Review #3. Chloe Leitch, MS4

Transcription

1 Review #3 Chloe Leitch, MS4

2 Outline Eating Disorders Forensic Psychiatry Defense Mechanisms Personality Disorders Child and Adolescent Psychiatry Autism Spectrum Disorders ADHD Psychotherapy

3 Eating Disorders Anorexia Nervosa: persistent energy intake restriction intense fear of weight gain disturbance in self-perceived weight/shape underweight BMI or <85% expected weight for age and height Restricting type: dieting, fasting, excessive exercise Binge/eating type-purging type: recurrent episodes of binge eating or purging behavior

4 Eating Disorders Bulimia Nervosa: Recurrent episodes of binge eating Inappropriate compensatory behaviors to prevent weight gain Self-evaluation that is unduly influenced by body shape and weight Normal weight (BMI ) or overweight Binge-Eating Disorder: binge eating 1x/week for 3 mos not associated with compensatory behavior

5 Forensic Psychiatry Capacity: determined by a physician; ability to make a specific (informed) decision Competency: determined by a judge; legal status Informed Consent Facts about intervention including risks, benefits and alternatives (including no intervention) Patient agrees with the plan (under freedom from coercion Malpractice Duty: physician has a duty to the patient Dereliction: physician breached that duty Damage: Patient suffered harm Direct: The breach of duty was what caused the harm

6 Risk Assessment for Violence A history of violence is the most reliable predictor of future violence late teens- early 20s, male, lower SES, lower IQ, less education, employment instability, homeless, h/o substance abuse Mental Illness > 4x more likely to be violent Substance abuse alone > 34 x more likely to be violent If you have a mental illness, you are more likely to be a victim of violence, than a perpetrator.

7 Personality Becoming a self: Mimicry: imitating another s behavior Introjection: incorporate part of another person but the person s identity remains the same Identification: taking over another s attitude/ behavior and making it part of one s own identity Attachment Styles: Secure attachment Insecure attachment- ambivalent, avoidant, disorganized

8 Immature Defenses Repression: withholding threatening/unacceptable memories from conscious awareness not subject to voluntary recall Denial: Refusing to perceive an unpleasant reality Displacement: Transferring avoided emotions to a neutral object (vs. projection) Projection: attributing an unacceptable internal impulse to an external source Reaction Formation: directing overt behavior in the opposite direction of one s underlying unacceptable impulses

9 Immature Defenses Rationalization: thinking up logical, socially approve reasons for our behavior Intellectualization: use of scientific of abstract as a means of avoiding stressful realities Isolation: (of affect) separation of feelings from ideas or events Splitting: perceiving the self and others as either all good or all bad 2/2 intolerance of ambiguity

10 Mature Defenses Suppression: temporarily intentionally holding an idea/ feeling from conscious awareness (vs repression) () Sublimination: diverting conflicts and impulses and channeling them into socially appropriate ways Humor: seeing the comic side of situations to express unpleasant/uncomfortable feelings Altruism: taking a negative experience and turning into a positive one by performing acts that benefit others

11 Personality Disorders- Cluster A Individuals appear odd and eccentric; poor interpersonal relationships, cold/aloof, odd/ suspicious, socially awkward Paranoid: pervasive suspiciousness Schizoid: lifelong pattern of social withdrawal; no desire for social relationships, prefer to be alone Schizotypal: eccentric behavior and peculiar thought patterns

12 Personality Disorders- Cluster C Anxious, fearfulness, need for approval/acceptance Avoidant: social inhibition and an intense fear of rejection Dependent: poor self-confidence, fear of separation; excessive need to be taken care of and allow others to make decisions for them Obsessive-Compulsive: perfectionism, inflexibility, orderliness; preoccupied with unimportant details > unable to complete tasks on time; egosystonic (vs. OCD egodystonic)

13 Personality Disorders- Cluster B emotional, impulsive, dramatic, dysphoric when left alone, often misdiagnosed as bipolar Histrionic: excessive emotionality and attention seeking, theatrical, sexuallyinappropriate, provocative Narcissistic: sense of superiority & entitlement, need for admiration, often envious/arrogant/haughty, lack empathy, (however, have low self-esteem > narcissistic injury) Antisocial: disregard and violation for the rights of others; 18 y/o for dx, conduct do as a child; risk taking, deceitful/repeated lying/manipulation for personal gain; lack of remorse for actions Borderline: instability of affect, interpersonal relationships, self-image and impulsivity; feeling of emptiness; fear of abandonment, marked reactivity of mood, inappropriate and intense anger

14 Child & Adolescent Psychiatry Intellectual Disability: Intellectual: confirmed with testing (IQ > 70= ID) Adaptive functioning: how well the individual functions in important areas of life including social and behavioral interactions, conceptual and intellectual life and ADLs Learning Disability: inability to achieve in a designated area of learning (ie reading, math, writing) at a level inconsistent with an individual s overall intellectual functioning

15 Child & Adolescent Psychiatry Normal Deviance > ODD > Conduct Disorder Oppositional Defiant Disorder: Angry/irritable mood: loses temper, easily annoyed, angry, resentful Argumentative/Defiant Behavior: argues with authority figures/adults, deliberately annoys others, blames others for mistakes/misbehavior Vindictiveness Comorbid with ADHD & mood disorders

16 Child & Adolescent Psychiatry Conduct Disorder: forerunner of antisocial PD in adults Aggression to people and animals: bullies/threatens/ intimidates, initiates physical fights, has used weapon, physically cruel to animals, stolen while confronting a victim, forced someone sexually Destruction of property: ex firesetting Deceitfulness or theft: cons others, broken into to someone s car/house Serious violation of rules: runs away from home, truancy from school

17 Child & Adolescent Psychiatry Developmental Perspective of Conduct Disorder: Adolescent onset has a better prognosis! Childhood Onset: < 10 yrs male physical aggression towards others disturbed peer relationships Adolescent Onset > 10 yrs male:female less likely to be physically aggressive more normative peer relationships Treatment of ODD and CD: behavioral interventions: parent training, MST (conduct disorder), preventive measures medications for comorbid disorders or decrease impulsive aggression

18 Child & Adolescent Psychiatry Disruptive Mood Dysregulation (DMDD): Severe, recurrent temper tantrums inconsistent with situation and developmental level occurring in at least 2 settings. Mood between tantrums is irritable or angry. Onset before age 10 y/o. Diagnosis made after 6 y/o and before 18 y/o. Depression: Children: tend to exhibit more somatic complaints, have poor self-esteem Adolescents: decreased school performance, school refusal, change in sleep pattens, behavioral disturbances, substance use. Tx: Psychotherapy, SSRIs (black box warning)

19 Bipolar Disorder: Child & Adolescent Psychiatry Mania: irritability, intense anger, aggression, hyperactivity, sexual preoccupation inconsistent with developmental level 20-40% of depressed children will develop bipolar d/o within 5 yrs of onset of MDD Risk factors for early-onset Bipolar Disorder: Early onset MDD (especially with psychotic features) Family history of bipolar disorder, depression with psychotic features, any mood disorder Pharmacologically induced mania Treatment: mood stabilizers, antipsychotics, psychosocial interventions, hospitalization

20 Child & Adolescent Psychiatry Separation Anxiety Disorder: excessive anxiety regarding separation from places/people to whom he/she has as strong emotional attachment; somatic sxs common; precursor to panic d/o in adults; Tx: CBT, family therapy, play therapy Posttraumatic Stress Disorder: in children younger than 6 yrs, may not have the cognitive ability to form memory; trauma may be expressed through play reenactment; and often re-experience trauma when relaxed Schizophrenia: rare in children- genetic loading, neurological soft signs, low IQ, increased anxiety, hyperactivity, impaired attention, delayed speech/language. Adolescents- prodrome

21 Autism Spectrum Disorders Impairment in reciprocal social communication Restricted/repetitive patterns of interests, behaviors or activities inflexibility to sameness,hypo/hyper reactivity to sensory input Symptoms occur early in developmental period Level 1 (requires least support) - Level 3 (requires most support) Social Communication Disorder: difficulties in the use of verbal and nonverbal communication (ie, for social purposes, contextual changes, following rules/cues for conversing, making inferences); do NOT have h/o repetitive behaviors

22 Autism Spectrum Disorder 4:1 male:female ratio associated with advanced paternal age Comorbities: sleep problems, seizures, psychiatric disorder, minor malformations Treatment: Social: speech & language therapy, OT, special education, social skills training, caregiver supports Psychological: Applied behavior, rewards/consequences, parent training, CBT, supportive therapy Pharmacological: Risperidone and aripiprazole > irritability associated with autism

23 ADHD Subtypes: Inattentive Hyperactive-Impulsive Combined Sx present before age 12 Several symptoms are present in >2 settings Hyperactivity is most likely to remit Treatment: behavioral therapy + medications Stimulants (methylphenidate, amphetamines) Non-stimulants: atomoxetine; clonidine, guanfacine (a-2 adrenergic agonists)

24 Psychotherapy Psychodynamic: resolve unconscious conflicts by bringing repressed experiences into awareness and integrating them into the patient s conscious awareness; insight-oriented Supportive: helps patients cope with specific crises or difficulties; listen in a sympathetic way, help build up the patient s defenses Cognitive Behavioral Therapy (CBT): identifying and challenging maladaptive patterns of thinking to change behavior