Peds Psych Exam 2 (part 3)

67問 • 11ヶ月前

問題一覧

DSM-5 Criteria/Definition: Major Depressive Disorder

Five or more of the following symptoms have been present during the same 2‐week period and represent a change from previous functioning: At least one of the symptoms is either(1) depressed mood or (2) loss of interest or pleasure. 1. depressed or sad mood experienced most of the day, nearly every day 2. diminished interest or pleasure in activities 3. meaningful unintended weight loss or weight gain, or meaningful decrease or increase in appetite 4. sleep disturbance (too little or too much) 5. psychomotor restlessness or slowing 6. low energy or fatigue 7. feelings of worthlessness or excessive guilt 8. reduced ability to make decisions or impaired concentration 9. recurrent thoughts of death, suicidal ideation, a plan for completing suicide, or a suicide attempt

Major Depressive Disorder: SIGECAPS; what does the first "S" stand for?

Sleep disorder (either increased or decreased sleep)

Major Depressive Disorder: SIGECAPS; what does the "I" stand for?

Interest deficit (anhedonia)

Major Depressive Disorder: SIGECAPS; what does the "G" stand for?

Guilt (worthlessness, hopelessness, regret)

Major Depressive Disorder: SIGECAPS; what does the "E" stand for?

Energy deficit

Major Depressive Disorder: SIGECAPS; what does the "C" stand for?

Concentration deficit

Major Depressive Disorder: SIGECAPS; what does the "A" stand for?

Appetite disorder (either decreased or increased appetite)

Major Depressive Disorder: SIGECAPS; what does the "P" stand for?

Psychomotor retardation or agitation

Major Depressive Disorder: SIGECAPS; what does the last "S" stand for?

Suicidality

-Depressed or sad mood for most of the day, for more days than not, lasting at least 1 year. Presence, while depressed, of at least two of the following: 1. poor appetite or overeating 2. sleep disturbance (too little or too much) 3. low energy or fatigue 4. low self‐esteem 5. reduced ability to make decisions or impaired concentration 6. having feelings or hopelessness -During the 2‐year period of the disturbance, the person has never been without significant symptoms for more than 2 months at a time.

Persistent Depressive Disorder

S/S of depresion in children include:

Somatic complaints, Psychomotor agitation, Anxiety, Behavior Problems, ADHD-like symptoms, Hallucinations, Depressed Affect

S/S of Depression in Adolescents include:

Melancholic symptoms (anhedonia, weight loss), Delusions, Suicidal Behavior, Substance Use

-Hypothalamic–pituitary–adrenal (HPA) abnormality -Serotonergic system abnormalities – increase release of prolactin in depressed children -Smaller left subgenal prefrontal cortex (girls) -Increased pituitary gland volume -Smaller amygdala volume -Sleep abnormalities mixed, based on REM studies

Neurobiology of MDD

-Mean length of an episode is 8 months -Recovery rates are high, even without treatment -90% recover within 1-2 years -Relapse: 34-50% -6-12 months after treatment discontinuation -Recurrence:20-60% after 2 years remission and up to 70% at 5 years

Course of MDD

Diagnosing MDD in 3-6 year old children look for?

Lacks pleasure from play, anhedonia, sadness & irritability/anger, sleep-change, somatic symptoms, activity level changes

Depression Screening -Ages 6-12 -Schoolwork, socialization, physical complaints -Given to both parents and child

Children’s Depression Inventory

Depression Screening Ages 8-12

Reynolds Child Depression Scale

Name two self reporting depression screenings

Reynolds Adolescent Depression Scale & PHQ-9

How long do you assess adolescence for depression?

3 weeks

Symptoms with this disorder and can mimic depression: -anhedonia (numbing of responsiveness) -social isolation (detachment from others) -hopelessness (sense of foreshortened future) -disrupted sleep patterns (increased arousal) -irritability (increased arousal) -difficulty concentrating (increased arousal)

PTSD

-Depressed youth may be more prone to oppositional and defiant behaviors as a consequence of irritability -Temper tantrums may be a manifestation of depressed mood

Oppositional defiant disorder (ODD)

-May have school failure -Difficulty with friendships -Depressed mood -Low self-esteem

ADHD

Depressive-like symptoms can appear to overlap with symptoms of autism: -Lack of social reciprocity -Failure to develop peer relationships -Poor eye contact

Pervasive developmental disorder

What are some reasons a child will inflict non-suicidal self injurious behavior (NSSIB)?

-Loss of sense of control -seeks to regain control through actions

Criteria for NSSIB

Engaging in behaviors 5+ days with damage to skin & at least 2 of the following: negative feelings or thoughts, preoccupation with behavior, frequent urges, and purposeful engagement of act, & it results in impairment in one or more areas of functioning

What is a safe way to inflict pain for children with NSSIB?

rubber bands

Psychotherapies for NSSIB

Skills training for stress management, family therapy, CBT, and DBT

Meds for impulsivity in Non-Suicidal Self Injury Behavior (NSSIB)

Risperidone, Abilify, Clonidine, Intuniv

NSSIB Medications

SSRIs, mood stabilizers, atypical antipsychotics, naltrexone to reduce cravings

-Depressive symptoms (sadness, tearfulness, hopelessness) appear after the occurrence of an identifiable stressor -Do not meet criteria for a major depressive episode, and does not last long enough to meet time criteria for dysthymic disorder -The symptoms should occur within 3 months of the onset of the stressor(s) -Must not last 6 months after the offset of the stressor(s).

Adjustment disorder with depressed mood

In the treatment algorithm for MDD what meds should be considered in stage 3?

Different Antidepressant Classes (venlafaxine, bupropion, mirtazapine, duloxetine)

At what age is Wellbutrin approved for ADHD in children?

> 12

At what age can children actively participate in their treatment plan?

>/= 7

Elevation of mood, lower anxiety

5HT1

-Increases side effects of anxiety, restlessness, insomnia, sexual dysfunction -Stimulation can cause agitation

5HT2

Gastric motility, Nausea, Vomiting -Activates brain stem vomiting center & receptors in the gut -Not good choice for child with GI disturbance

5HT3

Examples of 5HT2 drugs

fluoxetine (Prozac)

Examples of 5HT3 drugs

luvoxamine (Luvox) & sertraline (Zoloft)

New disorder; introduced in DSM-5 -Developed to provide a distinction of criteria for children and adolescents diagnosed with “broad phenotype” bipolar disorder -Arose out of research on a subgroup of children with severe mood dysregulation (SMD) aimed -Severe, non-episodic, chronic irritability and many of the hyperarousal symptoms of mania without the discrete, episodic nature of mania or hypomania. -High rates of comorbid ADHD, ODD, and anxiety -Lacked mood episodes -Low familial rates of bipolar disorder -Had different neurocognitive and neuroanatomic profile -Increased risk of developing depression and anxiety; not bipolar disorder

Disruptive Mood Dysregulation Disorder

-Recurrent verbal or behavioral temporal outbursts (>3 or more times per week) that are excessive and age inappropriate -Irritable or angry mood most of the day nearly every day -Symptoms occur in at least two settings (school, home, or with peers) -Duration of symptoms must be more than 12 months, without a 3 months symptom-free period in this time frame -Age of onset of the symptoms must be before 10 years old -Diagnosis should not be made before age 6 years or after age 18 years.

Disruptive Mood Dysregulation Disorder

-Onset of symptoms before 10 years old (cannot be diagnosed before 6 years old) -Many studies began monitoring preschool children for early signs (ages 3-4)

Course of Disruptive Mood Dysregulation Disorder

DMDD vs ODD

-ODD ongoing anger guided disobedience; hostilely defiant against authority figures -DMDD is considered more severe than ODD in these s/s -If child meet criteria for both dx, only diagnose with DMDD.

DMDD vs BD

-Bipolar disorder: irritable but this is episodic -DMDD has no episodic nature in the irritability. It is chronic, severe, and persistent.

Differential Diagnoses for DMDD: Bipolar Disorder

Irritability and severity is episodic in Bipolar. Cannot be diagnosed with DMDD if BPD is present OR full symptom criteria for a hypomanic or manic episode are met for more than one day.

If criteria for _____ and DMDD are met, only DMDD diagnosis is made

ODD

DMDD cannot be dually diagonised with ODD, Intermittent explosive disorder, and Bipolar, but can be with?

ADHD, Depression, and Anxiety

DMDD vs Intermittent explosive disorder

-DMDD includes irritability in-between outbursts -IED needs 3 mos. active symptoms for diagnosis vs. 12 mos. for DMDD

When treating mood for DMDD which medication as been effective?

Risperidone

Requires one lifetime manic episode (with/without depression)

Bipolar I disorder

One hypomanic episode and one lifetime episode of major depressive episode (MDE)

Bipolar II disorder

2 years (1 year for children) of both hypomanic and depressive periods, without fulfilling criteria for mania, hypomania or major depression

Cyclothymic disorder

May occur more frequently in children and adolescents, making the bipolar diagnoses challenging

Mixed Episodes and Rapid Cycling

Course of Bipolar I Disorder

Mania (1 week of sx); Hypomania (4 days; 3 or more sx); Depressive episode (2 weeks; 5 or more sx)

What are the most common s/s of depressed mood in children?

Irritability and lack of appetite

Explain the difference in cycling of Bipolar symptoms in children vs adults

Children cycle more frequently between mania an depression meaning less time without symptoms between episodes

Describe how mania presents in adolescents

Delusions (persecutory in nature), hallucinations (typically grandiose in nature) and flight of ideas and represents a distinct departure from previous behavior. Often occur after a depressive episode.

Describe mixed episodes in children with bipolar

-Agitated -Get upset easily or for no apparent reason -Have trouble falling or staying asleep -Lose his appetite, or start overeating -Think of, mention or threaten suicide -Experience any combination of the above noted symptoms of both mania and depression

What brain regions are smaller in children with bipolar?

hippocampus and thalamus

Most commonly used interview tool for children with bipolar

The Schedule for Affective Disorders and Schizophrenia in Children (K-SADS)

How do you treat a child with Bipolar and ADHD?

Discontinue Adderal and start Valproate

Atypical antipsychotics used to treat Bipolar

Olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone

Studies show that Quetiapine and Risperidone are superior to _______ in treating Bipolar

divalproex

What is the preferred mood stabilizer for bipolar in children, and what is a preferred augmentation to therapy?

Lithium and Lamotrigine

What is the downside to using SSRIs in Bipolar

It may destabilize mood

-Rates may be as high as 50% within children w/ bipolar disorders -May account for reports of increased suicidality in children on SSRIs -Risks factors include: -Bipolar family history -Psychomotor retardation -Atypical depression (hypersomnia, wt gain, reactive mood) -Acute onset of depression

SSRI-induced mania

What supplement has shown effective for improving medication compliance, prevent relapse, and assist with the developmental impact of biplar disorder?

Omega-3 fatty acids

SSRIs for MDD

fluoxetine, escitalopram, citalopram, sertraline

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