Special Populations

1. Special Populations

2. Elderly Statistics (Chapter 38) • 12% of population-30% of all prescriptions • 2/3 use medications daily • Average 5-12 meds/day • 1/3 elderly use 1 or more psychotropics • Less than 5% abstain from all medication • See depression, anxiety & dementia, delerium, sleep disorders in the elderly • Only 12% of the population but 20% of the suicides.

3. Adolescence • See Townsend Chapter 25 • 80 % of adolescents do not have psychological turmoil !!! • Adolescents do not reject family values! • Control is a big issue

4. Developmental tasks • Identity • Autonomy

5. Stages of adolescence • Early puberty to age 13 • develop abstract thinking • Middle stage ages 14-16 • social relationships • own decision making • Late stage age 17 + • independence from family • romantic attachments • (this is when we begin to see signs of schizophrenia)

6. Basic skills of adolescents • Education • Social skills • Emotional skills • Intimacy

7. Assessment of adolescents from both patient & family • Meet together: talk about issues, observe interactions • Talk with adolescent alone & assess • school information • parents (family situation) • relationships

8. Assessment • Chief complaint • Family hx: depression, bipolar, schizophrenia, alcohol or drug abuse • Medical hx: thyroid, diabetes • Medications: steroids, over the counter meds, alcohol • Developmental: age child talked, walked etc.

9. Mental Status Exam • Appearance, affect, orientation, memory • Cognitive • abstract ; concentration • Hallucinations, delusions • S/I or H/I ? attempts? • Speech patterns • idiosyncratic, slow, fast

10. Psychiatric Disorders • Affective • Major depression • suicide 2nd leading cause of death • SSRIs • Adjustment disorder with depressed mood • Bipolar- lithium, tegretol, valproate, depakote (prozac approved for chx)

11. Attention-Deficit & Disruptive Behavior • Attention-deficit hyperactive disorder • Ritalin, Cylert, Adderall, amphetamines, dexadrine, Wellbutrin (also tophranel???, strattera also used) • Conduct disorders • fighting, cruelty, lying, truancy, destroying property, • Oppositional defiant (typically begins by 8 yrs of age) • Negative, disobedient, defiant toward authority figures • Also see violence, runaways, drug use, occult

12. Tourette’s Disorder • Motor or vocal tics • Genetics: tics noted in relatives • Twin studies • Haldol, pimozide, catapres, Geodon

13. Anxiety Disorders • Panic • SSRI, Klonopin • Obsessive compulsive • SSRIs, Anafronil, Luvox (sometimes prozac as well) • General anxiety disorders, phobias • Separation anxiety (valium, librium)

14. Eating Disorders • anorexia • body image, loss of periods, hair loss • purpose to lose weight • bulimia • eat lots of food then get rid of it • dental erosion Obesity: biological, psychosocial, stress/adaptation. (Newer antipsychotics can cause weight gain, obesity & metabolic syndrome)

15. Personality Disorders • narcissistic, histrionic, borderline, tic disorders • dissociative identity disorder • psychogenic amnesia • developmental disorders, mental retardation

16. Schizophrenia • Antipsychotic • Autistic • (Withdrawal of child into self & into a fantasy world of his own. Onset prior to age 3)

17. Treatment for Adolescents • Group Therapy powerful for adolescents* (feel sense of belonging, often takes a while to gain trust) • Family Therapy • Individual therapy-need to gain trust • confidential unless dangerous • Hospital if suicidal, homicidal, promiscuous • Residential treatment • Therapeutic foster home

18. Special Populations: Adjustment Disorders • See Townsend Text Chapter 35 • maladaptive reaction to stressors • impairment in social & occupational functioning • Occurs w/in 3 months after the onset of the stressor & persents no longer than 6 months unless it is in response to a chronic disabling illness • Categories: • Adjustment disorder w/ anxiety • Adjustment disorder w/ depressed mood • Adjustment disorder w/ disturbance of conduct: truancy, vandalism • Psychosocial theories • Stress adaption model • Some more vulnerable • Childhood trauma • grieving

19. Impulse Control Disorders • intermittent explosive • Lithium, Tegretol, Buspar, SSRIs etc • Kleptomania (shoplifting) • pathological gambling • pyromania • Trichotillomania (pulling out hair) • (Thorazine, lithium & even SSRIs used… ch 35 in book) • Biological (genetic)Physiological • Psychosocial (family dynamics) • *Failure to resist an impulse drive or temptation to perform an act that is harmful to the person or others • *an increasing sense of tension or arousal before committing the act • *an experience of pleasure, gratification or relief @ the time of committing the act • Intermittent explosive: head trauma, seizures, family dynamics-assaultive parental figures • 2. Kleptomania-onset in adolescence. Cortical atrophy in frontal area, enlargement of ventricles, memories of childhood abandonment, loneliness, & deprivation • 3. Path. Gambling: genetic influence, alcoholism, minimal brain dysfunction, loss of parent by death, separation or divorce before child is 15 • 4. Pyromania-sexual gratification concerns about inferiority impotence & unconscious anger toward a parent figure • 5. Trichotillomania: begins in childhood, multiple factors: may be present as a sx of mental retardation, ocd, schiz. Borderline & depression. May be related to stress, mother-child relationships, emotional deprivation

20. Sexual & Gender Identity Disorders: Chapter 33 • paraphilias • preference for use of non human object • sexual activity that involves real or simulated suffering or humiliation • sexual activity with non consenting partners

21. Types of paraphilias • exhibitionism • fetishism (shoes, gloves, stockings) • frotteurism-touching, rubbing against non consenting person • pedophilia • masochism • sadism • Voyeurism • Exhibitionism: exposure of one’s genitals to an unsuspecting stranger. In almost 100% the perpetrators are men & victims are women • Pedophilia: fondling, oral sex or penetration • Masochism: humiliated, beaten, bound-may result in death • Sadism: psychological or physical suffering or humiliation of the victim is sexually exciting • Voyeurism: observing unsuspecting person who is naked, disrobing or engaged in sex—usually starts before age 15 • *also transvestic fetishism: heterosexual man who keeps a collection of women’s clothing he dresses in when alone. • p. 564: Treatments: • Biological: tmt. Focused on blocking or decreasing androgens to decrease libido • Psychoanalytical & behavioral therapy

22. Sexual Dysfunction • desire, arousal, orgasmic & pain • sexual dysfunction due to a general medical condition and substance-induced sexual dysfunction • Desire:hypoactive-persistent or recurring deficiency or absence of sexual fantasies & desire, or sexual aversion & avoidance • 2. Sexual arousal:inability to attain or maintain completion of sexual activity • 3. Orgasmic disorders: primary never experienced orgasm • Secondary-no longer does • p. 567 • 4. Sexual Pain: dyspareunia: • Intact hymen, episiotomy scar, vaginal infections, endometriosis, etc.(females) • Infection, phimosis (foreskin cannot be pulled back) prostate problems (males) • Biological: decreased testosterone in men, postmenopausal women (dry) • Medications: antihypertensives, antipsychotics, antidepressants, antihistamines, arterioscherosis, diabetes, neuropathies. • Arousal disorders may relate to doubt, fear, anxiety, shame, conflict, embarrassment etc.

23. Gender Identity Disorders • children, adolescents desire to be other sex • cross dressing • cross sex roles (make-believe play) • preference for playmates of other sex

24. Variations in Sexual Orientation • homosexuality • transsexualism • rare-may request hormonal or surgical reassignment • anxiety & depression common • bisexuality

25. Individuals with HIV Disease • See Townsend Chapter 39 • delirium • depressive syndromes • dementia (20-30% of patients with AIDS)

26. Psychiatric Disorders in HIV patients • major depression • mania (poor prognosis) • dementia & delirium • Delirium can also be an adverse reaction to high dose corticosteroids. • Sx include fluctuating levels of consciousness, misperceptions, delusions, sleep-wake cycle loss & agitation or withdrawal