Carlos A. Muralles, M.D. 1 EFFICIENT PRACTICES FOR TREATING THE DEVELOPMENTAL DISABLED WITH MENTAL...

Carlos A. Muralles, M.D.

1EFFICIENT PRACTICES FOR TREATING THE DEVELOPMENTAL

DISABLED WITH MENTAL ILLNESS

A DIDACTIC TRAINING FOR REGIONAL CENTER PSYCHIATRISTS

PRESENTED BY:ALMA FAMILY SERVICES

Carlos Muralles, M.D.



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DEVELOPMENTAL DISABILITIES (DD):DEFINITION

Diverse cluster of individuals with chronic barriers related to mental and/or physical conditions with severe impairment in their level of functioning. The areas must common affected is with their daily life activities such as independent living, mobility, self care and direction, language-communication, socio-economical self assistance, learning and relational-interaction with others.



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HISTORY OF DD Derogatory Connotations

Past Forms Society Dealt with DD Population Asylums 18th-19th century: Large organizations providing basic needs 1952: Development of workshops for Special Ed Teachers as well as Day Camps 1960: Elimination of asylums 1970: “The Developmental Disabilities Service and Facilities Construction Act of

1970”



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CLASSIFICATION: MENTAL RETARDATION Significant subaverage intellectual functioning: an IQ of 70 or below on an

individually administered IQ test

MILD (50 –55 to 70)

MODERATE (35–40) to (50-55)

SEVERE (20-25) to (35-40)

PROFOUND (<20) to 20

M.R. severity NOS (clinically MR unable to be tested)



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CLASSIFICATION: PERVASIVE DD

AUTISM SPECTRUM DISORDERS RETT’S DISORDER CHILDHOOD DESINEGRATIVE DISORDER ASPERGER’S DISORDER PERVASIVE DEVELOPMENTAL DISORDER NOS



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CLASSIFICATION: NEUROPHYSIOLOGICAL

CEREBRAL PALSY

SEIZURE DISORDERS

HEARING LOSS/DEAF & MUTE



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CONCOMITANT FACTORS LEARNING D/O FEEDING AND EATING D/O

MOTOR SKILL D/O TIC D/O

COMMUNICATION D/O ELIMINATION D/O

ATTENTION DEFICIT D/O OTHER DISORDERS OF INFANCY,

DISRUPTIVE BEHAVIOR D/O CHILDHOOD OR ADOLESCENCE



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ETIOLOGY UNKNOWN.

Efforts to track the disorders are inconclusive

Believed that both genetic and environmental factors play a role

Some disorders are more common with the existence of certain medical conditions



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EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES The risk of DD in a child increases 4-15 x’s if one of the parent’s has traits or

suffers from the same condition

MENTAL RETARDATION: Familial Pattern: None; this is due to its heterogeneous etiology Prevalence: 1% of the population Ethnic, cultural and linguistic background: Reflected in standardized test Ratio in Gender: Male to Female : 1.5:1



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EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES

MENTAL RETARDATION (cont..) MILD: “Educable”; 85% of MR population MODERATE: “Trainable”; 10% of MR population SEVERE: 3-4% of MR population PROFOUND: 1-2% of MR population



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EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES AUTISTIC DISORDER

Familial Pattern: among siblings of individuals w/ DO: 5% Median Prevalence Rate: 5 cases per 10,000 individuals

(*note: cases range from 2-20 cases / 10,000 individuals) Ethnic, cultural and linguistic background: None that is specific Male to female ratio: 4-5:1 Females more likely to exhibit profound MR



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EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES RETT’S DISORDER

Familial Patterns: Similar to AD; 5% correlation for individuals who have a sibling with d/o

Higher association with Severe and Profound MR Prevalence: less common than AD Ratio in Gender: Almost exclusively in females

(1 in every 10,000-20,000 females



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EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES CHILDHOOD DISINTEGRATIVE DISORDER

Termed as “Heller’s Sx”, “Dementia Infantillis”, “Disintegrative Psychosis” Familial Pattern: No information Prevalence: Very rare and much less than AD Conditions appear to be underdiagnosed Ratio in Gender: Equal (+0)

ASPERGER’S SYNDROME Familial Pattern: Depressive D/O and AD among siblings of individuals with AS Prevalence: Unknown Ratio in Gender: Male to Female: 5:1



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CONDITION FAMILIAL PATTERN

PREVALENCE CULTURAL/ETHNIC

GENDER RATIO

(M to F)

DEGREE

M.R. None 1-3% Reflected I standardized

test

1.5:1 Mild: 85%Moderate:

10%Profound: 1-

2%AUTISTIC D/O 5% (among

siblings)5 per 10,000 No specific

criteria4-5:1 No criteria

RETT’S D/O 5% (as in AD)

Less common than AD

No specific criteria

Almost exclusively in females

No criteria

CHILDHOOD D.D.

No information

Rare; Less than AD

No specific criteria

(+0)equal

No criteria

ASPERGER’S D/O

Depressive D/O and AD

among siblings

Unknown No specific criteria 5:1

No criteria



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SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF AUTISM

Impairment in social interaction Non use of nonverbal bx No development of age appropriate peer relationship Lack of spontaneous interest or seeking to share enjoyment No social or emotional reciprocity

Impairment in communication Delay or total lack of development of spoken language Inability to initiate or sustain conversation Idiosyncratic language Lack of play or social activities Restricted, repetitive and stereotyped play



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SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF RETT’S DISORDER

Initial Developmental Hx: Normal prenatal and perinatal development 0-5 months: Normal psychomotor development Normal circumference at birth

Onset of Sx After Normal Development 5-48 months: Deceleration of head growth Loss of previously acquired purposeful hand skill & development of stereotyped hand

movements Loss of social engagement Poor coordinated gait or trunk movements Impaired excessive & receptive language Severe psychomotor retardationCarlos A. Muralles, M.D.


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SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF CHILDHOOD DISINTEGRATIVE DISORDER

Regression in various areas of functioning after age 2 Verbal/Non-verbal, language, social, play and adaptive bx

is normal After age 2 (-10 yrs):

Loss of clinically and qualitative former acquired skills: Bowel or bladder control Motor skills Expressive or receptive language Social and adaptive bx’s Play



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SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF ASPERGER’S DISORDER

Qualitative Impairment in social interaction Impairment in the use of nonverbal bx Failure to develop peer relationships Lack of spontaneity or emotional reciprocity

Restricted repetitive and stereotyped patterns of bx Disturbance causes clinical interference with social occupation and functioning No clinical significant delay in language No delay in cognitive development, self help skills or adaptive

behavior



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SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF PERVASIVE DEVELOPMENTAL DISORDER N.O.S.

Severe and pervasive Impairment in the development of reciprocal social interaction

Associated with impairment in either verbal or nonverbal communication Presence of stereotyped behaviors, interests, and activities Does not meet criteria for

Pervasive Development D/O, Schizophrenia, Schizotypal P.D., Avoidant Personality D/O or “atypical autism”



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CONCOMITANT FACTORS LEARNING DISORDERS

READING DISORDER MATHEMATICS DISORDER DISORDER OF WRITTEN EXPRESSION LEARNING DISORDER NOS

MOTOR SKILLS DISORDERS Development Coordination Disorder



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CONCOMITANT FACTORS COMMUNICATION DISORDERS

Language Disorder Mixed Receptive Expressive Language Disorder Phonological Disorder Stuttering Communication Disorder NOS

ATTENTION DEFICIT DISORDER Hyperactive Type Combined Type Predominantly Inattentive Type Predominantly Hyper-Impulsive Type



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CONCOMITANT FACTORS

DISRUPTIVE BEHAVIOR DISORDER CONDUCT DISORDER

Childhood-Onset Type Adolescent-Onset Type Unspecified Type

OPPOSITIONAL DEFIANT DISORDER DISRUPTIVE BEHAVIOR DISORDER NOS



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CONCOMITANT FACTORS FEEDING AND EATING DISORDERS

Pica Rumination Disorder Feeding Disorder of Infancy or Early Childhood

TIC DISORDERS Tourette’s Disorder Chronic Motor or Vocal Tic Disorder Transient Tic Disorder

ELMINATION DISORDERS Encopresis: With or Without Constipation and Overflow Incontinence Enuresis: Not Due to a General Medical Condition: Nocturnal Only; Diurnal Only; Nocturnal

& DiurnalCarlos A. Muralles, M.D.


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OTHER DISORDERS OF INFANCY, CHILDHOOD OR ADOLESCENCE SEPARATION ANXIETY DISORDER

SELECTIVE MUTISM

REACTIVE ATTACHMENT DISORDER Infancy: Inhibited or Disinhibited Type Early Childhood: Inhibited or Disinhibited Type

STEREOTYPIC MOVEMENT DISORDER With or Without Self Injured Behaviors

DISORDER OF INFANCY, CHILDHOOD OR ADOLESCENCE NOSCarlos A. Muralles, M.D.


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SENSORY IMPAIRMENT OR DEPRIVATION

HEARING LOSS

DEAF

MUTISM



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MENTAL DISORDER AND DD DUE TO GENERAL MEDICAL CONDITION CATATONIC DISORDERS DUE TO GENERAL MEDICAL CONDITION

PERSONALITY CHANGE DUE TO GENERAL MEDICAL CONDITION Labile Type Disinhibited Type Aggressive Type Apathetic Type Combined Type Unspecified Type Other Type



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PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS

CEREBRAL PALSY (CP) DEFINITION

An abnormality of motor function (the ability to move and control movements) that is acquired at an early age, usually less than a year of age, and is due to a brain lesion that is non-progressive.

Result of abnormalities that occur in utero



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PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS CEREBRAL PALSY (CP)

CHARACTERISTIC SYMPTOMS Spastic paresis of the limbs (both children and adults) Choreoathetoid movement disorder: Chorea & Athetosis Unequal size of hands and feet Frequent MR Seizure disorder Impairment of senses

Visual: Strabismus, Myopia Blindness Auditory: Deafness Vocal Dysarthria



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PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS CEREBRAL PALSY (CP)

VARIETIES OF CELERBRAL PALSY SPASTIC (70%)

Subcategories Diplegic (25%): paresis of both legs; suffers from seizures and MR Hemiplegic (50%): paresis of arms and legs; suffers from seizures and MR Quadriplegic (75%): paresis of all limbs; suffers from seizures and MR

EXTRAPYRAMIDAL (15%): Choreoathetosis and involuntary writhing of the face/tongue, hands and feet punctuated by

jerking momvemnts; 10% Seizure D/O and MR MIXED FORMS OF CP (15%)

Combination of spastic para paresis and choreoathetosis Highest incidence (95%0 of seizure and MRCarlos A. Muralles, M.D.


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SEIZURE DISORDERS CLASSIFICATION

PARTIAL OR FOCAL SEIZURES 1. Partial Seizures with Elementary Symptomatology

Also called “motor seizures” Rhymic jerking Possible development of focal status or secondary generalization Post-ictal monoparesis Tod’s Hemiparesis Possible sensory sx (auditory, visual or olfactory hallucinations)



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PARTIAL OR FOCAL SEIZURES 2. Partial Seizures with Complex Symptomatology

Also called “Psychomotor and Temporal Lobe Seizure D” Characterized by automatisms Never occurs without accompanying loss of awareness Includes: swallowing, kissing, lip smacking, fumbling, scratching, etc. Utter or mutter brief phrases unintelligibly May suffer from visual hallucinations (macropsia and micropsia), delusions,

déjà-vu dream like states, mind-body dissociations



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GENERAL SEIZURE DISORDERS Absences or Petit Mal

Occurs in 1-10 second lapses; almost all cases are accompanied by automatisms

Blinking occurs rhythmically at 3 Hz Children’s mental and physical activity is affected (although they do not have

retrograde amnesia and maintain tone and bladder control) Following the ictus, there is no confusion, agitation or sleepiness



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TONIC-CLONIC OR GRAND MAL

Causes massive motor activity and profound postical residua

Pt’s may experience prodrome of malaise or mood change

Tonic Phase: Pt’s loose consciousness; eyes roll upward, neck, trunk and limbs all extend backwards

Clonic Phase: Limbs, neck and trunk are wracked by violent jerks

Postictal period may include confusion, disorientation, irrationality, agitation, amnesia and cognitive impairment…may last for several hours



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ADDIONAL ASSOCIATED FEATURES AND DISORDERS: PHYSICAL & GENERAL FINDINGS

PHYSICAL FINDINGS

MEDICAL CONDITION NEUROCONDITION

M.R.

M.R None; ONLY if assoc with

specific syndrome

Increase w/ severity in visual, auditory &

cardiovascular

Increases w/ severity (i.e., seizures)

N/A

AUTISM Nonspecified More prominent when assoc w/ other neuro-

med condtion

Nonspecified; 25% seizure d/o present

Most cases are assoc with MR

RETT’S N/A N/A Assoc w/ seizure d/o Severe / profound

ASPERGER N/A N/A No cognitive or language delay in 1st yrs; motor

clumsiness; over-activity & inattention are frequent

Generally none; some mild noted in school

years CHILD-

HOOD DDMetachomatic,

leukodystrophy, Schilder’s



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ADDITIONAL ASSOCIATED FEATURES AND DISORDERS: LABORATORY FINDINGS

LABORATORY FINDINGS

MENTAL RETARDATION

Other than psychological testing (WAIS-III=Wechsler Adult Intelligence Scale & WISC-III=Wechsler Intelligence Scale for Children) there ARE NO lab findings uniquely assoc w/ MR

AUTISTIC DISORDER

Reports of groups differences in measures of serotonergic activity exist; these are not diagnostic criteria for AD; No specific pattern noted in EEG

RETT’S DISORDER NO specific findings associated; Increased frequencies of EEG and seizure d/o may exist; Abnormalities in brain imaging have existed

CHILDHOOD DISENTEGRATIVE

Increased frequencies of EEG abnormalities and seizure d/o; Lab findings reflect any assoc general med conditions

ASPERGER’S D/O Lab findings reflect any assoc general med conditions



36COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE POOR IMPULSE CONTROL

Frequently related to poor tolerance to frustration This is often manifested by:

Outburst of anger Explosive violent and aggressive bx towards others If more impaired/severe DD, increased likelihood of self injurious bx

Lack of communication skills may predispose individual to disruptive, aggressive or impulsive bx



37COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE RANGE OF BEHAVIORAL SX

Hyperactivity Short attention span Temper tantrums (mostly seen in young population)

ODD RESPONSES TO CONDUCT Talking to self to keep conduct w/out ability to confirm auditory hallucinations Close imaginary friends Confabulation without being delusional



38COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE SPEECH

Mode of speech and associations are usually repetitive, echolalic and perseverant with the same theme or statement

Tone may be loud, without being irritated or demonstrating any aggressive behavior

ODD RESPONSES TO INTERNAL STIMULI High threshold for pain and fever (Autistic D/O) Oversensitivity to loud sounds or being touched Reactions to light and odors Fascination with certain moving objects



39COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE ABNORMALITIES IN EATING PATTERNS

Hyperphagos Limiting diet to select foods Pica Nocturnal eating

ABNORMALITIES WITH SLEEPING HABITS Recurrent awakening at night w/ unusual bx’s (i.e. rocking in Autistic D/O) Recurrent naps during the day Awakening at night with nightmares Insomnia or hyperinsomnia



40COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE FEAR RESPONSES

Lack of or over response to danger/harmless objects

SELF-INJURIOUS BEHAVIORS Head-banging (autistic), finger/hand/wrist-biting

MOOD CHANGES Higher level of functioning indiv have tendency to become depressed or dysphoric Some develop vegetative or autonomic sx Concomitant factors often lead to demoralization, low self-esteem and deficit in social skills Excitement is often shown by incongruent affect: weeping or giggling Intrusive bx or hyperactivity is often seen w/out having a diagnosis of Bipolar D/O



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COURSE OF THE CONDITIONS MENTAL RETARDATION

Influence of course is underlined by: medical condition and environmental factors Mild MR:

If dx earlier, manifested by failure in academic learning tasks May be appropriate to train May be able to acquire good adaptive skills Diagnosis required bf age 18 months Etiology and associations with syndromes may help for early detection (i.e. Down

Syndrome) Mild MR of unknown origin is recognized later

More severe MR resulting from acquired cause will develop more abruptly (i.e. encephalitis)



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COURSE OF THE CONDITIONS AUTISTIC DISORDER

Follows a continuous course Language skills and intellectual level are strongest factors for prognosis School aged children and adolescents:

Developmental gain in some areas (increased interest in social functioning) Some deteriorate behaviorally during adolescence; others improve

A small % of these individuals live and work independently 1/3 achieve partial independence Even the highest functioning adults exhibit problems in social interactions and

communication along with markedly restricted interest in activities



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COURSE OF THE CONDITIONS

RETT’S DISORDER Duration is lifelong Loss of skills is persistently progressive Communicative bx difficulties remain constant throughout life Recovery is very limited Gains (if any) will be in social interaction during adolescence



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COURSE OF THE CONDITIONS CHILDHOOD DISINTEGRATIVE DISORDER

Disorder follows continuous course Duration is lifelong Social, communicative and bx difficulties remain constant throughout life

ASPERGER’S DISORDER Disorder follows continuous course Most cases are lifelong Motor difficulties will be more apparent in the context of school Some adults may have problems with empathy and modulations of social interaction



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DIFFERENTIAL DIAGNOSIS

MENTAL RETARDATION Learning D/O Communication D/O Pervasive Developmental D/O Dementia Borderline Intellectual Functioning (IQ Range: 71-84)



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DIFFERENTIAL DIAGNOSIS AUTISTIC DISORDER

Other Pervasive Developmental D/O (Rett’s D/O) Childhood Disintegrative D/O Asperger’s D/O Schizophrenia Selective Mutism Expressive Language D/O Mixed Receptive-Expressive Language D/O Stereotype Movement D/O Mental Retardation



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DIFFERENTIAL DIAGNOSIS RETT’S DISORDER

Autistic D/O Childhood Disintegrative D/O Asperger’s D/O

CHILDHOOD DISINTEGRATIVE DISORDER Other Pervasive Developmental D/O Autistic D/O Rett’s D/O Demential



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DIFFERENTIAL DIAGNOSIS ASPERGER’S DISORDER

Pervasive Developmental D/O Schizophrenia Autistic D/O Rett’s D/O Childhood Disintegrative D/O Obsessive-Compulsive D/O Schizoid Personality D/O



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DIFFERENTIAL DIAGNOSIS: SIMILARITIES FOUND DIFFERENTIAL DIAGNOSIS

MENTAL RETARDATION

AUTISTIC D/O

RETT’S D/O

CHILD-HOOD D.D.

ASPERGER’S D/O

Childhood DD X X X

Autistic D/O X X X

Rett’s D/O X X

Pervasive DD X X

Other Pervasive DD

X X

Schizophrenia X X



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ASSESSING THE CHIEF COMPLAINT CHIEF COMPLAINT:

W H Y N O W ?

PRECIPIATATING FACTORS Change of routine Moving environment Separation from parents Death in the family Traumatic event



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ASSESSING THE CHIEF COMPLAINT MEDICAL EVENTS

Current medical condition/illness Substance use: past and present Any recent medication prescribed

NON-COMPLIANCE WITH TREATMENT Abruptly halt with medication Change of psychotropic medication



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ASSESSING THE CHIEF COMPLAINT HISTORY OF CHIEF COMPLAINT

Data base Onset of Symptoms Description of chronological symptoms and events Awareness/suspicion of precipitant factor Psychiatric History

Hospitalizations Medications: past & recent Best response to medication Side effects from other medication

Change of Psychosocial Environment Current Mental Status Examination



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DYNAMIC FORMULATION

Summary of current data base with summary of chronological symptoms and its evolution with specific rationalization for specific criteria and specific diagnosis.



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CONCLUSIVE CRITERIA FOR DIAGNOSISACCORDING TO DSM-IV-TR

RULE IN (R/I) With specific Code

RULE OUT (R/O) in a specific amount of time



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TREATMENT PLAN AND RECOMMENDATIONS IN-PATIENT TREATMENT

Voluntary Involuntary

OUT-PATIENT TREATMENT Individual Psychotherapy

Supportive & Short-term Cognitive-Behavioral Family Interventions (Educational & Support Groups)

PSYCHOPHARMACOTHERAPYCarlos A. Muralles, M.D.


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PSYCHOPHARMACOTHERAPY INDICATIONS FOR ANTIPSYCHOTICS

Primary treatment of psychotic conditions POSITIVE SYMPTOMS

Hallucinations, delusions, incoherence, disorganized/catatonic bx NEGATIVE SYMPTOMS

Flat affect, alogia abolition, anhedonia Bizarre or erratic bx Agitation, aggressive/assaultive bx Odd response to sensory stimuli Stereotypical motor movement, repetitive self-stimulatory bx



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ANTI-PSYCHOTIC DRUGS (TYPICAL TRADITIONAL)

ANTIPSYCHOTIC DRUGS (TYPICAL, TRADITIONAL)ALIPHATIC CHLORPROMAZINE: THORAZINEPIPERAZINE: FLUPHENAZINE=PROLIXIN (HCL-DECANOATE)

TRIFLUOPENRAZINE= STELAZINEPHERPHENAZINE=TRILAFON

PIPERIDINE: THIORIDAZINE= MELLARILMESORIDAZINE

THIOXANTHENES: THIOTHIXENE= NAVANEDIBENZOXAPINES: MOLINDONE= MOBANBUTYROPHENONES: HALDOPERIDOL= HALDOLBENZYMIDES: SULPIRIDERAWLPHIA ALKALOID: RESERPINECLOZARIL: CLOZAPINEZYPREXA: OLANZEPINESEROQUEL: QUETIAPINERESPERIDAL: RISPERIDONEGEODON: ZIPRASIDONEABILIFY: ARIPIPRAZOLDINVEGA: PALIPERIDOL



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PSYCHOPHARMACOTHERAPY INDICATIONS FOR ANTIDEPRESSANTS

Abnormalities in appetite and eating disorders Anorexia or limiting diet to a few foods Anergia Anxiety Dysphoria Irritability Phobias O.C.D. Enuresis Sleeping Disorders; insomnia, Nightmares Recurrent awakening at night



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ANTI-DEPRESSANTS

TRICYCLIC & TETRACYCLICS: TOFRANIL= IMPIPRAMINESURMONRIL= TRIMIPRAMINEPAMELOR= NORTRIPTYLINEASENDIN= AMOXEPINLUDIOMIL= MAPROTILINE

UNICYCLIC ANTIDEPRESSANTS: BUPROPION= WELBUTRIN

TRIAZOLOPYRIDINE DERIVATIVES: TRAZADONE/ALPRAXZOLAM

SSRI: FLUOXETINEPAROXETINECITALOPRAMESCITALOPRAMSERTRALINEFLUVOXAMINE

SNRI: VENLAFAXINE, DULOXATIN, SYMBIAX

NDRI: BUPROPION

MULTI MODE: MIRTAZAPINE

SARI: NEFAZODONE

MONOAMINE OXIDASE INHIBITORS: PHENELZINEHYDRAZINENARDILPARNATE

COMBINTION: FLUOXETINE/OLANZEPINE



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PSYCHOPHARMACOTHERAPY INDICATIONS OF MOOD STABALIZERS

Mood disorders Mood swings Irritability Poor impulse control disorders Aggressive/assaultive behaviors Agitation



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PSYCHOPHARMACOTHERAPYMOOD STABLIZERS

PRIMARY ADJUNCTIVE

LITHIUM THYROXINE

DIVALPROEX CLONAZEPAM

CARBAMAZEPINE LORAZEPAM

ECT (BILATERAL) PSYCHOTHERAPY



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MOOD STABILIZERSREFRACTORY BILPOLAR PATIENTS: RATIONAL OPTIONS WITH LITTLE OR NO DATAANTICONVULSANTS HORMONES

1. GABAPENTIN 1. ESTROGEN/PROGESTERONE

2. LAMOTRIGINE

3. TOPIRAMATE

4. TIAGABINE

5. ACETAZOLAMIDE

ADRENERGIC BLOCKING AGENTS PRECURSORS

1. CLONIDINE 1. TRYPTOPHAN

2. PROPRANOLOL 2. CHOLINE

3. GUANFACINE

CALCIUM CHANNEL BLOCKERS

1. VERAPAMIL

2. NIFEDIPINE

3. NIMODIPINE



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PSYCHOPHARMACOTHERAPY

INDICATIONS FOR ANTICONVULSANTS Seizure Disorder: Tonic, Clonic, Motor or Focal Mood Disorders Aggressive Disorder Poor Impulse Control Disorder Self Injurious Behavior Explosive Behaviors Assaultive Behaviors



64ANTICONVULSANTS

ACETAZOLAMIDE SODIUM OXCARBAZEPINE

CARBAMAZEPINE PHENOBARBITAL

CLONAZEPAM PHENOBARBITAL SODIUM

CLORAZEPATE DIPOTASSIUM PHENYTOIN

DIAZEPAM PHENYTOIN SODIUM

DIVALPROEX SODIUM PHENYTOIN SODIUM (EXTENDED)

ETHOSUXIMIDE PRIMIDONE

FOSPHENYTOIN SODIUM TIAGABINE HYDROCHLORIDE

GABAPENTIN VALPORATE SODIUM

LAMOTRIGINE VALPROIC ACID

LEVETIRACETAM ZONISAMIDE

MAGNESIUM SULFATE



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PSYCHOPHARMACOTHERAPY INDICATIONS FOR ANXIOLITICS

Muscle Relaxants Anesthetics Anticonvulsants Hypnotic agents Anti-Anxiety agents Automic symptoms agents Anti-hypertensive agents



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ANXIOLITCS: BENZODIAZEPINES

DIAZAPAM: VALIUM

CLORODIZAEPOXIDE: LIBRIUM

FLURAZEPAM: DALMANE

PRAZEPAM: CENTRAX

CLORAZEPATE: TRANXENE

TEMAZEPAM: RESTORIL

CLONAZEPAM: KLONOPIN

LORAZEPAM: ATIVAN

ALPRAZOLAM: XANAX

OXAZEPAM: SERAX

TRAIZOLAM: HALCION



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PSYCHOPHARMACOTHERAPYANXIOLITICS: HYPNOTICS BENZODIAZEPINES

ESTAZOLAM: PROSOM

QUAZEPAM: DORAL

ZOLPIDEM: AMBIEN

ZALEPION: SONATA


ANXIOLITICS: OTHER ANTI-ANXIETY AGENTS

BUSPIRONE: BUSPAR

HYDROXYZINE: ATARAX, VISTARIL

DIPHENEHYDRAMINE: BENADRYL

PROPRANONOL: INDERAL

ATENOLOL: TENORMIN

CLONIDINE: CATAPRES


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INDICATORS FOR STIMULANTS Appetite Suppressants Sleeplessness Agents Paradoxical ADD Agents None responsive depression



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PSYCHOPHARMACOTHERAPYPSYCHO-STIMULANTS

AMPHETATIVE DERIVATIVES METHYLPHENIDATEMETHYLPHENIDATE SRMETHYLPHENIDATEDESTROANPHETAMINEPEMOLINEALPHA AND B ALPHAMODAFINIL

RITALINCONCERTAMETADATEDEXEDRINECYLERTADDERALLPROVIGIL

ANTI-DEPRESANTS ATOMOXETIN HCLBUIPROPION

STRATERRAWELLBUTRIN



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INDICATION OF OTHER MEDICATIONS NARCOTIC ANTAGONIST

Naltrexone (trexan): Self Injurious behavior BETA BLOCKERS: PROPANOLOL

Explosive and range behavior, phobias CALCIUM BLOCKERS

Aggressive behavior, depression



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INTERVIEWING TECHNIQUES

SCREENING FOR DEVELOPMENTAL AND HEALTH CONDITIONS Aim is to identify the existence and probabilities of an exhibiting delay or

abnormal development in the early stages (in children) or current stages (in adults)

Such screening will detect biological problems (PKU-Fragil X syndrome, Sickle Cell A. etc.)



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INTERVIEWING TECHNIQUES DIAGNOSTIC ASSESMENT FOR DD

The aim is to conclusively determine whether an individual has an existing delay, disability and/OR special needs

This will identify the individual and family strengths as well as possible strategies for intervention

Diagnostic assessment should be based on multiple types of data obtained from multiple sources and team players or disciplines

DIAGNOSTIC ASSESMENT FOR INDIVIDUAL PROGRAM PLANNING This is done only after a decision is reached for early intervention



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PROCESS OF INTERVIEWING FOR DD ACKNOWLEDGEMENT

Acknowledgement of prior assessments and test results Referral

PARENTAL/CARE GIVER PARTICIPATION Tone of working relationship

OBSERVATION Formal or informal observations

SETTING Free from stress; appealing environment for Pt Can be formal or informal



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PROCESS OF INTERVIEWING FOR DD

GROUND-WORK FOR INTERVENTION Address directly the affected individual and caregiver This is done according to the appropriate level of functioning; may be done

conjointly or individually The willingness for either individual or conjoint assessment must be considered Confidentiality issues must also be considered



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PROCESS OF INTERVIEWING FOR DD INTERVENTION

To proceed with the interview process, I: Introduce myself or other participant(s) involved with the interview Explain the purpose of the interview Explain the need of Consent of Information with the involved caregiver and/or

individual Explain the expected outcome, impression and possible diagnosis with the the

caregiver and individual at the end of collecting data Discuss possible alternatives of tx and resources available Explain the pros/cons, risks and non risks of interventions


Carlos A. Muralles, M.D. 1 EFFICIENT PRACTICES FOR TREATING THE DEVELOPMENTAL DISABLED WITH MENTAL...

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Transcript of Carlos A. Muralles, M.D. 1 EFFICIENT PRACTICES FOR TREATING THE DEVELOPMENTAL DISABLED WITH MENTAL...