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A 4 year old boy is brought to the office for a routine visit. He has no medical problems and started preschool 3 weeks ago. The mother is concerned about his adjustment to school as he wants to stay home like his baby sister, frequently takes a long time to get dressed, and becomes upset when dropped off at school. On the first day of school, she was embarrassed when her son stomped his feet and yelled, “Take me home,” and wrapped his arms around her legs, physically preventing her from leaving the classroom. The teacher reports that the boy settles down a few minutes after the mother leaves. He is shy but plays with the other children and participates in all class activities. The boy’s sleep and appetite are normal, although he refuses to eat anything with peas in it. His growth and development milestones are within normal range. Which of the following is the most likely explanation for the boy’s behavior?
A)Adjustment disorder
B)Normal development
C)Oppositional defiant disorder
D)Parent-child relational problem
E)Separation anxiety disorder
F)Social anxiety disorder
G)Stranger anxiety
What is Normal Development?
Diagnose me!
“I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn’t let something go.”
What is Generalized Anxiety Disorder?
This is the treatment of choice for Specific phobias.
What is Cognitive Behavioral Therapy (CBT)?
Trichotillomania is recurrent pulling out of one’s hair, resulting in hair loss. Causes significant distress or impairment in daily functioning. Usually involves the scalp, eyebrows, or eyelashes, but may include facial, axillary, and pubic hair.
It is far more common in this gender.
What are females? (10:1 ratio)
This is the major difference between
Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)
Duration of time and onset
PTSD- Trauma occurred at any time in past. Symptoms last >1 month
ASD- Trauma occurred <1 month ago. Symptoms last <1 month
A 27 year old woman comes to the office due to persistent anxiety. The patient is brought by her husband as she is no longer able to drive. She is afraid that she will have a panic attack while driving and could faint and lose control of the car. The patient used to have panic attacks several times a week that were characterized by sudden onset of palpitations, sweating, and dizziness. She started medication a year ago, and the panic attacks have since resolved. However, the patient now has anxiety any time she has to leave the house. She has been reluctant to look for work, has stopped going to the gym, and frequently relies on her husband for transportation. The patient has no other medical problems. She takes citalopram 20mg. Physical examination is normal. The patient drinks 2 cups of coffee in the morning and a glass of wine at night. She does not use illicit drugs. ROS shows a weight gain of 5lbs, which the patient attributes to lack of exercise. Which of the following is the most appropriate next step in management of this patient?
A)Add clonazepam as needed
B)Add cognitive-behavioral therapy
C)Add supportive psychotherapy
D) Increase dose of citalopram
E)Switch to bupropion
F)Switch to fluoxetine
What is Add cognitive-behavioral therapy?
This type of phobia is associated with intense fear of being in public places where escape or obtaining help may be difficult. It often develops with panic disorder. The course of the disorder is usually chronic. Avoidance behaviors may become as extreme as complete confinement to the home.
What is Agoraphobia?
This drug is used for the treatment of performance anxiety and public speaking.
What are beta blockers (propranolol, atenolol)?
This disorder is characterized by recurrent skin picking resulting in lesions. Repeated attempts to decrease or stop skin picking. Causes significant distress or impairment in daily functioning. Course is chronic, with waxing and waning periods if untreated. Comorbidity with OCD, trichotillomania, and MDD.
What is Excoriation Disorder?
Adjustment disorders occur when behavioral or emotional symptoms develop after a stressful life event. Marked distress in excess of what would be expected after such an event and there is significant impairment in daily functioning
Development of these emotional or behavioral symptoms must manifest by this month in response to an identifiable stressful life event. Also these symptoms must resolve by this month after stressor has terminated.
What are 3 months and 6 months?
An 11 year old boy is brought to the office by his mother for a routine examination. She is worried that her son will be laughed at or bullied because of some unusual behaviors. The boy has a 4 year history of episodes in which he clears his throat, grimaces, and blinks his eyes. He has also recently started shrugging his left shoulder, which is his mother fears is very noticeable to others. His medical history is otherwise unremarkable. The boy is having difficulty in math but is earning passing grades in other subjects. He has a few friends at school but prefers to play piano and clarinet by himself at school. The mother notes that his shoulder movements stop when he plays a musical instrument. Physical examination is unremarkable with the exception of sporadic left-sided shoulder shrugs. Which of the following disorders is most likely to develop in this boy?
A)Antisocial personality disorder
B)Autism spectrum disorder
C)Conduct disorder
D)Major depressive disorder
E)Obsessive-compulsive disorder
F)Oppositional defiant disorder
G)Seizure disorder
What is Obsessive-compulsive disorder?
Primary anxiety disorders can only be diagnosed after determining that the signs and symptoms are NOT due to these
What are the physiological effects of a substances, medications, or medical conditions?
Benzodiazepines enhance activity of GABA at GABA-A receptors and work quickly and effectively, but they all can be addictive. Minimize the use, duration, and dose.
These medications should be avoided in patients with a history of substance use disorders, particularly this substance.
What is alcohol?
Patients with body dysmorphic disorder (BDD) are preoccupied with body parts that they perceive as flawed or defective, having strong beliefs that they are unattractive or repulsive. Though their physical imperfections are either minimal or not observable, patients view them as severe and grotesque.
They spend significant time trying to correct perceived flaws via these methods.
What is makeup, dermatological procedures, or plastic surgery?
Prazosin, an alpha1-receptor antagonist, targets this particular symptom of PTSD
What are nightmares (and hypervigilance)?
A young mother brings her 5-year old daughter to the office due to problems at school. The patient started kindergarten 2 months ago and appeared to be fine. Last week, the teacher called to say that the child refused to answer questions or speak to others in class since her arrival. The teacher did not report it earlier as she though the child was undergoing an adjustment period. During playtime , she prefers s to play by herself. In class she remains quiet while the other children sing songs or recite the alphabet. The mother finds this very surprising as the patient is talkative at home and plays with her siblings and neighborhood friends. In addition, the patient did not report any issues with school to her mother, saying it was “fine”. She is “a little shy” at social gathering but interacts with other kids and adults when she gets to know them. The child is able to tie her shoelaces, jump rope, and dress and feed herself. She can copy a triangle and is able to count to 10. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?
A)Adjustment Disorder
B)Normal Shyness
C)Selective mutism
D)Separation Anxiety Disorder
E)Social (pragmatic) communication disorder
F)Stranger Anxiety
What is Selective mutism?
These are a type of fear response involving an abrupt surge of intense anxiety which may be triggered or occur spontaneously. They peak within minutes and usually resolve within half an hour.
What are panic attacks?
This is the treatment of choice for panic disorder.
What are Pharmacotherapy and CBT?
First-line: SSRIs (e.g., sertraline, citalopram, escitalopram)
**Can switch to TCAs (clomipramine, imipramine) if SSRIs not effective
**Can use benzodiazepines (clonazepam, lorazepam) as scheduled or PRN especially until the other medications reach full efficacy.
Hoarding Disorder is diagnosed when there is persistent difficulty discarding possessions, regardless of value. Results in accumulation of possessions that congest/clutter living areas and causes clinically significant distress or impairment in social, occupational, or other areas of functioning.
Hoarding is far more prevalent in this age demographic population.
What are the older populations?
PTSD is characterized by the development of these symptoms after exposure to one or more traumatic events.
(Name at least 2)
What are…
Intrusive symptoms (nightmares, flashbacks)
Avoidance
Negative alterations in thoughts and mood
Increased arousal (hypervigilance, startle response, outburst, insomnia)
** The symptoms last for at least a month and may occur immediately after the trauma or with delayed expression.
A 29 year old emergency medical technician is reffered to the clinic by his supervisor. Two weeks ago, the patient responded to a call and found 3 young people with multiple stab wounds; 2 were dead at the scene and the third died from extensive blood loss during transport to the hospital. Since the incident, the patient has experienced insomnia, nightmares, and occasional flashbacks . He has returned to work and is following his usual schedule. He says, “I am fine now. I really don’t want to talk to anyone. I have my friends, and I really just want to get back to work.” The patient has no medical or psychiatric history. He usually drinks beers only on the weekends but lately has been having “a few” at night to help him fall asleep. On mental status examination, the patient is visibly tense and restless. He is cooperative, but his answers are brief. He says that he does not feel depressed. Which of the following is the most appropriate initial step in management of this patient?
A)Educate the patient about the range of reactions to trauma
B)Encourage the patient to discuss the incident in more detail
C)Prescribe lorazepam as needed for sleep and anxiety
D)Reassure the patient that his symptoms will likely remit in a few weeks
E)Recommend a trail of fluoxetine
F)Refer for group therapy with other first responders
G)Refer for individual psychotherapy
What is Educate the patient about the range of reactions to trauma?
As part of normal human development, infants become distressed when they are separated from their primary caregiver. When the anxiety due to separation becomes extreme or developmentally inappropriate, it is considered pathologic.
Stranger anxiety begins around this age, while Separation anxiety typically emerges at this age.
What is 6 - 9 months and 12 - 18 months?
This is the pharmacological treatment of choice for
PTSD.
What are SSRIs (sertraline, citalopram) or SNRIs (venlafaxine)?
**May augment with atypical antipsychotics in severe cases
OCD is characterized by obsessions and/or compulsions that are time- consuming, distressing, and impairing.
OCD has a high comorbidity with these other disorders. (name at least 2)
What is/are….
Other anxiety disorders (>75%)
Mood disorders (depressive or bipolar disorder (>60%)
Obsessive-compulsive personality disorder (up to 32%)
Tic disorder (up to 30%)
This is the major difference between PTSD/ASD and Adjustment Disorder.
What is a life threatening event?