Child Psych OCD/Gen Dysph

34問 • 11ヶ月前

問題一覧

Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or are clearly excessive. B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social or occupational functioning.

DSM-5 Criteria/Definition: Obsessive-Compulsive Disorder

-A recurrent and intrusive thought, feeling, idea, or sensation -It is a mental event

Obsession

-Is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding -Is a behavior (Rituals)

Compulsion

_______ acts are carried out in an attempt to relieve the anxiety associated with the ________.

Compulsive; obsession

1-2% in children and adolescents • Has been reported to be as high as 4% in children and adolescents • 2-3% lifetime prevalence in the general population • Mild or transient rituals, obsessions or compulsions are common • Boys tend to have earlier onset than girls • Males have an onset before the age of 10 • By adolescence gender distribution equalizes • In adulthood • Onset after age 35 unusual, but can occur • Females are affected at slightly higher rates than males • 4th most common outpatient psychiatric diagnoses

Epidemiology: OCD

If untreated, it becomes a chronic condition which waxes and wanes over the course of a lifetime • Bimodal peaks: first in adolescence then again in adulthood • Without treatment, remission rates are low (approx. 20%) • Childhood onset can lead to a lifetime of this disorder • 40% who get treatment during childhood or adolescence may experience remission by adulthood

Course and Prognosis: OCD

-Neuropsychiatric disorder • Serotonin hypothesis • abnormalities in connections between the basal ganglia and the cortex • A cortico-striatal-thalamic circuitry mechanism has been implicated, involving the neurotransmitters glutamate, dopamine, and serotonin -Genetic Factors • genetic diathesis, with greater genetic loading in pediatric OCD compared with adult-onset OCD • Monozygotic concordance rate of 0.57 • Environmental Factors • Physical or sexual abuse, stress, or traumatic event • Childhood onset: 10x greater with 1st degree relatives -Psychosocial and developmental factors • ADHD, anxiety and MDD -Infectious diseases • pediatric autoimmune neuropsychiatric disorders associated with streptococcus infections (PANDAS) • Controversial • Research is supportive and refutes linkage between group A beta-hemolytic streptococcus (GABHS) infection and symptoms and onset and/or tic behaviors

Etiology: OCD

Gold standard assessment tool for use at initial diagnosis and symptom monitoring • Standardized inventory of symptoms • Aids in assessing severity, subjective distress, impairment, internal resistance, and degree of control.

Children’s Yale-Brown Obsessive Compulsive Scale (C-YBOCS)

Goal: Accept thoughts as thoughts, while avoiding specific experiences that don’t support acceptance

Acceptance and commitment therapy (ACT)

FDA approved for OCD, ≥7 years • Dosing: 10-80mg/day in children: 20-80 mg/day in adolescents

Fluoxetine

FDA approved for OCD, ≥7 years • Dosing: 50-200mg/day in children: 50-300 mg/day in adolescents

Fluvoxamine

Off-label use for OCD, ≥6 years • Dosing: 10-60mg/day(12.5-75 mg CR)

Paroxetine

FDA approved for OCD, ≥6 years • Dosing: 10-40mg/day

Sertraline

Off-label use for OCD, ≥6 years • Dosing: 10-40mg/day

Citalopram

FDA approved for OCD, ≥10 years; need EKG for risk of QTc prolongation • Dosing: 100-250mg/day

Clomipramine

Explain the concerns with pharmacologic treatments for OCD

Half get better and the other half get worse, and it usually takes higher doses

Locations: scalp, eyebrows, eyelashes, axilla, body, pubic area • Localized or diffuse • Rituals: examining, rolling, biting, or ingesting the hair

Trichotillomania

Result from swallowing the hair (35-40%) • Anemia, abdominal pain, risk of obstruction or perforation

Trichobezoars

List the most effective behavorial therapy and some pharmacological treatments for trichotillomania

Most effective - Habit Reversal Therapy • SSRIs • SNRIs • Lithium • Pimozide • Naltrexone • Buspirone • Clonazepam • Trazodone

• Multiple irregular and angular lesions; various stages of healing • Face most common • Arms, hands, cuticles, legs etc. • Localized infections, rashes • Seek irregularities and pick at it until it opens and bleeds

Excoriation Disorder

• Fluoxetine • Naltrexone • Lamotrigine • N-Acetylcysteine • Especially in patients with Prader Willi Syndrome

Pharmacological Treatments: Excoriation Disorder

Refers to behaviors that are viewed as incompatible with culturally expected gender roles

Gender-nonconforming

To somatic features or behaviors that are not typical (in a statistical sense) of individuals with the same assigned gender in a given society and historical era

Gender atypical

The sense one has of being male or being female which corresponds, normally, to the person's anatomical sex

Gender identity

A general term used to refer to those who identify with a gender different from the one they were born with (sometimes referred to as their assigned or natal gender)

Transgender

Denotes an individual who seeks, or has undergone, a social transition from male to female or female to male

Transsexual

-A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1): -A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender). -In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing. -A strong preference for cross-gender roles in make-believe play or fantasy play. -A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. -A strong preference for playmates of the other gender. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. -A strong dislike of one’s sexual anatomy. -A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender. -The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following: 1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics). 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). 3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender

DSM-5 Criteria: Gender Dysphoria in Adolescents

Freudian concepts state this disorder can result from difficulties establishing gender identity in toddlerhood. • Gender identity is established through resolution of the Oedipal and Electra complexes in the Phallic stage of development from identification with the same-sex parent. • This disorder may result from identification with an inappropriate role model. • As psychoanalytic concepts rely on the unconscious mind and repressed childhood traumas which affect adult personality it is an impossible theory to test in any sort of scientific way.

Psychoanalytic (Freudian): Gender Dysphoria

There is a strong correlation between gender dyphoria in boys and _____.

Seperation Anxiety Disorder

What CYP allele is associated with FtM transsexuality?

CYP17 allele

In these persons with XY karyotype , the tissue cells are unable to use testosterone. Therefore the person is born as a girl and raised as a girl they have reported to be satisfied with their feminity. Persons with partial androgen insensitivity has been associated with the gender change from female to male.

Androgen insensitivity Syndrome

• 1 sex chromosome is missing so the karyotype is X. they may have shield shaped chests and webbed neck. • Due to dysfunctional ovaries they need hormonal support in the development of the female sexual characteristics • They identify themselves as female • They are infertile

Turner syndrome

- An extra X chromosome is present so the karyotype is XXY. • At birth the people are born as the normal males, there may be excessive gyneacomastia in the adolescence usually they are tall • Testes are small without sperm production • They are tall and bodily habitus is eunuchoid • Reportedly having gender identity

Klinefelter Syndrome

A teenager with gender dysmorphia is treated with GnRN analogues at what tanner stage?

Tanner 2

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