CAMS Psychopathology Final

BP I, BP II, cyclothymia

1 year or more of symptoms, no more than 2 months symptom free

ASD diagnostic criteria

1. Autistic Disorder 2. Asperger's Disorder 3. Childhood Disintegrative Disorder 4. Pervasive Developmental Disorder Not Otherwise Specified (NOS) • must have 6 symptoms from 3 domains 1. Social interaction 2. Communication 3. Behaviors, Interests & Activities • persistent deficits in social communication & interaction across multiple contexts as manifested by: 1. social/emotional reciprocity 2. non-verbal communication, 3. developing/maintaining/understanding relationships • restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: stereotyped or repetitive motor movements, use of objects or speech, insistence on sameness, inflexible adherence to routines or ritualized patterns or verbal non-verbal behavior, highly restricted, fixated interests that are abnormal in intensity or focus, hyper or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment • symptoms must be present in early developmental period • symptoms cause significant impairment in social, occupational, or other important areas of functioning • not better accounted for by intellectual disability

Anxiety d/o in DSM-IV

1. Separation Anxiety Disorders 2. Panic Disorder 3. Specific Phobia 4. Social Phobia 5. Obsessive-Compulsive Disorder 6. Posttraumatic Stress Disorder 7. Acute Stress Disorder 8. Generalized Anxiety Disorder • Selective Mutism • Somatic symptoms • Trichotillomania

autistic individuals watching "Who's Afraid of Virginia Woolf"

1. most impaired individuals look at everything.anything and are highly disorganized 2. moderately impaired individuals look at objects in the room 3. higher functioning individuals look at mouths

Pediatric Bipolar Disorder diagnostic dilemmas (irritability, "pure" diagnosis, and episode length

1. the centrality of irritability - recommending a diagnosis of BP if the child meets DSM criteria with irritability as a core symptom, even in the absence of elation, grandiosity, and episodicity -- versus unmodified DSM criteria 2. absence of "pure" BP disorder - almost always comorbid, making it difficult to discern what's really going on 3. episode length - DSM says you need bipolar disorder for a couple days (depression vs. mania), BPI - at least 7 day, not sleeping much when manic, hypermania - feel very energized, things are moving forward (DSM says at least 4 days like this)

Anorexia vs. Bulimia

Anorexia: • denies abnormal eating behavior • introverted • turns away food in order to cope • preoccupation with losing more and more weight Bulimia: • recognizes abnormal eating behavior • extroverted • turns to food in order to cope • preoccupation with attaining an ideal but often unrealistic weight

comorbidities

Anorexia: anxiety (OCD, social phobia), depression, personality d/o Bulimia: personality disorder, depression, substance use, anxiety d/o

CRAFFT screening tool

C - have you ever gotten into a car driven by someone (including yourself) who was "high" or using alcohol or drugs? R - do you use alcohol or drugs to relax? A - do you ever use alcohol or drugs while you are by yourself, alone? F - has any friend, family member, or other person ever thought you had a problem with alcohol or drugs? F - do you ever forget (or regret) things you did while using? T - have you ever gotten into trouble while using alcohol or drugs, or done something you would not normally do (break the law, rules, or curfew, engage in risky behavior to yourself or others?)

Panic attack vs. Panic D/O

Panic attacks: • not a disorder • quite common - 1/40 adults experience them • discrete period of intense fear or discomfort, in which 4 or more of the following develop abruptly and reach a peak within 10 minutes: palpitations, heart rate increase, sweating, trembling, shortness of breath/smothering, feeling of choking, chest pain, nausea, dizzy/lightheaded, derealization (feeling of unreality) or depersonalization (feeling detached from oneself), fear of going crazy or losing control, fear of dying • characteristic types of panic: unexpected (uncued), situation bound (cued), situationally predisposed • children may attribute their panic attack to external triggers Panic Disorder: • recurrent, unexpected panic attacks • at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: • persistent concern about having additional attacks • worry about the implications of the attack or its consequences (losing control, having a heart attack, going crazy) • a significant change in behavior related to the attacks • might look like: preoccupation with having future attacks, avoiding places or situations where child thinks a panic attack may occur, worry about being trapped in places where help would be unavailable if an attack occurred

risk factors for substance abuse

Risk factors: • younger age of initiation • early aggressive behavior, lack of parental supervision, drug availability, poverty • peers who abuse drugs • difficult temperament, lack of self-control, aggressive behavior (risk factors noted in infancy) • family conflict, lack of nurturing and attachment, caregiver drug abuse • individuals who abuse alcohol and drugs have high rates of physical, sexual, and emotional abuse, often live in disorganized and violent neighborhoods, have frequent psychiatric diagnoses, and high rates of chronic pain and disability • urban settings • homelessness • media promotion of use • negative attitude toward youth (not interested in what you're doing) • community codependency and secrecy • school/academic failure • poor social coping skills • exposure to violence • victimization by assault • transitions in life (changing schools, college, workforce, marriage)

addiction

a cluster of cognitive, behavioral, and physiologic signs that indicate compulsive use of a substance and inability to control intake despite negative consequences (eg. medical illness, failure in life roles, interpersonal difficulties)

withdrawal

a drug specific syndrome that occurs when blood or tissue concentrations of a substance decline in someone who had maintained prolonged heavy use

echopraxia

a mirror phenomena, such as involuntary, spontaneous imitation of someone else's movements (complex motor tic)

copraxia

a sudden, tic-like vulgar, sexual, or obscene gesture (complex motor tic)

most frequently abused drugs

alcohol, cigarettes, cannabis, amphetamine or methamphetamine, inhalants, crack, hallucinogens, tranquilizers, MDMA (ecstasy), heroin, steroids • marijuana is the most used illicit drug

Neurovegetative signs of depression

changes in sleeping patterns, appetite, and energy levels • children don't usually get as many neurovegetative signs of depression

Predictors of increased duration

depression severity, comorbidity, negative life events, parental psychiatric disorders, poor psychosocial functioning

Bipolar I

dysthymia + mania major depression + mania

manic episode

elevated, expansive, irritable mood for at least 1 week (shorter if hospitalized) • 3 symptoms or 4 if mood only irritable

acute

illness with a high incidence and low prevalence

chronic

illness with a low incidence and a high prevalence

Why does depression increase with age?

increase in stressors

The role of neuropsychological testing for kids with ASD

laterality, motor skills, attention, visual-spatial perception, verbal and visual memory, executive functioning

Bipolar II

major depression + hypomania

Mood cycles

normal mood = 0 depression = -10 dysthymia = -7 mania = +10 hypomania = +7 mixed episode = +10 and -10 at the same time mixed episode: combination of depression and mania - in worst form: crying and laughing at the same time, outward expression is mixed

incidence

number of new cases in a given time period

obsessions

recurrent, persistent, unwanted thoughts, impulses, or images, intrusive, cause distress

compulsions

repetitive behaviors or mental acts (praying or counting), person feels driven to perform in response to obsession or rigid rules, performed to neutralize obsessive thoughts or prevent some dreaded situation, not connected in realistic way, provide temporary relief, not performing causes marked increase in anxiety

tolerance

requiring a markedly increased dose of the substance to achieve the desired effect, or a markedly reduced effect when the usual dose is consumed

mixed episode hypomanic

symptoms for at least 4 days

Theory of Mind

the ability to attribute mental states - beliefs, intents, desires, pretending, knowledge, etc. to oneself and others and to understand that others have beliefs, desires, intentions, and perspectives that are different from one's own

Prevalence

total number of cases in a population at any given time

dependence

upon cessation of drug, an individual experiences pathological signs and symptoms (eg. tolerance and withdrawal)

frequency / epidemiology of addiction

• 10-20% of the population will at some point have an addiction • appx 10% of individuals with substance dependence (including alcohol) commit suicide • 9% of adolescents 12-17 y/o are classified as needing treatment for alcohol and substance abuse • greater use in adolescence translates into greater use as an adult (the earlier you start, the more likely it is to persist into later life) • gay, lesbian, and bisexual youth report more SUDS use than heterosexual youth • females more likely than males among GLB youth to use and males more than females among heterosexual youth

Epidemiology of depression, gender ratios, and prevalence

• 12 month prevalence in the US is about 7% • 1-year incidence is: Preschool age 1%, school age 2%, adolescent age 4-8% • sex ratio in childhood: 1:1 • sex ratio in adolescence: 2:1::female:male • lifetime prevalence of MDD among adolescents is 15-20%

Emil Kraepelin's findings regarding onset and mixed states

• 1917: percent of subjects diagnosed with mania 16-20 y/o = percent diagnosed with mania 21-25 y/o

DSM-5 diagnostic criteria

• 5/9 symptoms (1. depressed mood, in children irritable mood, 2. anhaedonia (diminished interest & pleasure), 3. significant decrease in weight (5%), 4. insomnia or hypersomnia 5. psychomotor agitation or retardation 6. fatigue or loss of energy 7. feelings of worthlessness or excessive guilt 8. diminished ability to think or concentrate or indecisiveness 9. recurrent thoughts of death or suicidal ideation) • at least two straight weeks in duration with symptoms present pretty much every day or most of every day • not better accounted for by another illness • MDD: Major depressive disorder (single or recurrent) • specifiers: severity, psychosis, anxious distress, mixed features, melancholic features, atypical features, peripartum, seasonal, catatonia

Gold Standard of testing for ASD

• ADOS (Autism Diagnostic Observation System) • ADI (Autism Diagnostic Interview) • Others (Gilliam, CARS, Wing, Atwood, Ornitz)

subtypes of AN and BN

• Anorexia nervosa (restricting type: hardly eating, binge eating/purging, introverted, decreased risk of substance abuse, family conflict is covert (bulimic type): laxatives or throwing up, binge eating or purging, more volatile, family frequently disengaged, prone to substance abuse) • bulimia nervosa • binge-eating disorder • unspecified feeding or eating • maybe take stimulants, exercise • eat a lot at certain times and binge later

Facial Inversion Effect

• Autistics tend to lack the facial inversion effect • most individuals by 6 months of age are better at recognizing faces when presented right-side up) • autistics recognize faces equally well right-side up or upside down

increase in comorbidities in earlier onset bipolar disorder

• Depression, Anxiety disorder (lifetime), Alcohol use disorder, drug use disorder, ADHD, suicide attempt • the likelihood of getting these comorbidities is significantly higher if bipolar disorder is attained before 13, less if 13-18, and lowest if onset is >18 years

ASD methods to clinically evaluate Autism

• Hearing and visual screening • speech and language evaluation • occupational and physical therapy evaluations • growth milestones - head circumference • imaging (CT or MRI to identify Tuberous Sclerosis, leukodystrophy) • EEG • Psychoeducational testing

ubiquity of irritability in child psychiatric disorders and common comorbidities

• Irritability seen in: ADHD, ODD, CD, MDD, Anxiety D/O, PTSD, ASD, SUDS, Psychotic disorders • comorbidities: ADHD (10-75%), Psychosis (16-60%), ODD (46-75%), CD (6-37%), Anxiety d/o (13-56%), SUDS (0-40%) • understanding development is important, DSM was written for adults(grandiosity: i think i'm better than you. - kids developmentally think that way anyway)

ASD etiological theory of vaccines

• MMR - Measles, Mumps, and Rubella vaccine given at 1 year 12-15 months, booster at 4/5 years before school • Wakefield in the UK suggested in 1998 that MMR might cause autism b/c small number of cases (8/12) who had severe GI problems along with autistic/behavioral symptoms post MMR vaccination • studies show that MMR vaccines haven't changed but the number of cases of PDD or autism has grown x7 • studies out of Japan documented there is no change in PDD/autism • US Institute of Medicine study conformed no connection between MMR and PDD

ASD common comorbidities

• Mental Retardation (Fragile X is MCC 5-15%, Down's Syndrome not uncommon) • Epilepsy • Developmental Syndromes (Turners, Tuberous Sclerosis, Metabolic Disorders, PKU) • ADHD • OCD • Depression & Anxiety (esp in higher functioning) • Other psychiatric disorders (eg. psychosis)

Alternative diagnostic concepts for Asperger's, particularly Nonverbal Learning Disorders

• Schizoid Personality Disorder: social isolation, emotional detachment, unusual communication style, rigidity of thought and behavior • Nonverbal Learning Disorder: deficits in neuropsych skills (tactile perception, psychomotor coordination, visual-spatial organization), occur in the presence of preserved rote verbal abilities • Developmental Learning Disability of the Right Hemisphere: the field of neurology's take on these symptoms • Semantic-Pragmatic Disorder: speech and language are adequate in form (syntax and phonology) but impoverished in content and use (semantics and pragmatics) • Asperger's looks like it is simply autism without "communication" problems • deficit in the social use of language despite relative strengths in verbal ability and weaknesses in nonverbal areas •Asperger's is associated with NVLD, but converse is not necessarily true • primary assets: proficiency in most rote verbal skills, proficiency in some simple motor and psychomotor skills • major characteristics: bilateral tactile-perceptual deficits, bilateral psychomotor coordination of deficiencies, visual-perceptual-organizational deficiencies, poor adaptation to novel and otherwise complex situations, deficits in nonverbal problem solving, concept formation & hypothesis testing, distorted sense of time, much verbosity in a repetitive, straightforward manner, relative deficiencies in mechanical arithmetic as compared to proficiencies in reading (word recognition) and spelling, significant deficits in social perception, judgment, and interaction, well developed rote verbal capabilities

Simple Tics vs. Tourette's

• Tic - a sudden, rapid, recurrent, non-rythmic, stereotyped motor movement or vocalization, may be simple (involving only a few muscles, or sounds) or complex (involving multiple groups of muscles recruited in orchestrated bouts or words or sentences) • simple motor tics (eye blinking, nose wrinkling, neck jerking, shoulder shrugging, facial grimacing, abdominal tensing) • simple vocal tics (throat clearing, grunting, sniffing, snorting, chirping) • tics are generally experienced as irresistible but can be suppressed for various lengths of time Tourette's • nonprogressive, hereditary neurological condition • disorder begins with a simple motor tic on the face • tics persist and generalize to other parts of the body; waxing and waning is typical • eventually, vocalizations (sniffing, snorting, throat clearing, barking, hiccuping, or uttering nonsense words or intelligible words) ensue and are typically explosive

DSM-5 diagnostic criteria

• a distinct period of elevated, expansive or irritable mood > 1 week (or any duration if hospitalization required) • symptoms (3 or 4 if irritable mood only) at the same time as criterion A 1. decreased need for sleep 2. increase in risk taking/pleasurable activities 3. pressured speech (more talkative than usual) 4. grandiosity or inflated self-esteem 5. extreme distractibility 6. Flight of ideas, racing thoughts 7. increase in goal directed behavior/psychomotor agitation • marked impairment • 3 of 7 symptoms if euphoric mood, 4 of 7 symptoms if irritable mood only • at least 1 week duration = BP I • at least 4 days = hypomania = BP II • psychosis or hospitalization = BP I

Behavioral inhibition

• a lab-based temperamental construct • the tendency to be unusually withdrawn or timid and show fear and withdrawal in novel and/or unfamiliar social and nonsocial situations • those who are withdrawn in social situations only are considered "shy" • both behavioral inhibition and shyness are associated with anxiety disorders in both children and adults • the tendency to approach or withdraw from novelty is an enduring, temperamental trait • studies of children who are behaviorally inhibited are more likely to have multiple psychiatric disorders and two or more anxiety disorders (avoidant d/o, separation anxiety d/o, agoraphobia) • behavioral inhibition is a risk factor for the development of anxiety disorders in children

ASD etiological theory of amygdala

• amygdala is important in fear conditioning, memory consolidation, generation of emotional responses, key to social learning • possibility of having fewer neurons in the amygdala of people with autism • possibility of autism as a degenerative process that occurs later in life and leads to neuron loss • difficulties in identifying emotions (given eyes) • those with autism were slower at identifying emotions, and spent less time looking at eyes • avoidance of eye contact

historical differences between anorexia nervosa and bulimia nervosa

• anorexia is a misnomer - it means lack of appetite (which is usually rare, anorexics are hungry) • hysterica - nervous reaction • thought to result from uterus running around the body • treatment - take out uterus • not simply a product of the modern society • both anorexia nervosa and bulimia nervosa patients share an intense preoccupation with body weight and shape • bulimia - ravenous hunger

ASD changing epidemiology and explanations

• autism is ubiquitous, occurring all over the world • current CDC estimates 1:100 • delays in diagnosis result in an average of 1.5 years from time parent first reported odd speech problems or social deficits, typically around the age of 3 • gender ratio of 4:1::male:female • are increasing numbers real or just the result of "switching" diagnoses • familial patterns are well established: child born into family with autistic child has 8-9% chance of having autism • twin studies show 60-85% concordance for identical twins vs. 10% for fraternal twins • are we better at diagnosing it? more inclusive diagnosis? environmental factors?

Risk and protective factors

• behaviorally inhibited young children have a greater likelihood of anxiety disorders in middle childhood • offspring of parents with anxiety disorders have greater risk of anxiety disorder and high levels of functional impairment • insecure attachment relationships with caregivers (specifically anxious/resistant attachment) increases the risk of childhood anxiety disorders

health consequences of Anorexia

• brain and nerves: can't think right, fear of gaining weight, sad, moody, irritable, bad memory, fainting, changes in brain chemistry • hair thins and gets brittle • low blood pressure, slow heart rate, fluttering of the heart (palpitations), heart failure • blood: anemia and other blood problems • muscles, joints, and bones: weak muscles, swollen joints, bone loss, fractures, osteoporosis • kidney stones, kidney failure • low potassium, magnesium, and sodium • constipation, bloating • periods stop, problems growing, trouble getting pregnant, if pregnant, higher risk for miscarriage, having a C-section baby with low birthweight, post-partum depression • skin bruises easily, dry, growth of fine hair all over body, get cold easily, yellow skin, nails get brittle

warning signs of drug and alcohol abuse

• changes in school performance (falling grades, skipping school, tardiness) • changes in peer group (hanging out with drug-using, antisocial, older friends) • breaking rules: home, school, community • affect changes: mood swings, depression, irritability, anger, negative attitude • activity level: sudden increases or decreases • withdrawal from family: secretiveness • changes in physical appearance (weight loss, lack of cleanliness, strange smells)

vulnerabilities to developing anxiety

• children who are passive, shy, fearful, and avoid new situations at 3 and 5 years are more likely to exhibit anxiety later in life • girls tend to endorse more anxiety symptoms than boys • younger children are more likely to experience anxiety symptoms than older children • anxious children interpret ambiguous situations in a negative way and may underestimate their competencies

Selective Mutism

• consistent failure to speak in specific social situations (in which there is an expectation for speaking, eg. at school despite speaking in other situations) • duration of at least one month with significant disturbance • associated features include: shyness, fear of social embarrassment, social isolation, and withdrawal, clinging, negativism, temper tantrums, and oppositional behavior (esp at home) • teasing by peers is common • although affected children usually have normal communication skills, SM is occasionally associated with a communication disorder • <1% of kids seen in mental health settings • onset usually before age 5

negative health effects of alcohol

• dehydration, addiction, accidents and injury, depression and psychosis, ulcers, cancer of mouth/throat/stomach, cirrhosis, brain damage, pancreatic damage, decreased fertility, fetal alcohol syndrome, high blood pressure, increased risk of breast cancer, decreased frontal cortex - brain shrinks

ASD domain 2: communication

• delay or lack of language development • impairment in ability to initiate or sustain a conversation • stereotyped, repetitive, or idiosyncratic use of language • lack of spontaneous make-believe or socially imitative play

health consequences of bulimia

• depression, fear of gaining weight, anxiety, dizziness, shame, low self-esteem • cheeks swell, sore • mouth: cavities, tooth enamel erosion, gum disease, teeth sensitive to hot and cold foods • sore, irritated throat and esophagus, can tear and rupture, blood in vomit • anemia • irregular heart beat, heart muscle weakened, heart failure, low pulse and blood pressure • muscle fatigue • stomach ulcers, pain, can rupture, delayed emptying • dehydration, low K, Mg, Na • constipation, irregular pooping, bloating, diarrhea, abdominal cramping • irregular or absent period • abrasion of knuckles, dry skin

Separation Anxiety Disorder (SAD)

• developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by 3 or more symptoms • duration of at least 4 weeks • affected children tend to come form closely knit families • may exhibit social withdrawal, apathy, and sadness or difficulty concentrating when separated • concerns about death and dying are common • these children are often viewed as demanding • adults with SAD are typically over-concerned about their children and spouses • prevalence estimates about 4% in children and young adolescents • more common in 1st degree relatives than general population • symptoms include: difficulty sleeping alone, nightmares with themes of separation, somatic complaints, school refusal • commonly earliest age of onset among anxiety disorders • gender ratios equal • often come from single-parent and low SES homes • nonspecific precursor to a number of adult psychiatric conditions, including depression and any anxiety d/o

increase in prevalence in hospital discharge diagnoses and outpatient diagnoses but no increase in large scale epidemiological studies

• discharge diagnoses • general population lower than outpatient • huge increases in inpatient-outpatient diagnoses in comparison with the general public • great overdiagnosis

influence of early drug/alcohol use

• dramatic relationship between age of first drug use and subsequent drug abuse/dependence • early first use (<13) triples odds of drug dependence in adulthood compared to first use >21 • strongest predictor of drug use is prior drug use • early first use of alcohol (<15) increases the rate of subsequent alcohol abuse/dependence by 6 fold compared to those who first >21 • each year drinking onset is delayed, risk of alcohol dependence is reduced by 14% • if risk factors discovered and treated early and drug initiation delayed --> adolescent SUDS can be prevented

etiology of eating disorders (psychosocial)

• early psychological theories proposed that anorexia represents a phobic avoidance to food and an association with the sexual tensions generated during puberty (women with anorexia aren't very sexual, their bodies are like young girls') • psychodynamic formulations have suggested that anorexic patients have fantasies of oral impregnation • social theories stress the importance of conforming to the American ideal of youth, beauty, and slimness • patients are avoidant of maturational changes (perceived as insurmountable) • aim for the antithesis of puberty - stay young and immature; they experience profound self-loathing, along with the illusion of competence because of the ability to follow rules • they feel incompetent, out of control, and delight in their weight loss because they're really good dieters • unconscious collusion among family members perpetuates the child's symptoms because focus on child diffuses parental conflicts • media cultural emphasis upon being thin cause eating disorders

When do anxiety disorders develop?

• early: separation anxiety, phobias • as you age: social anxiety, panic disorder, generalized anxiety • anxious in all situations: generalized • the usual course of most anxiety disorders is chronic with waxing and waning over time • individuals sometimes trade one anxiety disorder for another over time • commonly those with GAD report they've felt anxious their entire life, over half presenting for treatment report onset in childhood or adolescence, but onset occurring after 20 is not uncommon, chronic but fluctuating course • with panic d/o, attacks become less severe if they occur more often • some anxieties, such as specific phobias, often dissipate with age, but those that persist into adulthood remit only infrequently

most salient characteristics thought to separate BP disorder in children from other psychiatric conditions

• elevated / expansive mood • grandiosity • FOI/racing thoughts

Generalized Anxiety Disorder

• excessive anxiety and worry occurring more days than not for 6 months, about a number of events or activities • person finds it difficult to control the worry • associated with 3 or more of the following (restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance) • somatic symptoms common • autonomic hyper-arousal is less common in GAD than other anxiety d/o • comorbid with mood d/o, anxiety d/o, substance related d/o • in children/adolescents worry often focuses on school, sporting events, punctuality, catastrophic events, children may be conforming, perfectionistic, and overzealous in seeking approval • diagnosed somewhat more in women than men • one-year prevalence 3%, lifetime prevalence 5%, anxiety as a trait has a familial association

Psychoanalysis in the history of child and adolescent depression

• existence of childhood depression prior to 1960 was seriously doubted because it was felt that children's immature superego would not permit the development of depression • superego: moral compass dictated by society • thought that depression was a result of intrapsychic conflict between the ego and a persecutory superego • thought that superego was formalized only after resolution of the Oedipal conflict (late adolescence)

ASD etiological theory of fusiform area

• fusiform gyrus (medial temporo-occipital gyrus) • lies under temporal lobe • general recognition area for things that people enjoy or like • for autistic kids it might light up for whatever they're passionate about • 90% of information comes from the eyes (not mouth where autistics tend to look) • in non-autistic children, the fusiform gyrus is activated in response to a human face • in autistic children this activation is normal when shown pictures of their mothers but diminished when shown pictures of strangers • may suggest that autistic individuals can be trained to learn better face recognition, thereby improving social skills

etiology of eating disorders (biological)

• hypothalamus (region concerned with the regulation of body functions, such as temperature, weight, appetite, and general homeostasis); support for this theory comes from neurotransmitter studies showing an increase in corticotropin releasing factor (CRF, or CRH) in the CSF of anorexic patients (CRF is secreted by the hypothalamus in response to stress) • when administered to rats, CRF leads to a reduction in food intake, feeding time, and feeding episodes • the occurrence of amenorrhea before weight loss also suggests a hypothalamic disturbance • leptin - satiety hormone, may also have a role • low circulating levels of leptin are associated with key symptoms of anorexia, including amenorrhea and semistarvation-induced hyperactivity • leptin is secreted by adipose tissue and once fat levels drop, no more leptin is released • low levels of leptin are associated with anorexia • amenorrhea happens because you don't have enough body fat - if you can't take care of your own body, you can't take care of a baby • ghrelin - tells you when you're hungry • endocrine system is affected • central neurotransmitter system disregulation affecting 5HT, DA, NOREPI, strongest evidence supports reduced NOREPI activity and turnover • dopamine levels increase with vomiting, reinforcing the vomiting behavior

ASD domain 1: social interaction

• impairment in non-verbal behaviors • poor peer relations • lack of spontaneous sharing • lack of social or emotional reciprocity

differentiating "expected" anxiety from "disorders"

• intensity: is the degree of distress unrealistic given the child's developmental stage and the object/event? • impairment: does the distress interfere with the child's daily life? (social functioning: unable to make friends, academic functioning: failing classes, family functioning: creating conflicts, limiting family choices) • ability to recover: is the child able to recover from stress when the event is not present? (tend to worry about future occurrences of event/object, distress occurs across multiple settings)

hippocampus role in anxiety d/o

• involved in the storage of sensory information and is very sensitive to stress • threat alters the ability of the hippocampus and connected cortical areas to store certain types of cognitive information (verbal) but not nonverbal information • many of the cognitive distortions that are associated with anxiety disorders may be related to anxiety related alterations in the tone of the hippocampus and associated cortical areas

Theories of how fears develop

• learned responses • most specific fears (phobias) are related to paired or mis-paired internalization of cues with anxiety from previous experience • some anxieties may involve genetically fixed patterns developed over eons of evolution • during infancy and childhood, children mirror their caretakers' responses when interpreting internal state of pain, arousal, and anxiety • over time children may come to label a host of external cues as potentially threatening and certain internal sensations as fearful; the hypothesized mechanism of GAD, specific phobias, and some types of PTSD

ASD etiological theory of mirror neurons

• located in the inferior frontal gyrus, active when monkeys perform a task or watch someone perform a similar task • important for learning skills by imitation • may simulate observed actions and contribute to Theory of Mind skills • fMRI shows decreased MN activity in autistic children • may teach emotional engagement

mortality rates with AN, increased risks associated with BN

• long-term follow-up studies of anorexics show death rates of over 10% after 10 years and 18-30% at 30 year follow-up • highest mortality rate in psychiatry • 50% deaths due to complications of anorexia, 25% die by suicide, 25% of unrelated causes • fewer than 25% have good psychological outcome • poor outcome is generally associated with a longer duration of illness, older age at onset, prior psych hospitalizations, poor premorbid adjustment, comorbid personality d/o • prognosis of bulimia is better than anorexia: 50% recover, 25% improve but still suffer symptoms, 25% remain chronically ill • mortality rate due to bulimia is 1-6% after many years follow-up • relatively few bulimics become anorexic (only 15% after long-term follow-up

ADHD vs. bipolar symptoms

• mania: elevated/ expansive mood (NOT IN ADHD) • irritability (common in ADHD) • grandiosity (NOT IN ADHD) • decreased need for sleep (mild in ADHD, restless sleep) • more talkative (CRITERIA for ADHD) • FOI/racing thoughts (NOT IN ADHD) • hyperactivity / goal directed (CRITERIA for ADHD) • high risk activities (common in ADHD) • distractibility (CRITERIA for ADHD)

Social Anxiety Disorder

• marked and persistent anxiety in social or performance situation due to fears of rejection or embarrassment, must be present at least 6 months • prevalence 5% of children • usually described as painfully shy 1. avoidance of social situations 2. feels: scared or uncomfortable in social situations 3. difficulty: answering questions in class, reading aloud, initiating conversation, talking with unfamiliar people, and attending parties and social events 4. when they are not in social situations, they do not experience this anxiety, unlike GAD, when the anxiety is always there 5. person recognizes that the fear is excessive or unreasonable (children may not recognize) • may be inherited • behaviors learned from role models, overprotection by parents may cause social anxiety • life events and experiences - if a shy person is exposed to a stressful event, this may make them more shy, or if they feel pressure to interact, they may feel constantly criticized and will expect to be judged negatively by others, and be afraid to make mistakes and evaluated negatively by others • women>men • lifetime prevalence: 3-13% • 40% of social phobias start before the age of 10 and 95% before the age of 20

Clinical course of child/adolescent depression

• median duration: clinically referred: 7-9 months; community: 1-2 months • 90% of MDD episodes remit within 1-2 years after onset (where remission is 2 weeks - 2 months with only 1 clinically significant symptom • 50% relapse • 6-10% of MDD are protracted

Genetics in depression

• moderate genetic influence on depression • twin/adoption studies not conducted • children with a parent who suffered from depression as a child are up to 14x more likely than controls to become depressed prior to age 13 • children of parents with depression have about 2-4x the risk of having depression • children of depressed parents have an earlier age of onset for their depression by 3 years • lifetime history of MDD in mothers of children with MDD is high (50-75%) • family history of depression is more common in 1st degree relatives of children with MDD than in children without MDD

Developmental variants of MDD (Adolescents)

• more cognitive components to their depression than children • guilt and hopelessness become apparent • more sleep and appetite disturbances, delusions, suicidal ideation, and attempts • compared to adults, still more behavior problems and fewer neurovegetative difficulties

the role of education in drug abuse/addiction

• more education, better about our chances of life so we don't turn to addictive substances • illicit drug use is lower for college graduates (5.1%) than those who do not graduate from high school (9.3%), high school graduates (8.6%), and those with some college (8.9%) • by contrast, college graduates are more likely to try illicit drugs in their lifetime than adults who have not completed high school

Developmental variants of MDD (Children)

• more symptoms of anxiety (phobias, separation anxiety), somatic complaints, and auditory hallucinations • depression is expressed as temper tantrums and behavior problems • fewer delusions and serious suicide attempts • by middle childhood preoccupations w/ death, lowered self-esteem, social withdrawal/rejection, & poor school performance

the gateway concept

• people who use marijuana usually try something else first (cigarettes and alcohol) • alcohol is a gateway drug • when something is illegal, you're less likely to go to that right away

atypical presentation of child bipolar disorder

• predominant mood often irritable • irritability may be persistent, severe, violent • "complex cycling" (>80% are rapid cycling) • ultrarapid (5-364 cyc/year) • ultradian (>365 cyc/year) • ultradian cycling is not considered an episode or cycle of mania, hypomania, or depression per DSM comorbidity and family history of bipolar are common (15% of 1st degree relatives) • poor treatment response and recurrence

ASD domain 3: behaviors, interests, & activities

• preoccupation with stereotyped and restricted patterns of interest • inflexible adherence to specific and nonfunctional rules, routines, or rituals • stereotyped and repetitive motor mannerisms • persistent preoccupation with parts of objects

Predictors of good outcome

• prognosis is highly dependent upon the level of functioning 1. low functioning: verbal and nonverbal IQ<70 (50% of affected children) 2. mid-functioning: nonverbal IQ>70 but verbal IQ<70 (25% of affected children) 3. high functioning: verbal and nonverbal IQ>70 (25% of affected children) • factors related to outcome: • IQ by age 5-6 years • communication skills by age 5 • early educational intervention • some children with autism show improvement in adolescence which is related to good adult outcome: activity level usually decreases, behavior becomes more manageable, self-help skills improve, communication continues to develop, IQ usually remains stable, usually become more social • a large percentage (10-25%) of children will develop seizures as they age

Describe at least 3 theories of depression

• psychodynamic: anger turned inward; severe superego • attachment: insecure early attachment • behavioral: inability to obtain reinforcement • cognitive: depressive mindset • self-control: deficits in self-monitoring, self-evaluation, and self-reinforcement • interpersonal: characteristic to individual, roles and events • socioenvironmental: stressful life circumstances exacerbate vulnerabilities • neurobiological: neurochemical, endocrine, and receptor abnormalities

dopamine theory of addiction

• rapid, early physical and social changes that create emotion-based motivations (emotional capacity: drives and emotions, sensation seeking, risk taking, sensitivity to rewards, low self control) • gradual, later development of affect regulation and maturation of cognitive/self-control skills (cognitive capacity: planning, logic, reasoning, inhibitory control, problem-solving skills, capacity for understanding long-term consequences of behavior) • dopamine is high, and serotonin is low • ventral tegmental area-nucleus accumbens pathway is activated by all drugs of dependence • this pathway is important not only in drug dependence, but also in essential physiological behaviors such as eating, drinking, sleeping, and sex

DSM-5 diagnostic criteria Bulimia

• recurrent episodes of binge eating (eating in a discrete period of time an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances, a sense of lack of control over eating during the episode • recurrent inappropriate compensatory behaviors in order to prevent weight gain (self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise) • the binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months • self-evaluation is unduly influenced by body shape and weight • the disturbance doesn't occur exclusively during episodes of AN

Trichotillomania

• recurrent pulling out of hair resulting in noticeable hair loss (head, eyebrows, and eyelashes most common, but also axillary, pubic, perirectal) • an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior • pleasure, gratification, or relief when pulling out the hair • may occur in episodes scattered throughout the day or in less frequent but sustained periods lasting for hours • often occurs during periods of relaxation and distraction (but may occur during stress as well) • examining the hair root, twirling it off, pulling strand between teeth, or eating hair may occur • histological examination of affected areas shows damage to hair follicles and short, broken hairs • no gender differences among children; women > men • occurrence is unknown; 0.6% lifetime rate among college students • affected individuals deny hair pulling • may pull hair from pets, dolls, or clothes

Relapse of Depression

• relapse is an episode of MDD during a period of remission • 40-60% of youth with MDD experience relapse after successful treatment of acute episode (indicates the need for continual treatment • predictors for relapse: natural course of MDD, lack of compliance, negative life events, rapid decrease/discontinuation of therapeutic treatment

DSM-5 diagnostic criteria Anorexia

• restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental history • intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though underweight • disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight • discrepancy between weight and perceived body image is key to diagnosis of anorexia • changes in hormone levels, in females, result in amenorrhea (delay in sexual development) • driven to lose weight because they experience themselves as fat

familial transmission/genetics

• risk of AN among mothers and sisters of probands is 3% or 6x the rate among general population • twin registry study confirms that BN and AN are related • monozygotic twins show concordance of up to 90% for AN and 83% for BN • nearly all women in western society diet at some point in adolescence or young adulthood, yet fewer than 1% devlop AN

ASD etiological theory of diet

• some kids with PDD will show symptom improvement when gluten (wheat) and casein (dairy) are removed from diets • said that gluten and casein can be difficult for kids to digest and metabolites of problems may include opioid like substances • opioids can be tested in urine, some PDD children with self-injurious behavior have been found to have higher levels of opioids in their urine • naltrexone (opioid blocker) not really helpful

ASD etiological theory of basal ganglia

• stereotyped, ritualistic, repetitive motor behaviors and difficulties with environmental changes (similar to OCD and TS) • contrast "passion" or "desire" with feeling compelled • egosyntonic vs. egodystonic • functional and structural abnormalities of BG are present in these disorders, specifically the caudate nucleus

protective factors for drug abuse

• strong bonds with family • parental monitoring (clear rules of conduct within the family, involvement of parents in children's lives) • success in school performance • strong bonds with pro-social institutions (family, school, religious organizations or spiritual practice) • exposure to use prevention programs • adoption of conventional norms about drug abuse

The serotonin gene

• suicidal thoughts and intent: levels of major serotonin metabolite (5-HIAA) are lower in cerebrospinal fluid • adults with one or two copies of the short allele of the 5-HT transporter gene have been shown to exhibit more depressive symptoms, diagnosable depression, and suicidality in relation to stressful life events • short allele leads to reduced transcription of the 5-HT receptor and less serotonin uptake

methods of purging

• throwing up • laxatives • diuretics - makes you pee • enema - liquid into butt hole :(

Factors that increase the risk of bipolar disorder among children/adolescents with depression

•20-40% of depressed children & adolescents develop bipolar disorder within 5 years of index episode of MDD Predictors of Bipolar I Disorder: • early onset MDD • psychomotor retardation • psychotic features • family history of bipolar disorder • family history of psychotic depression • heavy familial loading for mood disorders • pharmacologically induced (hypo)mania