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.
1
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, languagecommunication, socio-economical self assistance, learning and relationalinteraction with others.
Carlos A. Muralles, M.D.
3
HISTORY OF DD

Derogatory Connotations

Past Forms Society Dealt with DD Population

Asylums

18th-19th 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
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
CLASSIFICATION: PERVASIVE DD

AUTISM SPECTRUM DISORDERS

RETT’S DISORDER

CHILDHOOD DESINEGRATIVE DISORDER

ASPERGER’S DISORDER

PERVASIVE DEVELOPMENTAL DISORDER NOS
Carlos A. Muralles, M.D.
6
CLASSIFICATION: NEUROPHYSIOLOGICAL

CEREBRAL PALSY

SEIZURE DISORDERS

HEARING LOSS/DEAF & MUTE
Carlos A. Muralles, M.D.
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
Carlos A. Muralles, M.D.
CHILDHOOD OR ADOLESCENCE
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
EPIDEMIOLOGY: FAMILIAL, CULTURAL AND
GENDER PATTERNS AND FEATURES

The risk of DD in a child increases 4-15 x’s if one of the parent’s has traits or
suffers from the same condition

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
EPIDEMIOLOGY: FAMILIAL, CULTURAL AND
GENDER PATTERNS AND FEATURES

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
EPIDEMIOLOGY: FAMILIAL, CULTURAL AND
GENDER PATTERNS AND FEATURES

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
EPIDEMIOLOGY: FAMILIAL, CULTURAL AND
GENDER PATTERNS AND FEATURES

RETT’S 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
EPIDEMIOLOGY: FAMILIAL, CULTURAL AND
GENDER PATTERNS AND FEATURES

CHILDHOOD DISINTEGRATIVE DISORDER






Termed as “Heller’s 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)
ASPERGER’S 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.
CONDITION
M.R.
FAMILIAL
PATTERN
PREVALENCE CULTURAL/ET
HNIC
GENDER
RATIO
(M to F)
DEGREE
Mild: 85% 14
Moderate:
10%
Profound: 12%
None
1-3%
Reflected I
standardized
test
1.5:1
5% (among
siblings)
5 per 10,000
No specific
criteria
4-5:1
No criteria
RETT’S D/O
5% (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
ASPERGER’S
D/O
Depressive
D/O and AD
among
siblings
Unknown
No specific
criteria
AUTISTIC D/O
Carlos A. Muralles, M.D.
No criteria
5:1
15
SYMPTOMS AND DX FEATURES OF DD AND
PSYCHIATRIC CONDITIONS

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
SYMPTOMS AND DX FEATURES OF DD AND
PSYCHIATRIC CONDITIONS

SYMPTOMS OF RETT’S 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
SYMPTOMS AND DX FEATURES OF DD AND
PSYCHIATRIC CONDITIONS

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 bx’s
 Play
Carlos A. Muralles, M.D.
18
SYMPTOMS AND DX FEATURES OF DD AND
PSYCHIATRIC CONDITIONS

SYMPTOMS OF ASPERGER’S 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
SYMPTOMS AND DX FEATURES OF DD AND
PSYCHIATRIC CONDITIONS

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
CONCOMITANT FACTORS


LEARNING DISORDERS

READING DISORDER

MATHEMATICS DISORDER

DISORDER OF WRITTEN EXPRESSION

LEARNING DISORDER NOS
MOTOR SKILLS DISORDERS

Development Coordination Disorder
Carlos A. Muralles, M.D.
21
CONCOMITANT FACTORS

COMMUNICATION DISORDERS






Language Disorder
Mixed Receptive Expressive Language Disorder
Phonological Disorder
Stuttering
Communication Disorder NOS
ATTENTION DEFICIT DISORDER




Hyperactive Type
Combined Type
Predominantly Inattentive Type
Predominantly Hyper-Impulsive Type
Carlos A. Muralles, M.D.
22
CONCOMITANT FACTORS

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.
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CONCOMITANT FACTORS

FEEDING AND EATING DISORDERS




TIC DISORDERS




Pica
Rumination Disorder
Feeding Disorder of Infancy or Early Childhood
Tourette’s Disorder
Chronic Motor or Vocal Tic Disorder
Transient Tic Disorder
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.
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OTHER DISORDERS OF INFANCY,
CHILDHOOD OR ADOLESCENCE

SEPARATION ANXIETY DISORDER

SELECTIVE MUTISM

REACTIVE ATTACHMENT DISORDER



STEREOTYPIC MOVEMENT DISORDER


Infancy: Inhibited or Disinhibited Type
Early Childhood: Inhibited or Disinhibited Type
With or Without Self Injured Behaviors
DISORDER OF INFANCY, CHILDHOOD OR ADOLESCENCE NOS
Carlos A. Muralles, M.D.
25
SENSORY IMPAIRMENT OR DEPRIVATION

HEARING LOSS

DEAF

MUTISM
Carlos A. Muralles, M.D.
26
MENTAL DISORDER AND DD DUE TO
GENERAL MEDICAL CONDITION

CATATONIC DISORDERS 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
PERVASIVE DEVELOPMENTAL DISORDER
DUE TO NEUROLOGICAL DISORDERS

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
PERVASIVE DEVELOPMENTAL DISORDER
DUE TO NEUROLOGICAL DISORDERS

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
PERVASIVE DEVELOPMENTAL DISORDER
DUE TO NEUROLOGICAL DISORDERS

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
SEIZURE DISORDERS

CLASSIFICATION

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

Tod’s Hemiparesis

Possible sensory sx (auditory, visual or olfactory hallucinations)
Carlos A. Muralles, M.D.
31
SEIZURE DISORDERS

CLASSIFICATION

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
SEIZURE DISORDERS

CLASSIFICATION

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

Children’s 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
SEIZURE DISORDERS

CLASSIFICATION

TONIC-CLONIC OR GRAND MAL

Causes massive motor activity and profound postical residua

Pt’s may experience prodrome of malaise or mood change

Tonic Phase: Pt’s 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.
ADDIONAL ASSOCIATED FEATURES AND DISORDERS:
PHYSICAL & GENERAL FINDINGS
PHYSICAL
FINDINGS
MEDICAL CONDITION
NEURO
CONDITION
M.R.34
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
Nonspecified
More prominent when
assoc w/ other neuromed condtion
Nonspecified; 25% seizure
d/o present
Most cases
are assoc
with MR
RETT’S
N/A
N/A
Assoc w/ seizure d/o
Severe /
profound
ASPERGER
N/A
N/A
CHILDHOOD
DD
Carlos A. Muralles, M.D.
Metachomatic,
leukodystrophy, Schilder’s
No cognitive or language
Generally
delay in 1st yrs; motor
none; some
clumsiness; over-activity & mild noted
inattention are frequent
in school
years
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
RETT’S DISORDER NO 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
ASPERGER’S D/O
Lab findings reflect any assoc general med conditions
Carlos A. Muralles, M.D.
COMMON DENOMINATORS/FEATURES FOUND
TO CO-EXIST IN DD POPULATION IN MY
PROFESSIONAL EXPERIENCE

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.
36
COMMON DENOMINATORS/FEATURES FOUND
TO CO-EXIST IN DD POPULATION IN MY
PROFESSIONAL EXPERIENCE


RANGE OF BEHAVIORAL SX

Hyperactivity

Short attention span

Temper tantrums (mostly seen in young population)
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.
37
COMMON DENOMINATORS/FEATURES FOUND
TO CO-EXIST IN DD POPULATION IN MY
PROFESSIONAL EXPERIENCE

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




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.
38
COMMON DENOMINATORS/FEATURES FOUND
TO CO-EXIST IN DD POPULATION IN MY
PROFESSIONAL EXPERIENCE

ABNORMALITIES IN EATING PATTERNS





Hyperphagos
Limiting diet to select foods
Pica
Nocturnal eating
ABNORMALITIES WITH SLEEPING HABITS




Recurrent awakening at night w/ unusual bx’s (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.
39
COMMON DENOMINATORS/FEATURES FOUND
TO CO-EXIST IN DD POPULATION IN MY
PROFESSIONAL EXPERIENCE

FEAR RESPONSES


SELF-INJURIOUS BEHAVIORS


Lack of or over response to danger/harmless objects
Head-banging (autistic), finger/hand/wrist-biting
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.
40
41
COURSE OF THE CONDITIONS

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
COURSE OF THE CONDITIONS

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
COURSE OF THE CONDITIONS

RETT’S 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
COURSE OF THE CONDITIONS

CHILDHOOD DISINTEGRATIVE DISORDER




Disorder follows continuous course
Duration is lifelong
Social, communicative and bx difficulties remain constant throughout life
ASPERGER’S 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
DIFFERENTIAL DIAGNOSIS

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
DIFFERENTIAL DIAGNOSIS

AUTISTIC DISORDER









Other Pervasive Developmental D/O (Rett’s D/O)
Childhood Disintegrative D/O
Asperger’s 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
DIFFERENTIAL DIAGNOSIS


RETT’S DISORDER

Autistic D/O

Childhood Disintegrative D/O

Asperger’s D/O
CHILDHOOD DISINTEGRATIVE DISORDER

Other Pervasive Developmental D/O

Autistic D/O

Rett’s D/O

Demential
Carlos A. Muralles, M.D.
48
DIFFERENTIAL DIAGNOSIS

ASPERGER’S DISORDER

Pervasive Developmental D/O

Schizophrenia

Autistic D/O

Rett’s D/O

Childhood Disintegrative D/O

Obsessive-Compulsive D/O

Schizoid Personality D/O
Carlos A. Muralles, M.D.
49
DIFFERENTIAL DIAGNOSIS: SIMILARITIES
FOUND
DIFFERENTIAL
DIAGNOSIS
MENTAL
RETARDATION
Childhood DD
AUTISTIC
D/O
RETT’S
D/O
X
X
Autistic D/O
X
Rett’s D/O
Pervasive DD
ASPERGER’S
D/O
X
X
X
X
X
X
X
Other
Pervasive DD
X
Schizophrenia
X
Carlos A. Muralles, M.D.
CHILDHOOD D.D.
X
X
50
ASSESSING THE CHIEF COMPLAINT

CHIEF COMPLAINT:


WHY NOW?
PRECIPIATATING FACTORS

Change of routine

Moving environment

Separation from parents

Death in the family

Traumatic event
Carlos A. Muralles, M.D.
51
ASSESSING THE CHIEF COMPLAINT


MEDICAL EVENTS

Current medical condition/illness

Substance use: past and present

Any recent medication prescribed
NON-COMPLIANCE WITH TREATMENT

Abruptly halt with medication

Change of psychotropic medication
Carlos A. Muralles, M.D.
52
ASSESSING THE 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
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
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
TREATMENT PLAN
AND RECOMMENDATIONS

IN-PATIENT TREATMENT



OUT-PATIENT TREATMENT


Voluntary
Involuntary
Individual Psychotherapy
 Supportive & Short-term
 Cognitive-Behavioral
 Family Interventions (Educational & Support Groups)
PSYCHOPHARMACOTHERAPY
Carlos A. Muralles, M.D.
56
PSYCHOPHARMACOTHERAPY

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.
ANTIPSYCHOTIC DRUGS (TYPICAL, TRADITIONAL)
ALIPHATIC CHLORPROMAZINE:
THORAZINE
PIPERAZINE:
FLUPHENAZINE=PROLIXIN (HCL-DECANOATE)
TRIFLUOPENRAZINE= STELAZINE
57
PHERPHENAZINE=TRILAFON
PIPERIDINE:
THIORIDAZINE= MELLARIL
MESORIDAZINE
THIOXANTHENES:
THIOTHIXENE= NAVANE
 ANTI-PSYCHOTIC DRUGS (TYPICAL TRADITIONAL)
DIBENZOXAPINES:
MOLINDONE= MOBAN
BUTYROPHENONES:
HALDOPERIDOL= HALDOL
BENZYMIDES:
SULPIRIDE
RAWLPHIA ALKALOID:
RESERPINE
CLOZARIL:
CLOZAPINE
ZYPREXA:
OLANZEPINE
SEROQUEL:
QUETIAPINE
RESPERIDAL:
RISPERIDONE
GEODON:
ZIPRASIDONE
ABILIFY:
ARIPIPRAZOLD
Carlos A. Muralles, M.D.
INVEGA:
PALIPERIDOL
58
PSYCHOPHARMACOTHERAPY

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.
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,
NDRI:
BUPROPION
MULTI MODE:
MIRTAZAPINE
SARI:
NEFAZODONE
MONOAMINE OXIDASE INHIBITORS:
PHENELZINE
HYDRAZINE
NARDIL
PARNATE
COMBINTION:
FLUOXETINE/OLANZEPINE
Carlos A. Muralles, M.D.
DULOXATIN,
59
SYMBIAX
60
PSYCHOPHARMACOTHERAPY

INDICATIONS OF MOOD STABALIZERS

Mood disorders

Mood swings

Irritability

Poor impulse control disorders

Aggressive/assaultive behaviors

Agitation
Carlos A. Muralles, M.D.
61
PSYCHOPHARMACOTHERAPY
MOOD STABLIZERS
PRIMARY
ADJUNCTIVE
LITHIUM
THYROXINE
DIVALPROEX
CLONAZEPAM
CARBAMAZEPINE
LORAZEPAM
ECT (BILATERAL)
PSYCHOTHERAPY
Carlos A. Muralles, M.D.
MOOD STABILIZERS
REFRACTORY BILPOLAR PATIENTS: RATIONAL OPTIONS WITH LITTLE OR NO DATA
ANTICONVULSANTS
HORMONES
1. GABAPENTIN
1. ESTROGEN/PROGESTERONE
2. LAMOTRIGINE
3. TOPIRAMATE
4. TIAGABINE
5. ACETAZOLAMIDE
ADRENERGIC BLOCKING AGENTS
PRECURSORS
1. CLONIDINE
1. TRYPTOPHAN
2. PROPRANOLOL
2. CHOLINE
3. GUANFACINE
CALCIUM CHANNEL BLOCKERS
1. VERAPAMIL
2. NIFEDIPINE
3. NIMODIPINE
Carlos A. Muralles, M.D.
62
63
PSYCHOPHARMACOTHERAPY

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
ANTICONVULSANTS
ACETAZOLAMIDE SODIUM
OXCARBAZEPINE
CARBAMAZEPINE
PHENOBARBITAL
CLONAZEPAM
PHENOBARBITAL SODIUM
CLORAZEPATE DIPOTASSIUM
PHENYTOIN
DIAZEPAM
PHENYTOIN SODIUM
DIVALPROEX SODIUM
PHENYTOIN SODIUM (EXTENDED)
ETHOSUXIMIDE
PRIMIDONE
FOSPHENYTOIN SODIUM
TIAGABINE HYDROCHLORIDE
GABAPENTIN
VALPORATE SODIUM
LAMOTRIGINE
VALPROIC ACID
LEVETIRACETAM
ZONISAMIDE
MAGNESIUM SULFATE
Carlos A. Muralles, M.D.
65
PSYCHOPHARMACOTHERAPY

INDICATIONS FOR ANXIOLITICS

Muscle Relaxants

Anesthetics

Anticonvulsants

Hypnotic agents

Anti-Anxiety agents

Automic symptoms agents

Anti-hypertensive agents
Carlos A. Muralles, M.D.
PSYCHOPHARMACOTHERAPY
66
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.
PSYCHOPHARMACOTHERAPY
ANXIOLITICS: HYPNOTICS BENZODIAZEPINES
ESTAZOLAM:
PROSOM
QUAZEPAM:
DORAL
ZOLPIDEM:
AMBIEN
ZALEPION:
SONATA
ANXIOLITICS: OTHER ANTI-ANXIETY AGENTS
BUSPIRONE:
BUSPAR
HYDROXYZINE:
ATARAX, VISTARIL
DIPHENEHYDRAMINE:
BENADRYL
PROPRANONOL:
INDERAL
ATENOLOL:
TENORMIN
CLONIDINE:
CATAPRES
Carlos A. Muralles, M.D.
67
68
PSYCHOPHARMACOTHERAPY

INDICATORS FOR STIMULANTS

Appetite Suppressants

Sleeplessness Agents

Paradoxical ADD Agents

None responsive depression
Carlos A. Muralles, M.D.
69
PSYCHOPHARMACOTHERAPY
PSYCHO-STIMULANTS
AMPHETATIVE DERIVATIVES METHYLPHENIDATE
METHYLPHENIDATE SR
METHYLPHENIDATE
DESTROANPHETAMINE
PEMOLINE
ALPHA AND B ALPHA
MODAFINIL
RITALIN
CONCERTA
METADATE
DEXEDRINE
CYLERT
ADDERALL
PROVIGIL
ANTI-DEPRESANTS
STRATERRA
WELLBUTRIN
Carlos A. Muralles, M.D.
ATOMOXETIN HCL
BUIPROPION
70
PSYCHOPHARMACOTHERAPY

INDICATION OF OTHER MEDICATIONS

NARCOTIC ANTAGONIST


BETA BLOCKERS: PROPANOLOL


Naltrexone (trexan): Self Injurious behavior
Explosive and range behavior, phobias
CALCIUM BLOCKERS

Aggressive behavior, depression
Carlos A. Muralles, M.D.
71
INTERVIEWING TECHNIQUES

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
INTERVIEWING TECHNIQUES


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

This is done only after a decision is reached for early intervention
Carlos A. Muralles, M.D.
73
PROCESS OF INTERVIEWING FOR DD

ACKNOWLEDGEMENT



PARENTAL/CARE GIVER PARTICIPATION


Tone of working relationship
OBSERVATION


Acknowledgement of prior assessments and test results
Referral
Formal or informal observations
SETTING


Free from stress; appealing environment for Pt
Can be formal or informal
Carlos A. Muralles, M.D.
74
PROCESS OF INTERVIEWING FOR DD

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
PROCESS OF INTERVIEWING FOR DD

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.