disorders. Etiology Freud saw fire as a symbol of sexuality. He believed the warmth radiated by fire evokes the same sensation that accompanies a state of sexual excitation, and a flame's shape and movements suggest a phallus in activity. Other psychoanalysts have associated pyromania with an abnormal craving for power and social prestige. Some patients with pyromania are volunteer firefighters who set fires to prove themselves brave, to force other firefighters into action, or to demonstrate their power to extinguish a blaze. The incendiary act is a way to vent accumulated rage over frustration caused by a sense of social, physical, or sexual inferiority. Several studies have noted that the fathers of patients with pyromania were absent from the home. Thus, one explanation of fire setting is that it represents a wish for the absent father to return home as a rescuer, to put out the fire, and to save the child from a difficult existence. Female fire setters, in addition to being much fewer in number than male fire setters, do not start fire to put firefighters into action as men frequently do. Frequently noted delinquent trends in female fire setters include promiscuity without pleasure and petty stealing, often approaching kleptomania. Biological Factors Significantly low CSF levels of 5-HIAA and 3-methoxy-4-hydroxyphenylglycol (MHPG) have been found in fire setters, which suggests possible serotonergic or adrenergic involvement. The presence of reactive hypoglycemia, based on blood glucose concentrations on glucose tolerance tests, has been put forward as a cause of pyromania. Further studies are needed. Diagnosis and Clinical Features Persons with pyromania often regularly watch fires in their neighborhoods, frequently set off false alarms, and show interest in firefighting paraphernalia. Their curiosity is evident, but they show no remorse and may be indifferent to the consequences for life or property. Fire setters may gain satisfaction from the resulting destruction; frequently, they leave obvious clues. Commonly associated features include alcohol intoxication, sexual dysfunctions, below-average intelligence quotient (IQ), chronic personal frustration, and resentment toward authority figures. Some fire setters become sexually aroused by the fire. Differential Diagnosis When fire setting occurs in conduct disorder and antisocial personality disorder, it is a deliberate act, not a failure to resist an impulse. Fires may be set for profit, sabotage, or retaliation. Patients with schizophrenia or mania may set Ores in response to delusions or hallucinations. Patients with brain dysfunction (e.g., dementia), mental retardation, or substance intoxication may set Ores because of a failure to appreciate the consequences of the act. The prognosis for treated children is good, and complete remission is a realistic goal. The prognosis for adults is guarded, because they frequently deny their actions, refuse to take responsibility, are dependent on alcohol, and lack insight. Although fire setting often begins in childhood, the typical age of onset of pyromania is unknown. Treatment: Incarceration may be the only method of preventing a recurrence. Behavior therapy can then be administered in the institution. Fire setting by children must be treated with the utmost seriousness. Intensive interventions should be undertaken when possible, but as therapeutic and preventive measures, not as punishment. In the case of children and adolescents, treatment of pyromania or Ore setting should include family therapy. OTHER SPECIFIED OR UNSPECIFIED DISORDERS Similarly, not all compulsions are ego-dystonic; for example, certain compulsive video game playing may have a pleasurable component. Both impulsive and compulsive behaviors are characterized by their repetitive nature; however, the repeated acting out of impulses leads to psychosocial impairment, whereas compulsive behavior does not always carry that risk. Because of the repetitive and pleasurable nature of many of the behavioral patterns in this group of disorders often referred to as addictions. Internet Compulsion Internet Use and Abuse VICTIMS. Deception can take a malignant turn as sexual predators deceive their victims with false identities only to exploit and harm them when they meet. These contacts are unregulated and difficult to detect except by monitoring and checking the computers used. Mobile or Cell Phone Compulsion Repetitive Self-Mutilation— Persons who repeatedly cut themselves or do damage to their bodies may do so in a compulsive manner. In all cases, another disorder will be found. Parasuicidal behavior is common in borderline personality disorder. Compulsive body piercing or tattooing may be a symptom of a paraphilia or a depressive equivalent. In DSM-5 there is a proposed diagnosis called “non-suicidal self-injury” to refer to persons who repeatedly damage their bodies, who, however, do not wish to die, contrasted with those persons who harm themselves with true suicidal intent. There is secondary gain to this self-injurious behavior such as getting the attention of others, the so-called “cry for help,” or obtaining relief from dysphoric states. It has been postulated that cutting the skin or inflicting bodily pain may release endorphins or raise dopamine levels in the brain, both of which contribute to a euthymic or elated mood, thus • An unfavorable childhood environment often filled with alcohol dependence beatings and threats to life • Predisposing factors include perinatal trauma, infantile seizures, head trauma, encephalitis, minimal brain dysfunction, and hyperactivity • Biological factors o Disordered brain physiology in the limbic system is involved in most episodes of violence • Evidence suggests that serotonergic neurons mediate behavioral inhibition. Decreased serotonergic transmission, which can be induced by inhibiting serotonin synthesis or by antagonizing its effects, decreases the punishment as a deterrent to behavior. The restoration of serotonin activity, by administering serotonin precursors such as L-tryptophan or drugs that increase synaptic serotonin levels, restores the behavioral effect of punishment. It also restores control of episodic violent tendencies. o Low levels of CSF 5-HIAA have been correlated with impulsive aggression • High CSF testosterone concentrations are correlated with aggressiveness and interpersonal violence in men. Antiandrogenic agents have been shown to decrease aggression • One discrete episode does not justify the diagnosis • Neuro exam sometimes reveals soft neurological signs such as left-right ambivalence and perceptual reversal • Persons with this disorder have a high incidence of nonspecific EEG findings, abnormal neuropsychological testing results, and accident susceptibility. • MRI may reveal changes in the prefrontal cortex which is associated with loss of impulse control • Blood chemistry, urinalysis, and syphilis serology may help r/o other causes of aggression • Differential Diagnoses • Diagnosis can only be made once other disorders associated with loss of control of aggressive impulses have been ruled out as the primary cause. These include psychotic disorders, personality changes because of a medical condition, antisocial or borderline personality disorder, and substance intoxication, epilepsy, brain tumors, degenerative disease, and endocrine disorders o Conduct disorder can be distinguished from intermittent explosive disorder by its repetitive and resistant pattern of behavior as opposed to an episodic pattern. o Intermittent personality disorder differs from antisocial and borderline personality disorders because, in personality disorders, aggressiveness and impulsivity are part of patient’s character and thus are present between outbursts o In paranoid and catatonic schizophrenia, patients may display violent behavior in response to delusions and hallucinations. o Hostile patients with mania may be impulsively aggressive but the underlying diagnosis is apparent from their MSE and clinical presentation o Amok is an episode of acute violent behavior for which the person claims amnesia. It can be distinguished from IED by a single episode and prominent dissociative features • Can begin at any stage of life but usually appears between late adolescence and early adulthood. The onset can be sudden or insidious and course can be episodic or chronic • In most cases, the disorder decreases in severity with the onset of middle age • Treatment o Combined pharmacological and psychotherapy is the best approach o Therapist may have problems with countertransference and limit setting. o Anticonvulsants o Lithium o Carbamazepine o Depakote o Phenytoin o Benzos have been shown to produce a paradoxical reaction of dyscontrol in some patients o SSRIs, Trazodone and buspirone are helpful in reducing aggression and impulsivity o Propranolol and other beta-adrenergic receptor antagonists and calcium channel inhibitors have also been effective KLEPTOMANIA • Essential feature is a recurrent failure to resist impulses to steal objects not needed for personal use or for monetary value • People with kleptomania usually have the money to pay for the objects they impulsively steal • Stealing is not planned and doesn’t involve others • When the stolen object is the goal, the diagnosis is not kleptomania. In kleptomania, the act of stealing is itself the goal. • Patients with kleptomania are said to have a high lifetime comorbidity of major mood disorders and various anxiety disorders • Associated conditions also include compulsive shopping, gambling, eating disorders and substance use disorders • Psychosocial factors o Symptoms tend to appear in times of significant stress • Biological factors o Brain diseases and mental retardation have been associated with kleptomania. o Focal neurological signs, cortical atrophy, and enlarged lateral ventricles have been found in some patients • Diagnosis and Clinical Features o Essential feature is recurrent, intrusive, and irresistible urges or impulses to steal unneeded objects o Patients may also be distressed about the possibility of being apprehended and may manifest signs of depression and anxiety. Patients feel guilty about their behavior. o Patients often have serious problems with interpersonal relationships and often show signs of personality disturbance. • Differential Diagnoses o Episodes of theft occasionally occur during psychotic illness such as acute mania, major depression with psychotic features, or schizophrenia o Antisocial stealing is done for personal gain and with some degree of planning, often executed with others. It also regularly involves o Little has been written about treatment and fire setters can be hard to treat because of lack of motivation o No single treatment has been proven effective ************************************************************************************* Kaplan & Sadock - Chapter 12 - Dissociative Disorders • Dissociation = unconscious defense mechanism involving the segregation of any group of mental or behavioral processes from the rest of the person’s psychic activity. This results in a disruption in one or more mental functions such as memory, identity perception, consciousness, or motor behavior. • Amnesia brought on by intrapsychic conflict is coded differently from amnesia brought on by a medical condition. • Dissociative amnesia criteria according to DSM5 Dissociative amnesia • Inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness. • Generally, begin to be reported in late adolescence and adulthood • Etiology - traumatic experiences such as physical or sexual abuse can induce this disorder. • Presentation - Overt, florid, dramatic clinical disturbance. Patients may present with intercurrent somatoform or conversion symptoms, alterations in consciousness, depolarization, derealization, trance states, spontaneous age regression, and even ongoing anterograde dissociative amnesia. • Many of these patients have histories of prior adult or childhood abuse or trauma. • Non-classic symptoms = these patients will frequently come in for symptoms such as depression, mood swings, substance abuse, sleep disturbances, somatoform symptoms, anxiety, and panic, suicidal or self-mutilation impulses and acts, violent outbursts, eating problems and interpersonal problems. • Differential diagnosis for dissociative amnesia o Ordinary forgetfulness and nonpathological amnesia o Dementia, delirium, and amnestic disorders due to medical conditions o Posttraumatic amnesia o Seizure disorders o Substance related amnesia o Transient global amnesia o Dissociative identity disorder (DID) o Acute stress disorder o PTSD o Somatic symptom disorder o Malinger and Factitious amnesia • Course & prognosis of dissociative amnesia o Acute dissociative amnesia frequently spontaneously resolves once the person is removed to safety from traumatic or overwhelming circumstances o Some patients do develop chronic forms of generalized, continuous or severe localized amnesia and are profoundly disabled and require high levels of social support o Clinicians should try to restore patient’s lost memories to consciousness as soon as possible, otherwise the repressed memory may form a nucleus in the unconscious mind for which future amnestic episodes may develop. • Treatments o Cognitive therapy - identifying the specific cognitive distortions that the trauma is based. As the patient becomes able to correct cognitive distortions, more detailed recall of the traumatic event(s) may occur. o Hypnosis - can be used to contain, modulate, and titrate the intensity of symptoms. Self-hypnosis may be taught as well. o Somatic therapies - There is no pharmacotherapy treatment for dissociative amnesia. Some agents have been used for this including sodium amobarbital, thiopental, oral benzos and amphetamines. o Group psychotherapy - During group therapy patients may recover memories for which they have had amnesia. Depersonalization & Derealization Disorder • Depersonalization disorder - persistent or recurrent feeling of detachment or estrangement from oneself. • Derealization disorder - feelings of unreality or of being detached from one’s environment. • The DSM 5 criteria for depersonalization and derealization criteria • Etiology of depersonalization/derealization o Psychodynamic - disintegration of the ego o Traumatic stress - hx of significant trauma o Neurobiological theories - depletion of Ltryptophan • Patients with DID may present with memory and amnesia symptoms. They often report significant gaps in autobiographical memory, especially for childhood events. • Differential diagnosis of DID • Course & Prognosis - Individuals with untreated DID may continue involvement in abusive relationships or violent subcultures or both that may lead to the traumatization of their children with potential for additional family transmission of the disorder. Some may die by suicide or as a result of risky taking behaviors. Prognosis is poorer in patients with comorbid organic mental disorders or psychotic disorders. Other factors that may contribute to a poor outcome is antisocial behavior. • Treatment - Psychotherapy. Psychoanalytic psychotherapy, CBT, hypnotherapy and a familiarity with the psychotherapy and psychopharmacological management of the traumatized patient. ECT is also an option. • Pharmacological interventions include antidepressant medications, SSRI, MAO, Beta blockers (catapres), anticonvulsants, benzos. • Adjunctive treatments include: group therapy, family therapy, self-help groups, expressive and occupational therapies and EMDR. Other specified or unspecified dissociative disorder • Dissociative trance disorder - manifested by a temporary marked alteration in the state of consciousness or by a loss of the customary sense of personal identity without the replacement by an alternate sense of identity. • Brainwashing - identity disturbance due to prolonged and intense coercive persuasion. Occurs largely in the setting of political reform. First stage linked to the artificial creation of an identity crisis. Coercive techniques include isolation of the subject, degradation, control over all communications and basic daily functions, induction of fear and confusion, peer pressure, assignment of repetitive and monotonous routines, unpredictability of environmental supplies, renunciation of past relationships and values and various deprivations. • Recovered memory syndrome - Under hypnosis or during psychotherapy a patient may recover a memory of a painful experience or conflict (esp of sexual or physical abuse). When the repressed material is brought back to consciousness, the person not only may recall the experience but may relive it, accompanied by the appropriate affective response (abreaction). • Ganser syndrome - characterized by giving of approximate answers (parologia) together with a clouding of consciousness and is frequently accompanied by hallucinations and other dissociative, somatoform or conversion symptoms. Etiology of Ganser syndrome - precipitating stressors such as personal conflicts and financial reverses, organic brain syndromes, head injuries, seizures or medical or psychiatric illness Diagnosis and clinical features of Ganser Syndrome - The symptom of passing over (vorbeigehen) the correct answer for a related, but incorrect one, is the hallmark of Ganser syndrome. The approximate answers often just miss the mark but bear an obvious relation to the question, indicating that it has been understood. Differential diagnosis of Ganser syndrome - organic dementia, depressive pseudodementia, the confabulation of Korsakoff’s syndrome, organic dysphasia and reactive psychoses. Treatment of Ganser syndrome - No systematic treatment available for this rare condition. Some cases low doses of antipsychotic medications have been beneficial. ****************************************************************************** Kaplan and Sadock Chapter 21 Neurocognitive Disorders Cognition includes memory, language, orientation, judgment, conducting interpersonal relationships, performing actions (praxis), and problem solving. Cognitive disorders reflect disruption in one or more of these domains and are frequently complicated by behavioral symptoms. Patients with factitious disorders may attempt to simulate the symptoms of delirium but usually reveal the factitious nature of their symptoms by inconsistencies on their mental status examinations, and an EEG can easily separate the two diagnoses. COURSE AND PROGNOSIS Although the onset of delirium is usually sudden, prodromal symptoms (e.g., restlessness and fearfulness) can occur in the days preceding. The older the patient and the longer the patient has been delirious, the longer the delirium takes to resolve. TREATMENT Treat the underlying cause. When the underlying condition is anticholinergic toxicity, the use of physostigmine salicylate (Antilirium), 1 to 2 mg intravenously or intramuscularly, with repeated doses in 15 to 30 minutes. Pharmacotherapy: The two major symptoms of delirium that may require pharmacological treatment are psychosis and insomnia. A commonly used drug for psychosis is haloperidol (Haldol), a butyrophenone antipsychotic drug. Depending on a patient’s age, weight, and physical condition, the initial dose may range from 2 to 6 mg intramuscularly, repeated in an hour if the patient remains agitated. Haloperidol has been associated with prolongation of QT interval. Clinicians should evaluate baseline and periodic electrocardiograms as well as monitor cardiac status of the patient. Droperidol (Inapsine) is a butyrophenone available as an alternative intravenous (IV) formulation, although careful monitoring of the electrocardiogram may be prudent with this treatment. The U.S. Food and Drug Administration (FDA) has issued a Black Box Warning because cases of QT prolongation and torsade’s de pointes have been reported in patients receiving droperidol. Phenothiazines should be avoided in delirious patients because these drugs are associated with significant anticholinergic activity. Insomnia is best treated with benzodiazepines with short or intermediate half-lives (e.g., lorazepam [Ativan] 1 to 2 mg at bedtime). Benzodiazepines with long half-lives and barbiturates should be avoided unless they are being used as part of the treatment for the underlying disorder (e.g., alcohol withdrawal). Routine consideration of ECT for delirium is not advised. If delirium is caused by severe pain or dyspnea, a physician should not hesitate to prescribe opioids for both their analgesic and sedative properties. Treatment in Special Populations Treatment in Special Populations Parkinson’s---In Parkinson’s disease, the antiparkinsonian agents are frequently implicated in causing delirium. If a coexistent dementia is present, delirium is twice as likely to develop in patients with Parkinson’s disease with dementia receiving antiparkinsonian agents than in those without dementia. If the antiparkinsonian agents cannot be further reduced, or if the delirium persists after attenuation of the antiparkinsonian agents, clozapine is recommended. If a patient is not able to tolerate clozapine or the required blood monitoring, alternative antipsychotic agents should be considered. Terminally Ill Patients The focus may change from an aggressive search for the etiology of the delirium to one of palliation, comfort, and assistance with dying. Dementia (Major Neurocognitive Disorder Dementia refers to a disease process marked by progressive cognitive impairment in clear consciousness. EPIDEMIOLOGY: 5 percent in the general population older than 65 years of age, 20 to 40 percent in the general population older than 85 years of age, 15 to 20 percent in outpatient general medical practices, and 50 percent in chronic care facilities. Of all patients with dementia, 50 to 60 percent have the most common type of dementia, dementia of the Alzheimer’s type. For persons age 65 years, men have a prevalence rate of 0.6 percent and women of 0.8 percent. At age 90, rates are 21 percent. The second most common type of dementia is vascular dementia, which is causally related to cerebrovascular diseases. Hypertension predisposes a person to the disease. Vascular dementias account for 15 to 30 percent of all dementia cases. Vascular dementia is most common in persons between the ages of 60 and 70 and is more common in men than in women. The most common causes of dementia in individuals older than 65 years of age are (1) Alzheimer’s disease, (2) vascular dementia, and (3) mixed vascular and Alzheimer’s dementia. Other illnesses that account for approximately 10 percent include Lewy body dementia; Pick’s disease; frontotemporal dementias; normal-pressure hydrocephalus (NPH); alcoholic dementia; infectious dementia, such as HIV or syphilis; and Parkinson’s disease. Many types of dementias evaluated in clinical settings can be attributable to reversible causes, such as metabolic abnormalities (e.g., hypothyroidism), nutritional deficiencies (e.g., vitamin B12 or folate deficiencies), or dementia syndrome caused by depression. The final diagnosis of Alzheimer’s disease requires a neuropathological examination of the brain; nevertheless, dementia of the Alzheimer’s type is commonly diagnosed in the clinical setting after other causes of dementia have been excluded from diagnostic consideration. Alois Alzhemier* noted the disease and named it with a 51-year-old woman who he was seeing and she progressively declined over the four years. Alzheimer’s type dementia has shown linkage to chromosomes 1, 14, and 21. 40 percent of patients have a family history of dementia of the Alzheimer’s type; The gene for amyloid precursor protein is on the long arm of chromosome 21 In Down syndrome (trisomy 21) are found three copies of the amyloid precursor protein gene, and in a disease in which a mutation is found at codon 717 in the amyloid precursor protein gene, a pathological process results in the excessive deposition of β/A4 protein. One study implicated gene E4 in the origin of Alzheimer’s disease. People with one copy of the gene have Alzheimer’s disease three times more frequently than do those with no E4 gene, and people with two E4 genes have the disease eight times more frequently than do those with no E4 gene. The classic gross neuroanatomical observation of a brain from a patient with Alzheimer’s disease is diffuse atrophy with flattened cortical sulci and enlarged cerebral ventricles. The classic and pathognomonic microscopic findings are senile plaques, neurofibrillary tangles, neuronal loss (particularly in the cortex and the hippocampus), synaptic loss (perhaps as much as 50 percent in the cortex), and granulovacuolar degeneration of the neurons. Neurofibrillary tangles are composed of cytoskeletal elements, primarily phosphorylated tau protein, although other cytoskeletal proteins are also present. Neurofibrillary tangles are commonly found in the cortex, the hippocampus, the substantia nigra, and the locus coeruleus. Senile plaques, also referred to as amyloid plaques, more strongly indicate Alzheimer’s disease, although they are also seen in Down syndrome and, to some extent, in normal aging. Senile plaques are composed of a particular protein, β/A4, and astrocytes, dystrophic neuronal processes, and microglia. The number and the density of senile plaques present in postmortem brains have been correlated with the severity of the disease that affected the persons. Neurotransmitters. The neurotransmitters that are most often implicated in the pathophysiological condition of Alzheimer’s disease are acetylcholine and norepinephrine, both of which are hypothesized to be hypoactive in Alzheimer’s disease. Other data supporting a cholinergic deficit in Alzheimer’s disease demonstrate decreased acetylcholine and choline acetyltransferase concentrations in the brain. Choline acetyltransferase is the key enzyme for the synthesis of acetylcholine, and a reduction in choline acetyltransferase concentration suggests a decrease in the number of cholinergic neurons present. Two other neurotransmitters implicated in the pathophysiological condition of Alzheimer’s disease are the neuroactive peptides somatostatin and corticotropin; decreased concentrations of both have been reported in persons with Alzheimer’s disease. Other Causes. Another theory to explain the development of Alzheimer’s disease is that an abnormality in the regulation of membrane phospholipid metabolism results in membranes that are less fluid—that is, more rigid—than normal. Several investigators are using molecular resonance spectroscopic imaging to assess this hypothesis directly in patients with dementia of the Alzheimer’s type. Aluminum toxicity has also been hypothesized to be a causative factor because high levels of aluminum have been found in the brains of some patients with Alzheimer’s disease, but this is no longer considered a significant etiological factor. Excessive stimulation by the transmitter glutamate that may damage neurons is another theory of causation. Vascular Dementia The primary cause of vascular dementia, formerly referred to as multi-infarct dementia, is presumed to be multiple areas of cerebral vascular disease, resulting in a symptom pattern of dementia. Vascular dementia most commonly is seen in men, especially those with preexisting hypertension or other The classic course of dementia is an onset in the patient’s 50s or 60s, with gradual deterioration over 5 to 10 years, leading eventually to death. The age of onset and the rapidity of deterioration vary among different types of dementia and within individual diagnostic categories. The average survival expectation for patients with dementia of the Alzheimer’s type is approximately 8 years, with a range of 1 to 20 years. Data suggest that in persons with an early onset of dementia or with a family history of dementia, the disease is likely to have a rapid course. In a recent study of 821 persons with Alzheimer’s disease, the median survival time was 3.5 years. After dementia is diagnosed, patients must have a complete medical and neurological workup because 10 to 15 percent of all patients with dementia have a potentially reversible condition if treatment is initiated before permanent brain damage occurs. Patients often benefit from a supportive and educational psychotherapy in which the nature and course of their illness are clearly explained. They may also benefit from assistance in grieving and accepting the extent of their disability and from attention to self-esteem issues. Any areas of intact functioning should be maximized by helping patients identify activities in which successful functioning is possible. Pharmacotherapy Pharmacotherapy Clinicians may prescribe benzodiazepines for insomnia and anxiety, antidepressants for depression, and antipsychotic drugs for delusions and hallucinations, but they should be aware of possible idiosyncratic drug effects in older people (e.g., paradoxical excitement, confusion, and increased sedation). In general, drugs with high anticholinergic activity should be avoided. Donepezil (Aricept), rivastigmine (Exelon), galantamine (Remiryl), and tacrine (Cognex) are cholinesterase inhibitors used to treat mild to moderate cognitive impairment in Alzheimer’s disease. They reduce the inactivation of the neurotransmitter acetylcholine and thus potentiate the cholinergic neurotransmitter, which in turn produces a modest improvement in memory and goal-directed thought. These drugs are most useful for persons with mild to moderate memory loss who have sufficient preservation of their basal forebrain cholinergic neurons to benefit from augmentation of cholinergic neurotransmission. Donepezil is well tolerated and widely used. Tacrine is rarely used because of its potential for hepatotoxicity. Fewer clinical data are available for rivastigmine and galantamine, which appear more likely to cause gastrointestinal (GI) and neuropsychiatric adverse effects than does donepezil. None of these medications prevents the progressive neuronal degeneration of the disorder. Prescribing information for anticholinesterase inhibitors can be found in Section 36.14. Memantine (Namenda) protects neurons from excessive amounts of glutamate, which may be neurotoxic. The drug is sometimes combined with donepezil. It has been known to improve dementia. ****************************************************************************** RUTTERS - Chapter 55 - ADHD The prehistory of ADHD is the formulations of mental disorder in childhood that stressed lack of control and wildly disruptive behavior and presumed roots in the individual’s constitution (Crichton, 1798; Haslam, 1809. George Frederick Still (1902) described disorders of “moral control,” in which aggressive, defiant, and overemotional conduct was attributed to constitutional failures of inhibitory volition. Clinical tools for ADHD Conners’ Teacher and Parent Rating Scales Strengths and Difficulties Questionnaire (SDQ) Child Behavior Problems Checklist Vanderbilt Rating Scale SNAP-IV scale Many of these rating scales have similar strengths and weaknesses. Test–retest reliability is typically around 0.7; most give a discrimination between cases and controls. Epidemiology ADHD is remarkable for the great disparity in rates of given diagnosis in different parts of the world. Estimates gathered of children who were medicated because of ADHD varied from around 60 per 1000 school-age children in the United States, through 10–30 per 1000 in Canada, to 3 per 1000 in the United Kingdom and less than 1 in Brazil and China. Estimates from other surveys suggested 9 per 1000 in Germany and 1.8 per 1000 in France. ADHD risk is made up of many interacting genetic and environmental factors, and is mediated by multiple brain networks—with different individuals affected in different ways and at different times and to different degrees by these factors. Risk factors Genetic influences It is pretty clear that genetic influences are involved. The strongest evidence comes from studies comparing the similarity of monozygotic and dizygotic twins: genetic influences account for 70–90% of the variance in different studies, on the (reasonable) assumption that environmental factors influence both twins more or less equally. Environmental influences Genetic and environmental influences are profoundly intertwined for ADHD and need to be considered jointly (see Chapter 24). Several, potentially harmful factors in the early environment are reliably associated with ADHD, but none is unequivocally established as a cause. Prenatal associations include maternal smoking during pregnancy maternal alcohol consumption, and use of non-prescribed drugs of abuse, prescribed drugs such as anticonvulsants and anxiolytics, maternal stress, and maternal hypothyroidism. Perinatal associations include low birth weight, prematurity, and obstetric complications. In postnatal life, associations include an inadequate diet, iodine deficiency and major B vitamin deficiencies, iron and lead poisoning, high exposure to industrially contaminated areas, old paint, and soft-water areas where lead water pipes are common. Some artificial food colorings and preservatives have been implicated as risk factors by contrasting them with inert substances in a community-based randomized double-blind trial as a consequence the implicated coloring has been regulated in the UK and Europe. Exposure to insecticides, such as dichlorodiphenyltrichloroethane (DDT), has been implicated in animal models but has not been confirmed clinically. Clinical implications Knowledge of risks has advanced to the point where it can inform advice to patients and their families. The understanding that there are genetic influences often comes as a liberation from personal guilt. Parents are vulnerable to societal views that their parenting failures have produced the features of ADHD, and can be freed by good advice to use their problem-solving and coping skills. It is also important to avoid any impression that genetic influences imply an unalterable course. Parents and teachers can have a major influence for good on their children’s ability to cope with ADHD. Parents have sometimes been led to give undue weight to single events in the history. Minor obstetric complications are seldom “the cause,” any more than minor infractions of health advice in pregnancy (such as low levels of alcohol intake). In many countries, there is a public view that broad social factors are responsible—for instance, rises in television viewing or internet use. It is therefore worth noting that shared environmental factors appear to play very little part. Pathogenesis ADHD and brain structure Structural alterations in multiple brain systems have been implicated in ADHD. Group comparisons with controls find significantly smaller brains in ADHD with cerebellum, corpus callosum, striatal—for example, caudate nucleus, putamen and globus pallidus − and frontal regions—for example, dorsolateral prefrontal cortex (DLPFC) especially affected. Reduced thickness of cortex, especially DLPFC, is evident. There is also evidence of altered patterns of cortical folding—effects perhaps related to early environmental influences. Diffusion tensor imaging suggests alterations in white matter integrity in a range of key fiber pathways thought to subserve cognitive functions implicated in ADHD. Key regions in the reward and emotion processing networks such as the ventral striatum and the amygdala may also be implicated. Treatment Treatment should begin with careful and responsive advice and explanation. Extended courses of “psychoeducation” can have beneficial effects on parental ratings of hyperactivity as well as on their intended target of assisting people to cope with the problems imposed. Specific treatments have been widely researched and reviewed. Drug trials especially provide a substantial evidence base. National guidelines generally agree on the forms of intervention that should be used, and that both psychological and pharmacological therapies should be available, but differ on the important question of indications. North American guidelines suggest either that both forms of treatment should be used, according to clinical judgment or that medication is primary, with psychosocial interventions an important adjunct. Medication Central nervous stimulants (methylphenidate, dexamfetamine and lisdexamfetamine) and atomoxetine are licensed in many countries. Bupropion, guanfacine, clonidine, and modafinil are also in widespread use as alternative antihyperkinetics, in spite of not being approved in Europe. Some preparations of methylphenidate are available in North America, but not widely elsewhere—for instance, a transdermal preparation and a dextro-enantiomer. Predominantly inattentive- fewer than six symptoms of hyperactive and impulsiveness. Restrictive inattentive ADHD- is not disruptive or aggressive, dreamy, inert, muddles, disorganized impersistent, shows neurocognitive problem, difficulty with working memory, poor spatial skills, language delay, poor motor coordination, low IQ. Clinical Assessment Conner ‘s teacher and Parent rating scale- developed to monitor responses to therapy IOWA conner-modified relevant subscales Strength and Difficulties Questionnaire (SDQ) is a the modified Rutter A2 and B2 scales Child Behaviors Problem Checklist ADHD Rating scale and Vanderbilt Rating scale -came from DSM III- or DSM IV criteria SNAP-IV, SWAN and SDQ= scores for intensity of ADHD symptoms Vanderbilt test and DePaul = test for frequency of ADHD symptoms Diagnosis criteria 1. Developmental appropriateness- symptoms need to be considered un the light of what is appropriate to different ages and level of development. Misdiagnosis is common for child with intellectual disability or low IQ, 2. Diagnosis in adult life – adult DSM criteria require five (5) rather than six to be present in attention and impulsiveness • It is rare for ADHD features to appear for the first item in adulthood, if suggest then r/o substance misuse, early dementia, mania or encephalopathy. • RETROSPECTIVE interview on onset before the age of 12 years Differential Diagnosis Some conditions may Masquerade as ADHD a. Other form of overactivity - Manic is goal directed ADHD overactivity is disorganized Autism spectrum overactivity is stereotype pattern b. Other form of Inattentiveness- Learning Disability due to reluctance to any task ADHD inattentive due to specific task c. Other form of Disruptive behavior- Insomnia leads to irritability with day sleepiness Oppositional defiant disorder is not listening, task refusal d. Other form of emotional dysregulation – Bipolar disorder is episodic, ADHD dysregulation is persistent trait Coexistent Disorders a. Other neurodevelopmental phenotypes like in Autism Spectrum occur 1/3 with ADHD, twin studies- half of genetic influence are common Epidemiology Prevalence- only significant in discriminating between North America , Africa and Middle east, meaning culture vary only a little in the true prevalence of activity and attention problems, rate of ADHD diagnosis is higher when the family’s primary language was English or when that had Medicaid cover for health care. Risk Factors a. Genetic Influences- serotonin – genetic influence is strong, the risk of ADHD on 1st degree and family members are 5(five folds). genetic variant 5HTP1B, serotonin transporter, DA,D4, and D5 receptors b. Environmental Influences- b.1 Prenatal association-maternal smoking, alcohol, anticonvulsant, anxiolytics, maternal stress ad maternal hypothyroidism b.2Perinatal association-low birth weight, prematurity, obstetric complications b.3 Postnatal-life- inadequate diet, iodine deficiency, major B deficiency, iron and lead poisoning b.4 Artificial food coloring, insecticides like DDT ( dicholorophenyltrichloethane). b.5 Social environment- extremely depriving institutional environment Pathogenesis 1. ADHD and brain structures- smaller brain reduced thickness of cortex,dorso-laterak prefrontal cortex (DLPFC). 2. ADHD and Brain Chemistry- ADHD is based on Dopamine (DA) dysregulation is supported by genetic, imaging, and pharmacologic studies. DA neurons innervate the brain network. Low tonic level of DA on task demand. 3. ADHD and Brain functions- alteration in the brain, lead to problem in Executive Functions, inhibitory based interface control process , working memory, planning, and attentional flexibility. Longitudinal Course Referral for ADHD is common in middle school as start to impact negatively on everyday functions but noticed symptoms across the life span. 1. Preschool- early emergence of extreme overactivity, noncompliance, tendency to temper outburst, these are Risk Markers or Prodromal State of later clinical condition. 2. Middle School- history of subclinical symptoms but exacerbate due to new challenging environment. Pattern of comorbid liker aggression, noncompliance. 3. Adolescence- during transition from child to adolesce then hyperactivity may recede But impulsiveness and inattention continue leading to low self-esteem, distorted self-concept, low mood and feeling of worthlessness. Educational underachievement is common and emergence of delinquency, early onset of substance use disorder 4. Adult Life- symptoms are replaced by feeling of internal agitation, restlessness risk of anxiety and depression, reduced quality of life, stubbornly problematic, conduct problems, problem with organization like paying bills, losing object, poor personal appearance. 5. Heterogeneity- different temporal pattern and impairment, some may have ADHD problem later in life in onset but persist into adult life. (Check all that apply. A. A history of MDD) includes which of the following? dysthymia B. Questions 52 American Academy of Child and Adolescent Psychiatry Code of Ethics Principle II: Promoting the Welfare of Children and Adolescents addresses which of the following ethical issues? A. Fidelity B. Autonomy C. Beneficenc e D. Nonmaleficence Question 53 Examples of atypical features in a patient with Major Depressive Episode include which of the following? A. Overeating and oversleeping B. Loss of appetite C. Insomnia D. Sleep walking Question 54 Indicators for a good prognosis in treatment of Major Depressive Disorder Absence of psychotic symptoms Question 52 The American Academy of Child and Adolescent Psychiatry Code of Ethics Principle II: Promoting the Welfare of Children and Adolescents addresses which of the following ethical issues? A. Fidelity B. Autonomy C. Beneficence-This centers on the obligation to assisst the optimal wellbeing, functioning and development of youth, both as individuals and as a group. This adherence must be prioritized over familial or societal pressures. The activities of the child and adolescent psychiatrist must be based on solid scientific knowledge, incorporating accurately conducted research, clinical experience and sound judgment, and an understanding of the important relationships between the child, adults, and agencies. The well-being, security and needs of the child must be uppermost. D. Nonmaleficence Question 53 Examples of atypical features in a patient with Major Depressive Episode include which of the following? A.Overeating and oversleeping- Atypical depression usually involves many specific symptoms, incorporating increased appetite or weight gain, sleepiness or excessive sleep, marked fatigue or weakness, moods that are powerfully reactive to environmental circumstances, and feeling extremely sensitive to rejection. B. Loss of appetite improper treatment, extreme initial symptoms incorporating psychosis, early age of onset, previous episodes, not complete recovery after one year of treatment, pre-existing severe mental or medical disorder, and family dysfunction. Question 55 When assessing a child who has presented with concerns of being anxious and worried, the provider asks the child "Do you get sudden surges of fear that make your body feel shaky or your heart race?" to screen for which of the following common diagnostic possibilities? A. Obsessive - compulsive disorder B.Posttraumatic stress disorder B. Ages 6- 12 C. Ages 13- 18 D. Ages 18+ Question 58 A patient in their early 20s presents reporting chronic fluctuating moods ranging from mild depression to at times some hypomania. Recalls being sensitive and moody as a child. These symptoms are consistent with which of the following diagnoses? A. Dysthymia B. Cyclothymia C. Bipolar II Disorder D. Bipolar I Disorder Question 59 A clinical course of one or more manic episodes and sometimes major depressive episodes is consistent with which of the following diagnoses? A. Bipolar II Disorder B. Bipolar I Disorder C. Cyclothymic Disorder D. Major Depressive Episode Question 60 The most powerful predictors of the onset of a depressive episode is which of the following? A. Resent stressful events B. Persons with antisocial personality disorder C. Persons with paranoid personality disorder D. Person with borderline personality disorder Question 61 C.Panic disorder -Shaking is one of the most usual symptoms of anxiety and a direct response to the activation of your sympathetic nervous system. If you have anxiety, you'll find yourself shaking. Panic attacks before, during, or after, shaking can be very usual. This type of shaking is entirely due to the intense fear that those with panic attacks experience. People with panic attacks may also experience from time to time shaking with no apparent provoke, and that shaking can actually cause a panic attack itself as the person worries that something is wrong. D.Separation anxiety disorder Question 56 Which of the following is not consistent with the purpose of The ANA's Code of Ethics for Nurses? A.It is a succinct statement of the ethical values, obligation, duties, and professional ideals of nurses individually and collectively. B. It is the profession's non-negotiable ethical standard. approved for the treatment of insomnia? A. Temazepam B. Pramipexole C. Desmopressin D. Sodium oxybate Question 62 Which of the following would be an initial screening question for a child with sleep problems? A. Do worries keep you awake? B. What is your routine before going to bed? C. Do you startle easily or get frequent nightmares? D. Do you feel tense, restless or worried most of the time? Question 63 A strategy by which caregivers shape a young child's behavior through selective and temporary removal of that child's access to desired attention, activities, or other reinforcements following a behavioral transgression is known as which of the following? A. Time-out B. Special time C. Behavioral activation D. Functional analysis of behavior Question 64 Biofeedback, deep breathing, mindfulness, and progressive muscle relaxation are strategies that are typically used in which of the following therapies? A. Question 57 ADHD, impulse-control, conduct disorder, and intellectual disabilities and anxiety disorders are predominant during which of the following age ranges? A. Ages 0-5- The usual onset is before ages 612. B. Ages 6-12 C. Ages 13-18 D. Ages 18+ Question 58 A patient in their early 20s presents reporting chronic fluctuating moods ranging from mild depression to at times some hypomania. Recalls being sensitive and moody as a child. These symptoms are consistent with which of the following diagnoses? A.Dysthymia B.Cyclothymia C.Bipolar II Disorder- It is characterized by at least one episode of hypomania and at least one episode of major depression. It necessitates that the individual must never have experienced a full manic episode. D.Bipolar I Disorder Question 59 A clinical course of one or more manic episodes and sometimes major depressive episodes is consistent with which of the following diagnoses? A.Bipolar II Disorder Relaxation therapy B. Social skills training C. Motivational Interviewing D. Applied behavioral analysis Question 65 When assessing a child with disruptive or aggressive behavior, the clinician asks "Have you been thinking about or planning to hurt anyone?" to screen for which of the following diagnostic categories? A. Safety B. Bullying C. Conduct disorder D. Oppositional defiant disorder Question 66 In evaluating an adolescent who has been referred from her PCP for recurrent abdominal pain, the clinician asks "Is there something stressful in the past 3 months that happened right before these symptoms appeared?" to screen for which of the following diagnostic categories? A. Adjustment disorder B. Anxiety disorders C. Depressive disorders D. Conversion disorder Question 67 Nightmares and night terrors are associated with disorganization and arousal during which stage of sleep? A. Stage 1 B. Stage 2 C. B. Bipolar I Disorder- It is characterized by the development of at least one manic episode, with or without mixed or psychotic features. C.Cyclothymic Disorder D.Major Depressive Episode Question 60 The most powerful predictors of the onset of a depressive episode is which of the following? A.Resent stressful events- Stressful life incidents along with current minor difficulties have been determined as predictors of an episode of depression. B.Persons with antisocial personality disorder C.Persons with paranoid personality disorder D.Person with borderline personality disorder Question 61 Which of the following medications are FDA approved for the treatment of insomnia? A.Temazepam- The prescribed and FDAapproved medications for the treatment of insomnia includes Temazepam a type of benzodiazepine. B. Pramipexole