Transcript Special Populationsx

Special Populations
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.
Adolescence
• See Townsend Chapter 25
• 80 % of adolescents do not have psychological
turmoil !!!
• Adolescents do not reject family values!
• Control is a big issue
Developmental tasks
• Identity
• Autonomy
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)
Basic skills of adolescents
•
•
•
•
Education
Social skills
Emotional skills
Intimacy
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
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.
Mental Status Exam
• Appearance, affect, orientation, memory
• Cognitive
– abstract ; concentration
• Hallucinations, delusions
• S/I or H/I ? attempts?
• Speech patterns
– idiosyncratic, slow, fast
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)
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
Tourette’s Disorder
•
•
•
•
Motor or vocal tics
Genetics: tics noted in relatives
Twin studies
Haldol, pimozide, catapres, Geodon
Anxiety Disorders
• Panic
– SSRI, Klonopin
• Obsessive compulsive
– SSRIs, Anafronil, Luvox (sometimes prozac as well)
• General anxiety disorders, phobias
• Separation anxiety (valium, librium)
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)
Personality Disorders
•
•
•
•
narcissistic, histrionic, borderline, tic disorders
dissociative identity disorder
psychogenic amnesia
developmental disorders, mental retardation
Schizophrenia
• Antipsychotic
• Autistic
• (Withdrawal of child into self & into a fantasy
world of his own. Onset prior to age 3)
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
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
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
1. 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
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
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
•
•
•
•
•
•
•
•
Sexual Dysfunction
• desire, arousal, orgasmic & pain
• sexual dysfunction due to a general medical
condition and substance-induced sexual
dysfunction
1. 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.
Gender Identity Disorders
• children, adolescents
desire to be other sex
– cross dressing
– cross sex roles (make-believe play)
– preference for playmates of other sex
Variations in Sexual Orientation
• homosexuality
• transsexualism
– rare-may request hormonal or surgical
reassignment
– anxiety & depression common
• bisexuality
Individuals with HIV Disease
•
•
•
•
See Townsend Chapter 39
delirium
depressive syndromes
dementia (20-30% of patients with AIDS)
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