Depression and Anxiety in Children

Depression
<1% of preschoolers
2-3% of school age hilden
No geder differences
Comorbid wih adhd and conduct disorder
Factors:
Heredity - genetics
Early adversity and negative life events cognitive distortions and attributional
styules
Parental factors having depressed arents, parental rejection, marital conflict
awkward kids = ultimate set up for depressed kids
Biological Therapies:
SSRIs as first line treatment > TCAs
The TASS (Treatment for adolescents with depression) was an RCT which
compared fluoxetine, CBTm or both for depression (no placebo = unethical to have)
Resuls: showed: combination therapy was superior vs all other groups even
after 36 weeks
However a sub analysis revealed that fluoxetine alone group experiences
more benefits than the CBT alone groups

Anxiety
Common fears arent usually pathological
Ex: fear of the dark and imaginary creatures <5 y/o (beyond, its nt
appropriate)
Fear of being separated from parents <10y/o
N> functioning impairment for fears and worries to be classified as disorders
However the child doesnt need to regad the fear as excessive and
unreasonable; kids can believe in the imaginary and itss ok
Epidemiology: prev = 12-20% among kids and adolescents
Social Phobia more prev if you have slow to warm up kids; can be comorbid with a
feature of selective mutism; may be related with specific situation such as reading
aloud, writing on the board, performing in front of others usu. React with crying,
avoidnc e and somatic

OCD
1-4% boys>girls
Bimodal onset depending on age: mostly boys in kids, but as they grow older,
mostly in girls
Symptoms are similar to adults
More common obsessions in childhood: dirt/contamination; aggressive thoughts
More common obsessions in adolescence: sex and religion, where compulsions
(religion) undo the obsession (to sex);
Etiology of Anx: heritable, 29-50%; psych factors: parental control, emotion-
regulaion prolems and insecure attachment in infancy
Treatment f Anx: CBT
CBT typically involves working with both kids and parents; includes psychoeduc, cog
restructung, modelling, skills training relapse prevention; coping cat workbook
iwith kids 7-13y/o which focuses on confronting fears and developing new ways to
think about fears, exposure, practice, and relapse prevention

Learning Disability:
Problem area of academic domain, language, speech or motor; not due to mental
retardation or lack of educ opps.
Includes 3 categories: learning disorders (reading[dyslexia is most prevalent, ad is
heritable; same genes associated with typical reading disabilities; common
problems include language processing problems in like phonological awareness],
writing, math), communication d/o (expressive language unclear speech and
improper articulation, phonological, stuttering), motor disorders:

More notes on dyslexia:

Perception off speech and analysis of spoke lange and relation to printed matter
Difficulty recognizing rhyme and alliteration
Problems with raidly naming familiar objects
Delays in learning syntactic rules
Temporal lobe problem to associate heard words and read words

Dyslexia: traditional linguistic approaches, phonics instruction

Communication d/o: speech stim modification (closing speech sounds to help them
discriminate certain sounds)

IDD =prev known as MR

Onset before age 18, diagnosed in childhood
Significantly below average IQ functioning, IQ less then 70
Deficits in adaptive functioning
Self care, communication, home living, decision making
DSM 5 no longer distinguishes severity of ID based on IQ alone; he basis will
be adaptive functioning
DSM4 TR have categories based on IQ
Treatment:
Residential treatment: small to medium sized community residences
Behavioral treatments
Skills training, method of successive approximation to teach basic self care
skills in the severely retarded
Cognitive treatments problem solving strategies
Computer-assisted instructions

Pervasive Developmental D/O

DSM 4 all these went into autism specrum d/o
Autistic D/o impaired social interaction, comm, repetitive behavior and interests
Aspergers less sveree and with fewer comm deficis than autism
Retts
Childhood Disintegrative DO

Autism: cant understand that you/I are different

Autism: have no pruning so brains are bigger/overgrowth but also keep information
on things they dont need or are harmful to them; neurons dont have proper
connections

Depression and adhd medication > therapy;

Autism: therapy > medication

Mood Disorders
Mood as a spectrum of being very very happy or very very sad; most people are in
the middle

Dx: MDE
DSM5 Crit: 5_ symptoms present during 2 week; if you have a major depressive
episode, it doesnt necessarily mean you have MDD.
MDE can be MDD or BPD (BPD1 or 2) or Schizoaffective DO
Sx of MDE: 5+ sx present in same 2 week period, with at least one core sx of
depressed mood or anhedonia with 4+ of the other sx: sig weight loss/weight gain
5% of bw; insomnia (wanna sleep but cant) or hypersomnia (too much sleep),
psychomotor agitation or retardation (very slowed down),

For all dsm critertia, dontstop with criterion A. look at the others: MDE: sig distress
and impairment ad symptoms arent due to substance/medical,

Becomes a disorder if you can rule out SAFF d/o schzo, delusional or other psychotic
disorders
MDD if no manic or hypomanic episode (because the MDE will be part of BPD)
Cant be both MDD or BPD; MDD with psychotic
Mood disorder cant be accompanied by psychotic disorders

Depressive episodes: anhedonia, depression,

Hospitzalied for suicide attempt = forever at risk for successful suicide

Epidemiology 15%; 25% for women; mean age of onset is 40 years old
2-fold greater prevalence of mDD in women than in men
MDD have happy moments

Dysthymic disorder (DSM5: Persistett Depressive D/O)

Less evere but more chronic and unrelenting form of major depression
Lifetime prevalence 6%
Never really happy, not so sad, BUT it is possible to get extra sad by having a MDE
= double depression
2 years observation of depressed mood for most of the day for more days than not,
Check dsm 5 criteria
Can coexist with mdd
Ealy onset: before 21 y/o
Late onset: 21 above

Disruptive mood dysregulation d/o DMDD (not in dsm4)

Dsm5 criteria
Angry 3 times a week
-childs mood is irritable in between outbursts;
Constant state is irritable with outbursts; never happy or normal

PMDD/premstrual dysphoric d/o (not in dsm4)

PMDD at least 5 sx in the final week efore period
1+ from crit B, and 1+ in crit C (where B + C = 5+)
Start to improve within a few days after onset of menses and become minimal or
absent in the week post menses

Etiology of Depressice D/O

Genetic studies:
MZ twins of 50%, DZ 10-25%
**Depression: 5HT; why SSRIs are extremely effective
Extra: NE = Inc ctivity and arousal; dopamine

Psychosocial Fx
Stressful life events preced very first episode of mood disorders
Life event most often associated with depresson: losing (dioverce, death) a parent
before the age of 11 and then the next episodes dot have to have severe triggers;
brain is rendered more vulnerable to the bad events; environmental fx: loss of
spouse followed by unemployment

Psych Theories of Depression:

Psychoanalytiv: anger turned inwards (disturbed oral phase, followed by real or
imagined loss of the mom who recently gave you the right amount left stcuk in a
conundrum: love hate ambivalent feeling towards mom; so you introject the mom
that left, and introject the love-hate inward; when loss is reactivated (like another
figure leaves) this hate turned inward is ggravated and this leads to sadness
Other theories: cognitive theory and interpersonal theory of depression and
rumination theory: overthinking negative stuff; digging up old memories and
thinking negativey

Bipolar Spectrum D/O

Dont need a MDE to have BPD1. You can or can not have it. You need instead a
manic episode at least oonce.
BPD2: characterized by episodes of MD+HypoMania (no mania)
Rule out Schizo and SA

Manic Episode dsm 5: happy or mad lasting 1 week or any duration if hospitalization
is necessary
Manic ep is possible to coexsist with psychotic features

If its predominantly mood with psychotic feature = manic ep with psychotic featu
Because mood d/o cant coexist w/ psychotic d/o

Bpd2 = no manic episode; has hypomania (at least 1ep) and 1+ MDD

Mood dsorder dx can change

Like mdd after 35 years but eventually at ge 40, you hav manic so it then changes
to bpd1
Once it is psychotic with mania = bpd1 (very very happy, veery very sad)

Cyclothymic d/o
Like dysthymia/pdd but with hypomania with depression that are NOT manic or
MDEs

Rapid cycling 4 eps in a year

Same triggers for sadness in MDD and BPD

Lack of sleep = trigger for manic eps

Carbamazeoine and divalproex = anticonvulsants; first line mood stabilitizers for
bpd

Anxiety D/O
DSM5 : not ocd and ptsd;
DSM5 = Phobias, Social AD, PD, Agoraphobia, GAD
Most Common psychiatric d/o 28%report anx sx

Phobia need to cause mpairment for it to be a d/o

More women vs men in specific phobia
Social phobie = social AD in dsm5 persistent irrational fears linked to presence
of other people
Lifetime prevalenc 3-13%

Psychosocial etiology of phobias

Behavioral theories: avoidance (more you avod, the scarier it gets),
conditioning(negative association), modeling(parent/figure who hates rats or scary
people, the kid copies), social skills deficits (Im so awkward omg people left)
Cognitive theories: irrational beliefs

Biological paradigm
Slides
Benzodiazepines are first line; increased GABA (relaxation)
Generalized social phobia = SSRIs are first line

Panic attack with phobia: cued, phobic

Panic disorder: uncued

DSM4 agoraphobia requires panic disorder

DSM5 agoraphobia is standalone scared to panic in a public place and cant
escape

Biologial Etiology
Neurochemical theory:
Increased NE
Decreased GABA or
Increased activity in locus ceruleus
SSRI for rapid control then slowly with benzodiazepine as it tapers

DSM 5
GAD
50% ina da of Worry in at least 2 life domains where the worry is sustained for
3mos+ AND is associated with the ff:
Restlessness, on edge; being easily fatigued; difficulty concentration;
irritability; muscle tension; sleep disturbance
1:2 male female onset
Most often comorbid: 75% of GAD people
Not enough GABAneuron activity
Ssri with tapering by benzo then maintenance with antideoressant therapy
OC and related D/O
DSM4tr vs DSM5 OC and Trauma were under Anxiety D/O
Body Dysmorphic D/O was in Somatoform before, not put into OC-D/O
Hoarding is new in DSm5

etiology
Psych theories:
psychanalytic theory and behavioral and cognitive theory
oc sexual/aggressive mpulses hard to moderate beause of overly harsh
toilet training person fixated in the anal stage
overcleanliness and meticulousness my be a reaction formation (which is now
thought to be more applicable for OCPD)
behavioral and cog:
operant conditioning
cog: yedasentience deficiency (sense of completeion/good enough)
biological theory
decreased 5HT
antidepressants and brain surgery (remove cingulate gyrus)

Body DD
Preoccupation is not resitricted to concerns about weight or fat (to rule out eating
disorders)

Trauma related
PTSD with fear and helplessness, relives the experiences persistently, tries
avoiding being reminded

In dsm4tr onl three criteria clusters: intrusive re-experiencing, avoidance of stimuli,

increased arousal activity
Dsm5: the 3 + other signs of mood and cognitive disturbance (memory loss,
negative thoughts and emotions, self blame, blaming other, withdrawal

ASD same symptoms but could resolve within 1 month; symptoms occur 3 days
1month; asd can become ptsd
Asd starts in 3 days because its normal naman to bounce back after 2 days
Neurochemical: NE inc levels = hypervigilance and inc startle response inc
sensitivitiy to noradrenergic receptors in ptsd

Treatment: like anx d/o exposure

Subs Abuse
Most common drugs
DSm5 criteri encompasses subs abuse d/o as a whole
Dsm5:No longer distinction between subs abuse and subs depenced.

Even if the womn still weighs the same as a man, alcohol still affects women more
Alcohol increases both 5ht and dopamine
Nicotine increases cerebral blood flow which causes short term increase in attention
and concetration
Mariuana mild to moderate = relaxation and sociability;; large dose: mood swing,
cognitive slowing, loss of short term memory, psychomotor impairment, extremely
heavy = schizo

Brain has cannabinoid receptors cb1 and cb2; able to recude nausea, vomiting, loss
of appetite or chemotherapy patient

Opiates
Downers sedatives
Addictive and pain relief, induces sleep

Uppers
Amphetamines meth las, synthetic stimulants; shabu to remove congestion;
vasoconstriction;
Acts by 2 mechanisms:
Causes release of ne and dopamine
Blocks reuptake of ne and dpamine
Cocaine coca plants
Local anes and vasoconstriction
Acts by blocking reuptake of dopamine in mesolimbic areas = pleasure

LSD nd other hallucinogens

Synthetic

Ecstasy or MDA/MDMA synthetic hallucinogen = contains compounds from

hallucinogen and meh
Behaves like meth froces release of NT and prevents reuptake for 5HT

Meth is for dopamine

Evstasy is for 5HT

Schizophrenia
Bimodal onset
10-25y/o for men
25-35 for women
NT etiology: before: high dopamine schizo but now we know there are 4 tracks in
the brain: tubero infundibular,mesocortical, mesolimbic and nigro striatal.
Now we know: meso limbic +dopamine for positive symptoms
Negative symptoms = not enough dopamine in mesocortical
Enlarged ventricles from lobes shrinking (brain vol shrinks) ventricles enlarge for the
loss of brain cells

Sociogenic hth for schizo: if you poor = schiz

Social selectio or downward drift theory: you will deift lower in the social strata if
you have schizo, eventually you end up poor that both try to explain for the SES
correatolation with schizo

Schizophreniform similar to schizophrenia but different duration sx must ast for 1

month
Brief psychotic disorder: duration is shortest; must lasts for one day, less than 1
mos
50% get schiz eventually, others normal

Schizoaffective
Mix of schizo and mood disorders
Has MDD or Manic Ep or a mixed episode while meeting criterion A for schizo for
uninterruoted period f illness
Delusions and hallucination occur for at least 2 weeks without the mood

Then specify type: bipolar type or depressive type

Can either be diagnosed as bpd1 with psychotic features or mdd with psychotic
features if more mood thn psychotic features

Delusional D/O men>women

Nonbizarre delusions: delusions that are possible to happen in real life (loved at a
distance, having a disease_ for at leat 1 mo
No crit a for schizo

Ex: crazy jealously (more likely in men) / othellos syndrome

Erotomania or de Clerembaults syndrome loved at a distance by a person of
higher sstatus than you (more likely in women)

Schizo people dont know they have schizo because they are so fixed in their reality;
many of them dont take medication

1st gen antipsychotics cheap! Work by directly blockin d2 receptors in all dopamine
pathways = more useful in preventing positive rather than negative symptoms
2nd gen antipsychotics - were found to be useful for those who didnt respond t
typical antipsychotics
Atypicals decreased both positive and negat and disorganized symptoms

Personality D/O
Comorbidity rates for personality d/o are high
1/22 meet criteria for another PD
2/3rds meet critera for an Axis I disorder

PASS - A: odd and eccentric: paranoid, schizoid, schotypal

B: dramatic and erratic: borderline, histrionic, narcissistic and antisocial
C: anxious and shy

Dsm4 tr exactly the same as dsm5. There are research criteria, but not used

Paranoid PD: have doubts about people; pervasive mistrust, believes others are
judging them
Schizoid: extreme apathetic loner; asexual, takes few pleasure in any activities ,
emotionally detached, flat affect
Schizotypal: odd magical beliefs, eccentric appearaces, very weird sila,
suspiciousness, inappropriate affect, alays awkward TRELAWNEY

My super ex girlfriend is borderline pd

Etiology of borderline pd: hereditary;

Deficient in 5ht receptor sensitivity
F>M

Narcs
M>F
Clinical population, Military, Surgeons

Silent narcs
Feels better than everyone; grandiose sense of self importance and needs respect
even w/o achievement
Preoccupied with fantasies of unli success, power, brilliance, beauty and ideal love
Believes they are special and unique and should only associated with high status
people
Requires excessive admiration, sense of entitlement, interpersonall exploitative,
lcks empathy, envious of others or thinks others are envious of her, arrogant,
haughty

Etiology:
Decreased sense of self worth
Failed to respond with them with warmth and respect
Parenting dimensions noted to increase risk: emotional coldness and overemphasis
on achievemens
Narc kid: if I dont achieve, I am worthless
So even in the outside world, they only talk about their achieveents

Before antisocial disorder, they have conduct disorder between age 15

ASD at least 18 years
Heritability

Cluster c: shy and anxious

Avoidant personality d/o // inadequate personality disorder extremely shy
because they dont think theyre inferior/inadequate

Avoidant pd and schizoid: similar they are loners, but avoidant pd is really really shy
nd desperately wnants to be with people but fear rejection

Dependent pd
Hghly prevalent in cultures thaht are socially invested (?)

Ocpd ate lisa

PASS CODA BHAN