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Carlos A. Muralles, M.D. 1 EFFICIENT PRACTICES FOR TREATING THE DEVELOPMENTAL DISABLED WITH MENTAL ILLNESS A DIDACTIC TRAINING FOR REGIONAL CENTER PSYCHIATRISTS.

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Presentation on theme: "Carlos A. Muralles, M.D. 1 EFFICIENT PRACTICES FOR TREATING THE DEVELOPMENTAL DISABLED WITH MENTAL ILLNESS A DIDACTIC TRAINING FOR REGIONAL CENTER PSYCHIATRISTS."— Presentation transcript:

1 Carlos A. Muralles, M.D. 1 EFFICIENT PRACTICES FOR TREATING THE DEVELOPMENTAL DISABLED WITH MENTAL ILLNESS A DIDACTIC TRAINING FOR REGIONAL CENTER PSYCHIATRISTS PRESENTED BY: ALMA FAMILY SERVICES Carlos Muralles, M.D. Carlos A. Muralles, M.D.

2 2 DEVELOPMENTAL DISABILITIES (DD): DEFINITION Diverse cluster of individuals with chronic barriers related to mental and/or physical conditions with severe impairment in their level of functioning. The areas must common affected is with their daily life activities such as independent living, mobility, self care and direction, language- communication, socio-economical self assistance, learning and relational- interaction with others. Carlos A. Muralles, M.D.

3 3 HISTORY OF DD Derogatory Connotations Past Forms Society Dealt with DD Population Asylums 18 th -19 th century: Large organizations providing basic needs 1952: Development of workshops for Special Ed Teachers as well as Day Camps 1960: Elimination of asylums 1970: The Developmental Disabilities Service and Facilities Construction Act of 1970 Carlos A. Muralles, M.D.

4 4 CLASSIFICATION: MENTAL RETARDATION Significant subaverage intellectual functioning: an IQ of 70 or below on an individually administered IQ test MILD (50 –55 to 70) MODERATE (35–40) to (50-55) SEVERE (20-25) to (35-40) PROFOUND (<20) to 20 M.R. severity NOS (clinically MR unable to be tested) Carlos A. Muralles, M.D.

5 5 CLASSIFICATION: PERVASIVE DD AUTISM SPECTRUM DISORDERS RETTS DISORDER CHILDHOOD DESINEGRATIVE DISORDER ASPERGERS DISORDER PERVASIVE DEVELOPMENTAL DISORDER NOS Carlos A. Muralles, M.D.

6 6 CLASSIFICATION: NEUROPHYSIOLOGICAL CEREBRAL PALSY SEIZURE DISORDERS HEARING LOSS/DEAF & MUTE Carlos A. Muralles, M.D.

7 7 CONCOMITANT FACTORS LEARNING D/O FEEDING AND EATING D/O MOTOR SKILL D/O TIC D/O COMMUNICATION D/O ELIMINATION D/O ATTENTION DEFICIT D/O OTHER DISORDERS OF INFANCY, DISRUPTIVE BEHAVIOR D/O CHILDHOOD OR ADOLESCENCE Carlos A. Muralles, M.D.

8 8 ETIOLOGY UNKNOWN. Efforts to track the disorders are inconclusive Believed that both genetic and environmental factors play a role Some disorders are more common with the existence of certain medical conditions Carlos A. Muralles, M.D.

9 9 EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES The risk of DD in a child increases 4-15 xs if one of the parents has traits or suffers from the same condition MENTAL RETARDATION: MENTAL RETARDATION: Familial Pattern: None; this is due to its heterogeneous etiology Prevalence: 1% of the population Ethnic, cultural and linguistic background: Reflected in standardized test Ratio in Gender: Male to Female : 1.5:1 Carlos A. Muralles, M.D.

10 10 EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES MENTAL RETARDATION (cont..) MENTAL RETARDATION (cont..) MILD: Educable; 85% of MR population MODERATE: Trainable; 10% of MR population SEVERE: 3-4% of MR population PROFOUND: 1-2% of MR population Carlos A. Muralles, M.D.

11 11 EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES AUTISTIC DISORDER AUTISTIC DISORDER Familial Pattern: among siblings of individuals w/ DO: 5% Median Prevalence Rate: 5 cases per 10,000 individuals (*note: cases range from 2-20 cases / 10,000 individuals) Ethnic, cultural and linguistic background: None that is specific Male to female ratio: 4-5:1 Females more likely to exhibit profound MR Carlos A. Muralles, M.D.

12 12 EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES RETTS DISORDER RETTS DISORDER Familial Patterns: Similar to AD; 5% correlation for individuals who have a sibling with d/o Higher association with Severe and Profound MR Prevalence: less common than AD Ratio in Gender: Almost exclusively in females (1 in every 10,000-20,000 females Carlos A. Muralles, M.D.

13 13 EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES CHILDHOOD DISINTEGRATIVE DISORDER CHILDHOOD DISINTEGRATIVE DISORDER Termed as Hellers Sx, Dementia Infantillis, Disintegrative Psychosis Familial Pattern: No information Prevalence: Very rare and much less than AD Conditions appear to be underdiagnosed Ratio in Gender: Equal (+0) ASPERGERS SYNDROME ASPERGERS SYNDROME Familial Pattern: Depressive D/O and AD among siblings of individuals with AS Prevalence: Unknown Ratio in Gender: Male to Female: 5:1 Carlos A. Muralles, M.D.

14 14 CONDITIONFAMILIAL PATTERN PREVALENCECULTURAL/ET HNIC GENDER RATIO (M to F) DEGREE M.R.None1-3%Reflected I standardized test 1.5:1Mild: 85% Moderate: 10% Profound: 1- 2% AUTISTIC D/O5% (among siblings) 5 per 10,000No specific criteria 4-5:1No criteria RETTS D/O5% (as in AD) Less common than AD No specific criteria Almost exclusively in females No criteria CHILDHOOD D.D. No information Rare; Less than AD No specific criteria (+0) equal No criteria ASPERGERS D/O Depressive D/O and AD among siblings UnknownNo specific criteria5:1 No criteria Carlos A. Muralles, M.D.

15 15 SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF AUTISM SYMPTOMS OF AUTISM Impairment in social interaction Non use of nonverbal bx No development of age appropriate peer relationship Lack of spontaneous interest or seeking to share enjoyment No social or emotional reciprocity Impairment in communication Delay or total lack of development of spoken language Inability to initiate or sustain conversation Idiosyncratic language Lack of play or social activities Restricted, repetitive and stereotyped play Carlos A. Muralles, M.D.

16 16 SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF RETTS DISORDER SYMPTOMS OF RETTS DISORDER Initial Developmental Hx: Normal prenatal and perinatal development 0-5 months: Normal psychomotor development Normal circumference at birth Onset of Sx After Normal Development 5-48 months: Deceleration of head growth Loss of previously acquired purposeful hand skill & development of stereotyped hand movements Loss of social engagement Poor coordinated gait or trunk movements Impaired excessive & receptive language Severe psychomotor retardation Carlos A. Muralles, M.D.

17 17 SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF CHILDHOOD DISINTEGRATIVE DISORDER SYMPTOMS OF CHILDHOOD DISINTEGRATIVE DISORDER Regression in various areas of functioning after age 2 Verbal/Non-verbal, language, social, play and adaptive bx is normal After age 2 (-10 yrs): Loss of clinically and qualitative former acquired skills: Bowel or bladder control Motor skills Expressive or receptive language Social and adaptive bxs Play Carlos A. Muralles, M.D.

18 18 SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF ASPERGERS DISORDER SYMPTOMS OF ASPERGERS DISORDER Qualitative Impairment in social interaction Impairment in the use of nonverbal bx Failure to develop peer relationships Lack of spontaneity or emotional reciprocity Restricted repetitive and stereotyped patterns of bx Disturbance causes clinical interference with social occupation and functioning No clinical significant delay in language No delay in cognitive development, self help skills or adaptive behavior Carlos A. Muralles, M.D.

19 19 SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS SYMPTOMS OF PERVASIVE DEVELOPMENTAL DISORDER N.O.S. SYMPTOMS OF PERVASIVE DEVELOPMENTAL DISORDER N.O.S. Severe and pervasive Impairment in the development of reciprocal social interaction Associated with impairment in either verbal or nonverbal communication Presence of stereotyped behaviors, interests, and activities Does not meet criteria for Pervasive Development D/O, Schizophrenia, Schizotypal P.D., Avoidant Personality D/O or atypical autism Carlos A. Muralles, M.D.

20 20 CONCOMITANT FACTORS LEARNING DISORDERS LEARNING DISORDERS READING DISORDER MATHEMATICS DISORDER DISORDER OF WRITTEN EXPRESSION LEARNING DISORDER NOS MOTOR SKILLS DISORDERS MOTOR SKILLS DISORDERS Development Coordination Disorder Carlos A. Muralles, M.D.

21 21 CONCOMITANT FACTORS COMMUNICATION DISORDERS COMMUNICATION DISORDERS Language Disorder Mixed Receptive Expressive Language Disorder Phonological Disorder Stuttering Communication Disorder NOS ATTENTION DEFICIT DISORDER ATTENTION DEFICIT DISORDER Hyperactive Type Combined Type Predominantly Inattentive Type Predominantly Hyper-Impulsive Type Carlos A. Muralles, M.D.

22 22 CONCOMITANT FACTORS DISRUPTIVE BEHAVIOR DISORDER DISRUPTIVE BEHAVIOR DISORDER CONDUCT DISORDER Childhood-Onset Type Adolescent-Onset Type Unspecified Type OPPOSITIONAL DEFIANT DISORDER DISRUPTIVE BEHAVIOR DISORDER NOS Carlos A. Muralles, M.D.

23 23 CONCOMITANT FACTORS FEEDING AND EATING DISORDERS FEEDING AND EATING DISORDERS Pica Rumination Disorder Feeding Disorder of Infancy or Early Childhood TIC DISORDERS TIC DISORDERS Tourettes Disorder Chronic Motor or Vocal Tic Disorder Transient Tic Disorder ELMINATION DISORDERS ELMINATION DISORDERS Encopresis: With or Without Constipation and Overflow Incontinence Enuresis: Not Due to a General Medical Condition: Nocturnal Only; Diurnal Only; Nocturnal & Diurnal Carlos A. Muralles, M.D.

24 24 OTHER DISORDERS OF INFANCY, CHILDHOOD OR ADOLESCENCE SEPARATION ANXIETY DISORDER SEPARATION ANXIETY DISORDER SELECTIVE MUTISM SELECTIVE MUTISM REACTIVE ATTACHMENT DISORDER REACTIVE ATTACHMENT DISORDER Infancy: Inhibited or Disinhibited Type Early Childhood: Inhibited or Disinhibited Type STEREOTYPIC MOVEMENT DISORDER STEREOTYPIC MOVEMENT DISORDER With or Without Self Injured Behaviors DISORDER OF INFANCY, CHILDHOOD OR ADOLESCENCE NOS DISORDER OF INFANCY, CHILDHOOD OR ADOLESCENCE NOS Carlos A. Muralles, M.D.

25 25 SENSORY IMPAIRMENT OR DEPRIVATION HEARING LOSS HEARING LOSS DEAF DEAF MUTISM MUTISM Carlos A. Muralles, M.D.

26 26 MENTAL DISORDER AND DD DUE TO GENERAL MEDICAL CONDITION CATATONIC DISORDERS DUE TO GENERAL MEDICAL CONDITION CATATONIC DISORDERS DUE TO GENERAL MEDICAL CONDITION PERSONALITY CHANGE DUE TO GENERAL MEDICAL CONDITION PERSONALITY CHANGE DUE TO GENERAL MEDICAL CONDITION Labile Type Disinhibited Type Aggressive Type Apathetic Type Combined Type Unspecified Type Other Type Carlos A. Muralles, M.D.

27 27 PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS CEREBRAL PALSY (CP) CEREBRAL PALSY (CP) DEFINITION An abnormality of motor function (the ability to move and control movements) that is acquired at an early age, usually less than a year of age, and is due to a brain lesion that is non-progressive. Result of abnormalities that occur in utero Carlos A. Muralles, M.D.

28 28 PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS CEREBRAL PALSY (CP) CEREBRAL PALSY (CP) CHARACTERISTIC SYMPTOMS Spastic paresis of the limbs (both children and adults) Choreoathetoid movement disorder: Chorea & Athetosis Unequal size of hands and feet Frequent MR Seizure disorder Impairment of senses Visual: Strabismus, Myopia Blindness Auditory: Deafness Vocal Dysarthria Carlos A. Muralles, M.D.

29 29 PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS CEREBRAL PALSY (CP) CEREBRAL PALSY (CP) VARIETIES OF CELERBRAL PALSY SPASTIC (70%) Subcategories Diplegic (25%): paresis of both legs; suffers from seizures and MR Hemiplegic (50%): paresis of arms and legs; suffers from seizures and MR Quadriplegic (75%): paresis of all limbs; suffers from seizures and MR EXTRAPYRAMIDAL (15%): Choreoathetosis and involuntary writhing of the face/tongue, hands and feet punctuated by jerking momvemnts; 10% Seizure D/O and MR MIXED FORMS OF CP (15%) Combination of spastic para paresis and choreoathetosis Highest incidence (95%0 of seizure and MR Carlos A. Muralles, M.D.

30 30 SEIZURE DISORDERS CLASSIFICATION PARTIAL OR FOCAL SEIZURES PARTIAL OR FOCAL SEIZURES 1. Partial Seizures with Elementary Symptomatology Also called motor seizures Rhymic jerking Possible development of focal status or secondary generalization Post-ictal monoparesis Tods Hemiparesis Possible sensory sx (auditory, visual or olfactory hallucinations) Carlos A. Muralles, M.D.

31 31 SEIZURE DISORDERS CLASSIFICATION PARTIAL OR FOCAL SEIZURES PARTIAL OR FOCAL SEIZURES 2. Partial Seizures with Complex Symptomatology Also called Psychomotor and Temporal Lobe Seizure D Characterized by automatisms Never occurs without accompanying loss of awareness Includes: swallowing, kissing, lip smacking, fumbling, scratching, etc. Utter or mutter brief phrases unintelligibly May suffer from visual hallucinations (macropsia and micropsia), delusions, déjà-vu dream like states, mind-body dissociations Carlos A. Muralles, M.D.

32 32 SEIZURE DISORDERS CLASSIFICATION GENERAL SEIZURE DISORDERS GENERAL SEIZURE DISORDERS Absences or Petit Mal Occurs in 1-10 second lapses; almost all cases are accompanied by automatisms Blinking occurs rhythmically at 3 Hz Childrens mental and physical activity is affected (although they do not have retrograde amnesia and maintain tone and bladder control) Following the ictus, there is no confusion, agitation or sleepiness Carlos A. Muralles, M.D.

33 33 SEIZURE DISORDERS CLASSIFICATION TONIC-CLONIC OR GRAND MAL TONIC-CLONIC OR GRAND MAL Causes massive motor activity and profound postical residua Pts may experience prodrome of malaise or mood change Tonic Phase: Pts loose consciousness; eyes roll upward, neck, trunk and limbs all extend backwards Clonic Phase: Limbs, neck and trunk are wracked by violent jerks Postictal period may include confusion, disorientation, irrationality, agitation, amnesia and cognitive impairment…may last for several hours Carlos A. Muralles, M.D.

34 34 ADDIONAL ASSOCIATED FEATURES AND DISORDERS: PHYSICAL & GENERAL FINDINGS PHYSICAL FINDINGS MEDICAL CONDITIONNEURO CONDITION M.R. M.R None; ONLY if assoc with specific syndrome Increase w/ severity in visual, auditory & cardiovascular Increases w/ severity (i.e., seizures) N/A AUTISM NonspecifiedMore prominent when assoc w/ other neuro- med condtion Nonspecified; 25% seizure d/o present Most cases are assoc with MR RETTS N/A Assoc w/ seizure d/oSevere / profound ASPERGER N/A No cognitive or language delay in 1 st yrs; motor clumsiness; over-activity & inattention are frequent Generally none; some mild noted in school years CHILD- HOOD DD Metachomatic, leukodystrophy, Schilders Carlos A. Muralles, M.D.

35 35 ADDITIONAL ASSOCIATED FEATURES AND DISORDERS: LABORATORY FINDINGS LABORATORY FINDINGS MENTAL RETARDATION Other than psychological testing (WAIS-III=Wechsler Adult Intelligence Scale & WISC-III=Wechsler Intelligence Scale for Children) there ARE NO lab findings uniquely assoc w/ MR AUTISTIC DISORDER Reports of groups differences in measures of serotonergic activity exist; these are not diagnostic criteria for AD; No specific pattern noted in EEG RETTS DISORDERNO specific findings associated; Increased frequencies of EEG and seizure d/o may exist; Abnormalities in brain imaging have existed CHILDHOOD DISENTEGRATIVE Increased frequencies of EEG abnormalities and seizure d/o; Lab findings reflect any assoc general med conditions ASPERGERS D/OLab findings reflect any assoc general med conditions Carlos A. Muralles, M.D.

36 36 COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE POOR IMPULSE CONTROL POOR IMPULSE CONTROL Frequently related to poor tolerance to frustration This is often manifested by: Outburst of anger Explosive violent and aggressive bx towards others If more impaired/severe DD, increased likelihood of self injurious bx Lack of communication skills may predispose individual to disruptive, aggressive or impulsive bx Carlos A. Muralles, M.D.

37 37 COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE RANGE OF BEHAVIORAL SX RANGE OF BEHAVIORAL SX Hyperactivity Short attention span Temper tantrums (mostly seen in young population) ODD RESPONSES TO CONDUCT ODD RESPONSES TO CONDUCT Talking to self to keep conduct w/out ability to confirm auditory hallucinations Close imaginary friends Confabulation without being delusional Carlos A. Muralles, M.D.

38 38 COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE SPEECH SPEECH Mode of speech and associations are usually repetitive, echolalic and perseverant with the same theme or statement Tone may be loud, without being irritated or demonstrating any aggressive behavior ODD RESPONSES TO INTERNAL STIMULI ODD RESPONSES TO INTERNAL STIMULI High threshold for pain and fever (Autistic D/O) Oversensitivity to loud sounds or being touched Reactions to light and odors Fascination with certain moving objects Carlos A. Muralles, M.D.

39 39 COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE ABNORMALITIES IN EATING PATTERNS ABNORMALITIES IN EATING PATTERNS Hyperphagos Limiting diet to select foods Pica Nocturnal eating ABNORMALITIES WITH SLEEPING HABITS ABNORMALITIES WITH SLEEPING HABITS Recurrent awakening at night w/ unusual bxs (i.e. rocking in Autistic D/O) Recurrent naps during the day Awakening at night with nightmares Insomnia or hyperinsomnia Carlos A. Muralles, M.D.

40 40 COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE FEAR RESPONSES FEAR RESPONSES Lack of or over response to danger/harmless objects SELF-INJURIOUS BEHAVIORS SELF-INJURIOUS BEHAVIORS Head-banging (autistic), finger/hand/wrist-biting MOOD CHANGES MOOD CHANGES Higher level of functioning indiv have tendency to become depressed or dysphoric Some develop vegetative or autonomic sx Concomitant factors often lead to demoralization, low self-esteem and deficit in social skills Excitement is often shown by incongruent affect: weeping or giggling Intrusive bx or hyperactivity is often seen w/out having a diagnosis of Bipolar D/O Carlos A. Muralles, M.D.

41 41 COURSE OF THE CONDITIONS MENTAL RETARDATION MENTAL RETARDATION Influence of course is underlined by: medical condition and environmental factors Mild MR: If dx earlier, manifested by failure in academic learning tasks May be appropriate to train May be able to acquire good adaptive skills Diagnosis required bf age 18 months Etiology and associations with syndromes may help for early detection (i.e. Down Syndrome) Mild MR of unknown origin is recognized later More severe MR resulting from acquired cause will develop more abruptly (i.e. encephalitis) Carlos A. Muralles, M.D.

42 42 COURSE OF THE CONDITIONS AUTISTIC DISORDER AUTISTIC DISORDER Follows a continuous course Language skills and intellectual level are strongest factors for prognosis School aged children and adolescents: Developmental gain in some areas (increased interest in social functioning) Some deteriorate behaviorally during adolescence; others improve A small % of these individuals live and work independently 1/3 achieve partial independence Even the highest functioning adults exhibit problems in social interactions and communication along with markedly restricted interest in activities Carlos A. Muralles, M.D.

43 43 COURSE OF THE CONDITIONS RETTS DISORDER RETTS DISORDER Duration is lifelong Loss of skills is persistently progressive Communicative bx difficulties remain constant throughout life Recovery is very limited Gains (if any) will be in social interaction during adolescence Carlos A. Muralles, M.D.

44 44 COURSE OF THE CONDITIONS CHILDHOOD DISINTEGRATIVE DISORDER CHILDHOOD DISINTEGRATIVE DISORDER Disorder follows continuous course Duration is lifelong Social, communicative and bx difficulties remain constant throughout life ASPERGERS DISORDER ASPERGERS DISORDER Disorder follows continuous course Most cases are lifelong Motor difficulties will be more apparent in the context of school Some adults may have problems with empathy and modulations of social interaction Carlos A. Muralles, M.D.

45 45 DIFFERENTIAL DIAGNOSIS MENTAL RETARDATION MENTAL RETARDATION Learning D/O Communication D/O Pervasive Developmental D/O Dementia Borderline Intellectual Functioning (IQ Range: 71-84) Carlos A. Muralles, M.D.

46 46 DIFFERENTIAL DIAGNOSIS AUTISTIC DISORDER AUTISTIC DISORDER Other Pervasive Developmental D/O (Retts D/O) Childhood Disintegrative D/O Aspergers D/O Schizophrenia Selective Mutism Expressive Language D/O Mixed Receptive-Expressive Language D/O Stereotype Movement D/O Mental Retardation Carlos A. Muralles, M.D.

47 47 DIFFERENTIAL DIAGNOSIS RETTS DISORDER RETTS DISORDER Autistic D/O Childhood Disintegrative D/O Aspergers D/O CHILDHOOD DISINTEGRATIVE DISORDER CHILDHOOD DISINTEGRATIVE DISORDER Other Pervasive Developmental D/O Autistic D/O Retts D/O Demential Carlos A. Muralles, M.D.

48 48 DIFFERENTIAL DIAGNOSIS ASPERGERS DISORDER ASPERGERS DISORDER Pervasive Developmental D/O Schizophrenia Autistic D/O Retts D/O Childhood Disintegrative D/O Obsessive-Compulsive D/O Schizoid Personality D/O Carlos A. Muralles, M.D.

49 49 DIFFERENTIAL DIAGNOSIS: SIMILARITIES FOUND DIFFERENTIAL DIAGNOSIS MENTAL RETARDATION AUTISTIC D/O RETTS D/O CHILD- HOOD D.D. ASPERGERS D/O Childhood DDXXX Autistic D/OXXX Retts D/OXX Pervasive DDXX Other Pervasive DD XX SchizophreniaXX Carlos A. Muralles, M.D.

50 50 ASSESSING THE CHIEF COMPLAINT CHIEF COMPLAINT: CHIEF COMPLAINT: W H Y N O W ? PRECIPIATATING FACTORS PRECIPIATATING FACTORS Change of routine Moving environment Separation from parents Death in the family Traumatic event Carlos A. Muralles, M.D.

51 51 ASSESSING THE CHIEF COMPLAINT MEDICAL EVENTS MEDICAL EVENTS Current medical condition/illness Substance use: past and present Any recent medication prescribed NON-COMPLIANCE WITH TREATMENT NON-COMPLIANCE WITH TREATMENT Abruptly halt with medication Change of psychotropic medication Carlos A. Muralles, M.D.

52 52 ASSESSING THE CHIEF COMPLAINT HISTORY OF CHIEF COMPLAINT HISTORY OF CHIEF COMPLAINT Data base Onset of Symptoms Description of chronological symptoms and events Awareness/suspicion of precipitant factor Psychiatric History Hospitalizations Medications: past & recent Best response to medication Side effects from other medication Change of Psychosocial Environment Current Mental Status Examination Carlos A. Muralles, M.D.

53 53 DYNAMIC FORMULATION Summary of current data base with summary of chronological symptoms and its evolution with specific rationalization for specific criteria and specific diagnosis. Carlos A. Muralles, M.D.

54 54 CONCLUSIVE CRITERIA FOR DIAGNOSIS ACCORDING TO DSM-IV-TR RULE IN (R/I) With specific Code RULE OUT (R/O) in a specific amount of time Carlos A. Muralles, M.D.

55 55 TREATMENT PLAN AND RECOMMENDATIONS IN-PATIENT TREATMENT IN-PATIENT TREATMENT Voluntary Involuntary OUT-PATIENT TREATMENT OUT-PATIENT TREATMENT Individual Psychotherapy Supportive & Short-term Cognitive-Behavioral Family Interventions (Educational & Support Groups) PSYCHOPHARMACOTHERAPY PSYCHOPHARMACOTHERAPY Carlos A. Muralles, M.D.

56 56 PSYCHOPHARMACOTHERAPY INDICATIONS FOR ANTIPSYCHOTICS INDICATIONS FOR ANTIPSYCHOTICS Primary treatment of psychotic conditions POSITIVE SYMPTOMS Hallucinations, delusions, incoherence, disorganized/catatonic bx NEGATIVE SYMPTOMS Flat affect, alogia abolition, anhedonia Bizarre or erratic bx Agitation, aggressive/assaultive bx Odd response to sensory stimuli Stereotypical motor movement, repetitive self-stimulatory bx Carlos A. Muralles, M.D.

57 57 ANTI-PSYCHOTIC DRUGS (TYPICAL TRADITIONAL) ANTIPSYCHOTIC DRUGS (TYPICAL, TRADITIONAL) ALIPHATIC CHLORPROMAZINE:THORAZINE PIPERAZINE:FLUPHENAZINE=PROLIXIN (HCL-DECANOATE) TRIFLUOPENRAZINE= STELAZINE PHERPHENAZINE=TRILAFON PIPERIDINE:THIORIDAZINE= MELLARIL MESORIDAZINE THIOXANTHENES:THIOTHIXENE= NAVANE DIBENZOXAPINES:MOLINDONE= MOBAN BUTYROPHENONES:HALDOPERIDOL= HALDOL BENZYMIDES:SULPIRIDE RAWLPHIA ALKALOID:RESERPINE CLOZARIL:CLOZAPINE ZYPREXA:OLANZEPINE SEROQUEL:QUETIAPINE RESPERIDAL:RISPERIDONE GEODON:ZIPRASIDONE ABILIFY:ARIPIPRAZOLD INVEGA:PALIPERIDOL Carlos A. Muralles, M.D.

58 58 PSYCHOPHARMACOTHERAPY INDICATIONS FOR ANTIDEPRESSANTS INDICATIONS FOR ANTIDEPRESSANTS Abnormalities in appetite and eating disorders Anorexia or limiting diet to a few foods Anergia Anxiety Dysphoria Irritability Phobias O.C.D. Enuresis Sleeping Disorders; insomnia, Nightmares Recurrent awakening at night Carlos A. Muralles, M.D.

59 59 ANTI-DEPRESSANTS TRICYCLIC & TETRACYCLICS:TOFRANIL= IMPIPRAMINE SURMONRIL= TRIMIPRAMINE PAMELOR= NORTRIPTYLINE ASENDIN= AMOXEPIN LUDIOMIL= MAPROTILINE UNICYCLIC ANTIDEPRESSANTS:BUPROPION= WELBUTRIN TRIAZOLOPYRIDINE DERIVATIVES:TRAZADONE/ALPRAXZOLAM SSRI:FLUOXETINE PAROXETINE CITALOPRAM ESCITALOPRAM SERTRALINE FLUVOXAMINE SNRI:VENLAFAXINE, DULOXATIN, SYMBIAX NDRI:BUPROPION MULTI MODE:MIRTAZAPINE SARI:NEFAZODONE MONOAMINE OXIDASE INHIBITORS:PHENELZINE HYDRAZINE NARDIL PARNATE COMBINTION:FLUOXETINE/OLANZEPINE Carlos A. Muralles, M.D.

60 60 PSYCHOPHARMACOTHERAPY INDICATIONS OF MOOD STABALIZERS INDICATIONS OF MOOD STABALIZERS Mood disorders Mood swings Irritability Poor impulse control disorders Aggressive/assaultive behaviors Agitation Carlos A. Muralles, M.D.

61 61 PSYCHOPHARMACOTHERAPY MOOD STABLIZERS PRIMARYADJUNCTIVE LITHIUMTHYROXINE DIVALPROEXCLONAZEPAM CARBAMAZEPINELORAZEPAM ECT (BILATERAL)PSYCHOTHERAPY Carlos A. Muralles, M.D.

62 62 MOOD STABILIZERS REFRACTORY BILPOLAR PATIENTS: RATIONAL OPTIONS WITH LITTLE OR NO DATA ANTICONVULSANTSHORMONES 1. GABAPENTIN1. ESTROGEN/PROGESTERONE 2. LAMOTRIGINE 3. TOPIRAMATE 4. TIAGABINE 5. ACETAZOLAMIDE ADRENERGIC BLOCKING AGENTSPRECURSORS 1. CLONIDINE1. TRYPTOPHAN 2. PROPRANOLOL2. CHOLINE 3. GUANFACINE CALCIUM CHANNEL BLOCKERS 1.VERAPAMIL 2. NIFEDIPINE 3. NIMODIPINE Carlos A. Muralles, M.D.

63 63 PSYCHOPHARMACOTHERAPY INDICATIONS FOR ANTICONVULSANTS INDICATIONS FOR ANTICONVULSANTS Seizure Disorder: Tonic, Clonic, Motor or Focal Mood Disorders Aggressive Disorder Poor Impulse Control Disorder Self Injurious Behavior Explosive Behaviors Assaultive Behaviors Carlos A. Muralles, M.D.

64 64 ANTICONVULSANTS ACETAZOLAMIDE SODIUMOXCARBAZEPINE CARBAMAZEPINEPHENOBARBITAL CLONAZEPAMPHENOBARBITAL SODIUM CLORAZEPATE DIPOTASSIUMPHENYTOIN DIAZEPAMPHENYTOIN SODIUM DIVALPROEX SODIUMPHENYTOIN SODIUM (EXTENDED) ETHOSUXIMIDEPRIMIDONE FOSPHENYTOIN SODIUMTIAGABINE HYDROCHLORIDE GABAPENTINVALPORATE SODIUM LAMOTRIGINEVALPROIC ACID LEVETIRACETAMZONISAMIDE MAGNESIUM SULFATE Carlos A. Muralles, M.D.

65 65 PSYCHOPHARMACOTHERAPY INDICATIONS FOR ANXIOLITICS INDICATIONS FOR ANXIOLITICS Muscle Relaxants Anesthetics Anticonvulsants Hypnotic agents Anti-Anxiety agents Automic symptoms agents Anti-hypertensive agents Carlos A. Muralles, M.D.

66 66 PSYCHOPHARMACOTHERAPY ANXIOLITCS: BENZODIAZEPINES DIAZAPAM:VALIUM CLORODIZAEPOXIDE:LIBRIUM FLURAZEPAM:DALMANE PRAZEPAM:CENTRAX CLORAZEPATE:TRANXENE TEMAZEPAM:RESTORIL CLONAZEPAM:KLONOPIN LORAZEPAM:ATIVAN ALPRAZOLAM:XANAX OXAZEPAM:SERAX TRAIZOLAM:HALCION Carlos A. Muralles, M.D.

67 67 PSYCHOPHARMACOTHERAPY ANXIOLITICS: HYPNOTICS BENZODIAZEPINES ESTAZOLAM:PROSOM QUAZEPAM:DORAL ZOLPIDEM:AMBIEN ZALEPION:SONATA Carlos A. Muralles, M.D. ANXIOLITICS: OTHER ANTI-ANXIETY AGENTS BUSPIRONE:BUSPAR HYDROXYZINE:ATARAX, VISTARIL DIPHENEHYDRAMINE:BENADRYL PROPRANONOL:INDERAL ATENOLOL:TENORMIN CLONIDINE:CATAPRES

68 Carlos A. Muralles, M.D. 68 PSYCHOPHARMACOTHERAPY INDICATORS FOR STIMULANTS INDICATORS FOR STIMULANTS Appetite Suppressants Sleeplessness Agents Paradoxical ADD Agents None responsive depression Carlos A. Muralles, M.D.

69 69 PSYCHOPHARMACOTHERAPY PSYCHO-STIMULANTS AMPHETATIVE DERIVATIVESMETHYLPHENIDATE METHYLPHENIDATE SR METHYLPHENIDATE DESTROANPHETAMINE PEMOLINE ALPHA AND B ALPHA MODAFINIL RITALIN CONCERTA METADATE DEXEDRINE CYLERT ADDERALL PROVIGIL ANTI-DEPRESANTSATOMOXETIN HCL BUIPROPION STRATERRA WELLBUTRIN Carlos A. Muralles, M.D.

70 70 PSYCHOPHARMACOTHERAPY INDICATION OF OTHER MEDICATIONS INDICATION OF OTHER MEDICATIONS NARCOTIC ANTAGONIST Naltrexone (trexan): Self Injurious behavior BETA BLOCKERS: PROPANOLOL Explosive and range behavior, phobias CALCIUM BLOCKERS Aggressive behavior, depression Carlos A. Muralles, M.D.

71 71 INTERVIEWING TECHNIQUES SCREENING FOR DEVELOPMENTAL AND HEALTH CONDITIONS SCREENING FOR DEVELOPMENTAL AND HEALTH CONDITIONS Aim is to identify the existence and probabilities of an exhibiting delay or abnormal development in the early stages (in children) or current stages (in adults) Such screening will detect biological problems (PKU-Fragil X syndrome, Sickle Cell A. etc.) Carlos A. Muralles, M.D.

72 72 INTERVIEWING TECHNIQUES DIAGNOSTIC ASSESMENT FOR DD DIAGNOSTIC ASSESMENT FOR DD The aim is to conclusively determine whether an individual has an existing delay, disability and/OR special needs This will identify the individual and family strengths as well as possible strategies for intervention Diagnostic assessment should be based on multiple types of data obtained from multiple sources and team players or disciplines DIAGNOSTIC ASSESMENT FOR INDIVIDUAL PROGRAM PLANNING DIAGNOSTIC ASSESMENT FOR INDIVIDUAL PROGRAM PLANNING This is done only after a decision is reached for early intervention Carlos A. Muralles, M.D.

73 73 PROCESS OF INTERVIEWING FOR DD ACKNOWLEDGEMENT ACKNOWLEDGEMENT Acknowledgement of prior assessments and test results Referral PARENTAL/CARE GIVER PARTICIPATION PARENTAL/CARE GIVER PARTICIPATION Tone of working relationship OBSERVATION OBSERVATION Formal or informal observations SETTING SETTING Free from stress; appealing environment for Pt Can be formal or informal Carlos A. Muralles, M.D.

74 74 PROCESS OF INTERVIEWING FOR DD GROUND-WORK FOR INTERVENTION GROUND-WORK FOR INTERVENTION Address directly the affected individual and caregiver This is done according to the appropriate level of functioning; may be done conjointly or individually The willingness for either individual or conjoint assessment must be considered Confidentiality issues must also be considered Carlos A. Muralles, M.D.

75 75 PROCESS OF INTERVIEWING FOR DD INTERVENTION INTERVENTION To proceed with the interview process, I: Introduce myself or other participant(s) involved with the interview Explain the purpose of the interview Explain the need of Consent of Information with the involved caregiver and/or individual Explain the expected outcome, impression and possible diagnosis with the the caregiver and individual at the end of collecting data Discuss possible alternatives of tx and resources available Explain the pros/cons, risks and non risks of interventions Carlos A. Muralles, M.D.


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