Behavioral Health Disorders
Treatment for Obsessive Compulsive and Related Disorders
-check of suicidality -psychotherapy -medications → Fluoxetine, Sertraline, Paroxetine, Citalopram
Age for conduct disorder
10y/o and younger
Autism Spectrum Disorder is typically diagnosed between what ages?
12-24months
Perpetrators involved in child abuse were between the ages of
18-44y/o
70% of deaths from child abuse were kids younger than
3y/o
Most children have a presentation of abuse before what age
7 months
In order to fit the DSM5 criteria for ADHD we have all except: A.Has to be impairment in one place (home or school) B.Has to be impairment in both places, home and school C.Needs 6 or more symptoms D.This impairment doesn't coincide with other psychological disorders
A.Has to be impairment in one place (home or school)
Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
ADHD
Manifested by diminished speech output.
Alogia
Decreased ability to experience pleasure from positive stimuli or a degradation in the recollection of pleasure previously experienced
Anhedonia
Conduct disorder can develop into _______
Antisocial personality disorder
Pervasive pattern of disregard for and violation of the rights of others, occurring since age 15
Antisocial personality disorder
•Repeated criminal activity- failure to conform to social norms of lawful behavior •Deceitfulness, lying, use of aliases, conning of others for personal profit or pleasure •Impulsivity or failure to plan ahead •Irritability and aggressiveness manifested in repeated fights or assaults •Reckless disregard for safety of self or others •Consistent irresponsibility in work or financial obligations •Lack or remorse, indifference to suffering of others
Antisocial personality disorder
Treating _______ and _______ improves somatic complaints
Anxiety and depression
Teleiophilia
Attraction to adults
Persistent deficits in social communication and social interaction across multiple contexts, as manifested by *ALL* of the following, currently or by history: •Deficits in social-emotional reciprocity •Deficits in nonverbal communicative behaviors used for social interaction Deficits in developing, maintaining, and understanding relationships Restricted, repetitive patterns of behavior, interests, or activities, as manifested by *AT LEAST TWO* •Stereotyped or repetitive motor movements, use of objects, or speech •Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior •Highly restricted, fixated interests that are abnormal in intensity or focus •Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment Symptoms must be present in the early developmental period
Autism spectrum disorder
•Avoids interpersonal contact for fear of criticism or rejection •Avoids interpersonal relationships unless certain of being liked •Restraint with intimacy for fear of shame or ridicule •Preoccupation with criticism or rejection in social situations •Inhibition in new interpersonal situations •Self image: socially inept, unappealing or inferior •Avoids personal risks, new activities for fear of embarrassment
Avoidant personality disorder
ADHD can be diagnosed as young as: A.2 B.4 C.6 D.1
B.4
FDA approved meds for Autism include: A.Antidepressants-SSRI like Prozac B.Antipsychotic like Risperadone C.Attention Deficit Meds like Methylphenidate D.Alpha 2 agonists like clonidine
B.Antipsychotic like Risperadone
The MCHAT R/F screening is filled out by: A.Certified professional B.Parents C.School psychologist D.Developmental pediatrician
B.Parents
Age for Disruptive Mood Dysregulation Disorder
Before 10 years of age, but not < 6 years
Treatment for oppositional defiant disorder
Behavioral therapy
Borderline personality disorder is commonly misdiagnosed as _______
Bipolar disorder
•Preoccupation with 1+ perceived defects or flaws not observable by others •Has performed repetitive behaviors •Mirror checking •Excessive grooming •Skin-picking •Comparing appearance to others
Body dysmorphic disorder
Most common personality disorder in the psychiatric population
Borderline personality disorder
•Frantic efforts to avoid real or imagined abandonment •Unstable and intense interpersonal relationships •Alternate between extremes of idealizing and devaluing people •Identity disturbance- unstable self image •Impulsivity in at least 2, potentially self-damaging areas: •Spending, Sex, Substance abuse, reckless driving, binge eating •Recurrent suicidal ideation, gestures, threats or self mutilation •Affective instability- marked mood reactivity •Chronic feelings of emptiness •Inappropriate, intense anger or difficulty controlling anger •Transient, stress-related paranoid ideation or severe dissociative symptoms
Borderline personality disorder
What is the most common sentinel injury
Bruising TEN 4 FACESp
What labs are involved in a child abuse workup
CBC Cogaulation studies AST, ALT or lipase Urinalysis Bone labs
What can be added to SSRIs (fluoxetine, sertraline, paroxetine, citalopram) for a patient with OCD that the medication alone is not enough?
CBT composed of exposure with response prevention *recommended as first-line treatment anyway
Treatment of choice for schizotypal personality disorder
CBT, individual or group therapy
Passive induction of a posture held against gravity
Catalepsy
Encompasses any sexual act involving a child that is intended to provide sexual gratification to a parent, caregiver, or other individual who has responsibility for the child. includes activities such as fondling a child's genitals, penetration, incest, rape, sodomy, and indecent exposure, noncontact exploitation of a child by a parent or caregiver— for example, forcing, tricking, enticing, threatening, or pressuring a child to participate in acts for the sexual gratification of others, without direct physical contact between child and abuser
Child sexual abuse
The patient is alert, irritable, restless on presentation. Vital signs: 115 HR, 166/95 BP, dilated pupils, yawning and piloerection. What is the recommended treatment?
Clonidine
•Suspects, without sufficient basis, others are harming, exploiting or deceiving them •Preoccupied with unjustified doubts about loyalty or trustworthiness of friends or associates •Reluctant to confide in others- fear info will be used maliciously against them •Reads hidden meanings/ threats into benign remarks or events •Persistently bears grudges •Perceives attacks on character, not apparent to others; quick to react angrily •Recurrent, unfounded suspicions of spouse/partner infidelity
Cluster A: paranoid
•Repetitive behaviors (e.g., hand washing, ordering, checking) •Mental acts (e.g., praying, counting, repeating words silently) •Person feels driven to perform in response to an obsession •Must rigidly follow "rules" •Behaviors or mental acts aimed at reducing distress or preventing some dreaded event or situation
Compulsions
A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated
Conduct disorder
Antisocial personality disorder occurring younger than 18y/o equals
Conduct disorder
Oppositional defiant disorder may progress to _____
Conduct disorder
≥1 symptoms of altered voluntary motor or sensory function that suggest a neurological or general medical condition
Conversion disorder
Prevalence of Autism is: A.1/100 B.1/1000 C.1/50 D.1/68
D.1/68
Vanderbilt scale screen for except: A.Attention issues B.Hyperactivity C.Oppositional symptoms D.Learning disabilities E.Anxiety
D.Learning disabilities
The presence of one (or more) delusions with a duration of 1 month or longer and criteria for schizophrenia had never been met
Delusional disorder
Beliefs that conflict with reality.
Delusions
Positive symptoms of schizophrenia
Delusions and hallucinations
•Trouble with everyday decisions- need for excessive advice, reassurance •Needs others to assume responsibility for most major areas of his/her life •Difficulty disagreeing with others for fear of losing approval or support •Difficulty initiating projects, doing things independently due to low self-confidence •Goes to excessive lengths to obtain nurturance and support from others (ex. Volunteering for unpleasant things) •Uncomfortable, helpless when alone due to exaggerated self-doubt •Urgently seeks another relationship when close relationship ends •Unrealistic fears of being left to care for self
Dependent personality disorder
Experiences of unreality or detachment from one's mind, self, or body
Depersonalization
Characterized by clinically significant persistent or recurrent depersonalization and/or derealization
Depersonalization/derealization disorder
The individual may switch from one topic to another
Derailment
Experiences of unreality or detachment from one's surroundings
Derealization
Negative symptoms of schizophrenia
Diminished emotional expression and avolition alogia, anhedonia, and asociality
A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults, The child has experienced a pattern of extremes of insufficient care
Disinhibited Social Engagement Disorder
Characterized by an inability to recall autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
Dissociative amnesia
Characterized by a) the presence of two or more distinct personality states or an experience of possession and b) recurrent episodes of amnesia. The fragmentation of identity may vary with culture and circumstance.
Dissociative identity disorder
Pattern of abuse behaviors in any intimate or familial relationship that are used to gain and maintain power and control over another person
Domestic violence
First-line therapy for schizophrenia
Dopamine receptor antagonist: -risperidone -olanzapine -quetiapine
Recommended interventions for a child with Autism: A.OT/PT B.Social skills therapy C.ABA D.Speech therapy E.All of the above
E.All of the above
-Thoughts and behaviors (dreams, compulsions, desires, etc.) that are in conflict, or dissonant, with the needs and goals of the ego -In conflict with a person's ideal self-image
Egodystonic
-Behaviors, values, and feelings that are in harmony with or acceptable to the needs and goals of the ego -Consistent with one's ideal self-image
Egosyntonic
ADHD is most identifiable during what age?
Elementary
•Recurrent skin picking resulting in lesions •Repeated attempts to slow down/stop
Excoriation (Skin-Picking Disorder)
Recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors
Exhibitionistic disorder
Recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors.
Fetishistic disorder
Recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.
Frotteuristic disorder
A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6mos duration.
Gender dysphoria
Gender that is insistent, consistent, persistent X 6mos. incongruence with ASAB with significant distress or problems function
Gender dysphoria
When an individual believes that he or she has exceptional abilities, wealth, or fame
Grandiose
Perception-like experiences that occur without an external stimulus.
Hallucinations
What must be ruled out for autism spectrum disorder
Hearing impairment
•Discomfort with not being center of attention •Often inappropriate sexual seductiveness or provocative behavior •Labile/shallow expression of emotions •Uses appearance to draw attention to self •Speech- impressionistic, lacking in detail •Melodramatic, theatrical, exaggerated emotional reactivity •Highly suggestible •Sees relationships as more intimate than they actually are
Histrionic personality disorder
•Persistent difficulty discarding possessions, regardless of value •Due to perceived need to save items or having distress without them •Results in item accumulation that substantially compromises use of living areas
Hoarding disorder
Treatment for avoidant personality disorder
Individual and Group Psychotherapy
Treatment for histrionic personality disorder
Individual psychotherapy is helpful and treatment of choice
Child abuse should be considered for all fractures in what ages
Infants and toddlers
the Pittsburg infant brain injury score takes into consideration what
Infants well appearing, but presenting with: ALTE/BRUE, Seizure/Like Activity, DermAbnormality, Vomiting W/O Diarrhea, Fussy, Poor feeding
Treatment for for reactive detachment disorder
Intensive psychotherapy & occupational therapy is treatment of choice.
Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either: verbal aggression or physical aggression toward property, animal or other individuals 3 behavioral outburst involving damage of destruction to property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period.
Intermittent Explosive Disorder
Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
Kleptomania
Schizophrenia time frame
Lasts for at least 6 months and includes at least 1 month of active-phase symptoms
Brief psychotic disorder time frame
Lasts more than 1 day and remits by 1 month.
Oral injuries to what area is the most common in sentinel injuries
Lips (bruising and lacerations)
Treatment for schizoid personality disorder
Little known about treatment; poor prognosis
Treatment for narcissistic personality disorder
Long-term individual psychotherapy
Age for antisocial personality disorder
MIN 18y/o
Age for voyeuristic disorder
MIN 18y/o
Time frame for conduct disorder
MIN 3 of the criteria in the past 12 months AND at least one criterion present in the past 6 months
Time frame for voyeuristic disorder
MIN 6months
Age for Intermittent Explosive Disorder
MIN 6y/o
No, or very little, verbal response
Mutism
What is the treatment for borderline personality disorder
Naltrexone (opiate receptor antagonist) dialectical behavioral therapy (TOC)
•Grandiose sense of self importance •Fantasies of unlimited success, power, beauty, love, brilliance •Belief that he/she is "special" and unique- can only be understood by, and should only associate with similarly elite individuals •Requires excessive admiration •Sense of entitlement; deserving of special treatment •Interpersonally exploitative •Lacks empathy •Often envious of others or believes that others are envious of him/her •Arrogant, haughty
Narcissistic personality disorder
What is the most common type of child maltreatment
Neglect
• Failure to provide adequate physical care • Failure to provide adequate supervision • Failure to provide emotional support
Neglect
What is the most common combination of child maltreatment
Neglect and physical abuse
•Obsessions, compulsions, preoccupations with appearance, hoarding, hair-pulling, skin-picking, body focused behaviors •Evidence on history, physical, lab findings that symptoms are direct result of medical condition
OCD due to Another Medical Condition
•Recurrent and persistent thoughts, impulses, or images experienced as intrusive and inappropriate •Cause marked anxiety or distress •Person attempts to ignore, suppress or to neutralize them with some other thought or action •Recognizes are a product of his or her own mind
Obsessions
•Are recognized as excessive or unreasonable •Are time-consuming (>1 hour a day) •Significantly interfere with normal routine
Obsessive Compulsive Disorder
•Preoccupation with rules, lists, details, order- "can't see forest from the trees" •Perfectionism interferes with task completion •Excessive devotion to work and productivity to the exclusion of leisure and social interactions •Over conscientious, scrupulous and inflexible on matters of morality, ethics or values •Excessive hoarding of worthless items •Reluctance to delegate or work with others •Miserly spending style •Rigidity and stubbornness
Obsessive compulsive personality disorder
Perpetrators that are involved in child abuse are most commonly
One or both parents
What medication do you avoid with somatic patients
Opiates
Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months, and exhibited during interaction with at least one individual who is not a sibling.
Oppositional Defiant Disorder
Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger).
Pedophilic Disorder
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. Manifested in cognition, affect, interpersonal interactions, impulse control
Personality disorder
Hitting, shaking, burning, beatings. Includes harsh physical punishment inappropriate for the child's age
Physical Abuse
Spontaneous and active maintenance of a posture against gravity
Posturing
What is the treatment for OCPD
Psychotherapy
What is the treatment for somatic patients
Psychotherapy (biofeedback) and SSRIs (duloxetine)
What is the treatment of dependent personality disorder
Psychotherapy is the treatment of choice
Treatment for paranoid personality disorder
Psychotherapy is the treatment of choice -Coping skills -Improving social interaction, communication, self-esteem
Psychotic symptoms are judged to be a direct physiological consequence of another medical condition.
Psychotic disorder due to another medical condition
Deliberate and purposeful fire setting on more than one occasion
Pyromania
A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, A persistent social and emotional disturbance, The child has experienced a pattern of extremes of insufficient care,
Reactive detachment disorder
Somatic patients who have chronic pain, what medication is useful
SNRIs
Mood episode and the active-phase symptoms of schizophrenia occur together and were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms.
Schizoaffective disorder
•1. Neither desires nor enjoys close relationships •2. Chooses solitary activities •3. Little interest in sex with people •4. Takes pleasure in few, if any, activities •5. No close friends/ confidants •6. Indifferent to praise or criticism •7. Emotionally cold, flat, or detached
Schizoid personality disorder
Characterized by a symptomatic presentation equivalent to that of schizophrenia except for its duration (less than 6 months) and the absence of a requirement for a decline in functioning.
Schizophreniform disorder
•Ideas of reference (not delusional) •Odd beliefs, magical thinking that's inconsistent with cultural norms •Ex. Superstition, ESP, fantasies •Unusual perceptual experiences, illusions •Odd thinking/speech (vague, circumstantial, metaphorical, stereotyped) •Suspiciousness or paranoid ideation •Inappropriate or constricted affect •Odd, eccentric, or peculiar behavior •Lack of close friends or confidants •Excessive social anxiety- mostly due to paranoid fears, not self-doubt
Schizotypal personality disorder
Dissociative Fugue
Seemingly purposeful travel or wandering associated with amnesia of identity or important autobiographical info
An injury, suspicious for abuse, reported to have been visible to at least 1 parent before the events leading to the current admission
Sentinel injury
Involvement of adults, adolescents & older children in sex acts with children who CANNOT give consent nor understand what is happening to them.
Sexual abuse
Infantophilia
Sexual attraction to infants
Hebephilia
Sexual attraction to prepubescent children
Ehebephilia
Sexual attraction to pubescent children
Recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors.
Sexual masochism disorder
Recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.
Sexual sadism disorder
Excessive thoughts, feelings, or behaviors associated with the somatic symptoms, as demonstrated by one or more of the following: -Persistent thoughts about the seriousness of the symptoms -Persistent, severe anxiety about the symptoms or one's general health -The time and energy devoted to the symptoms or health concerns is excessive
Somatic symptom disorder
Dependent personality disorder has a higher risk of developing _______
Somatoform disorders
A _______fracture in a non-ambulatory child is concerning
Spiral
Mirtazapine for somatic patients is useful for what kind of anxiety
Stomach pain
No psychomotor activity; not actively relating to environment
Stupor
•Obsessive, compulsive, skin-picking, hair-pulling, or other body-focused repetitive behaviors •Evidence from history, labs, physical exam of BOTH: •Symptoms developed during or soon after substance/medication exposure •Involved substance/medication is capable of producing symptoms
Substance/Medication-Induced OCD
Psychotic symptoms are judged to be a physiological consequence of a drug of abuse, a medication, or toxin exposure and cease after removal of the agent
Substance/medication-induced psychotic disorder
What is cataplexy?
Sudden loss of muscle tone
Answers to questions may be obliquely related or completely unrelated
Tangentiality
Time frame for reactive detachment disorder
The disturbance is evident before age 5 years. The child has a developmental age of at least 9 months.
Age for Pedophilic Disorder
The individual is at least age 16 years and at least 5 years older than the child or children
Treatment for Dissociative Disorders
Therapy and treating concomitant diagnoses
Catatonia requires how many psychomotor features
Three
Number one cause of dissociative identity disorder
Trauma
Treatment for OCD due to Another Medical Condition
Treat the underlying medical condition
•Recurrent pulling out of hair, leading to hair loss •Repeated attempts to slow down or stop pulling
Trichotillomania (Hair-Pulling Disorder)
Autism has been correlated to the use of what medication during pregnancy?
Valproate
Time frame for Intermittent Explosive Disorder
Verbal or physical aggression: twice weekly, on average, for a period of 3 months. Three behavioral outbursts within a 12-month period.
Recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors.
Voyeuristic disorder
Treatment for Substance/Medication-Induced OCD
Withdraw offending agent
Speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization
Word salad
Pharmacotherapy is used in paranoid personality disorder when they also have ______
agitation or anxiety (anxiolytics, antidepressants, antipsychotics)
What is included in domestic violence
animal abuse child abuse elder abuse intimate partner violence family violence teen dating violence
Most common in the prison populations
antisocial personality disorder
Age for personality disorder
at least 18y/o
Time frame for ADHD
at least 6months
Time frame for Exhibitionistic disorder
at least 6months
Time frame for Fetishistic disorder
at least 6months
Time frame for Frotteuristic disorder
at least 6months
Time frame for Pedophilic Disorder
at least 6months
Time frame for Sexual masochism disorder
at least 6months
Time frame for Sexual sadism disorder
at least 6months
Time frame for somatic symptom disorder
at least 6months
What are common sentinel injuries
bruising oral injuries fractures burns
What are mimics of sentinel injuries
cephalometoma, caput succedaneum, subgaleal hemorrhage
What are cutaneous mimics for child abuse
post inflammatory hyperpigmentation cupping petechiae due to ITP
What is the age for ADHD
prior to 12 y/o
What are the red flags in imaging for child abuse
• Classic Metaphyseal fractures • Rib fractures (posterior) • Any fracture in infants • Undiagnosed healing fractures • Subdural or Subarachnoid bleeds w/ no skull fx
What bones are less likely to indicate abuse
• Subperiosteal new bone formation • Clavicular fractures • Linear skull fractures • Long bone shaft fractures
What are the non-accidental areas of bruising in child abuse
• Torso • Ears • Neck • Buttocks • Anus • Genitalia
Cluster B personality disorders
•Antisocial, Borderline, Histrionic, Narcissistic Dramatic, acting out, problem with empathy
Cluster C personality disorders
•Avoidant, Dependent, Obsessive-Compulsive Prominent anxiety and novelty avoidance
Treatment for schizotypal personality disorder
•Cognitive behavioral therapy •Supportive therapy - coping skills •Family therapy •Antipsychotics may be used •Antidepressants or anxiolytics may be indicated
What are red flags in the history or presentation for child abuse?
•Fluctuating or conflicting history •Delay in obtaining care •Failure to thrive •Absent or uninterested caregiver • No or vague explanation for a significant injury • An important detail of the explanation changes dramatically • An explanation that is inconsistent with the presenting pattern, age, or severity of the injury • An explanation is inconsistent with developmental ability
what are the subtypes of ADHD
•Inattentive type •Hyperactive/impulsive type •Combined type
Treatment for antisocial personality disorder
•Individual psychotherapy mood stabilizer
Cluster A personality disorders
•Paranoid, Schizoid, Schizotypal Odd or eccentric
What are the red flags in physical exam for child abuse?
•Torn Frenulum/Oral Bleeding->NA child •ANY bruising in an infant under 4 months •Bruising in the TEN 4 regions •Patterned Bruising •Signs of physical neglect
