9

Psychiatric (DSM-5) Disorders

Learning Objectives

• Demonstrate understanding of the different psychiatric disorders that are identified in childhood and adolescence
• Demonstrate understanding of the different thought disorders that affect interpretation of reality
• Demonstrate understanding of the different mood and anxiety disorders
• Answer questions about the features of obsessive-compulsive disorder
• Answer questions about different eating disorders
• Answer questions about somatic symptom, dissociative, and personality disorders
• Demonstrate understanding about the types of sexual disorders

Childhood and Adolescence

Intellectual Disability

The most common known cause of intellectual disability is fetal alcohol syndrome (FAS), while the most common genetic causes are Down and fragile-X syndromes.

Table 9-1. Intellectual Disability Levels

Level	Functioning
Mild (85% of intellectually disabled; 2:1 male:female)	Self-supporting with some guidance; usually diagnosed first year in school
Moderate	Benefits from vocational training but needs supervision; sheltered workshops
Severe	Vocational training not helpful, can learn to communicate and manage basic self-care habits
Profound	Needs highly structured environment with constant nursing care and supervision

Autism Spectrum Disorders

The hallmark of autism spectrum disorders is an inability to connect with others. It is usually diagnosed age <3. Boys > girls.

Clinical features include:

• Problems with communication and reciprocal social interaction
  • Abnormal or delayed language development; impairment in verbal and non-verbal communication
  • No separation anxiety; problems with relationships
  • Pronoun reversal
  • Fails to assume anticipatory posture, shrinks from touch
  • Poor eye contact
• Restrictive and repetitive behaviors (RRBs), interests, or activities
  • Stereotype or repetitive movements (echolalia, lining up toys)
  • Inflexibility
  • Oblivious to external world
  • Preference for inanimate objects

With autism, monozygotic concordance is greater than dizygotic concordance. Severity correlates to IQ deficiency. EEG may be abnormal. Seizures are present in 25% of patients.

Differential diagnosis includes:

• Rett syndrome
  • Girls > boys
  • Microcephaly
• Social communication disorder
  • Communication disorder
  • Absence of RRBs

Treatment is behavioral techniques (shaping) and antipsychotics (for aggression only), e.g., risperidone.

Tourette Syndrome

Tourette syndrome is characterized by multiple motor and vocal tics that occur many times per day or intermittently for >1 year. Men > women 3:1.

• Mean onset is age 7 (onset must be age <18)
• Tics can be simple (rapid, repetitive contractions) or complex (appear as more ritualistic and purposeful); simple tics appear first
• Evidence of genetic transmission: ~50% concordance in monozygotic twins
• Associated with increased levels of dopamine
• Associated with ADHD and OCD

Treatment is haloperidol, pimozide, or clonidine.

Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is marked by inattention, impulsivity, and/or hyperactivity that lead to problems functioning at home, school, or work. Men > women 10:1.

Impairment must occur in at least 2 settings.

• Symptoms >6 months
• Symptoms age <12
• Associated with a dopaminergic and noradrenergic imbalance

Treatment is methylphenidate, dextroamphetamine, atomoxetine, or guanfacine.

Table 9-2. Conduct vs. Oppositional Defiant Disorder

	Conduct Disorder	Oppositional Defiant Disorder
Age	Until age 18	Preteens–teens
Gender	Boys > girls	Boys > girls (pre-puberty)
		Boys = girls (post-puberty)
Symptoms	6 months of aggressive behavior Violation of rules of society Destruction of property Deceitfulness or theft	6 months of negative, hostile, and defiant behaviors toward authority figures
Etiology	Genetic

Recall Question

1. An 8-year-old boy comes for evaluation to his primary care physician. He is suspected of having Tourette syndrome. Which of the following is a characteristic feature of this syndrome?

   1. More common in girls than in boys
   2. Restrictive and repetitive behaviors
   3. Abnormal or delayed language development
   4. Failure to keep eye contact
   5. Increased levels of dopamine
      

Answer: E