COMORBIDITY
By
Larry B. Silver, M.D.
THERE IS A CONTINUUM OF
NEUROLOGICALLY-BASED
DISORDERS THAT ARE OFTEN
FOUND TOGETHER
• If any one of the disorders on this
continuum is found, there is up to a 50
percent possibility that one or more of the
disorders on this continuum will be found.
• Thus, if any disorder on this continuum is
found, it is important to explore for the
other possible disorders.
THE CONTINUUM
• CORTEX-BASED DISORDERS
– Learning, Motor, Language Disorders
– Organization, Executive Function Disorders
• ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
• EMOTIONAL “REGULATORY” DISORDERS
–
–
–
–
Anxiety Disorders
Depression
Anger-Control Disorders
Obsessive-Compulsive Disorder
• TIC DISORDERS
• ??? BIPOLAR DISORDER
DIAGNOSTIC CLUES THAT
BEHAVIORS ARE
NEUROLOGICALLY-BASED
THERE IS A CHRONIC AND A
PERVASIVE HISTORY OF THE
CLINICAL PROBLEMS.
THERE OFTEN IS A FAMILY HISTORY OF THE
CLINICAL PROBLEMS
CORTICAL-BASED DISORDERS
• LEARNING DISABILITIES
• LANGUAGE DISABILITIES
• MOTOR DISABILITIES
ATTENTION DEFICIT
HYPERACTIVTY DISORDER
EMOTIONAL REGULATORY
DISORDERS
• ANXIETY DISORDERS
• DEPRESSION
• ANGER CONTROL DISORDERS
• OBSESSIVE-COMPULSIVE DISORDER
ANXIETY DISORDERS
• GENERALIZED ANXIETY DISORDER
• PANIC DISORDER
• PHOBIAS
• OBSESSIVE-COMPULSIVE DISORDER
DEPRESSION
• MAJOR DEPRESSIVE DISORDERS
– Present two or more weeks
• DYSTHYMIC DISORDER
– Present for two or more years
INTERMITTENT EXPLOSIVE
DISORDER
• Several discrete episodes of failure to resist
•
•
aggressive impulses that result in serious
assaultive acts or destruction of property.
The degree of aggressiveness expressed during
the episodes is grossly out of proportion to any
precipitating psychosocial stressors.
The aggressive episodes are not better
accounted for by another mental disorder.
OBSESSIVE-COMPULSIVE
DISORDER: OBSESSIONS
• OBSESSIONS ARE UNWANTED
THOUGHTS, IMAGES, OR IMPULSES THAT
THE INDIVIDUAL REALIZES ARE
SENSELESS OR UNNECESSARY, INTRUDE
INTO ONE’S CONSCIOUSNESS
INVOLUNTARILY, AND CAUSE
FUNCTIONAL IMPAIRMENT AND
DISTRESS
OBSESSIVE-COMPULSIVE
DISORDER: COMPULSIONS
• COMPULSIONS ARE ACTIONS THAT ARE
RESPONSES TO A PERCEIVED INTERNAL
OBLIGATION TO FOLLOW CERTAIN
RITUALS OR RULES. COMPULSIONS CAN
BE MOTIVATED DIRECTLY BY
OBSESSIONS OR EFFORTS TO WARD OFF
CERTAIN THOUGHTS, IMPULSES, OR
FEARS.
COMMON BEHAVIORS WITH
OBSESSIVE-COMPULSIVE
DISORDER
• Counting or repeating behavior
• Checking or questioning behavior
• Collecting or hoarding behavior
• Arranging and organizing behavior
• Cleaning and/or washing behavior
• “Preening” behaviors (nail biting, cuticle
picking, hair pulling, picking at sores)
TREATMENT FOR REGULATORY
DISORDERS
• THE “SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIs)
Trade Name
Prozac
Paxil
Zoloft
Luvox
Celexa
Generic Name
fluoxetine
paroxetine
sertraline
fluvoxamine
citalopram
THE TIC DISORDERS
THE TIC DISORDERS
• TRANSIENT TIC DISORDERS
• CHRONIC TIC DISORDERS
– Chronic Motor Tic Disorder
– Chronic Vocal Tic Disorder
• TOURETTE’S DISORDER
TREATMENT FOR TIC DISORDERS
TRADE NAME
Catapres
Haldol
Tenex
Orap
GENERIC NAME
clonidine
haloperidol
guanafacine
pimozide
BIPOLAR DISORDER
BIPOLAR DISORDER
A CLINICAL COURSE THAT IS
CHARACTERIZED BY THE OCCURRENCE
OF ONE OR MORE MANIC EPISODES OR
MIXED EPISODES. OFTEN THE
INDIVIDUAL HAS ALSO HAD ONE OR
MORE MAJOR DEPRESSIVE EPISODES
TYPES OF BIPOLAR DISORDER
• BIPOLAR I: SINGLE MANIC EPISODE
• BIPOLAR II: RECURRENT MAJOR
DEPRESSIVE EPISODES
WITH HYPOMANIC
EPISODES
BIPOLAR DISORDER IN CHILDREN
AND ADOLESCENTS
• OFTEN MORE RAPID CYCLING THAN
WITH ADULTS
• CYCLES INCLUDE:
– DEPRESSION TO HYPOMANIC OR MANIC
– CALM TO IRRITIBILITY TO RAGE
TREATMENT FOR BIPOLAR
DISORDER
• FOR MANIC AND RAGE BEHAVIORS:
– ANTI-CONVULSANT MEDICATIONS
– ATYPICAL ANTIPSYCHOTIC MEDICATIONS
• FOR DEPRESSION:
– A NON-SSRI MEDICATION
– MOST COMMONLY USED: WELLBUTRIN
ANTICONVULSANT MEDICATIONS
• DEPAKOTE
• TEGRETAL
• NEURONTIN
• LAMICTAL
• TRILEPTAL
• GABRITRAL
• (LITHIUM)
ATYPICAL ANTIPSYCHOTIC
MEDICATIONS
• RESPERDAL
• ZYPREXIA
• GEODON
• SEROQUIL
• ABILIFY
SIGNIFICANCE OF THE CONCEPT
OF A CONTINUUM OF
NEUROLOGICALLY-BASED
DISORDERS
• IF ONE DIAGNOSIS IS FOUND, THE
OTHER DIAGNOSES MUST BE LOOKED
FOR.
• UNLESS ALL DIAGNOSES ARE
ADDRESSED, THE CLINICAL OUTCOME
MAY BE LESS THEN DESIRED.