Psych 4540

Components of CBT for anxiety disorders include these.

Recognize then modify/challenge anxious thoughts Relaxation Modeling Reinforcement Skills Training Exposure (for OCD, need to add response prevention to the exposure)

Core Components of IPT for Adolescents

Interpersonal Formulation Grief or Loss Interpersonal Role Disputes Interpersonal Role Transitions Interpersonal Deficits Communication Analysis Encouragement of Affect Build Social Support Decision Analysis Communication Analysis --- somewhat parallel to CBT's assertive communication and general social skills training Encouragement of Affect - similar to CBT's affective education, labeling feelings, learning immediate ways to regulate emotions Build Social Support - similar to CBT's behavioral activation Decision Analysis - similar to CBT's problem solving

This disorder has the highest suicide rate of all mental disorders.

1. Bipolar Disorder 2. Panic Disorder 3. Substance Use Disorder 4. Major Depressive Disorder

The core components of IPT for adolescent depression.

Interpersonal Formulation (Grief or Loss; Interpersonal Role Disputes; Interpersonal Role Transitions; Interpersonal Deficits) Communication Analysis Encouragement of Affect Build Social Support Decision Analysis

The specialized form of Cognitive Behavioral Therapy that is very effective in treating patients with Obsessive Compulsive Disorder is abbreviated as ERP, what does it stand for?

1. Excellence in Response Practice 2. Evidence-based Response Prevention 3. Exposure to Relaxation Patterns 4. Exposure plus Response Prevention

Major Depressive Disorder (MDD)

1 or more Major Depressive Episodes No manic or hypomanic episodes Prevalence: @ 2% in children; @7% in adolescents/adults @ 1 in 5 will have a MDE in their lifetime Age and Sex Differences: Less common in preschool and school-age Risk increases with puberty Peak incidence @ 20yo No gender differences until puberty; after puberty, females 2-3x > males LOTS of specifiers now in DSM5 Mild; Moderate; Severe In partial remission In full remission With anxious distress With mixed features With melancholic features With atypical features With mood congruent Psychotic Features With mood incongruent Psychotic Features With catatonia With peripartum onset With seasonal pattern Increases for both genders in adolescence Note that this is when youths become able to evaluate themselves in comparison to others - begin to see self as less competent than others -when really young most children think capable of anything -then begin to see more limitations but don't really compare own limitations with others - not really able to do that complex thinking until around same time as puberty Why difference? Even more striking than with anxiety and yet not present until puberty May be hormonal differences?

Which of the following is NOT a subtype of a specific phobia?

1. animal 2. circumstantial 3. natural environment 4. situational 5. all of the above are subtypes of a specific phobia

Some common examples of compulsions are all of the following EXCEPT:

1. checking 2. contamination 3. cleaning 4. counting

The "cognitive triad" refers to:

1. the three parts of the brain that process information 2. attending to, processing, and interpreting information 3. the three cognitive theorists who have advanced our understanding of depression 4. a depressed individual's negative outlook about one's self, the world, and the future

What is the intent (or goal) of compulsive behaviors?

1. to reduce anxiety 2. to avoid focusing on other things 3. they have no intent or goal 4. to consume time

To be diagnosed with generalized anxiety disorder, a child must exhibit:

1. worry about illnesses and disease 2. worry about separation from parents 3. worry about multiple events 4. worry about academic performance

Rates of Substance Use disorders

2-8% adolescents (12-17 years) meet criteria for abuse or dependence 11-37% adolescents (12-17 years) with another DSM diagnosis meet criteria for abuse or dependence Now let's look at prevalance of alcohol and other drug abuse and dependence 2-8% of adolescents (12-17 yo) meet criteria for substance abuse or dependence 11-37% adolescents (12-17 yo) with other MH problems meet criteria for SUD (SUDs are comorbid with many other disorders, especially anxiety, depression, and Personality Disorders; Many more people with a MDE experience SUD) Still, most who use a substance do not develop a SUD (Most teens who use to not develop SUD) -- So... what causes someone to go from a nonuser or just an occasionaly user / social user / experimenter to abuse or dependence??? SUD more likely the younger the age of first use Delay first experimentation and decrease chance of SUD SUD more likely with increased frequency of use and with deviant peer group affiliation high comorbidity with ADHD and conduct problems Still, most who use a substance do not develop a SUD (Most teens who use to not develop SUD) -- So... what causes someone to go from a nonuser or just an occasionaly user / social user / experimenter to abuse or dependence??? SUD more likely the younger the age of first use Delay first experimentation and decrease chance of SUD SUD more likely with increased frequency of use and with deviant peer group affiliation high comorbidity with ADHD and conduct problems So... what causes someone to go from a nonuser or just an occasionaly user / social user / experimenter to abuse or dependence??? Distal factors are background factors that indirectly affect a person and can generally contribute to a mental disorder. Biological distal factors with respect to substance-related disorders include genetic predisposition and perhaps temperaments such as an impulsive personality. Environmental distal factors include association with deviant peers, problematic family relationships, parental drug use, culture, and early learning and drug experiences. May inherit a risk for substance abuse - Sensation Seeking; Behavioral Undercontrol; Negative Affectivity; Physiological Sensitivity / Reactivity to Specific Substances Personality and Beliefs / Attitudes - Increased sensation seeking: preference for novel, complex and ambiguous stimuli ; Positive attitudes / expectancies about substance use; Striving for adult roles; Little connection / involvement with school activities Family and Environment - Low parental involvement and monitoring; Low parent-child affection and high family conflict ; Low parental expectations for abstaining - parental use and abuse; Association with deviant and substance using peers (high comorbidity with ADHD and conduct problems ) Proximal factors are more immediate factors that directly affect a person and more specifically contribute to a mental disorder. Biological proximal factors include activation of the mesolimbic dopamine pathway upon drug use. Environmental proximal factors include stress, depression, peer pressure, positive expectancies about substance use, and availability of substances. Also consider consequences of drug use, both positive (reinforcers) and negative (punishers). SUD more likely the younger age of 1st use - delay 1st experimentation and decrease chance of SUD

Prevalence of Substance Use Disorder:

2-8% of 12-17 yo meet criteria for substance abuse disorder

Substance Use Disorder

: defined as 2 or more of the following in past 12 months Use more or longer than intended Persistent desire or unsuccessful efforts to cut down/control Spend a lot time getting, using or recovering Craving or strong desire to use substance Failure to fulfill role obligations due to recurrent use Continued use despite social or interpersonal problems exacerbated by use Give up or decrease social, occupational or recreational activities bc of use Recurrent use in hazardous situations Use despite knowledge of having physical or psychological problem caused or worsened by use Tolerance Withdrawal

Characteristics Associated with Anxiety Disorders

Academic Functioning: Normal IQ Lowered performance/achievement Excessive anxiety interferes with performance School refusal leaves them behind Attentional Biases: Hypervigilance to threatening stimuli Misattribution of threat Avoidance of threatening stimuli Note the similarity with ODD / CD, but here the reaction is not aggression but withdrawal and avoidance - perceive self as unable to cope / defend / protect against the threat Social Functioning: Difficulty initiating and maintaining friendships Withdrawal Loneliness Low self-esteem Physical (somatic) complaints: GI Problems: Stomachaches; Vomiting; Diarrhea Muscle Tension: Muscle Aches; Headaches Sleeping Problems: Insomnia; Nightmares; Nocturnal panic High comorbidity among the anxiety disorders Why? Maybe core underlying tendency (e.g., negative affectivity, behavioral inhibition, physiological arousal) High comorbidity with depression Why? Same or different disorder? Does one cause the other? Negative affectivity characterizes both anxiety and depression; more positive affectivity with anxiety

Biological Treatment of substance Related Disorders

Agonists: Drugs with similar chemical composition as abused drug Methadone; Nicotine replacement therapy Antagonists: Drugs that block effects of the drug Naltrexone; Naloxone Aversive Drugs: Drugs that make ingestion of drug uncomfortable Disulfiram Agonists are drugs that have similar chemical composition as the abused drug Methadone for people addicted to heroin or morphine or oxycodone; Methadone clinics, daily; Methadone is a similar chemical composition with opiate drugs and bonds to opiate receptors in the brain; Reduces cravings for the opiate and withdrawal Nicotine replacement therapy, patch (Nicoderm), gum (Nicorette), inhaler, nasal spray; Increase odds of quitting approximately 1.5 to 2 times with and without additional counseling; (573) 884-WELL (9355) to make an appointment to discuss your individual needs. Even if you're not ready to quit, we can answer questions and help you explore options. Your student health fee includes: Unlimited individual counseling appointments to explore options, develop a quit plan, develop relapse prevention strategies, and provide ongoing support. Antagonists are Drugs that block pleasurable effects of an addictive drug Naltrexone (blocks opiate receptors in brain), nucleus acumbens, decrease cravings for alcohol and reduce pleasurable effects; Reduces number of days a person drinks and heavy drinking as well as increase number abstinent days; Naloxone (Narcan) used in emergency rooms to treat opiate overdose Aversive Drugs make ingestion of addictive substance uncomfortable; Disulfiram (Antabuse); No ill effects until drink, then nausea, vomiting, diarrhea; Aldehyde dehydrogenase inhibitor, high levels of acetaldehyde build up quickly; May not take every day but during "high risk times"; Also some effectiveness for cocaine use

Evidence Based Treatments - Anxiety Disorders

Anxiety Disorders are VERY responsive to the EBT options currently available >75% response rates for our most effective treatments Some studies have found 95% response rates when combine effective treatments Relaxation Training Diaphragmatic / Controlled Breathing Progressive Muscle Relaxation Calming Self-statements Cue-controlled Relaxation Guided Imagery Meditation Exposure Graded vs Flooding Imaginal vs In Vivo Modeling vs Participant Modeling Reinforcement vs No Reinforcement Exposure to Thoughts, Images, Situations, Sensations Systematic Desensitization Relaxation Training Heirarchy Generation Graded Exposure using Relaxation Skills

Generalized Anxiety Disorder

Anxiety/worry about many events and activities Must be excessive; hard to control; persistent (>6months); occur most days; impairing Also see...restless or on edge; irritability; fatigue; muscle tension; trouble sleeping; trouble concentrating 1-3% of children/adolescents 2x more in females Usual onset as adult but report having it "as long as I can remember" High co-morbidity with depression; other anxiety Rule out question often used: Are you a worrier? Must occur more days than not Worry excessively about minor everyday occurrences - out of proportion to likelihood of event or impact of event Must last >= 6 months Must find it hard to control their worrying physical sx include headaches, stomachaches, muscle tension, trembling) worry about school, friends, athletic performance, health, money, things on the news, stuff kids don't usually worry about They overestimate likelihood of events happening to them (e.g., 10 yo who would not go for a hike with girl scouts bc of possibility of cougar attack) Talk about my case who worried about everything and it changed all the time - very smart and precocious and would look things up and then get worried about them - very attentive to scary things (mom is overweight - that is assoc with heart attack - mom might die, etc) Worry so much they have a hard time concentrating at school - need to differentiate from ADHD GIVE EXAMPLE HERE OF MY FIRST GAD CASE - WORRIED ABOUT EVERYTHING, ALSO HAD COMORBIDITY WITH SAD, a couple specific phobias (elevators-situational, and getting sick, and choking) AND PANIC ATTACKS (BUT NO FULL PD YET), (2) THE GRANDMOTHER COMING OVER TO MAKE SURE THE DAUGHTER AND GRANDDAUGHTER WERE OK BC DIDN'T ANSWER PHONE FOR 2 HOURS

CBT Conceptualization

Are thoughts, feelings, and behavior are all interconnected.

The criteria for a MDE.

At least 2 weeks with at least 5 most of the day, most days: depressed mood (irritable mood)*** diminished interest/pleasure in activities*** poor appetite or overeating, significant weight gain/loss (failure to make expected gains) insomnia or hypersomnia psychomotor retardation or agitation fatigue or loss of energy feelings of worthlessness or inappropriate guilt difficulty thinking or concentrating thoughts of death or suicidal ideation

DSM 5 Major Depressive Episode

At least 2 weeks with at least 5 most of the day, nearly every day: depressed (or irritable) mood** diminished interest/pleasure in activities** poor appetite/overeating, significant weight gain/loss (failure to make expected gains) insomnia or hypersomnia psychomotor retardation or agitation fatigue or loss of energy feelings of worthlessness or inappropriate guilt difficulty thinking or concentrating or making decisions Recurrent thoughts of death or suicide Description: depressed mood (in children, it can be predominantly irritable mood)*** (Intense depression - can't snap out of it; Excessive crying; Irritability / anger diminished interest/pleasure in activities*** (Anhedonia - things aren't fun anymore; Social withdrawal) poor appetite or overeating, significant weight gain/loss (in children, can be failure to make expected gains) insomnia or hypersomnia psychomotor retardation or agitation (mujst be observable to others - not just subjective feeling tired) fatigue or loss of energy (see lots of Somatic complaints - calling in sick) feelings of worthlessness or inappropriate guilt (also feel hopeless (negative outlook) difficulty thinking or concentrating (Worsened functioning at work; cant make decisions) thoughts of death or suicidal ideation *** at least one of the 5 sx must be one of these two - depressed/irritable mood OR anhedonia ***This must be a change from previous functioning At least 2 weeks with at least 5 most of the day, nearly every day: depressed (or irritable) mood** diminished interest/pleasure in activities** poor appetite/overeating, significant weight gain/loss (failure to make expected gains) insomnia or hypersomnia psychomotor retardation or agitation fatigue or loss of energy feelings of worthlessness or inappropriate guilt difficulty thinking or concentrating or making decisions Recurrent thoughts of death or suicide Description: depressed mood (in children, it can be predominantly irritable mood)*** (Intense depression - can't snap out of it; Excessive crying; Irritability / anger diminished interest/pleasure in activities*** (Anhedonia - things aren't fun anymore; Social withdrawal) poor appetite or overeating, significant weight gain/loss (in children, can be failure to make expected gains) insomnia or hypersomnia psychomotor retardation or agitation (mujst be observable to others - not just subjective feeling tired) fatigue or loss of energy (see lots of Somatic complaints - calling in sick) feelings of worthlessness or inappropriate guilt (also feel hopeless (negative outlook) difficulty thinking or concentrating (Worsened functioning at work; cant make decisions) thoughts of death or suicidal ideation *** at least one of the 5 sx must be one of these two - depressed/irritable mood OR anhedonia ***This must be a change from previous functioning

Persistent Depressive Disorder Dysthymia

At least 2 years (1 year) with depressed mood (irritable) most of the day, most days Plus 2 or more: poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self-esteem poor concentration or difficulty making decisions feelings of hopelessness No more than 2 months (1 month) without depressive symptoms No manic or hypomanic episodes This is a change from DSM IV - it now covers what used to be chronic MDD along with DD For kids, mood can be irritable and duration just 1 year and no more than 1 month without sx Basically same as MDE BUT lasts longer; doesn't require as many symptoms; and we don't see these MDE sx: (1) anhedonia (2) agitation/retardation observable to others (3) worthlessness/guilt, (4) thoughts of death or suicide

Course and prognosis of MDD

Average episode lasts 6-8 months Almost all recover Even after recovery, many still show adjustment and health problems Most experience recurrences High comorbidity with other mood, anxiety, behavior and substance use disorders Increased risk of suicide Developmental Course among youths Show graph to see the marked gender difs with adolescence Comorbidity is common: Manic/Hypomanic episode (Bipolar) or Dysthymia (double depression) Anxiety Disorders ADHD Conduct problems and Disorders Substance Use Disorder

BLUE

B blaning myself L Looking for the bad news U unhappy guessing E exaggerating

BioPsychosocial Etiology- Anxiety Disorders

Bio (genes): Heritability accounts for 1/3 variability in anxiety Inherited general vulnerability, not specific gene for specific disorder Temperament: Innate variation in reaction to novelty (overactive Behavioral Inhibition System) Corticotropin-releasing hormone (CRH) gene associated with proneness to anxiety (overactive Behavioral Inhibition System) Heritability accounts for about 1/3 of variance in anxiety Child is 5xmore likely to develop an anxiety disorder of parent has it. MZ twins more have stronger correlation than DZ twins Heritability especially strong for shy/Social problems, and for OCD Corticotropin-releasing hormone (CRH) gene associated with proneness to anxiety (It works on HPA axis and limbic system to produce increased CRH in nucleus of amygdala, and thus heightened fear in response to stressful situations - these individuals have a stronger fear reaction to potentially dangerous situations) Psychosocial (environment): No empirical support for Psychoanalytic Theory: Freud, Little Hans and horse Empirical Support for Learning Theory: Watson, Little Albert and white rat Attachment Theory: Bowlby, insecure attachment Family: Overprotective, anxious parenting Behavioral Inhibition System: corticotropin-releasing factor systems become hyper-reactive to stress Classical cond got him afraid of rat; operant conditioning (neg reinf) maintained his fear Attachment Theory: Bowlby - need for safety and security is normal, anxiety arises following negative early experiences that teach child the environment is harsh and/or unpredictable Overcontrolling, less likely to grant age-appropriate autonomy, in-your-face parenting, more critical of choices child makes on own encourages child to feel like have to ask parent about everyitnh bc they make bad choices These Parents also expect their child to be anxious and to do poorly - may convey those expectations But which comes first - did child have bad experiences and parent wants to protect them? And, perhaps that style of parenting is needed for a hyper or ODD-prone kid, but bad for an anxious-prone kid - like Malcolm in Middle episode Behavioral Inhibition System: neurobiology is not hardwired by genes but can respond to early stress: corticotropin-releasing factor systems become hyper-reactive to stress Corticotropin-releasing hormone (CRH) systems can become hyper-reactive with severe, early stress (overactive Behavioral Inhibition System)

Bipolar disorder

Bipolar I = 1 or more Manic Episodes Note: Usually also have 1 or more Major Depressive Episodes but not required for dx Bipolar II = Hypomanic Episode + Major Depressive Episode Cyclothymia = numerous episodes of hypomanic sx and numerous episodes of depressive sx over 2 years (1 year) NO full-blown Hypomanic, Manic or Major Depressive Episodes High risk for switching to BDI or BDII Bipolar I : 1 or more manic (or mixed) (do not actually need to experience depressive episode) BP I = at least one manic or mixed episode (MDE not required, but typical) Bipolar II : 1 or more hypomanic AND 1 or more major depressive episodes BP II = at least one hypomanic episode and one MDE (with no manic or mixed episodes) Cyclothymic : hypomanic and depressive sx - but do not meet full cx for mania (or mixed) or major depression Cyclothymia = fluctuating periods with hypomanic symptoms and depressive symptoms (with no major depressive, manic or mixed episodes) LOTS of specifiers now in DSM5 Mild; Moderate; Severe In partial remission In full remission With anxious distress With mixed features With rapid cycling With melancholic features With atypical features With mood congruent Psychotic Features With mood incongruent Psychotic Features With catatonia With peripartum onset With seasonal pattern

Graded Exposure

Class Activity Generate exposure heirarchy Conduct an exposure to a feared object or feared sensation Exposure Graph Rate Fear every 1-2 minutes on Graph Often see immediate increase in rating Look for decrease and stabilization of rating - indicates habituation Generate Exposure Heirarchy for Specific Phobia -- Conduct an exposure to a feared object (snake, spider, elevator) Generate Exposure Heirarchy for Panic or Phobia of Vomiting or Choking - Conduct an Interoceptive Exposure

Assessment of Anxiety Disorders

Clinical Interview Standardized Checklists Behavioral Observation Child report is very important

Evidence Based Psychosocial Treatments - Anxiety Disorders

Cognitive-Behavioral Therapy Cognitive Restructuring: (1) Recognize anxious thoughts, (2) Modify/challenge anxious thoughts Behavioral: Relaxation, Modeling, Graded Exposure, Reinforcement, Skills Training Examples Coping Cat (Coping Bear, Coping Koala) Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) Describe CBT for SAD, GAD and Soc Phob since all the same package and very similar Also note that there has been some success with a CBT-like program focused on Social Skills Training and Practice for those with social anxiety and shyness (Work on cognitions; Practice assertiveness and appropriate peer interaction skills)- also for test anxiety will spend some time working on study and test-taking skills - and in public speaking will spend some time improving those skills as well (as become more competent, fell less anxious - practice is good bc you habituate but also good to focus on skill enhancement as well to feel more competent and self-assured and less open to anxious thoughts) Describe treatment for PTSD and child sexual abuse - relaxation and exposure to anxiety-provoking thoughts about the event (imaginal exposure), can also include "re-writing" the event while thinking about it in order to change how feel about it - how helpless etc This a big part of all CBT although the particular types of unrealistic thoughts, and thus the particular challenges vary depending upon the clients problems Cognitive restructuring proceeds through the following steps: Identify / recognize / monitor automatic thoughts, What am I thinking, saying to myself? Challenge (examine evidence for) automatic thoughts, How realistic is this thought? Often the therapist will suggest conducting behavioral experiments to test the truth of their thoughts (e.g. ask if that is what they meant, try being late and see if the world collapses) Challenging leads naturally into Replace negative, dysfunctional, unrealistic thoughts with more positive, adaptive, realistic thoughts Here is an example... Note that it is NOT replacing negative with positive, rather its unrealistic with realistic - don't candy coat -- with anxiety and depression there is tendency to exaggerate the bad With some situations, you may need to emphasize the function of the belief/thought, (e.g., they steadfastly insist it is true, get into how helpful it is to think that way. Family Anxiety Management (FAM) Parent/family add-on to child CBT (1) psychoeducation (2) behavioral parenting skills (3) family communication and problem solving skills (4) personal anxiety management Parents not blamed for problem, but involved in solutions May result in larger, longer-lasting effects than child-only CBT Some research suggests that this works better than child CBT alone (note that parents are always involved in child's tx but here it would be much more so). These stronger effects seem especially true for those cases where one of the parents had their own significant levels of anxiety. CBT vs CBT+PAM --- they were equal in child anxiety only cases (about 80% response); in cases where both child and parent had anxiety the CBT+PAM was waaaaay better (almost 80% response vs 40% response). (1) Psychoeducation about anxiety, about child development, about family interaction styles and how people can influence and "train" each other (reinforcement patterns etc) (2) behavioral parenting skills to help child with their anxiety - stop inadvertently rewarding anxious/avoidant behavior, start rewarding courageous behavior, planned ignoring for whining or trying to get out of things they are afraid of (first listen and be empathic but don't allow them to get out of it, and stop paying attention if they keep it up) (3) family interactions, communication, and problem solving especially focused on those interactions around anxious and avoidant child behaviors - how do they react to child's anxiety, how do they currently handle it, what could they do differently to help child cope (4) personal anxiety management - many have own anxiety at subclinical or clinical level and often having their child in treatment and beginning to face fears is anxiety-provoking for them. They may need referral for their own tx as well, but at the very least they often need to learn some basic anxiety management skills to use on themselves in order to cope with child's new behaviors and to be a good coping model for their child

Evidence-Based Treatments for Depressive Disorders

Cognitive-Behavioral Therapy (CBT) Interpersonal Therapy (IPT; with adolescents) Antidepressant Medications (some types, with adolescents) Combination Medication and Therapy AGAIN - less research on depression and depression treatment for kids than ADHD, conduct and Anxiety CBT - talk more in a minute - most researched, programs for kids and teens IPT - couple studies with teens - focus on interpersonal relationships - key factor in initiating and maintaining depression - grief over loss, interpersonal disputes, role transitions, peer and family relationships, plus social skills deficits and unassertive passive style - so the social problem solving and social skills trng in CBT is also a party of IPT Meds - TCAs work with adults but not with kids SSRIs (e.g., prozac) have some positive effects with teens, less so with younger children, but results are not as consistent as with adults - ALSO FDA recently issued warnings and stopped some trials due to problems of INCREASED suicidal ideation in depressed youths taking SSRIs.

The core components of CBT for child and adolescent depression.

Conceptualization and Goal-setting? Psychoeducation re: CBT and depression? Increase Pleasant Activities- behavioral activation? Skills Training: affect regulation (including relaxation); problem solving; social skills? Cognitive Restructuring?

Mood Disorder

Extreme, persistent, or poorly regulated emotional states 2 types in DSM-5: Depressive Disorders Bipolar Disorders Diagnosis determined by episodes Major Depressive Episode (MDE) Manic Episode (ME) Hypomanic Episode (HME) Depressive Disorders: MDD (MDE); Persistent DD (aka Dysthymia); Disruptive Mood Dysregulation Disorder (designed to decrease the overdx of Bipolar in kids -it is basically a diagnosis of (1) CHRONIC IRRITABILITY + (2) FREQUENT TEMPER OUTBURSTS - not covering it this semester) (also premenstrual dysphoric disorder and various substance induced and other categories) Bipolar Disorders: bipolar I, bipolar II, cyclothymia Over time, prevalence is increasing; age of onset is decreasing

Selective Mutism

Consistent failure to speak in social situations where there is expectation for speaking (e.g. school) despite speaking on other situations Must be impairing; persistent (>1month) Must not stem from lack of knowledge/comfort with the language or communication disorder Prevalence 0.5% to 1% (Girls=Boys) Usual onset before 5 yo; rarely referred until school age 90% also meet criteria for Social Phobia Must last >= 1 month, and not just be the first month of school, not be due to language barrier More common in females than males Usually occurs before age 5, but not referred until school age Selective mutism is associated with severe shyness and social anxiety - 90% also meet social phobia cx, and some feel this is just one very extreme way social phobia can be expressed in very young chidren (whereas the more traditional social phobia don't tend to see until puberty) (May be an early or extreme form of Social Phobia (prevalence about 1%)

Characteristics Associated with Mood Disorders

Decreased school/work performance Increased interpersonal difficulties Very high risk for comorbid disorders Other Mood (switching diagnosis) Anxiety Disorders Conduct problems and Disorders Substance Use Disorder Increased risk of suicide (15x general pop) Outlook poorer with younger age of onset, greater number of episodes, more time spent sick Interference with academic performance, but not necessarily related to intellectual deficits; may have problems on tasks requiring attention, coordination, and speed Social difficulties: few close friendships, feelings of loneliness and isolation, social withdrawal, ineffective coping in social situations (problems with peers, family, other adults) Poor relations with parents and siblings families of children with depression display more anger and conflict, greater use of control, poorer communication, over-involvement, less warmth and support, more disorganization, higher levels of stress, and a lack of social support Cognitive disturbances: feelings of worthlessness, attributions of failure, self-critical automatic thoughts, depressive ruminative style, pessimistic outlook, hopelessness, and suicidal ideation Low or unstable self-esteem Suicidal Ideation and attempts:Community Samples of Adolescents: 19.4% suicidal ideation/thought (23.7% female; 14.8% males) 7.1% suicide attempts (10.1% female; 3.8% males) Re-attempt more likely for >2 years (39% males; 33% females) Ideation higher in youths with depression: most depressed youths report at least some ideation Attempts higher in those with mood disorders: 1/4 to 1/3 attempt What is suicidal ideation? Not all youths who attempt suicide are clinically depressed Completed suicide rates are about 1-2 per 100,000 children; 3-15 per 100,000 teens Attempts by males more likely to be fatal Often associated with depressive disorders, suicidal thoughts and behaviors are reported by a substantial number of youth. In a recent administration of the Youth Risk Behavior Survey to a nationally representative sample, 8.5% of the total sample of high school students self-reported having attempted suicide in the past year (many of these were characterized by a low level of lethality), and 16.9% of the total sample reported having seriously considered making such an attempt (Grunbaum et al., 2004). Although suicidality is not limited to youth with depressive disorders, the majority of adolescents with depressive disorders report significant suicidal ideation, and a significant minority report having made a suicide attempt during the course of their depression (Myers, McCauley, Calderon, &Treder, 1991). 1-2 per 100,000 children 3:1 males:females 3-15 per 100,000 adolescents 5:1 males:females 3rd leading cause of death in 15-24 yo 88% attempts preceded by ideation and planning; only 12% impulsive Those with BD account for nearly 25% of all completed suicides - risk is 15x higher than general population Completed Suicides:1-2 per 100,000 children 3:1 males:females 3-15 per 100,000 adolescents 5:1 males:females 3rd leading cause of death in 15-24 yo 88% attempts preceded by ideation and planning (only 12% impulsive) Completion rates much higher among those with mood disorders: 15% ultimately commit suicide Often associated with depressive disorders, suicidal thoughts and behaviors are reported by a substantial number of youth. In a recent administration of the Youth Risk Behavior Survey to a nationally representative sample, 8.5% of the total sample of high school students self-reported having attempted suicide in the past year (many of these were characterized by a low level of lethality), and 16.9% of the total sample reported having seriously considered making such an attempt (Grunbaum et al., 2004). Although suicidality is not limited to youth with depressive disorders, the majority of adolescents with depressive disorders report significant suicidal ideation, and a significant minority report having made a suicide attempt during the course of their depression (Myers, McCauley, Calderon, &Treder, 1991). Lewinsohn et al 1996 and some other sources 15 per 100,000 male adolescents 3.3 per 100,000 female adolescents Not all depressed - vast majority will have some psychopathology but not necessarily clinical levels of depression (rarely occurs with no pathology) Neither selected for depression -both selected for suicide attempt (or Huey actually selected for any psychiatric emergency) Huey's MST study found that MST was better than hospitalization at decreasing future suicide attempts, but not at helping with depression, hopelessness or suicidal ideation (Huey et al 2004) MJ R-B's study in special intervention for suicide attempted helped decrease depression, but did not decrease future attempts

Types of Substances

Depressants: Alcohol, anesthestics for surgery, antiseizure for epilepsy, barbiturate for antianxiety, hynotics for sleep (Ambien, Lunesta) Depressants are sedatives, inhibit the central nervous system, whereas stimulants activate the central nervous system. Alcohol most well known and widely used depressant; Alcohol initally affects a NTs system responsible for inhibition (GABA, gamma aminobutyric acid) Inhibiting a key inhibitory system, leads to Disinhibition, Talk more, dance, "high"; Blood alcohol level - Males and females different dose - Book says start to feel drunk at .08, NOT TRUE, most feel drunk sooner; Binge drinking = 5+men 4+women in 2 hours; Cirrhosis of the liver (Chronic consumption impairs liver's ability to detoxify blood, leading to development of scar tissue and loss of liver function); Korsakoff's syndrome (amnestic disorder from thiamine deficiency because a person drinks alcohol instead of eating a balanced diet; memory problems, confusion, disorientation, Confabulation, creation of fables or stories to fill memory gaps and hide problems); Delirium Tremens (DTs is severe, as many as 5% of individuals will die); Fetal Alcohol Syndrome Stimulants: Caffeine, Nicotine, Cocaine, Amphetamines Caffeine - Over 80% of the world uses caffeine daily - Boosts energy, mood, awareness, concentration, wakefulness; Less harmful than most other substances, but still a drug that leads to tolerance, dependence, and withdrawal (If prone to anxiety, even small doses can cause feelings of anxiety, fear or panic), Consumption of large doses leads to acute caffeine intoxication - Can even die from caffeine consumption, although very rare and requires 50 to 100 cups of coffee per day; Restlessness, nervousness, insomnia, flushed face, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, fast or irregular heartbeat Nicotine - Most cigs have about .5-2 mg nicotine, about 10% absorbed during smoking; Addictive, withdrawal involves restlessness, irritability, concentration and sleep problems; ¼ college students smoke cigarettes regularlyl Largest preventable cause of death in the world! Smoking during pregnancy related to low birth weight, stillbirth, SIDs, Smoking rates declining dramatically in the U.S. in past 40 years, 46% of smokers make attempts to quit each year BUT how many succeed? Only 2.3%; Many individuals say nicotine temporarily relieves tension and helps boost alertness and attention; Fast action makes it highly addictive; Releases DA, directly affecting the brain's pleasure and motivation centers; Withdrawal of cigarettes can last up to a month and will include depressed mood, insomnia, irritability, frustration or anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased appetite, and weight gain Cocaine - Powerful stimulant, Sniffing or snorting crystals, Smoking = crack cocaine, Mix with alcohol or other drugs, Heroin = speed ball; Stimulates DA, NE, and 5HT systems to produce euphoria, mania, bizarre, paranoid, and occasionally violent behavior, Physically addictive, Heart attacks, respiratory failure, death; 9.5% of college students have tried cocaine and 6.6% used in past year Amphetamines - 90% of all amphetamine abuse today involves meth (strong euphoria, enhanced sexual drive and stamina, lowered sexual inhibition; helps stimulate pleasure centers in the brain to release large amounts of dopamine); very addictive; Downsides include brain and liver damage, malnutrition, skin infections, immune system problems, convulsions, stroke, and death; "meth mouth" severe decay or loss of teeth from exposure to the drug's toxic chemical composition; 5.2% of college students have tried with 2.9% using in past year Opiates: Opiates/Opioids/Narcotics, Morphine, Codeine, Heroin (.9% college students have tried heroin, .4% past year) ; Opiate receptors; Sudden "rush" of euphoria; Physical and psychological dependence; Withdrawal effects: Agitation, chills, drowsiness, cramps, vomiting, sweating, diarrhea; PAIN RELIEVERS - OxyContin, Darvon, Vicodin, Percoset (Perscription drugs becoming one of the fastest-growing forms of substance related disorder - 2.5% college students used OxyContin in past year) Hallucinogens: peyote, LSD (lysergic acid diethylamide); Ecstacy (MDMA, methylenedioxymethamphetamine - both a stimulant and a hallucinogen); spurs DA in the brain (cause symptoms of psychosis such as hallucinations, disorganized thinking, odd perceptions, and delirium; Tolerance to LSD develops and dissipates quickly; Withdrawal not common; 12% college students tried hallucinogens, 5.9% past year; 10.2% college students have tried MDMA Marijuana: Cannabis sativa or the hemp plant THC (delta-9-tetrahydrocannabinol); Cannabinoid receptors; maybe be associated with dependence and decreased fertility; 49.1% college students, 33.3% past year; Gateway drug?

Manic Episode

Distinct period lasting at least 1 week (or causing hospitalization) of... (1) abnormally and persistently elevated, expansive or irritable mood and (2) abnormally and persistently increased goal-directed activity Plus at least 3 of the following: Inflated self esteem, grandiosity Decreased need for sleep Pressured speech, talking too much Racing thoughts, flight of ideas Distractibility Psychomotor agitation, excessive energy, increase in goal-directed activity Excessive involvement in pleasurable activities with high potential for negative consequences If mood predominantly irritable (instead of elevated/expansive), then need 4 of those sx Excessive involvement in pleasurable activities with high potential for negative consequences (e.g., reckless behavior, out of control spending, gambling, high-risk sex, investments) Must be markedly impairing, require hospitalization, or show psychoses MANIA: the hallmark of bipolar disorder At least 1 week of abnormal and persistently elevated/expansive or irritable mood with at least 3 of following: Inflated self-esteem/grandiosity Decreased need for sleep Pressured speech (have to keep talking - you can't interrupt them, almost no pauses for breath) Flight of ideas (racing thoughts) (change subject a lot, you can't follow them) Distractibility (move from one thing to another very quickly) Increase in goal-directed activity or psychomotor agitation Excessive involvement in pleasurable activities with high potential for neg consequences (e.g., shopping, sex, business deals) NOTE - they can seem elated and euphoric but if you thwart them or frustrate them, they can turn to anger/tantrum/crying quickly NOTE - can see hallucinations, delusions, psychosis during manic and during depressive episodes (they will be mood-congruent though, and a history should let you know it is bipolar and not schizo) (DURATION NOT IMPORTANT IF GET HOSPITALIZED B/C OF IT)

longterm outcome for people with substance related Disorders

Stability rates of use over 5 years (untreated) : Cigarettes = 96% Alcohol = 82% Cocaine = 74% Marijuana = 66% Other Stimulants = 60% Opiates = 55% Sedatives = 33% SUDS are resistant to treatment and stable over time, success related to quality of treatment, less severe use, commitment to abstinence, treatment tailored to IDs These rates are untreated. Overall, about half of people who seek treatment for a substance-related disorder successfully control the problem, but many people experience severe problems much of their life.

Etiology of OC spectrum Disorders

Empirical evidence suggests strong genetic component to OCD (starting to make headway on identifying specific alleles and chromosomes) Likely inherit neurologic vulnerability - Often see OCD, other anxiety, tics, related dx in family members Rates of OCD are 2x higher for those with any first degree relative with OCD Rates of OCD are 10x higher for those with first degree relative who showed childhood onset of OCD Parents with Tourette's have around a 50% chance of passing the condition on to one of their children however tics are more likely to be expressed in men rather than women. It is also thought that some forms of obsessive-compulsive disorder may be genetically linked to Tourrette's and similarly there is evidence which suggests some forms of Tourette's are linked to attention-deficit hyperactivity disorder (ADHD). PANDAS is a form of OCD and tics or other repetitive behaviors following strep infection sx onset with fever and for weeks or months after strep infection . Can take up to a year to get over compulsions/tics after an infection though - so may prescribe antibiotics on ongoing basis. For those with genetic loading they also see place for environment to influence expression - from not expressing it at all to showing minimal levels to severe

Ethnicity and Culture in Anxiety Disorders

Experience of anxiety, and clinically elevated anxiety, is pervasive across cultures Ethnicity and culture may affect: Outward expression of inward experience of anxiety Developmental course Help-seeking behaviors Rates of fears similar in Af Am and Wh Am, but whites (and higher SES) more likely referred for OCD, Af Am (and low SES) show more PTSD, Hispanic slightly more SAD, Weisz et al found higher rates of referrals for anx in Thailand vs US; but higher rates of referral for beh probs in US Weisz also found higher rates of parents reports of anx/dep problem in Embu (Af country); but higher parent reports of under controlled problem in US (found Thai lower than US on both) When they looked at referrability index (how often referred over prevalance) they found US more likely to refer period. Thai parents more likely to see probs as transient/likely to go away, than US parents (did not ask Embu parents) Behavior + Lens Principle (Weisz) Child psychopathology reflects mix of actual child behavior and the lens through which others view it

Specific Phobia

Fear of specific object or situation 5 subtypes: animal, natural environment, blood-injection-injury, situational, "other" Must be persistent (>6mos) Must be excessive (disproportionate to threat) May not recognize just how unreasonable fear is Must avoid or endure with extreme distress 5% children; 16% adolescents 2x more in girls Usual onset in late childhood (e.g. 10-13 yo) Animal = snakes, spiders, sharks, bugs Environment = heights, the dark, storms, water Blood-injection-injury = getting a shot, seeing blood (fainting common with this one) Situational = elevator, flying, tight enclosed spaces Other = costumed characters (clowns), choking, vomiting, getting an illness (not like hypochondriasis where you think you already have a disease - here you worry you will get it) Note that Children may not realize the fear is extreme and unreasonable Can develop after traumatic experience (e.g. fear of choking after choking experience is common); observing others; by experiencing unexpected panic attack and then developing fear of that situation

Agoraphobia

Fear or anxiety about >1 of these places: public transportation; open spaces; enclosed spaces; lines/crowds; outside of home alone Concern that escape will be difficult or help unavailable if experience panic or other incapacitating embarrassing sx Must avoid; require companion; endure with extreme distress Must be excessive; impairing; persistent (>6months) 1-2% adolescents (rare before puberty) 2x more in females Usual onset late teens to 20yo Agoraphobia is rare without PD (often still have panic attack but not uncued attacks) Now a clearer separate dx (used to be PD with or without AG) public transportation (bus train plane) open spaces (parking lot bridge) enclosed spaces (movies malls) lines/crowds outside of home alone

Separation Anxiety Disorder

Fear or anxiety about being apart from parents Must be developmentally inappropriate; excessive; impairing; persistent (>1month) Often see...refuse to sleep alone; refuse to be alone in room; refuse school, camps, sleepovers; nightmares with separation themes; somatic complaints when anticipate separation; worries about things that would cause separation (e.g. parents dying; child kidnapped or lost) 4% of children; 1.6% adolescents Girls>Boys in community studies but = in clinics Earliest onset of all anxiety dx (e.g. 6-8 yo) Must be age inappropriate Must last >= 4 weeks in kids Must occur before age 18 Must cause significant distress or fx impairment Must have 3 or more sx from dx cx on p 187 of text Distress when - Anticipating or experiencing separation from home or major attachment figures Worry about losing parents or possible harm to them (illness death disaster etc) Worry about something happening to self that would cause separation (kidnap getting lost etc) Reluctance or refusal to go away from home; refuse school camp etc Refuse to sleep alone Refuse to be alone (room by self etc) Repeated nightmares with separation theme Repeated physical complaints when anticipate separation (can dx in adults - overconcerned with their spouse or offspring - need to continuously check on them)

Social Anxiety Disorder (Social Phobia)

Fear or anxiety of social situations Situations are those where individual is exposed to possible scrutiny and negative evaluation Must be excessive and impairing Must avoid or endure with extreme distress Up to 7% of children/adolescents 2x more in girls (but = in clinics) Typical onset early adolescence (e.g. 13 yo) Performance Only: public speaking or test anxiety 1 or more social situations (usually multiple) Worry will do something embarssing or show anxiety and be negatiuvely evaluated or be rejected by others or offend others One subtype to specify - Performance Only (for those who only fear public speaking or test taking) Even though typical onset for diagnosis is 13 years old they are often described as "always shy" Also -- Some do develop it following a bad expereince (so these would NOT be the always shy kids)

Medication Options

For OCD, clear support for SSRIs, fda approval for lucox, prozac, zoloft. Also aproval for 2 tricyclic; anafranil For obsessive compulsive disorder in children and teenagers, FDA has approved only fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine, and clomipramine (Anafranil) . Can use meds alone or in combination with behavior therapy Pediatric OCD Treatment Study Team (POTS, 2004) 3 sites: Duke, Penn, Brown 112 children age 7-17 years with OCD Combination ERP + Sertraline: 54% remission ERP: 39% remission Sertraline: 21% remission Placebo: 3% remission Notes: Superiority of Combination > ERP was not significant ; ERP varied by site: optimal ERP may preclude need for Med The POTS trial provides the only controlled data regarding the efficacy of combined (CBT plus medication) treatment for youngsters with OCD. This trial used a multicenter approach to compare CBT, sertraline (SER), and their combination (COMB) to pill placebo (PBO) in 112 OCD youngsters aged 7-17 years (POTS, 2004). Using an intent-to-treat analytic strategy, all three active treatments significantly outperformed pill placebo. In addition, COMB was found superior to both CBT and SER, results of which did not differ from one another. However, a significant advantage was found for the two CBT conditions using "excellent response" as the outcome (COMB: 54%; CBT: 39%; SER: 21%; PBO: 3%). Study results were tempered by a significant Site x Treatment interaction, where CBT alone was equivalent to COMB at one site but not at the other. Therefore, under certain circumstances, optimal CBT may preclude the need for medication augmentation. The Pediatric OCD Treatment Study, a balanced, masked randomized controlled trial conducted in 3 academic centers in the United States and enrolling a volunteer outpatient sample of 112 patients aged 7 through 17 years with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of OCD and a Children's Yale-Brown Obsessive-Compulsive Scale (CYBOCS) score of 16 or higher. Ninety-seven of 112 patients (87%) completed the full 12 weeks of treatment. Intent-to-treat random regression analyses indicated a statistically significant advantage for CBT alone (P=.003), sertraline alone (P=.007), and combined treatment (P=.001) compared with placebo. Combined treatment also proved superior to CBT alone (P=.008) and to sertraline alone (P=.006), which did not differ from each other. Site differences emerged for CBT and sertraline but not for combined treatment, suggesting that combined treatment is less susceptible to setting-specific variations. The rate of clinical remission for combined treatment was 53.6% (95% confidence interval [CI], 36%-70%); for CBT alone, 39.3% (95%CI, 24%-58%); for sertraline alone, 21.4% (95% CI, 10%-40%); and for placebo, 3.6% (95% CI, 0%-19%). The remission rate for combined treatment did not differ from that for CBT alone (P=.42) but did differ from sertraline alone (P=.03) and from placebo (P.001). CBT alone did not differ from sertraline alone (P=.24) but did differ from placebo (P=.002), whereas sertraline alone did not (P=.10). The 3 active treatments proved acceptable and well tolerated, with no evidence of treatment-emergent harm to self or to others. Exclusion criteria ascertained on the ADIS-C were the presence of major depression or bipolar illness; primary diagnosis of Tourette disorder; any pervasive developmental disorder; psychosis; concurrent treatment with psychotropic medication or psychotherapy outside study; 2 previous failed SRI trials for OCD or a failed trial of CBT for OCD; intolerance to sertraline; any medical or neurologic disorder that posed a contraindication to one of the study treatments or that would interfere with the study assessment protocol; and pregnancy.

In a clinical interview, it is common to ask "Are you a worrier?" to assess for the possibility of this disorder.

General Anxiety Disorder

Etiology of Mood Disorders

Genetics and Neurobiological models Heritability estimates range from 35-75% What is inherited? Neuroendocrine malfunctioning leading to Heightened stress reactivity Greater negative affectivity Several neurotransmitters (serotonin, dopamine, norepinephrine) implicated 65% chance identical twin will have it - so not all genetics - must be some environmental influence Neurobiological models: emphasize the role of genetic vulnerabilities and neurobiological abnormalities - male-femal difs in neuroendocrine system (hormones) What is inherited? Negative Affectivity Genetic and family risk 2-3x more likely to develop depression is parents had it sometime 14x more likely to develop MDD as a child if parent had it as a child Note that this does not mean it is all genetics - env can play big role - mom not very attentive if depressed Twin studies give heritability estimates ranging from .35 to .75 what is inherited is likely a vulnerability to negative affect (depression/anxiety), with certain environmental stressors needed for these disorders to be expressed Neurobiological influences may involve heightened stress reactions - heightened attention to potentially negative stimuli like see in anxiety (notice neg tone of voice etc) amygdala and hippocampus, HPA axis, sleep architecture, growth hormone, and neurotransmitters (serotonin, dopamine, and norepinephrine) have been implicated - much research with adults though and many reasons to think it may not work same way with kids HERITABLE - Bipolar especially is one of the most heritable disorders; 5x more likely to have it if parent has it; probably multiple genes - complex inheritence - Perhaps environment matters DEF OF KINDLING (coined by Goddard in rats with seizures): Many people with Bipolar I have more episodes of mania or depression as time goes on The idea of "kindling" is based on the finding that a region of mouse brain repeatedly exposed to small electric shocks will eventually start to have spontaneous seizure-like electrical events. That is, repeated episodes seem to make subsequent episodes more likely to occur spontaneously. This is precisely the pattern observed in bipolar I If a bipolar person goes untreated for a period of years, he or she could begin to experience rapid cycling, or become treatment-resistant? If stressors initially set off episodes, in time could episodes appear without any such triggers? Research says the answer to all these questions is yes, and the reason may be a process that has been termed "kindling." initial periods of cycling may begin with an environmental stressor, but if the cycles continue or occur unchecked, the brain becomes kindled or sensitized - pathways inside the central nervous system are reinforced so to speak - and future episodes of depression, hypomania, or mania will occur by themselves (independently of an outside stimulus), with greater and greater frequency Because of this potential worsening with time, you should not count on being able to "go back" to a previously effective medication. Though I have not heard it stated as such, as I read the experts, and watching what happens to my patients, the "name of the game" may be to prevent cycling. That might be how you keep from getting worse. If that's true, now you have two reasons to get your symptoms controlled: first, because you'd rather not have symptoms; but also because they could mark a worsening process that you might be able to interrupt with a fully effective treatment Socioenvironmental theories: focus on the relationship between stressful life events and depression (need to exp little stress or have great social support and internal coping skills to get through) Stressful life events - depression is associated with severe stressful life events; triggers for depression often involve interpersonal stress or actual or perceived personal losses Family influences - families of children with depression display more anger and conflict, greater use of control, poorer communication, over-involvement, less warmth and support, more disorganization, higher levels of stress, and a lack of social support -note how it is similar to cognitive theories in that prone to focus on negative, and so at great risk when experience neg life event Psychosocial Models Early psychoanalytic theory Attachment theory Interpersonal Theory Self Control Theory Learning/Behavior Theory Cognitive Theory Psychosocial models focus on Individual differences in personality, cognitions, skills, etc. Differences in family and larger environment Stressful life events Psychodynamic theory: Anger turned inward is short description - depression results from the actual or symbolic loss of a love object - mad at loved one for abandonment/rejection but turn it against self bc would be too terrible to express it outward (superego stops you) - Since Freud felt kids did not have a mature superego, they would not do this and so would not experience. Anger turned inward Children incapable of depression Attachment theory: insecure early attachments, parental separation and disruption of a secure attachment bond are predisposing factors for depression. Unresponsive or emotionally unavailable caregiving leads child to see self as unworthy and unlovable and others as undependable, so at risk for depression esp in response to interpersonal stress Interpersonal theories: Similar to attachment, in that relationships are the key stressors for individual perhaps due to the early parental failure - they view disruptions in relationships as the basis for the onset and maintenance of depression - role dispute, friend/romantic break-up, someone moved - -may also be due to poor skills that make you more likely to experience rel problems -sort of similar psychodynamic in that early relationships are key - but tx would be different - here focus on improving interpersonal skills directly, in analysis you'd figure out why you're worried about the loss of a loved one - go back and fix the initial broken relationship at least in your mind Self-control theories: difficulty regulating negative emotions may lead a child to be prone to depression, avoidance or negative behavior may be used to regulate distress, rather than problem-focused and adaptive coping strategies - MAY ALSO BE ATTACHMENT RELATED - Some feel the poor bond with parent means they never learned how to regulate emotions - Parents job is to help child regulate emotions - notice how child is feeling and help them feel better - child learns eventually how to care for themselves this way - when this is messed up child doesn't learn and so has difficulty regulating negative emotions - may lead a child to be prone to depression - avoidance or negative behavior may be used to regulate distress, rather than problem-focused and adaptive coping strategies -see child as somehow ending up in a place where they are not good at regulating own emotions - I also put this under attachment b/c it is in early relat. That you are supposed to learn and event master affect regulation - these kids don't master it and so are at risk - they have hard time organizing behavior in relation to long-term goals - focus on immediate consequences rather than future - can't get what want right now so get upset - hard time monitoring and regulating emotions - use self-punishment too much and not enough self-reward (basically beating themselves up) Behavioral: Behavior is learned; adaptive behaviors can be learned and maladaptive behaviors can be extinguished Behavioral theories: emphasis on importance of learning, environmental consequences, and skills and deficits in the onset and maintenance of depression; Depression results from lack of response-contingent positive reinforcement (e.g., b/c too anxious to enjoy social reinf; or too unskilled to get much tru postive rewards, or may experience a loss and so experience a loss of the positives that came from that relationship); Also Seligman describes a learned helplessness model whereby they learn they can't control their env and get good stuff so they simply give up - I'm not good enough; I have no control over my life/env/destiny Cognitive (Beck): Our thoughts determine our feelings and actions; changing the way we think can change the way we feel and act Cognitive theories: focus on "depressogenic" cognitions or depressive mindset (interesting to note this is common in depressed individuals, abates a lot when not depressed but always higher than non-depressive individuals) - Depression-prone individuals tend to make internal, stable, and global attributions for the cause of negative events (my fault bc I suck and will always suck at everything) Beck's negative Beck's cognitive model proposes that depressed individuals have: Information processing problems - focus on the negative, ignore the positive. cognitive triad: negative outlook regarding oneself, the world, and the future (I'm not good enough; they are mean and unfair or it is too hard; it is alwsays going to be this bad) - negative cognitive schemata - the more stable depressive beliefs - rigid and resistent to change - make you more at risk for depression when experience neg life event Diathesis-Stress models Not completely accounted for by genes or environment Stressful life events serve as triggers for those with vulnerability (diathesis) Early life experiences contribute to neuroendocrine, cognitive, behavioral fx Kindling - episodes beget episodes Neurobiological models: emphasize the role of genetic vulnerabilities and neurobiological abnormalities - male-femal difs in neuroendocrine system (hormones) What is inherited? Negative Affectivity Genetic and family risk 2-3x more likely to develop depression is parents had it sometime 14x more likely to develop MDD as a child if parent had it as a child Note that this does not mean it is all genetics - env can play big role - mom not very attentive if depressed Twin studies give heritability estimates ranging from .35 to .75 what is inherited is likely a vulnerability to negative affect (depression/anxiety), with certain environmental stressors needed for these disorders to be expressed Neurobiological influences may involve heightened stress reactions - heightened attention to potentially negative stimuli like see in anxiety (notice neg tone of voice etc) amygdala and hippocampus, HPA axis, sleep architecture, growth hormone, and neurotransmitters (serotonin, dopamine, and norepinephrine) have been implicated - much research with adults though and many reasons to think it may not work same way with kids HERITABLE - Bipolar especially is one of the most heritable disorders; 5x more likely to have it if parent has it; probably multiple genes - complex inheritence Perhaps environment matters DEF OF KINDLING (coined by Goddard in rats with seizures): Many people with Bipolar I have more episodes of mania or depression as time goes on The idea of "kindling" is based on the finding that a region of mouse brain repeatedly exposed to small electric shocks will eventually start to have spontaneous seizure-like electrical events. That is, repeated episodes seem to make subsequent episodes more likely to occur spontaneously. This is precisely the pattern observed in bipolar I If a bipolar person goes untreated for a period of years, he or she could begin to experience rapid cycling, or become treatment-resistant? If stressors initially set off episodes, in time could episodes appear without any such triggers? Research says the answer to all these questions is yes, and the reason may be a process that has been termed "kindling." initial periods of cycling may begin with an environmental stressor, but if the cycles continue or occur unchecked, the brain becomes kindled or sensitized - pathways inside the central nervous system are reinforced so to speak - and future episodes of depression, hypomania, or mania will occur by themselves (independently of an outside stimulus), with greater and greater frequency Because of this potential worsening with time, you should not count on being able to "go back" to a previously effective medication. Though I have not heard it stated as such, as I read the experts, and watching what happens to my patients, the "name of the game" may be to prevent cycling. That might be how you keep from getting worse. If that's true, now you have two reasons to get your symptoms controlled: first, because you'd rather not have symptoms; but also because they could mark a worsening process that you might be able to interrupt with a fully effective treatment Socioenvironmental theories: focus on the relationship between stressful life events and depression (need to exp little stress or have great social support and internal coping skills to get through) Stressful life events - depression is associated with severe stressful life events; triggers for depression often involve interpersonal stress or actual or perceived personal losses Family influences - families of children with depression display more anger and conflict, greater use of control, poorer communication, over-involvement, less warmth and support, more disorganization, higher levels of stress, and a lack of social support -note how it is similar to cognitive theories in that prone to focus on negative, and so at great risk when experience neg life event

Sex Differences in Anxiety Disorders

Girls report more anxiety symptoms in general Several anxiety disorders are more prevalent in females than males in population studies Female: Male ratio is 2:1 for many anxiety dxes Clinic referral rates do not always match population prevalence Female: Male ratio is 1:1 for many anxiety dxes Why? By age 6, twice as many girls as boys have experienced anxiety sx Lewinsohn et al 1998 tried controlling for stress, perceived competence, emotional reliance and it did not acount for all gender difs, so perhaps girls have greater genetic risk Culture/Society could be leading girls to more readily report non-clinical levels of anxiety whereas boys deny it.

Inhalants

Inhalants Teenagers are the most common users Commonly inhaled chemicals: Paint thinner, rubber cement, lighter fluid, fuel, permanent markers, and nail polish remover Potentially fatal, irregular heartbeat and respiratory failure Damage to all vital organs, brain, nerve damage A class of drug not on the list but pretty relevant for children and adolescents are inhalants Rapid onset of sedation, euphoria, and disinhibition, but also dizziness, slurred speech, confusion, impaired motor skills

Assessment informs treatment

Improve motivation for treatment. review of problems caused by ocd, tics, etc Establish frequency, severity, situational dependence. what, when, where, how often, how bad/ how interfering Useful in deciding where to start intervention and providing baseline for comparison to see if imporiving Use this to decide where to intervene first, but also to give baseline so can see if improving

How does Dysthymia compare to MDD?

Less common than MDD NO sex differences Longer duration, fewer sx required Chronic, low-grade depression May not seem like a big change - "depressive personality" Less anhedonia, withdrawal, impaired functioning, morbid/suicidal ideation, guilt, and somatic complaints than MDD DD is more ... Chronic, low-grade depression May not seem like a change from normal - depressive personality Focus on the negative; negative outlook Low self-esteem; feel inadequate; self-depreciation Subjective feelings of irritability / anger Less anhedonia, social withdrawal, impaired fx, death/morbid thoughts, and physical complaints than MDD Think of Eeyore from Winnie the Pooh, or maybe Debbie Downer from Saturday Night Live we don't see these MDE sx: (1) anhedonia (2) agitation/retardation observable to others (3) worthlessness/guilt, (4) thoughts of death or suicide

he key feature of this tic disorder is the occurrence of both motor and vocal tics for more than 1 year

Tourette's Disorder

Evidence-Based Treatments for Bipolar Disorders

Mood Stabilizing Medication: Lithium Anticonvulsants Child and Family Therapy: Psychoeducation Importance of (a) medication, (b) consistent sleep schedule, (c) mood monitoring Coping Skills for dealing BP symptoms Skills Training to address specific deficits Mood stabilizers - most well-known is Lithium, but increasingly Depakote (an antiseizure med) is becoming the 1st line treatment. Others include... divalproex (Depakote) or carbamazepine (Tegretol), Psychoed about the disorder, warning signs of an episode, need to take meds forever... Skills to help cope with remaining sx Family Support Child Coping Skills Skills training programs (coping skills; social skills; problem solving; affect regulation) Treatment of disrupted sleep and the maintenance of a regular sleep/wake cycle are important components of the prophylaxis of mood episodes in bipolar disorder. Sleep disturbance is a cardinal feature of bipolar disorder. During acute mania, patients exhibit markedly reduced sleep time and report a reduced need for sleep. Even when euthymic, sleep disturbance is common. In a recent study, 55% of euthymic bipolar patients had chronic insomnia (Harvey et al 2005). Children with bipolar disorder (who often display ultradian rapid cycling rather than distinct mood episodes) exhibit reduced sleep efficiency and frequent nocturnal awakenings (Mehl et al 2006).

Handwashing and counting are 2 common compulsions for this disorder.

OCD

This disorder is characterized by repeated, intrusive, irrational, and anxiety causing thoughts and ritualized behaviors to relieve the anxiety.

OCD

Obsessive-Compulsive Disorder

Obsessions are ego-dystonic - they do not like them, find them intrusive Contamination (I an being contaminated) Doubts (about whether or how well you did something) Need to have things in particular order (symmetry, just right) Aggressive impulses (I will hurt someone, I have hurt someone) Sexual Imagery Compulsions are done to relieve the anxiety caused by the obsession (or just feel have to do it in set way - even if individual does express clear connection with the obsession) - done to relieve displeasure, not to give pleasure Some (esp Children) may not have a clear obsession that they can describe that drives their behvaior - may just feel they have to do these things or something bad will happen, or they just will not feel right Hand washing Ordering/straightening Repeating actions - retracing steps, sit up and down, up and down stairs Checking Telling on self - seeking reassurance Mental acts included like praying, counting, repeating words Specify level of insight: good/fair insight - realize obsession not rational/true and/or compulsion not really needed (or at least thinks probably not true) poor insight - thinks obsessions are probably true/real and/or compulsion probably really needed absent insight/delusional beliefs - completely convinced obsessive-compulsive beliefs are true Contamination (concerns with dirt, germs, illness, feces, household cleaners) Aggressive/Harm (fear might harm self or be harmed, violent images, concern about stealing, blurting obscenities, or hurting others) Just-So (concerns with having things "just-so", need for symmetry and order) Sexual (concerns about sexual thoughts, images, urges) Scrupulosity (concerns about offending God, right/wrong behavior, having bad thoughts or behaving immorally) Other (lucky and unlucky words, colors, numbers) Washing/cleaning (handwashing, ritualized grooming/toileting, excessive cleaning) Checking (locks, homework mistakes, checking with grooming, checking that did not harm self or others) Counting (counting objects, words, floor/ceiling tiles) Repeating (e.g., rereading, erasing and rewriting, repeating steps, words or phrases certain # of times or until it "feels right") Ordering/arranging (straightening, lining up objects) Hoarding/saving (notes, school papers, old toys) Touching (needing to touch, tap, rub certain # of times or until it "feels right") Needing to tell on self, confess, pray Distinction from Normal Rituals: Ritualistic and repetitive activity common in young children (peaks @2-3 yrs of age, then declines); Even as adults, most of us have some habits, patterns or rituals Functional impairment or distress: Often leads to severe functional impairment(home, school, peers); Child distress may be limited to when compulsions prevented Insight: Required for OCD dx in adults, not for children; Even when have insight, OCD is very resistant to reason Prevalence: 2-3% of children (1-2% in adults); Boys>girls (no gender difference by adulthood); Boys typically show earlier prepubertal onset (7-10yrs); Girls typically show onset during adolescence Chronic course with fluctuating severity High co-morbidity with other anxiety disorders, depression, tics and other impulse-control disorders, disruptive behavior problems Often unrecognized/untreated and misdiagnosed/mistreated Males w OCD also more likely to show comorbid tic disorder

Panic Disorder

Panic attack: a sudden surge of intense fear/discomfort peaks within minutes and accompanied by flight/fight symptoms Panic disorder: recurrent unexpected panic attacks, plus persistent (>1month) concern about additional attacks, their consequences, or significant behavior change 2-3% adolescents (very rare before puberty) 2x more in females Usual onset late teens to 20yo Panic attacks more common than panic disorder About 5-15% of teens/adults (lower end for teens higher end for adults) will have at least one panic attack in their lives; only about 2-3% actually meet dx cx for panic disorder Some also experience "nocturnal panic" Symptoms Include: Racing heart Sweating Trembling/shaking Shortness of breath - feel like can't breath Feel like you're choking Chest pain Nausea or stomach upset Dizzy, lightheaded, faint Chills or hot flashes Paresthesias (numbness or tingling) Depersonalization (feeling like detached from self) or derealization (feeling of unreality) Fear losing control, going crazy or dying At least one attack must be followed by >1month of worry about it or changing your behavior bc of it

age and drug use

Percentage of individuals by age using illegal drugs in the past month (so not including alcohol and tobacco) SU peaks late adolescence; begins to decline during young adulthood Note the peak is 18-20, then starts to decline Substance use and abuse higher in late adolescence and early adulthood (17-25) than any other time Average age of first use of illegal drug (alcohol and tobacco not on here) Note that inhalants are the drug with youngest age of 1st use, then marijuana

Hoarding Disorder

Persistent difficulty getting rid of possessions due to anxiety about needing the items and general distress about losing them. Leads to severe impairment 80-90% also show excessive acquisition Specify Insight Level: good/fair; poor; absent/delusional About 2% males-females. typical onset in late childhood/early adolescent

Body Dysmorphic Disorder

Preoc with one or more perceived defects or flaws in apperance that are not observable or appear slight to others results in significant anxiety/distress results in repetitive checking, grooming, picking, reassurance seeking or mental comparison in order to reduce distress Not better explained by body fat/weight concerns in someone with ED Specify insight level: good/fair; poor; absent/delusional About 2%. Male- femals, typical onset in adolescent Perceived defects - make them ugly hideous abnormal deformed Range from convinced look unattractive to convince absolutely deformed and look like monster Common foci: skin (wrinkle; scars; acne; paleness) hair (thinning or excessive) nose (size or shape) (but any body part can be focus) Muscle dysmorphia is subtype almost exclusive to males (too small not muscular enough) About 2%; males=females; typical onset adolescents (12-13 years for subclinical with clinical levels reached by 15-17 yrs) Where see these folks? Not MH offices - instead at dermatology offices and plastic surgeon offices High suicide rates High comorbidity

Prevalence and Course of DD

Prevalence: 0.5 - 1.5% adolescents and adults Age and Sex Differences: Incidence increases with puberty No gender differences Course/Prognosis Chronic course; incomplete recovery High comorbidity with other mood, anxiety, behavior and substance use disorders Increased risk of suicide Age of onset 11-12 years (bit earlier than MDD) Average episode 2-5 years or more (longer than MDD) High risk for developing other disorders (MDD, Bipolar, anxiety, substance use, and conduct problems) May be a precursor to MDD for some children NO major gender differences with DD Comorbidity is common (high risk for developing other disorders) Manic/Hypomanic episode (Bipolar) or Dysthymia (double depression) Anxiety Disorders Conduct problems and Disorders Substance Use Disorder MDE (double depression) anxiety disorders conduct problems substance use problems

Prevalence and Course of Bipolar Disorders

Prevalence: 0.5-1% adults Age and Sex Differences: Rates in children and adolescents unknown; Males=Females Course: Peak onset late adolescence to early adulthood Most often referred for mania; many report depression came first Episodes last few weeks to several months Recurrent episodes and incomplete recovery are the norm High comorbidity with other mood, anxiety, behavior and substance use disorders Very high risk of suicide (1/3 attempt) PREVALENCE: Note the problems in dx with kids (rapid cycling - some say multiple times per day - that doesn't meet cx) Not really dx in kids until the last 5-10 years Currently it is the new ADHD - very popular, lots of pop psychology books about it, lots of parents read them and think their child is bipolar Kids with Bipolar often have atypical pictures - not the clear mania and then clear depression, but more likely to have mixed episodes, mood is more volatile than euphoric, big changes in self esteem are common (go from feeling like a loser to feeling and talking about how they are the most popular kid in school, they are the smartest etc) They are more likely to be rapid cyclers (which means at least 4 mood episodes per year) Also - rarely meet the one week duration - many parents claims their child cycles daily - or even hourly - this is controversial Also - likely to show hallucinations, delusions, paranoia - sometimes look like psychotic break so have to do good history COURSE: About 20% of adults with bipolar had 1st onset during adolescence 15-19, (early adulthood is big time; then another small peak is in later life like age 50) Onset in childhood/early adolescence MAY poorer prognosis than adult onset Recurrent manic and depressive episodes are the norm - chronic disease (90% have multiple episodes); most return to normla fx between episodes, but some do not and some evidence that rapid cycling without return to full fx in between becomes increasingly likely as age IF UNTREATED Major suicide risk - Suicide risk is 15x that of general population Some estimates indicate 15% of individuals with BP will ultimately complete suicide Once considered rare before puberty... Youth prevalence estimates being revised Different presentation makes diagnosis difficult Some indication of more severe disorder and poorer prognosis with child onset Longitudinal studies needed to verify child presentation and prognosis (about 1-1.5% in adults)

SSRIs and Suicidality

Recent evidence that SSRIs are associated with small but significant increase in suicidal thoughts and behaviors amongst depressed adolescents 2004, FDA issued black box warning for all SSRIs Risk vs benefits? June 2003 big controversy over research evidence - what was being hidden, or downplayed. This suicide link showed up again in TADS with Prozac Have also seen in in OCD kids with Paxil Why? Perhaps bc suicidal acts often increase temporarily as start to improve in energy level Often, with meds, improvements in physical areas (appetite, energy, sleep), occur BEFORE mood - so they have more energy but still feel hopeless This can explain the problem in those with MDD - BUT they also found this same effect in children with OCD being treated with SSRIs - that is harder to understand unless it is being driven by a subsample of OCD who also have MDD When combine with therapy, do not see these problems; Also, not all studies have found this - many find decrease in suicidal thoughts October 2004 Food and Drug Administration (FDA) directed manufacturers of all antidepressant drugs to revise the labeling for their products to include a boxed warning and expanded warning statements that alert health care providers to an increased risk of suicidality (suicidal thinking and behavior) in children and adolescents being treated with these agents, and to include additional information about the results of pediatric studies. Risk of suicide without tx is very high Medication (esp Prozac) has been shown to decrease MDD, and more than any other treatment, so perhaps in combo with close monitoring and therapy, that is the better option for those with severe depression http://www.fda.gov/cder/drug/antidepressants/SSRIPHA200410.htm The risk of suicidality for these drugs was identified in a combined analysis of short-term (up to 4 months) placebo-controlled trials of nine antidepressant drugs, including the selective serotonin reuptake inhibitors (SSRIs) and others, in children and adolescents with major depressive disorder (MDD), obsessive compulsive disorder (OCD), or other psychiatric disorders. A total of 24 trials involving over 4400 patients were included. The analysis showed a greater risk of suicidality during the first few months of treatment in those receiving antidepressants. The average risk of such events on drug was 4%, twice the placebo risk of 2%. No suicides occurred in these trials. Based on these data, FDA has determined that the following points are appropriate for inclusion in the boxed warning: Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with MDD and other psychiatric disorders. Anyone considering the use of an antidepressant in a child or adolescent for any clinical use must balance the risk of increased suicidality with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised to closely observe the patient and to communicate with the prescriber. A statement regarding whether the particular drug is approved for any pediatric indication(s) and, if so, which one(s). Among the antidepressants, only Prozac is approved for use in treating MDD in pediatric patients. Prozac, Zoloft, Luvox, and Anafranil are approved for OCD in pediatric patients. None of the drugs is approved for other psychiatric indications in children.

CBT vs Medication

Recent multimodel study comparing CBT to sertraline (Zoloft) for SAD, GAD and SocPh Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline. (Interestingly Zoloft still not FDA approved for treating pediatric anxiety - only for pediatric OCD)

The disorder characterized by an intense fear of being away from your parents.

SEP ANX

This is the most common anxiety dx in kids (10% of children (equally referred in boys and girls, more girls in pop studies)

SEP ANX

This class of medication has shown some support in the treatment of anxiety in youths

SSRIs There is come support for SSRIs in GAD, SEP ANX, SocPh (SOC ANX)

This class of medication has shown some support in the treatment of OCD in youths

SSRIs? Luvox (fluvoxamine), Prozac (fluoxetine), Zoloft (sertraline) FDA approved for child OCD

Hypomaniac Episode

Same as Manic Episode BUT Only has to last at least 4 days Can NOT be severe enough to cause marked impairment, hospitalization, or psychoses Still must be (1) a clear change and uncharacteristic of their usual behavior, (2) noticeable to others, and (3) cause functional interference in some area (Like Manic Episode) If mood predominantly irritable (instead of elevated/expansive), then need 4 of those sx HYPOMANIA: At least 4 days, sx must be uncharacteristic - BUT NO NEED for hospitalization, no psychosis, no major deterioration in fx

Interviews and Psychological testing

Screening with the CAGE interview: Have you ever felt you needed to Cut down your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever felt you need a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? MI is both an assessment and treatment strategy Gather info about drug use and provide feedback to increase readiness for change First step is to identify which stage of change the addicted individual is currently in and meet the person where they are Uses principles from motivational psychology to activate person's internal motivation for change rather them telling them they have to change Meets the addicted individual where they are (i.e., identify current stage of change) Unique, non-confrontational approach Roll with resistance Elicit change-talk Disadvantages of continued use Advantages of change Intention to change Optimism about change Often see MI as a Brief Interventions: 1-4 sessions, harm reduction strategies change behavior as much as possible in a limited period of time, 1-4 sessions; Identify high risk situations for substance use, pros and cons, negative consequences, not necessarily to promote abstinence but increase safetyOther Treatments Inpatient/Residential: 30 days, Detox, Rehab Group Therapy/Self-Help: 12 step, AA, NA Few controlled trials targeting children or adolescents with SUDs Detoxification, withdrawing from drug under medical supervisionl Rehabilitation, Minnesota model, emphasizes complete abstinence, education about SUD and consequences, CBT techniques; Most about 4 weeks; More likely to work if person volunteered for treatment rather than court or employer referred; Spousal and family support helps Inpatient or Residential Treatment Little controlled research Often espouse 12 step model Half of patients for SUDs relapse within first three months Only 20-30% remain abstinent 12-step program, abstinence; Alcoholism is a disease controlled only by complete abstinence; Realization that the individual is powerless over the addiction; Cost-effective; 2/3 people with SUD seek help with AA; Continued support to remain sober - Regular meetings and Sponsor Success of AA led to Narcotics Anonymous (NA), Cocaine Anonymous, Overeaters Anonymous (OA), Al-Anon/Alateen Nar-Anon NOTE this is VERY Different from CBT or MI Research-Supported Treatments Functional Family Therapy (FFT) Brief Strategic Family Therapy (BFST) Multisystemic Therapy (MST) Few controlled trials targeting children or adolescents with SUDs FFT and BFST is office-based family therapy MST is intensive outpatient intervention that targets family, peer, school, and community systems All are Family based approaches improve communication and parent-child relationship modify negative interactions between family members develop effective problem solving skills to deal with areas of conflict

stimulants

See Missouri on the map - state with some of the highest rates of use The pleasurable effects of meth are extremely intense and include strong euphoria, enhanced sexual drive and stamina, and lowered sexual inhibition. The drug helps stimulate pleasure centers in the brain to release large amounts of dopamine. Downsides include brain and liver damage, malnutrition, skin infections, immune system problems, convulsions, stroke, and death. DA and NE 90% of all amphetamine abuse today involves meth Sudden "high" that lasts hours Addicted after just a few doses "meth mouth" severe decay or loss of teeth from exposure to the drug's toxic chemical composition 5.2% of college students have tried 2.9% in past year

Evidence Based Medication Treatment- Anxiety Disorders

Selective Serotonin Reuptake Inhibitors (SSRI) Some support for GAD, Social Anxiety, Separation Anxiety Examples: Luvox (fluvoxamine), Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), Lexapro (escitalopram). None of these have FDA approval for pediatric anxiety Benzodiazepines (e.g. lorazepam) No support Why different than with adults? High placebo response rate in youths Immature metabolism until late teens / early 20s In general, when they do not find effects with kids like they did with adults they suggest it may be due to 2 things (1) high placebo response rate in youths for many disorders (esp anxiety and depression) (2) different metabolism (youths do respond very different - faster metab, sometimes need stronger dose than would be expected by bodyweight, sometimes show opposite effect from adults - benedryl keeping an infant up all night; Sudafed putting them to sleep - the way you metabolize drugs is not mature until teens or 20s) Young children's bodies handle medications differently than older individuals and this has implications for dosage. The brains of young children are in a state of very rapid development, and animal studies have shown that the developing neurotransmitter systems can be very sensitive to medications. A great deal of research is still needed to determine the effects and benefits of medications in children of all ages. Yet it is important to remember that serious untreated mental disorders themselves negatively impact brain development. Note that there are basically 2 scenarios for which we have tested and found meds to work really well with dev psychopath - stim for ADHD and SSRI for OCD. Little research on anything else - and sometimes the research conflicts what folks expected based on adult studies. This doesn't mean kids aren't prescribed drugs - very common, just do it based on adult lit and own clinical experience and intuition. Of all the antidepressants, fluoxetine (Prozac) has been FDA approved to treat pediatric depression and Lexapro (escitalopram) for depressive disorder in adolescents between 12 and 17 years of age. For obsessive compulsive disorder in children and teenagers, FDA has approved only fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine, and clomipramine (Anafranil) . There are four stimulant medications that are FDA approved for use in the treatment of attention deficit hyperactivity disorder (ADHD), the most common behavioral disorder of childhood. These medications have all been extensively studied and are specifically labeled for pediatric use. (Interestingly Zoloft still not FDA approved for treating pediatric anxiety - only for pediatric OCD)

Antidepressant Medication

Selective Serotonin Reuptake Inhibitors (SSRIs) are most widely prescribed Fluoxetine (Prozac) is FDA approved to treat depression in children 8 and up Escitalopram (Lexapro) is FDA approved to treat depression in teens 12 and up Other SSRIs are used "off-label" Of all the antidepressants, only fluoxetine (Prozac) has been FDA approved to treat pediatric depression. FDA extended the indications for escitalopram to include treatment of major depressive disorder in adolescents between 12 and 17 years of age. This action makes escitalopram only the second SSRI to be approved by the FDA for use in teens, following the earlier approval of fluoxetine For obsessive compulsive disorder in children and teenagers, FDA has approved only fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine, and clomipramine (Anafranil) . Meds - TCAs work with adults but not with kids SSRIs (e.g., prozac) have some positive effects with teens, less so with younger children, but results are not as consistent as with adults - ALSO FDA recently issued warnings and stopped some trials due to problems of INCREASED suicidal ideation in depressed youths taking SSRIs. The medications most widely prescribed for these disorders are the selective serotonin reuptake inhibitors (the SSRIs). In the human brain, there are many "neurotransmitters" that affect the way we think, feel, and act. Three of these neurotransmitters that antidepressants influence are serotonin, dopamine, and norepinephrine. SSRIs affect mainly serotonin and have been found to be effective in treating depression and anxiety without as many side effects as some older antidepressants (like TCAs). fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) *** citalopram (Celexa) escitalopram (Lexapro) *** fluvoxamine (Luvox) venlafaxine (Effexor)—another antidepressant closely related to the SSRIs

Being afraid of approaching an unfamiliar group of kids would be most likely to be a part of this anxiety disorder.

Social Phobia (or SOC ANX)?

This anxiety disorder has 5 subtypes: animal, natural environment, blood-injection-injury, situational, "other".

Specific Phobia Animal = snakes, spiders, sharks, bugs Environment = heights, the dark, storms, water Blood-injection-injury = getting a shot, seeing blood (fainting common with this one) Situational = elevator, flying, tight enclosed spaces Other = costumed characters (clowns), choking, vomiting, getting an illness (not hypochondriasis where you worry you already have a disease - here you worry you will get it)

Prevention

Still, most who use a substance do not develop a SUD (Most teens who use to not develop SUD) -- So... what causes someone to go from a nonuser or just an occasionaly user / social user / experimenter to abuse or dependence??? SUD more likely the younger the age of first use - so Delay first experimentation and decrease chance of SUD SUD more likely with increased frequency of use - so try to monitor so use less often SUD more likely with deviant peer group affiliation - so promote more prosocial peer affiliations (maybe there is something to not allowing teen to hang out with 'bad influences') high comorbidity with ADHD and conduct problems and depression Education, Accurate Information, Changing normative beliefs but note that not all programs or individuals involved in the programs stick with accurate information - some myths make it in on the other side as well, some use Scare Tactics (e.g., reefer madness; marijuana causes boys to develop breasts and girls not to) Also, the evidence for efficacy of many of these programs is mixed - A well-known example in the field of drug abuse prevention is the Drug Abuse Resistance Education program (Project DARE) which continues to be the most frequently used prevention program despite credible research that fails to support its effectiveness. (Glantz & Compton, 2004) Clayton, Richard R; Cattarello, Anne M; Johnstone, Bryan M. (1996) The effectiveness of Drug Abuse Resistance Education (Project DARE): 5-year follow-up results. Background.This article reports the results of a 5-year, longitudinal evaluation of the effectiveness of Drug Abuse Resistance Education (DARE), a school-based primary drug prevention curriculum designed for introduction during the last year of elementary education. DARE is the most widely disseminated school-based prevention curriculum in the United States. Method.Twenty-three elementary schools were randomly assigned to receive DARE and 8 were designated comparison schools. Students in the DARE schools received 16 weeks of protocol-driven instruction and students in the comparison schools received a drug education unit as part of the health curriculum. All students were pretested during the 6th grade prior to delivery of the programs, posttested shortly after completion, and resurveyed each subsequent year through the 10th grade. Three-stage mixed effects regression models were used to analyze these data. Results.No significant differences were observed between intervention and comparison schools with respect to cigarette, alcohol, or marijuana use during the 7th grade, approximately 1 year after completion of the program, or over the full 5-year measurement interval. Significant intervention effects in the hypothesized direction were observed during the 7th grade for measures of students' general and specific attitudes toward drugs, the capability to resist peer pressure, and estimated level of drug use by peers. Over the full measurement interval, however, average trajectories of change for these outcomes were similar in the intervention and comparison conditions. Conclusions.The findings of this 5-year prospective study are largely consonant with the results obtained from prior short-term evaluations of the DARE curriculum, which have reported limited effects of the program upon drug use, greater efficacy with respect to attitudes, social skills, and knowledge, but a general tendency for curriculum effects to decay over time. The results of this study underscore the need for more robust prevention programming targeted specifically at risk factors, the inclusion of booster sessions to sustain positive effects, and greater attention to interrelationships between developmental processes in adolescent substance use, individual level characteristics, and social context. Also consider this compilation from NIDA Research-based prevention programs focus on intervening early in a child's development to strengthen protective factors before problem behaviors develop. Again - delay 1st use and decrease chance of developing SUD Risk factors can influence drug abuse in several ways. The more risks a child is exposed to, the more likely the child will abuse drugs. Some risk factors may be more powerful than others at certain stages in development, such as peer pressure during the teenage years; just as some protective factors, such as a strong parent-child bond, can have a greater impact on reducing risks during the early years. An important goal of prevention is to change the balance between risk and protective factors so that protective factors outweigh risk factors.Several school-based programs targeting risk factors for SU are promising Parent and Youth Education Personal Well-being, Physical and Mental Health Social Competence Beliefs and Expectancies Some Examples of evidence-based programs are unfortunately not as widespread as DARE (tend to occur at only one or two sites close to a researcher/university): Caring School Community Program Classroom-Centered (CC) and Family-School Partnership (FSP) Intervention Guiding Good Choices (GGC) Life Skills Training (LST) Program Promoting Alternative Thinking Strategies (PATHS). Research-based prevention programs focus on intervening early in a child's development to strengthen protective factors before problem behaviors develop. SUD more likely the younger the age of first use - Delay first experimentation and decrease chance of SUD DARE MU Mythbusters and "Most of Us" Education, Accurate Information, Changing normative beliefs but note that not all programs or individuals involved in the programs stick with accurate information - some myths make it in on the other side as well, some use Scare Tactics (e.g., reefer madness; marijuana causes boys to develop breasts and girls not to) Also, the evidence for efficacy of many of these programs is mixed - A well-known example in the field of drug abuse prevention is the Drug Abuse Resistance Education program (Project DARE) which continues to be the most frequently used prevention program despite credible research that fails to support its effectiveness. (Glantz & Compton, 2004) Clayton, Richard R; Cattarello, Anne M; Johnstone, Bryan M. (1996) The effectiveness of Drug Abuse Resistance Education (Project DARE): 5-year follow-up results. Background.This article reports the results of a 5-year, longitudinal evaluation of the effectiveness of Drug Abuse Resistance Education (DARE), a school-based primary drug prevention curriculum designed for introduction during the last year of elementary education. DARE is the most widely disseminated school-based prevention curriculum in the United States. Method.Twenty-three elementary schools were randomly assigned to receive DARE and 8 were designated comparison schools. Students in the DARE schools received 16 weeks of protocol-driven instruction and students in the comparison schools received a drug education unit as part of the health curriculum. All students were pretested during the 6th grade prior to delivery of the programs, posttested shortly after completion, and resurveyed each subsequent year through the 10th grade. Three-stage mixed effects regression models were used to analyze these data. Results.No significant differences were observed between intervention and comparison schools with respect to cigarette, alcohol, or marijuana use during the 7th grade, approximately 1 year after completion of the program, or over the full 5-year measurement interval. Significant intervention effects in the hypothesized direction were observed during the 7th grade for measures of students' general and specific attitudes toward drugs, the capability to resist peer pressure, and estimated level of drug use by peers. Over the full measurement interval, however, average trajectories of change for these outcomes were similar in the intervention and comparison conditions. Conclusions.The findings of this 5-year prospective study are largely consonant with the results obtained from prior short-term evaluations of the DARE curriculum, which have reported limited effects of the program upon drug use, greater efficacy with respect to attitudes, social skills, and knowledge, but a general tendency for curriculum effects to decay over time. The results of this study underscore the need for more robust prevention programming targeted specifically at risk factors, the inclusion of booster sessions to sustain positive effects, and greater attention to interrelationships between developmental processes in adolescent substance use, individual level characteristics, and social context.

Substance Use

Substance-related disorders, like other disorders, occur on a continuum of normal to severe disorder. What substances are commonly used by children, adolescents, adults? How common is ANY substance use? When does it become a problem? Intoxication - being under the immediate effects Tolerance - need to ingest greater amounts of a drug to achieve the same effect Withdrawal - experiencing phys and/or psych syndrome characterized by stopping using a substance that was used heavily over long period of time; i.e., withdrawal refers to maladaptive behavioral changes when a person stops using a drug. Intoxication: reversible behavioral and physiological effects of substance Tolerance: central nervous system becomes less responsive to stimulation by particular drugs Withdrawal: noxious physical/psychological effects when reduce/stop substance intake Physical Dependence: tolerance + withdrawal So with tolerance - you get less of an effect from same amount of the drug (diminished effect) - you need more of the drug in order to get the effect (increased amounts) Psychological Dependence: craving or compulsion to use despite harm (tolerance and withdrawal not required) Substance-related disorders include substance intoxication, abuse, and dependence and withdrawal. Substance intoxication is a reversible condition brought on by excessive use of alcohol or another drug. A person who becomes intoxicated experiences maladaptive changes in behavior, aggression, inappropriate sexual advances, impaired judgment, rapid shifts in mood Difficulty staying awake, thinking clearly, impaired performance, rt Substance abuse refers to repeated use of substances that lead to recurring problems Substance dependence refers to a maladaptive pattern of substance use potentially defined by tolerance and withdrawal. Combination of Abuse and Dependence Cx Specifiers: MILD (2-3 criteria) MODERATE (4-5 criteria) SEVERE (6 or more criteria) In Controlled Environment In Early Remission (3-12mos) In Sustained Remission (<12mos) What drugs are most commonly used by adolescents??? #1 = Alcohol #2 = Cigarettes #3 = Marijuana #4 = Other illegal drugs (rates are increasing though for other drugs besides marijuana) How many junior high students? How many high school students? Grade 8th 12th Any Alcohol 53% 77% Been Drunk 20% 60% Marijuana 16% 46% Any Illicit Drug (besides marijuana) 12% 29% Lifetime Prevalence Data from Monitoring the Future, University of Michigan, 2004

Assessment- OCD and Tic

The YGTSS provides an evaluation of the number, frequency, intensity, complexity, and interference of motor and phonic symptoms Young children have ritualistic activity that is normal Is it due to a drug or medical condition? Some tics are so severe they interfere with reading, talking, engaging in other behaviors like writing, sports They can also lead to injury - from the tic itself, through muscle strain from repeated movement, Some lit indicates that many youths are not properly dxed and ever fewer receive approp tx Many families may choose not to seek tx bc the sx wax and wane - so they will decrease for periods even with no tx (misdx - if have sexual thoughts, some therapists assume sexual abuse) (misdx - if spacey, or not paying attention; and sometimes the compulsive behavior can be very high energy) (misdx - Autism spectrum bc both share rigidity and some stereotypic compulsive behaviors, BUT when not disturbed by obs or comp, children with OCD wil not show social difficulties or communication problems; also, the specific compulsive behaviors tend to change over time in kids with OCD but less so in ASD) Can have parents discretely monitor and count at home or at school or with friends (so can get good base rate level) Young children have ritualistic activity that is normal Purpose - must do it in order to prevent something bad, reduce tension, act is pleasurable, For tics, rule out purposeful habits, OCD, medical conditions like sydenham's chorea, myoclonic jerks of seizures, tremor, dyskinesias from meds OCD is asociated with Tourette's syndrome and Sydenham's chorea, which are believed to involve basal ganglia pathology, is also consistent with this model. Sydenham chorea (SD) is a neurological disorder of childhood resulting from infection via Group A beta-hemolytic streptococcus (GABHS), the bacterium that causes rheumatic fever. SD is characterized by rapid, irregular, and aimless involuntary movements of the arms and legs, trunk, and facial muscles. It affects girls more often than boys and typically occurs between 5 and 15 years of age. Some children will have a sore throat several weeks before the symptoms begin, but the disorder can also strike up to 6 months after the fever or infection has cleared. Symptoms can appear gradually or all at once, and also may include uncoordinated movements, muscular weakness, stumbling and falling, slurred speech, difficulty concentrating and writing, and emotional instability. The symptoms of SD can vary from a halting gait and slight grimacing to involuntary movements that are frequent and severe enough to be incapacitating. The random, writhing movements of chorea are caused by an auto-immune reaction to the bacterium that interferes with the normal function of a part of the brain (the basal ganglia) that controls motor movements. Due to better sanitary conditions and the use of antibiotics to treat streptococcal infections, rheumatic fever, and consequently SD, are rare in North America and Europe.

Tic Disorders

Tic= sudden, rapid, recurrent, nonrhythmic Motor movement (eg eye blink) vs vocalization (throat clear) Simple vs Complex Diagnoses: Tourettes: Both motor and vocal (at some time) for > 1 year Chronic Motor or Vocal Tic Disorder: Only motor or vocal for > 1 year Provisional Tic disorder: motor and or vocal for <1 year NOTES - DSM-5 does NOT consider tics an OC spectrum dx; instead, tics are part of neurodevelopmental disorders (like the LDs, Autism, ADHD) Simple = involving only a few muscle groups, or only simple sounds, and usually lasting only milliseconds e.g. Simple Motor -- eye blink, nose wrinkle, neckjerk, shoulder shrug Simple Vocal - throat clear, sniff, grunt, snort, chirp, bark Complex = involving multiple muscle groups, words or sentences, and usually lasting seconds or more e.g., Complex Motor -- hand gestures, jumping, touching, pressing, stomping, repeatedly smelling an object, squatting, twirling, rarely can include copropraxia (vulgar gesture) Complex Vocal - repeating phrases, sometimes mimicking last heard phrases, rarely can include coprolalia (vulgar words) Tourettes - multiple motor and at least one vocal tic (at same or different times) - many times per day nearly everyday for at least 1 yr, with never more than 3 mos without tics Chronic Motor/Vocal - same as tourettes but only show motor or only show vocal - once show the other, then get tourettes dx Transient - for at least 1 mo but less than 1 yr Tics experienced as irresistible not intentional. May have premonitory urge and some degree of control. Tics vary throughout day (depending on situation) and often worsen during periods of stress. Leads to severe functioning problems, sometimes physical injury. <1% of children; boys 2-5x > girls; typical onset 4-6 yo (tics may worsen until peak at 10-12yo; then decrease in adolescence and adulthood) Very high comorbidity with ocd, also some comorbidity with ADHD, behavior problems May have premonitory urge (aura, rising tension) and some degree of control or ability to suppress for a period of time - EVEN though a tic is generally experienced as involuntary (that's what differentiates it from a compulsion) Note that also get the increasing tension and relief of tension when tic Tics worsened by stress, excitement, exhaustion Some tic more during relaxation like watching TV, and less when doing something purposeful, directed, focused (albeit calm) effortful like sewing or working in a lab (or performing surgery) Tics rare during sleep Tics may be worse during periods of stress, illness, final exam week OCD + Tourette's may be a specific subtype of OCD - more males, younger age of onset, less responsive to SSRI medication, more aggressive OCD sx (less hoarding and contamination - more obsessions about hurting others and compulsions to prevent self from doing it) Base rate issue here again - as many as maybe 5-7% of individual with OCD have Tourettes disorder, with maybe 20-30% having had a tic at some time (so rates of tics are definitely higher among those with OCD even though most kids with OCD do NOT have tics); BUT among those with Tourettes, the rate of OCD is very high - up to 50% (again - all girl scouts are girls but not all girls are girl scouts)

Evidence- Based Treatments- OCD and Tic

Theory: OCD is maintained via negative reinforcement - need to break this cycle and habituate Core Components Exposure to obsessions Prevent (resist) urge to respond by doing compulsions Goal is habituation Clinical Trials indicate about 60-85% decrease in OCD sx among children and adolescents Core Components of ERP: Psychoeducation about OCD Self-monitoring of OCD Training in Anxiety Management Skills (as needed) Breathing, Relaxation, Mindfulness, Cognitive Challenging, Positive Self-talk Develop and work through heirarchy Reinforcement and praise for all attempts Make a list of feared situations / triggers Give each situation a Subjective Units of Distress (SUDS) rating Order the situations into a hierarchy Get creative in setting up exposures Exposures in and out of office Sessions may need to last from 30 minutes to 2 hours Either Homework or more frequent sessions needed Remind about using skills during exposures (e.g., helpful self-talk, controlled breathing) Specialised form of BT very effective for tics, trich, and excoriation: Habit reversal training (HRT), awareness training, relaxation training (sometimes), Heirarchy, use competing response when feel urge, Comprehensive Behavioral Intervention for Tics (CBIT), HRT + functional analysis of behavior (FAB)

Core Components of CBT for Child and Adolescent Depression

This a big part of all CBT although the particular types of unrealistic thoughts, and thus the particular challenges vary depending upon the clients problems Cognitive restructuring proceeds through the following steps: Identify / recognize / monitor automatic thoughts, What am I thinking, saying to myself? Challenge (examine evidence for) automatic thoughts, How realistic is this thought? Often the therapist will suggest conducting behavioral experiments to test the truth of their thoughts (e.g. ask if that is what they meant, try being late and see if the world collapses) Challenging leads naturally into Replace negative, dysfunctional, unrealistic thoughts with more positive, adaptive, realistic thoughts Here is an example... Note that it is NOT replacing negative with positive, rather its unrealistic with realistic - don't candy coat -- with anxiety and depression there is tendency to exaggerate the bad With some situations, you may need to emphasize the function of the belief/thought, (e.g., they steadfastly insist it is true, get into how helpful it is to think that way. Skip: Eventually the goals would be to get at the core dysfunctional beliefs underlying the automatic thoughts (like that I am unlovable, or that everyone is out to get me, or that the world is a dangerous place where you have to be on guard at all times). Do this by looking for themes in the automatic thoughts and sometimes by doing something called the downward arrow technique that we won't go into (e.g. what would that mean? Why would that be bad?) DOUBLE BUBBLE Same as the other chart but a bit more simple and straightforward for kids to use Here is a role play with a girl to help her learn about negative thinking and its impact. Show 6minute video clip 6. (ACT AND THINK SESSION SIX) This girl is pretty grown-up acting and gets it right away - not always this easy. STOP at end of role-play (before getting into BLUE)

Combination Medication + Therapy

Treatment for Adolescents with Depression Study (TADS) Adolescents with MDD CBT vs Prozac vs Combination Combination more effective than either alone First multisite study of adolescent depression The clinical trial of 439 adolescents with major depressive disorder (MDD) compared cognitive-behavioral therapy (CBT) with fluoxetine (Prozac), currently the only antidepressant approved by the FDA for use in children and adolescents. Combo > Prozac > CBT for MDD But due to some increased risk of suicidality with SSRI, CBT along is recommended as first-line treatment for milder depression; combo for those meeting full dx criteria for MDD

The only FDA approved medication to treat depression in children age 8 and older.

What is Fluoxetine (Prozac)? (Note that this is an SSRI)

The reversible behavioral and physiological effects experience when consume/ingest a substance.

What is Intoxication?

The hallmark of a manic episode.

What is abnormally and persistently elevated, expansive or irritable mood with abnormally increased goal-directed activity, lasting at least 1 week (or causing hospitalization) Plus 3 or more of the following: Inflated self esteem, grandiosity Decreased need for sleep, unable to sleep Pressured speech, talking too much Racing thoughts, flight of ideas Distractibility, Difficulty concentrating Psychomotor agitation, excessive energy, increase in goal-directed activity Excessive involvement in pleasurable activities with high potential for negative consequences (e.g., reckless behavior, out of control spending, gambling, high-risk sex, investments)

This is the most prevalent substance used by adolescents.

What is alcohol (90% of seniors have used alcohol)? (cigarettes are 2nd most common at 60%; marijuana is 3rd)

This mood disorder shows the greatest risk of suicide completion.

What is bipolar disorder? (15% complete suicide during their lives)

The distinction between manic and hypomanic episode.

What is exact same criteria BUT hypomanic need only last 4 days and cannot be severe enough to cause marked impairment, hospitalization, or psychosis

OC Spectrum Disorders and Tic Disorders share this characteristic.

What is increased anxiety or tension build-up that is released upon engaging in a repetitive behavior? All share feature of repetitive behaviors that reduce anxiety/tension/discomfort

Example Short Answer:

What is meant by the term "double depression"? (1pt) Briefly describe a well-publicized risk for using SSRI medications to treat youths with anxiety, OCD or depression. (1pt) Define and distinguish anxiety, fear and panic. (3pts) Define and distinguish obsessions and compulsions (be sure to describe the relationship between them). (2pts) Define and distinguish between intoxication, tolerance, withdrawal and dependence. (4pts)

Dependence is characterized by these two features.

What is tolerance + withdrawal?

Prevalence of BD in youths.

What is unknown? BUT 0.5-1% in adults so likely less than 1%

The term for noxious physical/psychological effects some substance users experience when reducing or stopping substance intake

Withdrawal

The most effective treatment for bipolar disorder.

are mood-stabilizing medications?

Although often featured in popular media accounts, this complex vocal tic is rare and involves uttering vulgar words.

coprolalia

A child must show at least one of these two symptoms to meet criteria for a Major Depressive Episode.

depressed mood (irritable mood)*** diminished interest/pleasure in activities (anhedonia)*** Note that irritable mood is especially common - up to 80% kids with MDE show it

Trichotillomania is characterized by this.

hair-pulling

Trichotillomania

recurrent pulling out of one's hair, resulting in noticeable hair loss usually see increasing anxiety/tension before pulling, or if try to stop, pluse gratification or release of tension when pull Common sites are sclp, eyelashes and eybrows leads to significant distress, embarassment, social impairments about 1% boys - girls but females 10x more than males by adolescence; typical onset in puberty Also do see other areas like pubic area and arms etc (some even pull out other's hair - like parent, friend, etc) Note that some due chew on hair; some swallow it which can actually cause some pretty serious GI problems Not the same as grooming designed to make you look better Not the same as twirling or playing as habit without significant pulling

Excoriation disorder is characterized by this.

skin picking

These are sudden, rapid, recurrent, nonrhythmic behaviors

tics

The term for the central nervous system becoming less responsive to stimulation by particular drugs

tolerance