Psych

TBL 1- Normal Child Psychology development

Chapter 34.1, Jean Piaget and Cognitive Development, pp. 1007-1009, including Tables 34-1 and 34-2. (Stop reading just before the
heading "Psychiatric Applications.")

Piaget
- Intro
o Piaget created a broad theoretical system for the development of cognitive abilities; Piaget emphasized the ways
that children think and acquire knowledge
o Widely renowned as a child (or developmental) psychologist, Piaget referred to himself primarily as a genetic
epistemologist; he defined genetic epistemology as the study of the development of abstract thought on the basis
of a biological or innate substrate.
- Cognitive development Stages
o The rate at which different children move through different stages varies with their naïve endowment and
environmental circumstances.

- Sensorimotor Stage (2 -7 years)

o Infants begin to learn through sensory observation and gain control of their motor functions through activity,
exploration, and manipulation of the environment.
o Piaget divided this stage into six substages.
 o From the outset, biology and experience blend to produce learned behavior. For example, infants are born with a
sucking reflex, but a type of learning occurs when infants discover the location of the nipple and alter the shape of
their mouths. A stimulus is received, and a response results accompanied by a sense of awareness that is the first
schema, or elementary concept.
o As infants become more mobile, one schema is built on another, and new and more complex schemata are
developed. Infants’ spatial, visual, and tactile worlds expand during this period.
o The critical achievement of this period is the development of object permanence or the schema of the permanent
object. This phrase relates to a child’s ability to understand that objects have an existence independent of the
child’s involvement with them. Infants learn to differentiate themselves from the world and are able to maintain a
mental image of an object, even when it is not present and visible.
o At about 18 months, infants begin to develop mental symbols and to use worlds, a process known as
symbolization. Infants are able to create a visual image of a ball or a mental symbol of the word ball to stand for or
signify, the real object.

- Stages of Preoperational thought (2 -7 years)

o During this stage of preoperational thought, children use symbols and language more extensively than in the
sensorimotor stage. Thinking and reasoning are intuitive; children learn without the use of reasoning. They are
unable to think logically or deductively, and their concepts are primitive; they can name objects but not classes of
objects.
o Children in this stage also cannot grasp the sameness of an object in different circumstances
 The same doll in a carriage, a crib, or a chair is perceived to be three different objects.
o Things are represented in terms of their function
 A bike as “to ride”, a hole as “to dig”
o In this stage, children begin to use language and drawing in more elaborate ways. From one-word utterances, two-
word phrases develop, made up of either a noun and a verb or a noun and an objective.
 Bobby eats, Bobby up.
o Children in the preoperational stage cannot deal with moral dilemmas, although they have a sense of what is good
and bad
o Children in this stage have a sense of immanent justice, the belief that punishment for bad deeds is inevitable.
o Children in this developmental stage are egocentric: they see themselves as the center of the universe; they have a
limited point of view; and they are unable to take the role of another person. Children are unable to modify their
behavior for someone else.
 They don’t understand to be quiet because their brother needs to study
o During this stage, children also use a type of magical thinking called phenomenalistic causality, in which events that
occur together are thought to cause one another
 (e.g., thunder causes lightning, and bad thoughts cause accidents).
o In addition, children use animistic thinking, which is the tendency to endow physical events and objects with life-
like psychological attributes, such as feelings and intentions.
o Semiotic function emerges during this period. Children use a symbol or sign to stand for something else.
- Stages of Concrete Operations (7-11 years)
o In this period children operate and act on the concrete, real, and perceivable world of objects and events.
Egocentric thought is replaced by operational thought, which involved dealing with a wide array of information
outside the child. Therefore, children can now see things from someone else’s perspective.
o Children in this stage begin to use limited logical thought processes and can serialize, order, and group things into
classes on the basis of common characteristics. Syllogistic reasoning, in which a logical conclusion is formed from a
series of steps (premises), appears during this stage.
 All horses are mammals (premise); all mammals are warm-blooded (premise); therefore, all horses are
warm-blooded (conclusion)
 o Children who become overly invested in rules may show obsessive-compulsive behavior; children who resist a code
of values often seem willful and reactive. The most desirable development outcome in this stage is that a child
attains a healthy respect for rules and understands that there are legitimate exceptions to rules.
o Conservation is the ability to recognize that, although the shape of objects may change, the objects still maintain or
conserve other characteristics that enable them to be recognized as the same.
 If a ball of clay is rolled into a long, thin sausage shape, children recognize that each form contains the
same amount of clay.
o Reversibility is the capacity to understand the relationship between things, to realize that one thing can turn into
another and back again
 Ice and water
o The most important sign that children are still in the pre-operational stage is that they have not yet achieved
conservation or reversibility. The ability of children to understand concepts of quantity is one of Piaget’s most
important cognitive development theories.

- Stage of Formal Operations (11 years to end of adolescence)

o Young persons’ thinking operates in a formal, highly logical, systematic, and symbolic manner. This stage is
characterized by the ability to think abstractly, reason deductively, define concepts, and deal with probabilities.
o Hypotheticodeductive thinking
 This is the highest organization of cognition, enables persons to make a hypothesis or proposition and to
test it against reality. Deductive reasoning moves from the general to the particular and is a more
complicated process than inductive reasoning, which moves from the particular to the general.
 As adolescents attempt to master new cognitive tasks, they may return to egocentric thought, but on a
higher level than in the past.
 Depending on the individual capacity and intervening experience, some may not reach the stage of formal
operational thought at all and may remain in the concrete operational mode throughout life.

Chapter 34.4, Theories of Personality and Psychopathology. 1059-1060, the Topographical Theory of Mind. 
Freud
- Psychoanalysis
o The science of psychoanalysis is the bedrock of psychodynamic understanding and forms the fundamental
theoretical frame of reference for a variety of forms of therapeutic intervention, embracing not only
psychoanalysis itself but al various forms of psychoanalytically oriented psychotherapy and related forms of
therapy employing psychodynamic concepts
o Psychoanalysis today is recognized as having three crucial aspects: it is a therapeutic technique, a body of scientific
and theoretical knowledge, and a method of investigation
- Beginnings of Psychoanalysis
o Freud immersed himself in the serious study of the disturbances in his hysterical patients, resulting in discoveries
that contributed to the beginnings of psychoanalysis. These beginnings had a threefold aspect: Emergence of
psychoanalysis as a method of investigation, as a therapeutic technique, and as a body of scientific knowledge
based on an increasing fund of information and basic theoretical propositions.
o Case of Anna O
 Young woman of approximately 21 years of age who had developed a number of hysterical symptoms in
connection with the illness and death of her father. These symptoms included paralysis of the limbs,
contractures, anesthesia, visual and speech disturbances, anorexia, and a distressing nervous cough.
 Her illness was also characterized by two distinct phases of consciousness: One relatively normal, but the
other reflected a second and more pathological personality.

The Interpretation of Dream

- In his landmark publication The Interpretation of Dreams in 1900, Freud presented a theory of the dreaming process that
paralleled his earlier analysis of psychoneurotic symptoms.
- He viewed the dream experience as a conscious expression of unconscious fantasies or wishes not readily acceptable to
conscious waking experience. Thus, dream activity was considered to be one of the usual manifestations of unconscious
processes.
- The dream images represented unconscious wishes or thoughts, disguised through a process of a symbolization and other
distorting mechanisms. This reworking of unconscious contents constituted the dream work. Freud postulated the existence
 of a “censor,” pictured as guarding the border between the unconscious part of the mind and the preconscious level. The
censor functioned to exclude unconscious wishes during conscious states but, during regressive relaxation of sleep, allowed
specific unconscious contents to pass the border, only after transforming these unconscious wishes into disguised forms
experienced in the manifest dream contents by the sleeping subject.
- Freud assumed that the censor worked in the service of the ego —that is, as serving the self-preservative objectives of the
ego. Although he was aware of the unconscious nature of the processes, he tended to regard the ego at this point in
developing his theory more restrictively as the source of conscious processes of reasonable control and volition.
- The analysis of dreams elicits material that has been repressed. These unconscious thoughts and wishes include nocturnal
sensory stimuli (sensory impressions such as pain, hunger, thirst, urinary urgency), the day residue (thoughts and ideas
connected with the activities and preoccupations of the dreamer's current waking life), and repressed unacceptable
impulses. Because the sleep state blocks motility, the dream enables partial but limited gratification of the repressed
impulse that gives rise to the dream.
- Freud distinguished between two layers of dream content.
o The manifest content refers to what is recalled by the dreamer;
o The latent content involves the unconscious thoughts and wishes that threaten to awaken the dreamer.
o Freud described the unconscious mental operations by which latent dream content is transformed into the
manifest dream as the dream work. Repressed wishes and impulses must attach themselves to innocent or neutral
images to pass the scrutiny of the dream censor. This process involves selecting meaningless or trivial images from
the dreamer's current experience, which are dynamically associated with the latent images that they resemble in
some respect.

- Condensation is the mechanism by which several unconscious wishes, impulses, or attitudes can be combined into a single
image in the manifest dream content. Thus, in a child's nightmare, an attacking monster may come to represent not only
the dreamer's father but may also represent some aspects of the mother and even some of the child's primitive hostile
impulses as well. The converse of condensation can also occur in the dream work, namely, irradiation or diffusion of a
single latent wish or impulse distributed through multiple representations in the manifest dream content. The combination
of mechanisms of condensation and diffusion provides the dreamer with a highly flexible and economic device for
facilitating, compressing, and diffusing or expanding the manifest dream content, which is derived from latent or
unconscious wishes and impulses.
- Displacement refers to the transfer of amounts of energy (cathexis) from an original object to a substitute or symbolic
representation of the object. Because the substitute object is relatively neutral—that is, less invested with affective energy
—it is more acceptable to the dream censor and can pass the borders of repression more easily.
- Symbolic Representation. Freud noted that the dreamer would often represent highly charged ideas or objects by using
innocent images that were in some way connected with the idea or object being represented. In this manner, an abstract
concept or a complex set of feelings toward a person could be symbolized by a simple, concrete, or sensory image
- The mechanisms of condensation, displacement, and symbolic representation are characteristic of a type of thinking that
Freud referred to as primary process. This primitive mode of cognitive activity is characterized by illogic, bizarre, and absurd
images that seem incoherent.
- Freud believed that a more mature and reasonable aspect of the ego works during dreams to organize primitive aspects of
dreams into a more coherent form. Secondary revision is Freud's name for this process, in which dreams become
somewhat more rational. The process is related to mature activity characteristic of waking life, which Freud
termed secondary process.
- Affects in Dreams. Secondary emotions may not appear in the dream at all, or they may be experienced in somewhat
altered form. For example, repressed rage toward a person's father may take the form of mild annoyance. Feelings may
also appear as their opposites.
- Freud understood anxiety dreams as reflecting failure in the protective function of the dream-work mechanisms. The
repressed impulses succeed in working their way into the manifest content in a more or less recognizable manner.
o His understanding of dreams stresses the importance of discharging drives or wishes through the hallucinatory
contents of the dream. He viewed such mechanisms as condensation, displacement, symbolic representation,
projection, and secondary revision primarily as facilitating the discharge of latent impulses, rather than as
protecting dreamers from anxiety and pain
- Dreams in which dreamers experience punishment represented a unique challenge for Freud because they appear to
represent an exception to his wish-fulfillment theory of dreams. He came to understand such dreams as reflecting a
compromise between the repressed wish and the repressing agency or conscience.

Topographical Model of the Mind

 - Freud divided the mind into three regions: the conscious system, the preconscious system, and the unconscious system.
Each system has its unique characteristics.
o The Conscious.
 The part of the mind in which perceptions coming from the outside world or within the body or mind are
brought into awareness.
 Consciousness is a subjective phenomenon whose content can be communicated only using language or
behavior.
 Freud assumed that consciousness used a form of neutralized psychic energy that he referred to
as attention cathexis, whereby persons were aware of a particular idea or feeling as a result of investing a
discrete amount of psychic energy in the idea or feeling.
o The Preconscious. 
 Composed of those mental events, processes, and contents that can be brought into conscious awareness
by focusing attention. Although most persons are not consciously aware of the appearance of their first-
grade teacher, they ordinarily can bring this image to mind by deliberately focusing attention on the
memory.
 Conceptually, the preconscious interfaces with both unconscious and conscious regions of the mind. To
reach conscious awareness, the contents of the unconscious must become linked with words and thus
become preconscious.
 The preconscious system also serves to maintain the repressive barrier and to censor unacceptable wishes
and desires.
o The Unconscious. 
 The unconscious system is dynamic.
 Its mental contents and processes are kept from conscious awareness through the force of censorship or
repression, and it is closely related to instinctual drives.
 Instincts were thought to consist of sexual and self-preservative drives, and the unconscious was thought
to contain the mental representations and derivatives of the sexual instinct primarily.
 The content of the unconscious is limited to wishes seeking fulfillment. These wishes motivate dreams
and neurotic symptom formation. This view is now considered reductionist.
 The unconscious system is characterized by primary process thinking, principally aimed at
facilitating wish fulfillment and instinctual discharge.
 It is governed by the pleasure principle and, therefore, disregards logical connections; it has no
concept of time, represents wishes as fulfillments, permits contradictions to exist simultaneously,
and denies the existence of negatives.
 The primary process is also characterized by extreme mobility of drive cathexis; the investment
of psychic energy can shift from object to object without opposition.

- Limitations of the Topographical Theory. 

o Many patients’ defense mechanisms that guard against distressing wishes, feelings, or thoughts were not initially
accessible to consciousness. Thus, repression cannot be identical with preconscious, because, by definition, this
region of the mind is accessible to consciousness.
o Patients frequently demonstrated an unconscious need for punishment. This clinical observation made it unlikely
that the moral agency making the demand for punishment could be allied with anti-instinctual forces available to
conscious awareness in the preconscious.

Stages of Development Table 34.10, pp. 1062-1063.

Table 34-10 Stages of Psychosexual Development

Oral Stage- Birth to one year

Definition Earliest stage of development in which the infant's needs, perceptions, and modes of expression are primarily centered in
mouth, lips, tongue, and other organs related to oral zone and around the sucking reflex.
 Oral zone maintains dominance in psychic organization through approximately first 18 mo of life. Oral sensations include
thirst, hunger, pleasurable tactile stimulations evoked by the nipple or its substitute, and sensations related to swallowing
and satiation. Oral drives consist of two components: libidinal and aggressive. States of oral tension lead to seeking oral
gratification, as in quiescence at the end of nursing. Oral triad consists of wishes to eat, sleep, and reach that relaxation that
Description
occurs at the end of sucking just before onset of sleep. Libidinal needs (oral erotism) predominate in early oral phase,
whereas they are mixed with more aggressive components later (oral sadism). Oral aggression is expressed in biting,
chewing, spitting, or crying. Oral aggression is connected with primitive wishes and fantasies of biting, devouring, and
destroying.

To establish a trusting dependence on nursing and sustaining objects, establish comfortable expression and gratification of
Objectives
oral libidinal needs without excessive conflict or ambivalence from oral sadistic wishes.

Excessive oral gratifications or deprivation can result in libidinal fixations contributing to pathologic traits. Such traits can
Pathologic
include excessive optimism, narcissism, pessimism (as in depressive states), or demandingness. Envy and jealousy are often
traits
associated with oral traits.

Successful resolution of the oral phase results in capacities to give to and receive from others without excessive
Character dependence or envy and to rely on others with a sense of trust as well as with a sense of self-reliance and self-trust. Oral
traits characters are often excessively dependent and require others to give to them and look after them and are often extremely
dependent on others for maintaining self-esteem. These are readily amalgamated with narcissistic needs.

Anal Stage

The stage of psychosexual development promoted by maturation of neuromuscular control over sphincters, particularly the
Definition
anal sphincter, permitting greater voluntary control over retention or expulsion of feces.

This period extends roughly from 1 to 3 yr of age, marked by recognizable intensification of aggressive drives mixed with
libidinal components in sadistic impulses. Acquisition of voluntary sphincter control is associated with an increasing shift
from passivity to activity. Conflicts over anal control and struggles with parents over retaining or expelling feces in toilet
Description training give rise to increased ambivalence, together with conflicts over separation, individuation, and independence. Anal
erotism refers to sexual pleasure in anal functioning, both in retaining precious feces and presenting them as a precious gift
to the parent. Anal sadism refers to expression of aggressive wishes connected with discharging feces as powerful and
destructive weapons. These wishes are often displayed in fantasies of bombing or explosions.

The anal period is marked by greater striving for independence and separation from dependence on and control of
Objectives parents. Objectives of sphincter control without overcontrol (fecal retention) or loss of control (messing) are matched by
attempts to achieve autonomy and independence without excessive shame or self-doubt from loss of control.

Pathologic Maladaptive character traits, often apparently inconsistent, derive from anal erotism and defenses against it. Orderliness,
traits obstinacy, stubbornness, willfulness, frugality, and parsimony are features of anal character. When defenses against anal
traits are less effective, anal character reveals traits of heightened ambivalence, lack of tidiness, messiness, defiance, rage,
 and sadomasochistic tendencies. Anal characteristics and defenses are typically seen in obsessive-compulsive neuroses.

Successful resolution of the anal phase provides the basis for development of personal autonomy, a capacity for
Character independence and personal initiative without guilt, a capacity for self-determining behavior without a sense of shame or
traits self-doubt, a lack of ambivalence, and a capacity for willing cooperation without either excessive willfulness or self-
diminution or defeat.

Urethral Stage

This stage was not explicitly treated by Freud but serves as a transitional stage between anal and phallic stages. It shares
Definition
some characteristics of anal phase and some from subsequent phallic phase.

Characteristics of the urethral phase are often subsumed under phallic phase. Urethral erotism, however, refers to pleasure
in urination as well as pleasure in urethral retention analogous to anal retention. Similar issues of performance and control
Description are related to urethral functioning. Urethral functioning may also have sadistic quality, often reflecting persistence of anal
sadistic urges. Loss of urethral control, as in enuresis, may frequently have regressive significance that reactivates anal
conflicts.

At stake are issues of control and urethral performance and loss of control. It is not clear whether or to what extent
Objectives objectives of urethral functioning differ from those of anal period, except that they are expressed in a later developmental
stage.

The predominant urethral trait is competitiveness and ambition, probably related to compensation for shame due to loss of
Pathologic
urethral control. This may instigate development of penis envy, related to feminine sense of shame and inadequacy in being
traits
unable to match male urethral performance. This may also be related to issues of control and shaming.

Besides healthy effects analogous to those from the anal period, urethral competence provides a sense of pride and self-
Character competence based on performance. Urethral performance is an area in which the small boy can imitate and try to match his
traits father's more adult performance. Resolution of urethral conflicts sets the stage for budding gender identity and subsequent
identifications.

Phallic Stage

Definition Phallic stage begins sometime during year 3 and continues until approximately the end of year 5.

Description The phallic phase is characterized by a primary focusing of sexual interests, stimulation, and excitement in the genital area.
The penis becomes the organ of principal interest to children of both sexes, with lack of penis in females being considered as
evidence of castration. The phallic phase is associated with an increase in genital masturbation accompanied by
predominantly unconscious fantasies of sexual involvement with the opposite-sex parent. Threats of castration and the
related anxiety are connected with guilt over masturbation and oedipal wishes. During this phase oedipal involvement and
 conflict are established and consolidated.

To focus erotic interest in genital area and genital functions. This lays the foundation for gender identity and serves to
integrate residues of previous stages into a predominantly genital–sexual orientation. Establishing the oedipal situation is
Objectives
essential for furtherance of subsequent identifications, serving as a basis for important and perduring dimensions of
character organization.

Derivation of pathologic traits from phallic–oedipal involvement is sufficiently complex and subject to such a variety of
modifications that it encompasses nearly the whole of neurotic development. Issues, however, focus on castration in males
and penis envy in females. Patterns of internalization developed from resolution of the Oedipus complex (males view father
Pathologic
as competition for affection from mother) provide another important focus of developmental distortions. The influence of
traits
castration anxiety and penis envy, defenses against them, and patterns of identification are primary determinants of the
development of human character. They also subsume and integrate residues of previous psychosexual stages, so that
fixations or conflicts deriving from preceding stages can contaminate and modify oedipal resolution.

The phallic stage provides the foundation for an emerging sense of sexual identity, curiosity without embarrassment,
initiative without guilt, as well as mastery not only over objects and persons in the environment but also over internal
Character
processes and impulses. Resolution of the oedipal conflict gives rise to internal structural capacities for regulation of drive
traits
impulses and their direction to constructive ends. The internal sources of such regulation are the ego and superego, based
on introjections and identifications derived primarily from parental figures.

Latency Stage- Ages 6 thru Puberty

This is the stage of relative instinctual quiescence or inactivity of sexual drive during the period from the resolution of the
Definition
Oedipus complex until pubescence (from about 5–6 yr until about 11–13 yr).

The institution of the superego at the close of the oedipal period and further maturation of ego functions allow for
considerably greater degrees of control of instinctual impulses and motives. Sexual interests are generally thought to be
quiescent. This is a period of primarily homosexual affiliations for both boys and girls, as well as a sublimation of libidinal and
Description
aggressive energies into energetic learning and play activities, exploring the environment, and becoming more proficient in
dealing with the world of things and persons around them. It is a period for development of important skills. The relative
strength of regulatory elements often gives rise to patterns of behavior that are somewhat obsessive and hypercontrolling.

The primary objective is further integration of oedipal identifications and consolidation of gender and sex-role identity.
Relative quiescence and control of instinctual impulses allow for development of ego apparatuses and mastery of skills.
Objectives
Further identificatory components may be added to the oedipal ones on the basis of broadening contacts with other
significant figures outside the family (e.g., teachers, coaches, and other adult figures).

Pathologic Dangers in the latency period can arise either from the lack of development of inner controls or an excess of them. Lack of
traits control can lead to failure to sufficiently sublimate energies in the interest of learning and the development of skills; an
excess of inner control, however, can lead to premature closure of personality development and precocious elaboration of
obsessive character traits.
 The latency period is frequently regarded as a period of relatively unimportant inactivity in the developmental schema. More
recently, greater respect has been gained for the developmental processes in this period. Important consolidations and
additions are made to basic postoedipal identifications and to processes of integrating and consolidating previous
Character
attainments in psychosexual development and establishing decisive patterns of adaptive functioning. The child can develop a
traits
sense of industry and capacity for mastery of objects and concepts that allows autonomous functioning and a sense of
initiative without risk of failure or defeat or a sense of inferiority. These are all important attainments that need to be further
integrated, ultimately as the essential basis for a mature adult life of satisfaction in work and love.

Genital Stage

The genital or adolescent phase extends from the onset of puberty from approximately ages 11–13 until young adulthood.
Definition Current thinking tends to subdivide this stage into preadolescent, early adolescent, middle adolescent, late adolescent, and
even postadolescent periods.

Physiologic maturation of systems of genital (sexual) functioning and attendant hormonal systems leads to intensification of
instinctual, particularly libidinal, drives. This produces a regression in personality organization, which reopens conflicts of
Description
previous stages of psychosexual development and provides opportunity for re-resolution of these conflicts in the context of
achieving a mature sexual and adult identity. This period has been described as a “second individuation.”

Primary objectives are the ultimate separation from dependence on and attachment to parents and establishment of
mature, non-incestuous, heterosexual object relations. Related are the achievement of a mature sense of personal identity
Objectives
and acceptance and integration of adult roles and functions that permit new adaptive integrations with social expectations
and cultural values.

Pathologic deviations due to failure to achieve successful resolution of this stage of development are multiple and complex.
Defects can arise from a whole spectrum of psychosexual residues, since the developmental task of adolescence is in a sense
Pathologic
a partial reopening, reworking, and reintegration of all of these aspects of development. Previous unsuccessful resolutions
traits
and fixations in various phases or aspects of psychosexual development will produce pathologic defects in the emerging
adult personality and defects in identity formation.

Successful resolution and reintegration of previous psychosexual stages in the adolescent genital phase set the stage
Character normally for a fully mature personality with the capacity for full and satisfying genital potency and a self-integrated and
traits consistent sense of identity. This provides the basis for a capacity for self-realization and meaningful participation in areas of
work, love, and in creative and productive application to satisfying and meaningful goals and values.
Erikson's Psychosocial Stages, Table 34-16, page 1073.
- According to Erikson, life stages are important because each involves a conflict or challenge.

- Piaget's Stages of Cognitive Development, table 32-9, page 890

 - Attachment, page 891-892, including Stranger Anxiety and Table 32-9, Stages of Separation Individuation Proposed by
Mahler

Emotional and Social Development.

- By the age of 3 weeks, infants imitate the facial movements of adult caregivers. They open their mouths and thrust out
their tongues in response to adults who do the same.
- By the third and fourth months of life, we can easily elicit these behaviors. These imitative behaviors are likely the
precursors of the infant's emotional life. The smiling response occurs in two phases: the first phase is endogenous smiling,
which occurs spontaneously within the first 2 months and is unrelated to external stimulation; the second phase is
exogenous smiling, usually stimulated by the mother, and occurs by the 16th week.
- The stages of emotional development parallel those of cognitive development. The caregiving person provides the primary
stimulus for both aspects of mental growth. Human infants depend totally on adults for survival. Through warm and
predictable interactions, an infant's social and emotional repertoire expands with the interplay of caregivers’ social
responses

- In the first year, infants’ moods are highly variable and intimately related to internal states such as hunger.
- Toward the second two-thirds of the first year, infants’ moods grow increasingly related to external social cues; a parent
can get even a hungry infant to smile. When the infant is internally comfortable, a sense of interest and pleasure in the
world and its primary caregivers should prevail.
- Prolonged separation from the mother (or other primary caregivers) during the second 6 months of life can lead to
depression that may persist into adulthood as part of an individual's character.

Temperamental Differences
- Infants vary in their autonomic reactivity and temperament. Chess and Thomas identified nine behavioral dimensions in
which reliable differences among infants can be observed (Table 32-7). In studies of temperament, most temperamental
 dimensions of individual children remain stable through adulthood, but some do not persist. This is likely due to genetic and
environmental effects on personality. A complex interplay exists among the initial characteristics of infants, the mode of
parental interactions, and children's subsequent behavior. Observations of the stability and plasticity of certain
temperamental traits support the importance of interactions between genetic endowment (nature) and environmental
experience (nurture) in behavior.

Attachment
- Bonding is the term used to describe the intense emotional and psychological relationship a mother develops for her baby.
- Attachment is the relationship the baby develops with its caregivers. Infants in the first months after birth become attuned
to social and interpersonal interaction. They show a rapidly increasing responsivity to the external environment and an
ability to form a special relationship with significant primary caregivers—that is, to form an attachment.

John Bowlby.
- John Bowlby studied the attachment of infants to mothers and concluded that early separation of
infants from their mothers had severe adverse effects on children's emotional and intellectual
development.
- He described attachment behavior, which develops during the first year of life, as the maintenance of
physical contact between the mother and child when the child is hungry, frightened, or in distress.

Mary Ainsworth.
 - Expanded on Bowlby's observations and found that the interaction between mother and baby during
the attachment period influences the baby's current and future behavior significantly.
- Many observers believe that patterns of infant attachment affect future adult emotional relationships.
Patterns of attachment vary among babies; for example, some babies signal or cry less than others.
Sensitive responsiveness to infant signals, such as cuddling the baby when it cries, causes infants to cry
less in later months. Close bodily contact with the mother when the baby signals for her fosters self-
reliance, rather than clinging dependence.
- Unresponsive mothers produce anxious babies.
- Ainsworth also confirmed that attachment serves to reduce anxiety. What she called the secured base
effect enables a child to move away from the attachment figure and explore the environment.
Inanimate objects, such as a teddy bear or a blanket (called the transitional object by Donald
Winnicott), also serve as a secure base, one that often accompanies children as they investigate the
world.
- Maternal sensitivity and responsiveness are the main determinants of secure attachment. However,
when the attachment is insecure, the type of insecurity (avoidant, anxious, or ambivalent) is
determined by infant temperament.
- Overall, male infants are less likely to have secure attachments and are more vulnerable to changes in
maternal sensitivity than are female infants.
- The birth of a second child decreases the attachment of the firstborn child. This decrease is most
notable when the firstborn is 2 to 5 years of age as opposed to younger. Not surprisingly, the extent of
the decrease also depends on the mother's sense of security, confidence, and mental health.

Social Deprivation Syndromes and Maternal Neglect.

- Investigators, especially René Spitz, have long documented the severe developmental retardation that
accompanies maternal rejection and neglect.
- Infants in institutions characterized by low staff-to-infant ratios and frequent turnover of personnel
tend to display marked developmental retardation, even with adequate physical care and freedom
from infection. The same infants, placed in adequate foster or adoptive care, exhibit marked
acceleration in development.

Fathers and Attachment.

- Babies become attached to fathers as well as to mothers, but the attachment is different.
- Generally, mothers hold babies for caregiving, and fathers hold babies for purposes of play. Given a
choice of either parent after separation, infants usually go to the mother, but if the mother is
unavailable, they turn to the father for comfort.
- Babies raised in extended families or with multiple caregivers can establish many attachments.

Stranger Anxiety.
- A developmentally expected fear of strangers first appears in infants at about 26 weeks of age and is
more fully developed by 32 weeks.
- At the approach of a stranger, infants cry and cling to their mothers.
- Babies exposed to only one caregiver are more likely to have stranger anxiety than babies exposed to a
variety of caregivers.
- Stranger anxiety likely results from a baby's growing ability to distinguish caregivers from all other
persons.
- Separation anxiety, which occurs between 10 and 18 months of age, is related to stranger anxiety but
is not identical to it.
o Separation from the person to whom the infant is attached precipitates separation anxiety.
Stranger anxiety, however, occurs even when the infant is in the mother's arms. The infant
 learns to separate as it starts to crawl and move away from the mother, but the infant
continually looks back and frequently returns to the mother for reassurance.
- Margaret Mahler (1897–1985) proposed a theory to describe how young children acquire a sense of
identity separate from that of their mothers’. Her observations of children and their mothers lead to
her theory of separation-individuation.
TBL 2- Depressive Disorders

- Describe and understand the diagnoses and treatment of major depressive disorder, persistent depressive disorder, and
premenstrual dysphoric disorder.
o Major Depressive Disorder (MDD)
 Must have at least five of these symptoms (SIGECAPS) during the same 2 week period
 Management: requires the integration of psychological, social, and medical treatments. Usually begins
with an SSRI. If pt has no minimal response within 3-5 weeks, the prudent course is to change or augment
the current treatment plan as well as reevaluate diagnosis.

 Prevalence: Female>>> Male

 Tx: SSRIs and CBT are first line

o Persistent Depressive Disorder (PDD) - Dysthimia

 a milder but more chronic and lasting form of depression
 Sx last for at least two years- (1 year in children) and have never been without sx continuously for more
than 2 months at a time.

o Premenstrual dysphoric disorder (PMDD):

 In the majority of menstrual cycles, at least five symptoms must be present in the final week before the
onset of menses, start to improve within a few days after the onset of menses, and become minimal or
absent in the week post menses
 A severe form of premenstrual syndrome associated with behavioral changes severe enough to cause
clinically significant disturbance of daily functional capacity.
 Symptoms may include
 anger/increased interpersonal conflicts,
 affective lability,
 depressed mood/feelings of hopelessness/self-deprecating thoughts,
 anxiety/feelings of being “keyed up” or “on edge”,
 difficulty in concentration,
 sleep disturbance,
 lethargy/lack of energy,
 changes in appetite,
 loss of interest,
 sense of being overwhelmed or out of control, and/or physical symptoms (e.g., headaches,
breast tenderness, joint or muscle pain, etc.).
 Treatment: SSRIs
 o Criteria for Substance/Medication-Induced Depressive Disorder (SMDD)
 The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after
exposure to a medication
 Sx are in excess of those usually associated with the intoxication or withdrawal syndrome and are
sufficiently severe to warrant independent clinical attention.

 The involved substance/medication is capable of producing the symptoms in Criterion A

 It is essentially MDD that is likely to be caused by the physiological effects of a chemical substance with
psychotropic properties
 Sx begin within 1 month after use of a substance capable of inducing depression, or in the context of
substance withdrawal

o Criteria for Depressive disorder due to another medical condition

 A depressive disorder attributable to another medical condition
 Depends on whether the clinician is approaching a patient with known medical disease (cancer,
cardiovascular disease, or neurological disease) and evaluation whether MDD is present, or whether the
patient is presenting with depressive sx and is in need of a comprehensive medical work up.

o Mood is a pervasive and sustained feeling tone that is experienced internally and that influences a person’s
behavior and perception of the world

o Affect is the external expression of mood – the objective and behavioral expression of internal mood states, with
concomitant observable motor components, in the form of expressive features of facial and other bodily
movements.
 flat affect have no response to emotional stimuli
 may appear to be completely unemotional or apathetic. Other associated
symptoms include speaking in a monotone voice and a reduction in facial
expressions.

o Comorbidity
 In both unipolar depression (MDD) and Bipolar disorder- men more frequently present with substance use
disorders and women more frequently present with anxiety disorders and eating disorders

- Describe and understand the pathophysiology, treatment, and basic principles underlying pharmacotherapy for these
disorders.
o An SSRI is generally the initial medication tried for the management of depression and related disorders
o MAO-I are generally shunned by the prescribing care provider because of concerns about the needs for dietary
restriction and for monitoring patients for drug interactions.
Atypical Antidepressants
o Bupropion
 does not cause sexual dysfunction; less likely to cause weight gain
 Contraindicated in Bulimia and Anorexia Nervosa
 ↑ NE and Dopamine (NET & DAT)
 Treats TOBACCO Dependance
o Mirtazapine
 Blocks alpha 2 receptors  ↑ presynaptic release of Serotonin and NE
 Blocks 5HT2 and 5HT3 receptors
 Potent H1 receptor  sedation, can cause weight gain
 Lacks Sexual side effects
o Trazodone
 Serotonin Modulator – antagonizes 5HT2 receptors
 No effects in Dopamine or NE
 Antagonizes alpha1 receptors.
 SE – can cause priapism (use with caution in PTS w/sickle cell or MM)
 Postural Orthostatic hypotension
 H1 receptor antagonist – good for insomnia and Major Depression
  Can cause Sexual dysfunction.
 Serotonin Syndrome
o Vilazodone
 Inhibits 5 HT reuptake, 5 HT1A receptor partial agonist
 Toxicity= Headache, Diarrhea, Nausea, anticholinergic effects
 May cause serotonin syndrome
o Vortioxetine
 Inhibits 5HT reuptake (5HT1A receptor agonist and 5HT3 receptor antagonist)
 Toxicity: Nausea, Sleep disturbances, sexual dysfunction, anticholinergic effects
 May cause Serotonin Syndrome

- Understand the principles of suicide assessment, including risk factors and protective factors.
o Risk factor= Mood disorders
o Features associated with an increased risk for completed suicide include male sex, being single or living alone, and
prominent feelings of hopelessness.

- List elements included in a suicide risk assessment.

- Explain the following mechanisms of disease of depressive disorders:

o Pathways and neurotransmitters
o Etiologic theories

o Depletion of serotonin may precipitate depression

 Some patients with suicidal behavior have low CSF levels of serotonin metabolites and low levels of
serotonin uptake sites on platelets
o Thyroid hormone
 5-10% of people evaluated for depression have previously undetected thyroid dysfunction
 20-30% of depressed patients how a blunted TSH response to TRH challenge
o Alterations to sleep physiology
 ↑ nocturnal awakenings
 ↓ slow wave sleep
 ↓ REM latency (a ↓ in how soon after falling asleep the first REM episode appears)

o Life events and environmental stress

 Stress more likely to trigger first episode of depression or bipolar disorder than later episodes
 Early stressors may cause long standing brain changes that predispose to recurrent episodes of mood
disorder
 Loss of parent before age 11
 Stress-Diathesis Model: an interaction between life events/environmental stress and genetic
predisposition/family history
 Endogenous vs. Exogenous depression
 Recent stressful events are the most powerful predictors of the onset of a depressive episode

o Cognitive Theory
 Beck’s Triad:
1. Negative views about the self
2. Negative views about the environment (experiencing the world as hostile and demanding)
3. Negative views about the future (expectations of suffering and failure)
 Cognitive Behavioral Therapy (CBT)
 Learned Helplessness
 Depression is related to the experience of uncontrollable events.
 Internal causal explanations are thought to produce a loss of self-esteem after adverse external
events
 Improvement depends on learning a sense of control and mastery of the environment
 Learned helplessness is a behavior pattern involving a maladaptive response characterized by
avoidance of challenges, negative affect, and the collapse of problem-solving strategies when
obstacles arise
  Ex: if a child regularly performs poorly on exams even after studying, they may start to believe
that preparing for tests is ineffective and won't have any impact on their grade

- Describe the epidemiology of depressive disorders, including suicide rates.

o Estimates of recurrence range from ~ 50% within the first year to up to 85% during a lifetime

o Postpartum Depression
 Often associated with family history of depression, future episodes of depression, thoughts of harming
the baby, feelings of guilt, and suicidal ideation
 Postpartum psychosis with delusions and/or hallucinations, thoughts of harming the baby or self
 Must be closely monitored for suicide or infanticide: hospitalization may be necessary

o Course and Prognosis

 Mood disorders tend to have long courses and patients tend to have relapses.
 Untreated depressive episodes usually last 6 to 13 months
 Treated episodes last about 3 months
 As Major Depressive Disorder progresses, patients tend to have more frequent episodes that last longer
 Over a 20-year period, the mean number of depressive episodes is 5 or 6
 About 5-10% of patients with an initial diagnosis of major depressive disorder have a manic episode
within 6 to 10 years of the first depressive episode
 The mean age for this switch is 32 years, and it often occurs after 2 to 4 depressive episodes.

- Describe depressive disorder diagnoses using DSM-5 criteria and apply to cases.  TBL cases in class

- Describe the following principles of management, and apply to cases:

o Psychotherapeutic modalities
 Interpersonal therapy
 Cognitive Behavioral Therapy (CBT)

o Psychopharmacology- Antidepressants
 Indications: unipolar and bipolar depression, organic mood disorders, schizoaffective disorders, anxiety
disorders including OCD, panic, social phobia, PTSD, premenstrual dysphoric disorder, and impulsivity
associated with personality disorders.
 There is a delay typically of 3-6 weeks after a therapeutic dose is achieved before symptoms improve
 If no improvement is seen after a trial of adequate length (at least 2 months), either switch to another
antidepressant or augment with another agent

 Antidepressant classification  SKETCHY

 Tricyclics (TCA’s)
 Monoamine Oxidase Inhibitors (MAOIs)
 Selective Serotonin Reuptake Inhibitors (SSRIs)
 Serotonin/ Norepinephrine Reuptake Inhibitors (SNRIs)
 Novel antidepressants

 Most common side effect is SEROTONIN SYNDROME

o Abdominal pain, diarrhea, sweats, tachycardia, HTN, myoclonus, irritability, delirium.
o Can lead to hyperpyrexia, cardiovascular shock and death
o To avoid need to wait 2 weeks before switching from an SSRI to and MAO-I. The
exception of fluoxetine – need to wait 5 weeks because of long half-life.
 SSRI
o Paroxetine (Paxil)
 Pros
 Short half-life with no active metabolite means no build up (which is
good if hypomania develops)
 Sedating properties (dose at night) offer good initial relief from anxiety
and insomnia.
 Cons
  Significant CYP2D6 inhibition
 Sedating, wt gain, more anticholinergic effects
 Likely to cause a discontinuation syndrome
o Sertraline (Zoloft)
 Pros
 Very weak P450 interactions (only slightly CYP2D6)
 Short half-life with lower build-up of metabolites
 Less sedating when compared to paroxetine
 Cons
 Max absorption requires a full stomach
 ↑ number of GI adverse drug reactions
o Fluoxetine (Prozac)
 Pros
 Long half-life so ↓ incidence of discontinuation syndromes. Good for
pts with medication non-compliance issues
 Initially activating so may provide ↑ energy
 Secondary to long half-life, can give one 20 mg tab to taper someone
off SSRI when trying to prevent SSRI discontinuation syndrome
 Cons
 Long half-life and active metabolite may build up (e.g. not a good
choice in patients with hepatic illness)
 Significant P450 interactions so this may not be a goof choice in
patients already on a number of meds
 Initial activation may ↑ anxiety and insomnia
 More likely to induce mania than some of the other SSRIs
o Citalopram (Celexa)
 Pros
 Low inhibition of P450 enzymes so fewer drug-drug interactions
 Intermediate ½ life
 Cons
 Dose-dependent QT interval prolongation with doses of 10-30 mg
daily – due to this risk doses of > 40mg/day not recommended!!!
 Can be sedating (has mild antagonism at H1 histamine receptor)
 GI side effects (less than sertraline)
o Escitalopram (Lexapro)
 Pros
 Low overall inhibition of P450s enzymes so fewer drug-drug
interactions
 Intermediate ½ life
 More effective than citalopram in acute response and remission
 Cons
 Dose-dependent QT interval prolongation with doses of 10-30 mg
daily
 Nausea/ Headache

o Fluvoxamine (Luvox)  indicated for OCD

 Pros
 Shortest ½ life
 Found to possess some analgesic properties
 Cons
 Shortest ½ life
 GI distress, headaches, sedation and weakness
 Strong inhibitor of CYP1A2 and CYP2C19
 SNRIs
o Inhibit both serotonin and noradrenergic reuptake like the TCAs but without the anti-
histamine, anti-adrenergic, or anti-cholinergic side effects
o Used for anxiety, depression, and possibly neuropathic pain.
 o Venlafaxine (Effexor)
 Pros
 Minimal drug interactions and almost no P450 activity
 Short half-life and fast renal clearance avoid build-up (good for
geriatric populations)
 Cons
 Can cause a 10-15 mmHG dose-dependent ↑ in diastolic BP
 May cause significant nausea, primarily with immediate release (IR)
tabs
 Can cause a bad discontinuation syndrome, and taper recommended
after 2 weeks of administration
 Notes to cause QT prolongation
 Sexual side effects in > 30%

o Desvenlafaxine (Pristiq)
 Pros
 Minimal drug interactions
 Short half-life and fast renal clearance avoid build-up (good for
geriatric populations)
 Cons
 GI distress in 20% +
 Dose-related ↑ in total cholesterol, LDL, and Triglycerides
 Dose-related ↑ in BP

o Duloxetine (Cymbalta)
 Pros
 Some data suggests efficacy for the physical symptoms of depression
 Thus far less BP ↑ as compared to venlafaxine, however this may
change in time
 Cons
 CYP2D6 and CYP1A2 inhibitor
 Cannot break capsule, as active ingredient not stable within the
stomach
 In pooled analysis had higher dropout rate

 Novel Antidepressants (Atypicals)

o Mirtazapine (Remeron)
 Pros
 Different mechanisms of action may provide a good augmentation
strategy to SSRIs. Is a 5 HT2 and 5HT3 receptor antagonist
 Can be utilized as a hypnotic at lower doses secondary to
antihistaminic effects
 Cons
 Increases serum cholesterol by 20% in 15% of patients and TAGs in 6%
of patients
 Very sedating at lower doses. At doses 30 mg and above it can become
activating and require change of administration time to the morning
 Associated with weight gain (particularly at doses below 45 mg)
o Buproprion (Wellbutrin)
 Pros
 Good for use as an augmenting agent
 Mechanism of action likely reuptake inhibition of dopamine and
norepinephrine
 No weight gain, sexual side effects, sedation, or cardiac interactions
 Low induction of mania
 Is second line ADHD agent so considering if the patient has a co-
occurring diagnoses
  Cons
 May ↑ seizure risk at high doses (450 mg+) and should avoid in
patients with Traumatic Brain Injury, bulimia and anorexia
 Does not treat anxiety, unlike many other antidepressants and can
actually cause anxiety, agitation and insomnia
 Has abuse potential because can induce psychotic sx at high doses

o Nutritional and metabolic counseling

 Omega-3 and Fatty acids (O3FAs) have the strongest evidence of efficacy for bipolar depression
 Weak evidence supports the efficacy of vitamin C for bipolar depression
 Preliminary randomized, controlled trials suggest that choline, magnesium, folate and tryptophan may be
beneficial for reducing symptoms of mania.
 Vitamin D supplementation may be effective for reducing depressive symptoms
 Serum vitamin D levels are found to be associated with post-stroke depression
 Vitamin D is independently associated with depression and inflammation in overweight women
both with/wo PCOS
 Depression and Methyl folate
 Adjunctive L-methyl folate at 15 mg/day may constitute an effective, safe, and relatively well-
tolerated treatment strategy for patients with Major Depressive Disorders (MDD) who have a
partial response or no response to SSRIs.

TBL- 3
 Personality Traits, Disorders, and Coping Styles
o Personality traits and coping styles are individuals' unique ways of responding to the environment and
interpersonal relationships. These characteristics are influenced by genetic temperament and life experiences, and
they are important determinants of how people react to illness. 
o Everyone has personality traits. However, if these traits lead to personal distress or to problems in social or
occupational functioning, the person may have a personality disorder (PD). 
o Personality disorders
 PDs are chronic and lifelong. The DSM-5 places each personality disorder into either Cluster A (paranoid,
schizoid, and schizotypal), Cluster B (histrionic, narcissistic, antisocial, and borderline), or Cluster C
(avoidant, obsessive-compulsive, and dependent) based on certain shared characteristics and genetic
associations. 
 ***See Table 24.4 Below
 Individuals with atypical personality traits or mixtures of abnormal personality traits are diagnosed with
other specified personality disorder and unspecified personality disorder. For example, passive-aggressive
PD is currently in this last category in the DSM-5.
o Characteristics of the Personality Disorders
 Histrionic, borderline, dependent, antisocial, and schizotypal PD may be somewhat more common (each
occurring in 2% to 3% of the population) than obsessive-compulsive, narcissistic, avoidant, and schizoid
PD (each occurring in 1% or less of the population). 
 For the DSM-5 diagnosis, a PD must be present by early adulthood. 
 Most personality disorders cannot be diagnosed in individuals under age 18 years unless the
characteristics have been present for at least one year. 
 Antisocial PD cannot be diagnosed until 18 years of age; before 18 years of age, the diagnosis of a person
with these characteristics is conduct disorder  
o Management of the Personality Disorders
 Typically, patients with PDs have no insight and lack awareness that they are the cause of their own
relationship problems. Thus, they rarely seek psychological help unless compelled by others.
  Patients with PDs do not show frank psychosis and, unless the PD brings the person into conflict with
others, they typically do not show disabling psychiatric symptoms, such as anxiety or depression. 
 Pharmacological treatment has no proven usefulness in PDs.
 Medications can, however, be used when patients with PDs also show depression and anxiety. 
 Individual and group psychotherapy and self-help groups may also benefit patients with PDs. 
o Personality Traits and Coping Styles
  Even if a patient does not have a diagnosable personality disorder, his or her personality characteristics
can affect the way he or she copes with (i.e., manages) illness. 
 For example, patients who have one of the Cluster A personality types are likely to respond to their illness
by becoming even more withdrawn or suspicious. The physician may have to take more time establishing
a trusting relationship with such patients. 
 Patients with Cluster B personality types are more likely to become emotional and seductive when
stressed by illness. For these patients, the doctor may have to set limits on inappropriate behavior and
use closed-ended questions that limit the patient's responsiveness. 
 Cluster C-type patients show increased anxiety and may be even more fearful than other patients about
losing control and becoming dependent during illness. They may therefore respond to illness by becoming
more controlling or angry (the obsessive-compulsive type) or more needy (the dependent type)

Table 24.4 Characteristics of Personality Disorders

The American Psychiatric Publishing Textbook of Psychiatry: Chapter 18: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating
Disorder, Conclusion, Key Clinical Points (pp. 560–582, 584)
Anorexia Nervosa


 Anorexia nervosa is a serious disorder, with a point prevalence of about 0.5% in female adolescents and young adults,
making it the least common of the classic eating disorders. 
 Anorexia nervosa usually emerges in adolescence, with peak onset at about 14 years of age. However, anorexia nervosa
tends to persist if it is not treated successfully in adolescence, with high mortality rates from suicide and organ failure due
to persistent starvation
 Psychiatric disorders comorbid with anorexia nervosa include major depressive disorder (MDD), obsessive-compulsive
disorder, and anxiety disorders. 
 Although restrictive eating based on fear of weight gain is the primary presentation of anorexia nervosa, binge eating and
purging follow in about half of cases. 
 Medical complications associated with malnutrition and purging include pericardial effusions; electrolyte abnormalities;
delayed gastric emptying; anemia; osteopenia and osteoporosis; evidence of atrophy of both gray and white matter in the
brain; and sudden death due to cardiac arrest
 Anorexia nervosa runs in families, and twin studies have shown that it is highly heritable
o A genome-wide association study implicated loci influencing metabolic pathways affecting insulin, glucose, and
lipid phenotypes
 Both family and cultural influences are important risk factors
 Clinical Presentation of Anorexia Nervosa in an Adult vs. Adolescent
o There is evidence that anorexia nervosa symptoms may be expressed differently in childhood and adolescence
compared with adulthood. 
o Children and adolescents are often incapable of verbalizing abstract thoughts; therefore, behaviors such as food
refusal that lead to malnutrition may manifest as nonverbal representations of emotional experiences. 
 For this reason, parental reports about the child’s behavior are critical, given that self-report is often
unreliable due to of lack of insight, minimization, and denial by the child or adolescent. 
o Children and adolescents with anorexia nervosa are less likely than adults with the disorder to engage in binge-
eating and purging behaviors. These young patients sometimes deny any drive for thinness but often claim to be
trying to eat less, avoid fattening foods, and exercise more for health reasons. 
o Other young patients deny body image or weight concerns at assessment and insist they just are not hungry or
complain of abdominal discomfort. 
o While self-starvation persists, academic and athletic pursuits usually continue and sometimes become more
compulsive and driven. 
o Patients often appear withdrawn, depressed, and anxious. Usually they remain cognitively intact until more severe
malnutrition develops.
o In some instances, compensatory behavior such as purging develops, but for younger patients such behavior
usually occurs later in the course of the disorder.
 Treatment
o Hospitalization and Other Intensive Treatment Settings
 Despite its common use for anorexia nervosa, there is little evidence that psychiatric hospitalization is
more effective than outpatient treatment 
 Such programs usually have potentially negative effects, especially for younger patients. These include
separation of the developing child from family, friends, and community as well as stigma and shame. 
  Nonetheless, hospitalization and more intensive programs are sometimes clinically necessary because of
poor response to or lack of availability of appropriate specialty outpatient treatment. 
 In those instances, negative impacts can be mitigated by keeping the length of stay short, using the lowest
safe level of care, involving families in programming, and employing highly expert and experienced staff.
 Hospitalization for medical complications related to severe malnutrition and purging is sometimes
needed. There are no agreed-on indications for adults with persistent anorexia nervosa, but indications
for medical hospitalization for children and adolescents have been published by the American Academy of
Pediatrics and the Society of Adolescent Health and Medicine 
 These indications include severe abnormality of heart rate (bradycardia and orthostatic heart rate
changes), blood pressure (orthostatic hypotension), and/or body temperature (hypothermia); electrolyte
abnormalities; and severe malnutrition. 
 Nasogastric tube feeding, especially for nocturnal feeds, is sometimes used with the aim of increasing the
efficiency of weight gain, but the long-term benefits of this approach are not clear, and the clinical need
for the approach is not established.
o Evidence-Based Psychotherapy
 Despite many years of research, no empirically supported psychosocial treatments are available for adults
with persistent anorexia nervosa 
 Dropout rates from treatment trials are high, often reaching 40%–50%. Trials have included
psychotherapies, such as cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT)
 In contrast to adult anorexia nervosa, studies of psychosocial interventions for short-duration adolescent
anorexia nervosa are more promising 
 The findings from these randomized controlled trials suggest that family approaches, particularly family-
based treatment (FBT), are effective and superior to comparison individual therapies. 
 FBT helps parents learn how to disrupt their child’s starvation and overexercise and to take charge of
weight restoration. Once the child is able to eat independently without parental supervision and has
reached a normal weight, the treatment briefly focuses on developmental issues of adolescence. 
 Although individual therapy was not as effective as FBT in these trials, individual approaches are
nonetheless beneficial and could be offered to patients in cases in which FBT is not an acceptable or
tenable option. 
 In particular, adolescent-focused therapy (AFT), which is an individual therapy focused on individuation
and self-efficacy, was found to be useful, especially for adolescents with less severe symptoms 
 The main focus of AFT is to encourage an increased awareness and tolerance of emotions, particularly
negative ones. 
 Although the results are preliminary, CBT for adolescents with anorexia nervosa appears to be acceptable
to patients and leads to clinical improvements.
o Evidence-Based Pharmacotherapy
 Although a wide array of pharmacological agents, including antidepressants, antipsychotics, appetite
stimulants, prokinetics, and hormonal treatments, among others, have been tested in controlled studies,
no evidence-based medication for the treatment of anorexia nervosa has yet 
 No systematic studies of selective serotonin reuptake inhibitors (SSRIs) have been conducted in
adolescents with anorexia nervosa. 
 Feasibility and acceptability of medication are a major problem because of fear of weight gain. 

Bulimia Nervosa
 Bulimia nervosa has a population prevalence of about 2% in women and 0.5% in men, although the female-to-male ratio in
treatment-seeking samples is 10 to 1 
o Hence, it is a relatively common disorder but is often overlooked by clinicians and underreported by patients. 
 The disorder usually emerges in adolescence or young adulthood, often following a period of weight loss due to excessive
dieting. These behaviors eventually lead to binge eating followed by compensatory purging. 
 The disorder may have a fluctuating course, with bulimic behaviors exacerbated by stress, and often persists for many
years; a 20-year follow-up study revealed that about one-third of patients with bulimia nervosa were not recovered despite
having adequate access to treatment 
 The overall death rate in patients with bulimia nervosa is elevated compared with that in women without eating disorders,
with a standard mortality ratio of 1.93, although it is not as high as in anorexia nervosa
 The primary presenting symptoms in bulimia nervosa are binge eating and compensatory behaviors such as purging, fasting,
the use of diuretics, excessive exercise, and, more rarely, chewing and spitting out food.
o Binge eating is defined by two characteristics: loss of control over eating and eating a large amount of food in one
sitting (varying between 1,500 and 5,000 kcal or more). 
 o Binge eating is clinically subdivided into objective binge eating, in which large amounts of food are eaten, and
subjective binge eating, in which loss of control is experienced but small amounts of food are consumed. Both
types of binge eating may lead to purging. 
 Secondary symptoms stemming directly from binge eating and purging behaviors range from fainting to cardiac arrhythmias
and can include hypokalemia, metabolic syndrome, laxative dependence, tooth decay (sometimes associated with bone
necrosis), esophageal tears with bleeding, and injuries and bone fractures. The DSM-5 diagnostic criteria specify the
occurrence of one or more episodes of binge eating and compensatory behaviors per week
 About 25% of patients are diagnosed with current MDD.


 Bulimia nervosa runs in families, and both genetics and the nonshared environment—that is, environmental factors specific
to individuals—influence the development of the disorder. 
o It appears that environmental factors are more influential early in development and that genetic contributions
increase with age. 
 Replicated risk factors for bulimia nervosa in studies meeting strict criteria include dieting, psychiatric morbidity (especially
negative affect), and weight and shape concerns. 
o Studies of appetitive regulation suggest that appetite is dysregulated in bulimia nervosa, probably at both central
and peripheral levels, with disturbances of taste- and reward-processing regions of the brain likely contributing to
the psychopathology. 
 Bulimia nervosa was essentially unknown in non-Western cultures until Western influences, particularly television and
other media sources, prompted the emergence of the disorder, usually among adolescent females. 
o The critical factor transmitted appears to be preoccupation with the thin ideal weight and shape prevalent in
Western settings but alien to many other cultures. Hence, cultural factors (largely Western culture), family
environment, genetics, and appetitive dysregulation all contribute to the disorder.
 Clinical Presentation of Bulimia Nervosa in an Adult vs. Adolescent 
o As with anorexia nervosa, there are additional challenges in diagnosing bulimia nervosa in childhood and
adolescence because of developmental differences between adults and younger patients. 
o Some studies have found that for younger patients, a feeling of a loss of control over eating is a better indicator
than the amount eaten in assessing whether an eating episode should be categorized as a binge. 
o Because parents and other adults often have greater control over the child’s access to food, the number of binge
episodes that young patients can engage in are likely more constrained, which may lead to fewer binge-eating
episodes than might have taken place if these controls were not in place. 
o As with younger patients with anorexia nervosa, difficulties with abstract thinking and verbal expression of
emotional states, as well as minimization, are common among adolescents with bulimia nervosa. For this reason, it
is usually helpful to include parental interviews to obtain a more comprehensive clinical picture.
 Treatment
o Evidence-Based Psychotherapies
  Among the psychotherapies, CBT currently has the largest evidence base for the treatment of adults with
bulimia nervosa. CBT is based on the hypothesis that concerns about weight and shape and dietary
restriction are the two processes that maintain bulimia nervosa 
 Treatment directly addresses these processes and consists of psychoeducation about bulimia nervosa and
its maintaining factors, detailed self-monitoring of eating and purging behaviors, and the use of self-
monitoring to gradually reduce dietary restriction by working toward three nutritionally adequate meals
and two snacks daily, which reduces hunger and therefore loss of control over eating. 
 Usually, self-induced vomiting requires little specific attention because it is tightly aligned with binge
eating. 
 As the diet becomes regulated, feared and avoided foods are gradually added. This phase of treatment is
often accompanied by a marked reduction in binge eating and purging. 
 The cognitive and behavioral components of concerns about weight and shape are then addressed while
modifications to dietary restriction continue. In this phase of treatment, events that trigger either dietary
restriction or weight and shape concerns are addressed, and alternative coping behaviors are discussed. 
 Special attention needs to be given to diuretic and laxative use. 
 Diuretics can usually be phased out fairly quickly, although the underlying reasons for their use,
notably relief of weight and shape concerns, need to be addressed. 
 Laxatives, because they are habit-forming, are often more difficult to stop. 
 Patients have to choose between an abrupt withdrawal and a tapered withdrawal. 
 A series of controlled trials has shown that CBT is more effective than comparable treatments such as
psychodynamic psychotherapy, IPT, weight loss treatment, and medication. Hence, CBT is regarded as the
primary treatment for bulimia nervosa. 
 However, with remission rates around 30%–40%, there is still much to improve. An enhanced
version of CBT, CBT-E, has been developed and shows promise in more effectively treating
patients with severe comorbid psychopathology 
 Therapist-assisted CBT is a self-help version that uses brief therapy sessions but has the patient rely on a
treatment manual or book. Controlled studies suggest that this treatment may be as effective as CBT and
hence is more widely usable because of the lower cost. 
 Treatment with CBT is associated with a rapid early decrease in bulimic symptoms, such that a 50%–60%
decline in purging by session 4 is a reasonably strong indicator of good outcome. 
 A second-line treatment adapted from the treatment of depression, IPT, has also been shown to be
effective in treating bulimia nervosa, although it is slower to work than CBT or CBT-E in the short term,
and in at least in one controlled study, it was shown to be less effective than CBT in both the short and the
long term 
 Treatment usually focuses on one interpersonal issue pertinent to binge eating in one of four
areas: grief, role disputes, role transitions, and interpersonal deficits.
  A major advantage of IPT is that it is a transdiagnostic treatment, with evidence of effectiveness
in treating MDD and anxiety disorders without requiring much alteration in treatment
procedures.
 Although a number of randomized controlled trials have examined treatment for adults with bulimia
nervosa, only three examined treatment for adolescent bulimia nervosa. 
 Some indicate FBT was more effective than supportive psychotherapy both at the end of
treatment and at 6-month follow-up, but  these differences were no longer statistically different
at 12 months post treatment, although both groups continued to improve.
o Evidence-Based Pharmacotherapy
 The first controlled studies were of the tricyclic antidepressants and monoamine oxidase inhibitors,
demonstrating the superiority of both to placebo in reducing binge eating and purging. These studies
were eventually followed by studies demonstrating that fluoxetine was superior to placebo in treating
bulimia nervosa, as are most of the serotonin reuptake inhibitors. 
 Fluoxetine is currently the only medication approved by the U.S. Food and Drug Administration (FDA) for
the treatment of bulimia nervosa. 
 Treatment studies in adults with bulimia have shown that adding antidepressants to CBT is more effective
than the use of CBT alone; hence, the combined approach should be considered if early improvement is
not seen with CBT. 
 Overall, antidepressant medications are regarded as less effective than CBT, which remains the primary
treatment of choice for bulimia nervosa. 
 Dropout rates are also significantly higher for medication than for CBT. 
Binge-Eating Disorder
 Although BED often begins in adolescence, it can also have a later onset. Hence, the BED patients seen in the clinic or
enrolled in clinical trials are usually older than the patients with anorexia nervosa or bulimia nervosa. The DSM-5 criteria for
the diagnosis of BED include binge eating (eating a large amount of food with loss of control over eating) at least once a
week for a period of 3 months. 
 DSM-5 criteria also specify that the binge eating is associated with at least three of five of the following behaviors: eating
more rapidly than normal; eating large amounts of food when not hungry; eating until uncomfortably full; eating alone
because of embarrassment about how much one is eating; and feeling guilty, disgusted, or depressed after binge eating. 
 Unlike bulimia nervosa, BED does not involve compensatory behaviors such as self-induced vomiting, excessive exercise, or
laxative and diuretic abuse.


 The lifetime prevalence of BED is between 1% and 3%, with prevalence tending to increase in midlife, making BED the most
common eating disorder 
 As in the other eating disorders, the prevalence of lifetime comorbid MDD is about 60%, and that of current MDD is about
25% 
 Patients with overvaluation of weight and shape tend to have more associated psychopathology. Because of these
psychological and physical comorbidities, quality of life is generally lower in patients with BED than in comparison groups
without BED. 
 In addition to its psychological comorbidities and because of its association with obesity, BED carries a heightened risk of
developing diabetes, hypercholesterolemia, and cardiovascular disease. 
 Although studies differ, about 30% of individuals undergoing bariatric surgery have BED prior to surgery, and about one-
third of that number will be diagnosed with BED post-surgery 
 Studies suggest that loss of control post-surgery predicts poor outcomes in terms of weight loss 
 Because there have been few long-term observational studies, the course of BED is not well understood. There is some
crossover with bulimia nervosa and, rarely, with anorexia nervosa
 Similar to the other eating disorders, BED runs in families, probably reflecting both genetic and specific family influences. 
 Other findings implicate brain reward systems and opioid secretion 
 Environmental influences on binge eating include negative emotion, with both laboratory and naturalistic studies showing
that negative emotion regularly precedes and probably triggers binge eating
 Clinical Presentation
o There are similar challenges in diagnosing BED and bulimia nervosa in childhood and adolescence because of
developmental differences between younger patients and adults. 
o A sense of being out of control when eating is likely more important than eating an objectively large amount of
food in younger patients because younger patients often cannot gain access to food as easily as adults. 
o For these reasons, clinicians treating children and adolescents should consider using a lower threshold for the
frequency and duration of binge-eating episodes. 
 A suggested frequency of once per month (instead of once per week) over the previous 3-month period
was recommended by a consensus group of experts in child and adolescent eating disorders
o In addition, as with anorexia nervosa and bulimia nervosa, children and adolescents are limited in their abstract
thinking ability and self-expression. They also may minimize any discomfort or shame they experience when binge
eating. 
 Thus, parental interviews and other collateral reports are often necessary for making a definitive diagnosis
of BED in children or adolescents. 
 o Bulimia nervosa usually occurs in patients who are of normal weight or who are slightly overweight; BED more
often occurs in overweight and obese individuals. 
o In bulimia nervosa, binge eating is considered to be a response to restriction of food intake, whereas in BED, binge
eating occurs in the context of overall chaotic and unregulated eating pattern
 Treatment
o Evidence Based Psychotherapy
 The placebo response is higher in BED than in bulimia nervosa; as a result, a treatment’s effectiveness in
BED is inflated relative to its effectiveness in bulimia nervosa. 
 Well-designed controlled studies have shown that both CBT and IPT are effective in reducing binge eating,
with 50%–60% of patients achieving remission at end of treatment 
 It appears that CBT and IPT are similarly effective in BED, both at the end of treatment and at follow-up. 
 A third treatment, behavioral weight loss therapy, has also been used to treat BED on the basis of the
finding that binge eating decreases with weight loss. 
 Controlled comparisons of CBT with weight loss therapy have found that CBT is superior in reducing the
frequency of binge eating; however, CBT does not reduce weight. 
 At present, CBT and IPT are the recommended first-line treatments for BED for reducing binge eating but
do not lead to weight loss. 
 In adolescents with BED, preliminary studies support the use of IPT, but BED has otherwise been relatively
unexamined in younger patients.
 As in bulimia nervosa, a shorter variant of CBT, therapist-guided self-help, has been shown to be as
effective as full-scale CBT in reducing binge eating in the treatment of BED = loss costly
o Evidence Based Pharmacotherapy 
 Antidepressants, particularly SSRIs, used at dosages similar to those used for the treatment of depression,
are effective in the treatment of BED, with response rates of about 40% 
 Rates of dropout due to side effects tend to be higher for antidepressants than for CBT or IPT. 
 Controlled studies suggest that CBT is more effective than antidepressants in treating BED
 More recently, several studies have examined the efficacy of lisdexamfetamine (LDX), a medication used
in the treatment of attention-deficit/hyperactivity disorder, resulting in FDA approval of LDX for the
treatment of BED in 2015. In placebo-controlled trials of LDX (at dosages between 50 and 70 mg/day),
approximately 50% of patients receiving LDX achieved abstinence from binge eating, compared with 21%
of patients receiving placebo and also showed significant weight loss. 
 In a further 6-month maintenance trial, only 3.7% of patient on LDX relapsed to binge eating, compared
with 32.1% of patients switched to placebo. 
 Hence, LDX appears to be a promising medication for the treatment of BED.

Conclusion
 Research into the etiology and treatment of the eating disorders has progressed rapidly in the past quarter-century but still
lags behind progress in other areas, such as anxiety and depression. 
 For the long term, research in genetics, neurobiology, and neurochemistry together with treatment research may shed light
on the etiology and maintenance of eating disorders and improve treatment. 
 However, a major problem facing the provision of mental health services is that a large proportion of the population in the
United States has little or no access to effective treatment. One promising way to address this problem is to use technology
to provide treatment through either the Internet or the use of mobile apps (apps) 
o Several controlled studies have suggested that CBT provided via telehealth is more effective in treating bulimia
nervosa than no treatment but not as effective as full CBT
o One problem with the use of apps in conditions such as depression is the very high rate of nonuse and dropout. 
o Treatment via the Internet or solely via apps does raise ethical and practical issues. 
 Studies have shown that many community practitioners do not use evidence-based treatments for patients with eating
disorders. 
o The reasons for this lack of use are complex and include the challenges surrounding the adoption of new
psychotherapy modalities and the difficulty of implementing existing evidence-based therapies in community
practice settings; for example, many community clinics cannot afford to provide the 18 sessions of treatment that
most evidence-based therapies require. 
o In addition, clinician adherence to the specific protocols of an evidence-based psychotherapy tends to fall over
time, leading to lower effectiveness. 
o Evidence-based psychotherapies will need to be adapted to differing clinical situations.

Key Clinical Points

  Family-based treatment is effective for anorexia nervosa and bulimia nervosa in adolescents.
 Cognitive-behavioral therapy is effective for bulimia nervosa and binge-eating disorder in adults.
 No medications have yet shown systematic effectiveness for anorexia nervosa.
 Selective serotonin reuptake inhibitors are effective for adults with bulimia nervosa, especially in combination with
cognitive-behavioral therapy.
 Lisdexamfetamine is FDA approved for the treatment of binge-eating disorder.
 Binge-eating disorder and avoidant/restrictive food intake disorder are new diagnoses in DSM-5.
 Access to empirically supported treatments for eating disorders is limited, and the use of technology, including
telepsychiatry and mobile apps, may be helpful in overcoming this problem.

Substance Abuse Disorder

- PENDING

11 criteria
Mild – presence of 2- 3 sx
Moderate – presence of 4 -5 sx
Severe – Presence of 6 or more sx
TBL4- Schizophrenia – Notes from the Slides
DSM5 criteria Schizophrenia
a. Two (or more) of the following, each present for a significant portion of time during 1-month period (or
less if successfully treated). At least one of these must be (1), (2) or (3)
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g. Frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative Symptoms (i.e. diminished emotional expression or avolition)
b. For a significant portion of the time since the onset of the disturbance, level of functioning in one or
more major areas, such as work, interpersonal relations, or self-care, is markedly below the level
achieves prior to the onset
c. Continuous signs of the disturbance persist for at least 6 months.
a. This 6-month period must include at least 1 month of symptoms
d. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out
because either
a. No major depressive or manic episodes have occurred concurrently with the active-phase
symptoms
b. If mood episodes have occurred during active-phase symptoms, they have been present for a
minority of the total duration of the active and residual period of the illness

Timeline
 - Definition of Psychosis
o Core features
 Delusions
 Hallucinations
 Disorganized speech (thought disorder)
o Accompanying features
 Catatonia
 Disorganized behavior
 Negative symptoms
 Mood symptoms

DSM-5 Criteria Schizoaffective Disorder

A. An uninterrupted period of illness during which there is a major mood disorder (major depressive or manic) concurrent with
Criterion A symptoms of schizophrenia
B. Delusions and/or hallucinations are present at least for 2 weeks in the absence of a major mood episode during the lifetime
duration of the illness.
a. Psychotic sometimes without the mood sx
b. “She is not really depressed but says she is still hearing the voices”
C. A major mood episode is present for the majority of the total duration of the illness
D. Disturbance is NOT due to a physiological effect of a substance or general medical condition.
 - Mood disorder with psychotic features
o They are never psychotic in the absence of mood symptoms
- Psychosis with superimposed mood disorder
o They can be Psychotic without mood sx
- Catatonia
o The same criteria used to diagnose catatonia whether the context is a psychotic, bipolar, depressive, or other
medical disorder, or an unidentified medical condition
o Coded as a specifier for neurodevelopmental, psychotic, mood and other mental disorders; as well as other
medical disorders
o Sx
 Stupor, Waxy flexibility, negativism, mannerism, agitation, echolalia, catalepsy, mutism, posturing,
stereotypy, grimacing, echopraxia
 Bush-Francis Catatonia Rating Scale

o TX=
 High doses of Lorazepam
 ETC

TBL 5- Bipolar and related disorders

- Bipolar I disorder: at least one episode of mania. Major depressive or hypomanic episodes usually occur but are not
required for diagnosis.
o The vast majority of patients experience recurrent episodes
o Mania: most of the day for at least ≥ 7 consecutive days
 A distinctive period of abnormally and persistently elevated, expansive, or irritable mood and abnormally
and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the
day, nearly every day
 (or any duration if HOSPITALIZATION is necessary)
 3/7 or more of the following sx: DIG FAST
o The mood disturbance is sufficiently severe to cause MARKED impairment in social or occupational functioning or
to necessitate hospitalization to prevent harm to self or others, or there are psychotic features
o The episode is not attributable to the physiological effects of a substance.
 Note: a full manic episode that emerges during antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a full syndrome level beyond the physiological effect of that
treatment is sufficient evidence for a manic episode  BIPOLAR I diagnosis
 NEVER give and SSRI (alone) to manic patient  will flip them into MANIA

- Bipolar II disorder: at least one episode of hypomania and one major depressive episode
o no previous episodes of mania (distinguishing feature from bipolar I)
o DSM-5 criteria – at least one hypomanic episode + at least one major depressive episode & there has never been a
manic episode.
o Criteria A. Hypomania: a distinct period of abnormally and persistent elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of
the day, nearly every day.
o Criteria B. + ≥ 3 symptoms of DIG FAST
o Criteria C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the
individual when not symptomatic.
o Criteria E. The episode is not severe enough to cause marked impairment in social or occupational functioning or
to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

-
Mixed

episodes of Depression & Mania at same time

- Rapid Cycling: 4 or more episodes of depression or mania within 1 year.

- Changes during a manic episode may include

o Sleeping only a few hours but not feeling tired
o Difficulty staying focused in school
o ↑ interest in risky activities (e.g. dangerous sports without proper training)

- Changes during depressive episode may include

 o Sleeping more than usual (e.g. more than 12 hours several days in a row)
o Lack of interest in activities that were previously enjoyed
o Feeling of doing everything wrong

- Major Depressive Episode

o ≥ 5 of the SIGECAPS sx present during the same 2- week period
o At least one sx is either (1) depressed mood or (2) loss of interest or pleasure

- Diagnosis and Tx challenging pts may present with other presentations such as anxiety disorders, substance abuse
disorders, ADHD, personality disorders
- No cure
o Most effective treatment – Lithium salt – MOOD stabilizer
o Better at treating manic episodes
o Other drugs include
 Antipsychotics
 Anticonvulsants
 Benzodiazepines
- Cyclothymia
o Alternating mood
o Criteria: “hypomanic episodes” + “Dysthymic episodes”
o Happens for at least 2 years, the hypomanic and depressive episodes have been present for at least half the time
and the individual has not been without Sx for more than 2 months.

o CD may not be diagnosed if there has been any major depressive, manic, or hypomanic episode during the first 2
years of the disturbance
 If such an episode occurs in this time period, the chronic subsyndromal mood swings may be considered
to be residual symptoms of bipolar I disorder or bipolar II disorder

- Other causes of mania

o Steroid-induced
o Substance-induced (stimulants)
o Drug-induced
o Autoimmune-induced
o Neurosyphilis
o HIV
o Subacute Combined Degeneration
o Hyperthyroidism
o Wilson’s Disease
https://www.youtube.com/watch?v=-TOs6cceTlA

Phenomenology
- Bipolar II is more common in women than in men
- Bipolar I affected men and women equally
- Children and adolescent
o Approximately 40% of patients w/severe major depressive episodes in late adolescence to early adulthood (Ages
18-25 years) ultimately receive a bipolar disorder diagnosis
Epidemiology
- Bipolar and related disorders have a lifetime prevalence as high as 4%
o 1% bipolar I disorder
o 1% bipolar II disorder
o 2% subthreshold bipolar disorder
- The peak age at onset for bipolar and related disorder is in the late teens to early 20s
- The prevalence of bipolar I or II disorders in adolescents in the US is approximately 2.5%
- Pts with bipolar and related disorders are commonly not able to maintain full-time employment, even if they have at least
some college education
- Family member ↑ 10x risk
- Bipolar and related disorders are inversely related to age and education level
o Common in previously married
o Unemployed-disabled
o Unrelated to race/ethnicity and family income.
- Second among mental illnesses causing disability in working-age adults.

Pathogenesis of Bipolar and Related Disorders

- Relevant mechanisms – important neurochemical themes include
o Hormonal (hypothalamic-pituitary-adrenal, hypothalamic-pituitary-thyroid, hypothalamic-pituitary-gonadal axes)
o Monoaminergic (Dopamine, Norepinephrine, and Serotonin)
o Ion channel (Calcium, Sodium)
o Excitatory/ Inhibitory neurotransmitter (Glutamate- Y-aminobutyric acid [GABA])
o Intracellular signaling (inositol monophosphate, protein kinase C, and glycogen synthase kinase-3 beta)
o Mitochondrial (impaired energy production, altered phospholipid metabolism)

- Neuroimaging studies consistently indicate that dysfunction in ANTERIOR PARALIMBIC and overlying prefrontal regions that
contribute importantly to normal human emotions, mood, and cognition may contribute to the pathogenesis and clinical
phenomenology of bipolar-related disorders.
- Deficit in neuroplasticity and neurotrophic factors (e.g. brain-derived neurotrophic factor) have also been implicated in the
pathophysiology of bipolar and related disorders.
- Post mortem neuropathological studies suggest regional neuronal and glial deficits in patients with bipolar disoders

Treatment

TBL 6-
Bold stuff
- Specific phobias are most common in childhood, though they are also surprisingly prevalent among older adults
- Panic attacks seen to occur out of the blue and without explanation
- Antidepressants are the pharmacological treatment of choice for most anxiety disorders
- Efficacious Cognitive-Behavioral Therapies (CBT) exist for each of the anxiety disorders
- Amygdala dysfunction may also be a critical underlying factor in anxiety proneness more generally

- Disparate Behavioral Therapy and CBT strategies (ERP and HRT) appear to be effective across OCD and its related disorders.
- Habit reversal training (HRT) – highly effective behavioral therapy for people with unwanted repetitive behaviors or habits.
o Tics, Hair Pulling, Nail biting and skin picking
- Exposure and Response Prevention (ERP)- most effective forms of treatment for OCD
- SSRIs and Clomipramine (TCA) are effective for OCD and BDM
TBL8 – Child & Adolescent Psychiatry, Neuro-Developmental Disorders, Elimination Disorders

Intellectual Disabilities
- Intellectual developmental disorder
o Disorder with onset during the developmental period that includes both intellectual and
adaptive functioning deficits in conceptual, social and practical domains
o Three criteria must be met
 Deficits in intellectual function
 Deficits in adaptive functioning
 Onset of intellectual and adaptive deficits during the developmental period

- DSM 5 states that diagnosis should be based on both clinical assessment & the results of standardized
intelligence testing – Wechsler Intelligence Scale for children – Overall IQ score
o 2 SD below the mean for the general population – equates IQ score from 65 to 75 or lower
- The criteria for establishing severity level in DSM-5 are focused on the individual’s ability to cope with
the demands of the environment

- Global developmental delay

o Individuals under the age of 5
o When clinical severity level cannot be reliably assessed during early childhood
o Diagnosed when an individuals fails to meet expected developmental milestones in several
areas of intellectual functioning
o Children who are too young to participate in standardized testing

- Unspecified Intellectual Disability

o Individuals over the age of 5
o When assessment of the degree of ID by means of locally available procedures is rendered
difficult or impossible because of
o Associated sensory or physical impairment – blindness or prelingual deafness, locomotor
disability

Autism Spectrum Disorder (SD)

a. Persistent deficits in social communication and social interaction across multiple context:
1. Deficits in social-emotional reciprocity – from abnormal social approach and failure of
normal back-and-forth conversation; to reduced sharing of interest, emotions, or affect;
to failure to initiate or respond to social interactions
2. Deficits in nonverbal communicative behaviors- poorly integrated verbal and nonverbal
communication; to abnormalities in eye contact and body language or deficits in
understanding and use of gestures; to a total lack of facial expressions and nonverbal
communication
3. Deficits in developing, maintaining, and understanding relationships- difficulties
adjusting behavior to suit various social contexts to difficulties in sharing imaginative
play or in making friends; absence of interest in peers.
b. Restricted, repetitive patterns of behavior, interests, or activities; at least 2 of the following
1. Stereotyped or repetitive motor movement
2. Insistence on samenessss
3. Highly restricted, fixated interests that are abnormal in intensity or focus
 4. Hyper or hyporeactive to sensory input

Social (Pragmatic) communication disorder

- Difficulties in social verbal and non-verbal communication WITHOUT repetitive disruptive behavior or
altered sensory perception

ADHD
a. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development
1. Inattention: six or more & persisted for at least 6 months
2. Hyperactivity and Impulsivity
b. Several inattentive or hyperactive- impulsive sx were present prior to age 12 YO
c. Present in 2 or more setting (at home, school, work, with friends or relatives; etc)
d. There is clear evidence that the sx interfere with, or reduce the quality of, social, academic, or
occupational functioning
e. The sx do not occur exclusively during the course of schizophrenia or another psychotic
disorder & are not better explained by another mental disorder
- Therapy  Applied Behavioral Analysis & (also language therapy)

Specific Learning Disorders

a. Difficulties learning and using academic skills, as indicated by the presence of at least one of the
following (sx must have persisted for at least 6 months)
1. Inaccurate or slow and effortful word reading
2. Difficulty understanding the meaning of what is read
3. Difficulties with spelling
4. Difficulties with written expression
5. Difficulties mastering number sense, number facts, or calculation
 6. Difficulties with mathematical reasoning

Tic Disorders

- Criteria for Tic disorders

o
- Persistent (Chronic) Motor or Vocal Tic disorder
o
- Provisional tic disorder
o Single or multiple motor and/or vocal tics
o The tics have been present for less than a year
o Onset is before age 18
o Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic
disorder

Key Clinical Points

Disruptive Mood Dysregulation Disorder

a. Severe recurrent temper outbursts manifested verbally (verbal rages) and/or behavioral (e.g. physical
aggression toward people or property) that are grossly out of proportion in intensity or duration to the
situation or provocation
b. The temper outburst are inconsistent with the developmental level
c. The temper outburst occurs, on average ≥3 times per week
d. The mood between temper outbursts is PERSISTENTLY irritable or angry most of the day, nearly every
day, and is observable by others (e.g. parents, teachers, peers)
e. Criteria A-D has been present for 12 or more months
f. The diagnosis should not be made for the first time before age 6 years or after age 18 years
g. The age of onset of criteria A-E before age 10.

Oppositional Defiant Syndrome

- Need more than 4 to meet criteria
- > 6 months
- Three categories of symptoms:
1. Anger/ Irritability
2. Argumentative/ Defiant behavior
3. Vindictiveness

Elimination Disorders
- Enuresis
o Repeated voiding of urine into bed or clothes, whether intentional or involuntary
o Frequency of at least twice a week for at least 3 consecutive months
o Chronological age is at least 5 YO
o Specify
 Nocturnal only
 Diurnal only
 Nocturnal and diurnal
o Pharmacological Tx
 First line – Vasopressin
 2º  Imipramine (TCA)
 Caution for log QT arrhythmia, get an EKG before starting
o Behavioral therapy
 1st line  Ball & Pad method

- Encopresis
o Repeated passage of feces into inappropriate places (e.g. clothing, floor), whether involuntary
or intentional
o At least one such event occurs each month for at least 3 months
o Must be > 4YO
o 2 primary sub-types
 Retentive = constipation and related overflow incontinence
 Non-Retentive
o The most accepted form of tx is a protocol that contains educational, psychological, behavioral
and physiological components.

- Key Clinical Points

o Enuresis is a self-limited disorder
 High rate of spontaneous remission from 12% to 14% per year
o The bell and pad method of treatment is the most appropriate first choice of tx
o Children w/ secondary enuresis are more apt to have a psychological or stressful underlying
condition
What is the tx of Delirium  Treat the underlying cause

Cognitive Impairment

- When evaluating for MCI, it is important to rule out reversible causes of cognitive impairment such as
depression-related cognitive impairment, hypothyroidism, vitamin B 12 deficiency, impaired sleep (eg,
obstructive sleep apnea), and adverse effects of pharmacotherapy (eg, benzodiazepines).

Pharm HY
- Bulimia Nervosa
o Fluoxetine (SSRI)
 o + CBT and nutritional rehabilitation
- Anorexia Nervosa
o Start with + CBT and Nutritional rehabilitation
o Olanzapine (to ↑ weight gain) if no response to above
- Binge Eating Disorder
o CBT
o Behavioral weight loss therapy
o SSRIs
o Lisdexamfetamine

- Alzheimer’s disease
o Cholinesterase inhibitors
 Rivastigmine
 Donepezil
 Galantamine
o NMDA antagonist
 Memantine
o Aducanumab  Anti-amyloid monoclonal antibody

- Antipsychotic medications – also called neuroleptics

o Typical (1st gen) – MOA is D2 blockade- also known as dopamine antagonists
 Have lots of movements EPS side effects
o Atypical (2nd gen) – also known as serotonin dopamine antagonists
 They have fewer side effects
 Lower Risk of Extrapyramidal symptoms
 Higher risk of metabolic syndrome
 Higher morbidity in Schizophrenic pt due to cardiovascular disease

o 2mg- 5mg haloperidol IM- high potency 1st gen (the prototype)
 High potency
 More chances to give NME
o Lowest Risk/ chance of causing NME  CLOZAPINE
 NMS
 Muscle rigidity
 Autonomic instability (fever, tachycardia, unstable blood pressure)
 Confusion, delirium (altered mental status, encephalopathy)
  Elevated CPK, Rhabdomyolysis- Acute renal failure
 What is the main tx?
o STOP antipsychotic
 The more dopamine blockade  ↑ risk
o Intensive medical care: IV fluids, supportive care, treat any co-occurring
infections
 Lorazepam – 1 step metabolism
o Bromocriptine (a potent D2 agonist)
 Central effect – counteracts the dopamine blockade
o Dantrolene (a muscle relaxant)
 RyR receptor

o High potency
 Haloperidol & Fluphenazine
o Low potency
 Chlorpromazine & Thioridazine
 Less Tardive Dyskinesia
 More likely to drop the blood pressure (this is why we end up giving them Haloperidol)
o Long acting injectable
 Risperidone
 Aripriprazole
 Why? Due to compliance, patients don’t want to take/forget to take their medications
o 2nd generation
 AKA Serotonin Dopamine antagonists (SDA)
 Atypical antipsychotics
 Do not do a good job at treating negative sxs
 Atypical neuroleptics
 All SDAs are thought to improve both positive and negative sx of schizophrenia
 Blocking dopamine in the mesocortical makes negative sx worse
 Blocking dopamine in the mesolimbic makes negative sx better
 Monitor weight, blood glucose, lipids  more likely to cause Metabolic Syndrome
 Lower risk of EPS and Tardive Dyskinesia (TD)
 Tx for TD – Valbenazine (blocks storage of Dopamine in the pre-synaptic vesicle)
 Less chance of causing TD – Clozapine and Olanzapine

o Low potency ->

 More sedating
 Drops BP more -> Hypotension
 More anticholinergic
o What is more potent/sedating 500 mg Haloperidol or 150 mg of Chlorpromazine???
 C is more sedating
 C has less EPS
 However, C drops the BP
o High potency
 More EPS
 Diphenhydramine (helps with EPS)
  More anticholinergic side effects
 ↑ risk of delirium, dry mouth, slow motility – constipation, urinary retention
 Tx= Benztropine (anticholinergic)
o B52 injection (IM) =
 5 mg haloperidol
 2 mg lorazepam
 50 mg diphenhydramine

o Receptors interactions and their resulting side effects

 Alpha 1 adrenergic antagonism = postural hypotension + sedation
 Muscarinic cholinergic antagonism = sedation + anticholinergic side effects
 Histamine 1 antagonism = sedation
 Dopamine-1 (D1) & Dopamine-1 (D2) antagonism = EPS including dystonias &
parkinsonian sxs
 Acute dystonic reactions: including torticollis, oculogyric crisis, laryngospasm
 Drug-induced parkinsonian sx: tremor, bradykinesia, muscle rigidity (cogwheel
rigidity), mask-like facies
 Akathisia
o Tx Akathisia and Anticholinergic = diphenhydramine and benztropine
o 2nd gen most likely to cause Akathisia = Aripiprazole
o Risperidone
 2 gen antipsychotic D2 >>>>> 5HT2
 Most dopamine blockade
 Less serotonin blockade

- Blockade of dopamine in the different Dopaminergic pathways

o Nigrostriatal = EPRs
o Mesolimbic = Relief of psychosis
 Overactivity = positive sx of psychosis
 Normally, dopamine suppresses Acetylcholine activity  if dopamine is blocked, Ach
becomes overly active  ↑ in EPRs
 Anticholinergic overcome excess Acetylcholine activity caused by the removal of
dopamine inhibition when dopamine receptors are blocked by neuroleptics
 If 5HT is blocked, it increases DA release thus reversing the effects of D2 blockade
o Mesocortical = underactivity  ↑ in negative sx
o Tuberoinfundibular = prolactin levels rise due to loss of D blockade
 Galactorrhea, gynecomastia, amenorrhea

o 2nd gen antipsychotics

 Clozapine
 Agranulocytosis - monitor WBC
 Myocarditis (arrythmias)
 Good for resistant schizophrenia & BD - Refractory Psychosis
 Give Pt a trial of this drug prior to institutionalization
 Reduces suicidal ideation in psychotic patients
 Minimal risk of TD, EPS
 High incidence of anticholinergic effects
 Significant weight gain (Antihistaminic)
  High D4 antagonism; weak D2 antagonism
 High 5-HT 2A/2C antagonism
 Risperidone
 Very low risk of TD
 Low risk of EPS at doses < 6 mg per day
 Significant D2 & 5HT2 antagonism
 Risk of elevated prolactin levels
 Olanzapine
 High risk of weight gain and sedation
o Good for pts struggling w/insomnia
o Need to monitor for metabolic syndrome
 Low risk of prolactin elevation
 Significant 5-HT2 and D2 antagonism
 Effective for + and - sxs
 Quetiapine
 Significant D1 and D2 antagonism; 5HT1 and 5HT2
 Minimal anticholinergic SE
 Intermediate
o Sedation is common
o Moderate weight gain
 Possibility of cataracts, eye exams recommended
 Ziprasidone
 D2 and D3 antagonism; 5 HT1 and 5HT2
 Potential arrhythmias due to prolonged QTc interval
 Aripiprazole
 D2 partial agonist- unique MOA
 Dopamine balancing effect
 Not too sedating, or weight gain
 SE: AKATHISIA
o Need to start low dose
 Paliperidone
 Long-acting injectable form (Invega Sustenna)
 Try oral first
 Lurasidone
 Good to use for acute bipolar depression
 Asenapine
 Low EPS
 Little chance of other side effects
 Iloperidone

 Good augment agents to treat depression  Quetiapine + Aripiprazole

o Long-acting antipsychotics
 Haldol decanoate
 Proxilin decanoate
 Risperdal consta
 Invega sustenna
 All are given by injection, usually every 2 to 4 weeks
  Useful for patients who are not compliant with w/oral antipsychotics

o Black box warning  Antipsychotics are contraindicated in PATIENTS WITH DEMENTIA-

RELATED PSYCHOSIS
o High-potency, first-generation antipsychotics (eg, haloperidol) and some second-generation
antipsychotics (eg, quetiapine) can be used for the acute treatment of agitation and psychosis
associated with delirium

Treatment of Depression
- What is the major advantage?  Won't Kill you
- Paroxetine -> most anticholinergic
o Tachycardia, dilated sluggish reactive pupils, blurred vision, warm dry skin, urinary retention
- SE:
o Weight gain
o Sexual dysfunction (anorgasmia, decrease libido, ejaculatory dysfunction)
o Paroxetine - treats premature ejaculation
 
- Bupropion (atypical)
o NE and Dopamine reuptake inhibitor
o Contraindication: anorexia, bulimia, and seizure disorders
o Taken in the morning
o 2-line treatment for ADHD
o Not good for anxiety
 
- Mirtazapine (atypical)
o Antihistamine
o Stimulates appetite
o Good for depression with insomnia and lack of appetite
 
- Trazodone (atypical)
o Used at night for insomnia
o Problem with itself- 800 mg too much -> will be sleepy all-day
 
- SNRI
o Work to treat depression that does not work only with SSRI
 
- Anxiety, GAD, Chronic Pain -> SNRI
- TCA’s not prescribed that much -> hard to treat SE
 - Clomipramine -> Tx of OCD (most serotonergic TCA)
- Doxepin (TCA) -> indicated for insomnia in the elderly
 
- MAO- Inhibitors
o Useful for tx atypical depression
o Mood reactivity, leaden paralysis, hypersomnia, and hyperphagia
o But do not jump to it
o Why not first line? Side effect -> Cheese reaction (tyramine) + HTN crisis (with meperidine -
does not have miosis)
 
- Fluoxetine
o Longest half-life
o 4-5 weeks before switching to another SSRI- MAO-i

- Antidepressants are helpful for both depression & ADHD

o Wellbutrin (Bupropion)
o Effexor (Venlafaxine)
o TCA such as Desipramine and Nortriptyline (but these have more cardiac side effects and are
dangerous in overdose
o Electroconvulsive Therapy (ETC) – requires anesthesia + more costly!!
- Importance of treating Depression and ADHD
o Untreated ADHD significantly limits the effectiveness of treatments for depression
o Untreated depression significantly limits the effectiveness of treatments for ADHD (poor
concentration often exacerbated by depression)
- ADHD and Depression – BUPROPION

Treatment of Seizure, Insomnia and Panic Disorder

- Temazepam  insomnia
- Alprazolam and Clonazepam  indicated for Panic disorder
- Diazepam  indicated for muscle spams
- Which BZD is the most rapidly absorbed when given orally?
o Diazepam -reached peak serum concentration in 45 minutes
 o Common SE: ataxia, falling
- LOT  1st metabolism in the liver (glucuronidation only)
o Lorazepam
o Oxazepam
o Temazepam
- Tx for alcohol withdrawal
o Chlordiazepoxide – preferred
- All have potential for addiction
- High Therapeutic Index  relative safe
- Life-threatening withdrawal = seizures

Treatment for Bipolar Disorder

- Lithium is the goal standard
o Tx of both acute and maintenance
- Mood Stabilizers  Lithium Carbonate
- Carbamazepine
o Monitoring
 Blood level – therapeutic range 6-12 ng/mL
 CBC with differential and platelet count
  Serum electrolytes and BUN/creatinine
 LFTS
 EKG if indicated
o Side effects
 Agranulocytosis, neutropenia, thrombocytopenia
 Rash (may be severe)
 Elevated LFTs
 SIADHs
 Hyponatremia
 Fetal abnormalities
- Oxcarbazepine
- Valproate (Valproic Acid)
o Useful for mania mainly
o Before tx
 LFTS
 CBC w. diffx and platelet count
 Pregnancy test
o Monitoring
 Blood levels therapeutic range 50-125 microg/mL
 CBC w diffx
 LFTs
o SE
 ↑ LFTs, Liver failure
 Pancreatitis
 Thrombocytopenia
 N/V
 Drowsiness
 Alopecia
 Weight gain
- Lamotrigine
o Maintenance to prevent the recurrence of mood episodes
 Shows good antidepressant efficacy for Bipolar depression and unipolar depression
 Dangerous SE: SJS
 Blood level monitoring not required
o Good to combine with Lithium
- Topiramate
o ↑ incidence of kidney stones
o ↓ appetite – good to counteract weight gain caused by other mood stabilizers
o Useful for migraine headache
- Neurontin (Gabapentin) + Gabitril (Tiagabine) =
o used OFF LABELED
o elimination is mostly renal
o useful as adjunct when added to other mood stabilizer – if anxiety and/or chronic pain are also
present
- 2º gen Antipsychotics are also used – useful in treating mania
- Lithium treatment
o Indications
 Effective agent of choice ACUTE MANIA AND BIPOLAR PROPHYLAXIS
 Effective, but other agents preferable = Acute Bipolar Depression
o Common side effects
 Excessive thirst, polyuria, memory problems, tremor
 Weight gain, drowsiness/tiredness, diarrhea
o Before beginning lithium
 Physical exam
 CBC, Cr, BUN, T4, TSH
 Pregnancy test  high risk of Ebstein Anomaly
 Consider EKG
o Monitoring
 Lithium blood levels, more frequently at beginning
 Then every 3 to 6 months or if indicated
 Creatinine, TSH- every 6 to 12 mo
 Therapeutic range: 0.5 to 1.5 mEq/L
o Lithium toxicity
 N/V, tremor
 Confusion, lethargy, altered mental status
 Coma -? Death X_X
 Cardiac conduction disturbances
 Treat w/gastric lavage, hydration
 Hemodialysis for severe cases
- Treatment of breakthrough manic or depressive episodes
o Add antidepressant, Lamictal or Lithium
o Check blood levels if applicable; adjust dosage if indicated
o Check THYROID STATUS
 - Medications indicated for Acute treatment of Bipolar Disorder
o Quetiapine
o Lurasidone
o Olanzapine/ Fluoxetine (Symbyax)
o DO NOT GIVE SSRIs/SNRIs  triggers mania

Treatment of ADHD and Tics

- 3 signs of ADHD
o Impulsivity
o Hyperactivity
o Inattentiveness
- Medications used to treat ADHD
o Stimulant
 Methylphenidate (Ritalin)
 Very effective
 SE
o Headache, insomnia, ↓ appetite, tics, rebound symptoms
o Short half-life
o Multiple dosages usually required
 Amphetamine (Adderall)
 Immediate release and time release
 Longer half-life
 Usually given one or two times per day
 Same SE as Dexedrine
 Long-acting preparations
o Helpful in the school-age child
o Adderall XR
o Dexedrine Spansule
o Vyvanse (12 hrs)
o Non-stimulant
 Atomoxetine (Strattera):
 MOA- NE reuptake inhibitor
 Not a controlled substance
 qd- BID
 SE: N/drowsiness
 Bupropion (Wellbutrin):
 Atypical Antidepressant
o Hypotensive Meds
 Clonidine (alpha 2 antagonist)
 Modulates NE release
 Useful for comorbid tic disorders such as Tourette’s
 SE:
o Sedation & hypotension
o More useful for motoric hyperactivity
o Less useful for inattentiveness
 Clonidine ER
 Guanfacine
  Similar to clonidine but less sedating
 Usually given in divided doses

- Management
o Sometimes switching from one stimulant to another improves outcome:
o Better efficacy of fewer side effects
o Stimulants as a class are about 80%-90% effective for ADHD FIRST CHOICE

Treatment of Tic Disorders

- Educate families not to punish the child for tics
- Wax and Wane
- Behavioral interventions
- Pharm:
o Haloperidol  1st line
o Pimozide
o Risperidone
o Aripiprazole
o Clonidine alpha 2- agonist
o Guanfacine

Treatment of Selective Mutism

- Multimodal treatment using CBT & Family Therapy
- Pharmacotherapy
o SSRI – especially fluoxetine

Treatment of Autistic Disorder

- What medication is indicated for core sx of autism? NONE
- Risperidone
- Aripiprazole  for mood irritability
- Naltrexone for self-injurious behavior
- SSRIs for obsessive and stereotypical behaviors + comorbid depression
 - Mood stabilizers for aggressive behaviors
o Haloperidol
o Risperidone
o Zyprexa

- Alpha-2 adrenergic agonist – Clonidine

o To treat aggression and insomnia
- Psychostimulants
o To target hyperactivity, impulsivity, and inattention (ADHD)

- What medication is indicated for depression for children

o Fluoxetine ~~ 8YOs
o Escitalopram ~~ 12 YOs

- What is the main worry of using TCAs in children?

o Sudden unexplained cardiac death
o If needed- needs EKG

Optional Final Review

- Jean Piaget
o Cognitive developmental stages
o Four major stages leading to the development of adult thought
 Sensorimotor (birth to 2 years)
 Object permanence develops here
 At about 18 mo, infant begins to develop mental symbols and use words, a
process known as symbolization
 Preoperational thought (2 to 7 years)
 Attainment of object permanence
 Begins to use symbols and language more extensively
 Unable to think logically
 Semiotic function
 Immanent justice
 Egocentric view of the world
 Phenomenalistic causality: events that occur together cause one another (e.g
bad thoughts cause accidents, physical illness interpreted as punishment
 Magical thinking (something can happen because I made it happen; its my fault
parents got divorced
 Animistic thinking: imaginative play endowing physical object with life-like
psychological attributes, like feelings and intentions
 Concrete Operations (7 to 11)
 Children operate and act on the concrete, real and perceivable world of objects
and events
 Egocentric thought is repleaced by operational thoughts, children can now see
things from someone else’s perspective
 Rules and regulation become important
 Syllogistic reasoning develops
  Conservation develops
 Reversibility : Water  Ice water
 Formal Operations (11 to end)
 Abstract thinking- leading interest to philosophy, religion, ethics and politics
 Adolescence: psychological response to puberty
 Deductive reasoning develops (from the general to the particular)
 Able to deal with permutations and combinations and grasp concepts of
probabilities
 Adolescents attempt to deal with all possible relations and hypotheses to explain
data and events
 Language use becomes more complex
 2 medications indicated in adolescence from
o Fluoxetine – 8 and above
o Escitalopram – 12 and above
o Each stage is a pre-requisite for the following one
o Different children

- Freud’s Stage
o Oral birth
 Earliest stage: the infant’s needs, perceptions and modes of expression are primarily
centered in the mouth, lips and tongues
 objectives to establish a trusting
o Anal stage
 A period of striving for independence and separation
o Phallic/Oedipal (3 to 6 years)
 Play involves imagination, role-playing “wanting to be like the big people”
o Latency (6 years to puberty)
 Relative quiescence of the sexual drive
 Lacks of development of necessary skills for adolescence
 Rules are of paramount importance
o Genital stage (puberty to adulthood)
 Libidinal drives intensified
 Regression occurs to resolve previously unresolved conflicts
 Primary objectives 0> ultimate separation from dependence

- Erikson
o All stages
o Trust vs Mistrust
o Autonomy vs. Shame
o Initiative vs. Guilt
o Industry vs. Inferiority
o Identity vs. Role confusion
o Generativity vs. Stagnation
 Person in their 50s struggling with life and whether they have been productive. He is
getting depressed.
o Integrity vs. despair
 o Elderly people who are depressed need tx  high rate of suicide (completed stats are higher
than younger people)

o Be able to correlate the Freudian stages with the Erikson stages

- Margaret Mahler: Object relation

o Object constancy: referring to a person, attachment figure, mother. Relations with important
attachment figures in life
o Achieving object constancy by By 2-3 years – the child better able to cope with mother’s
absence and engage substitutes

- John Bowlby: attachment theories

o The essence of attachment is proximity
o Development is severely compromised without secure base
- Review Child development stages  CHARTs
- Mary Ainsworth The strange situation
 o Inanimate objects such as a teddy bear or blanket (transitional objects, Winicott) also serves as
a secure base.
o Attachment serves to reduce anxiety. The secure base effects enables children to move away
from their mother safely
- Temperamental constellations
o Children with the difficult child pattern of temperament are most vulm

- Adolescence
o Peter Bloss has described adolescence as the second individuation process, the first one
completed by age 3
o The process of object losing, and object functions is central to adolescence
 Parents, friends, people – important attachment people

- The most/high-risk factor for suicide

o Previous attempt
o Firearm  high in the list too
o Hopelessness & feeling like a burden

- Rapid cycling bipolar

o 4 or more episodes manic, hypomanic, or depressive episodes have taken place within a
twelve-month period.