Psychiatry lecturesPsychiatry lectures

Prof. János Kálmán

Her (Gabriella’s) main complaints

PMDD

No Overview

Moodswings

Tired

Low self-esteem Lazy

Panic

Depressed

Unmotivated

Overwhelmed

DistractedChaotic

ADD

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The Complete Picture…

Periods of Productivity - ADHD

Time’s passage

Emotional intensity

Blah-ness

Interest-based performance

Importance-based performance

Normal ADHD

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Developmental Trajectories of Brain Volume

Abnormalities in Youth with ADHD

• Smaller brain volumes in all regions– regardless of medication status (cortical white & gray

matter)

• Smaller total cerebral (-3.2%) and cerebellar (-3.5%) volumes

• Volumetric abnormalities (except caudate) persist with age

• No gender differences

• Volumetric findings correlate with severity of the disorder

• (Castellanos et al, 2002)

Positron Emission Tomography (PET) studies show that methylphenidate acts predominantly in the striatum of the human brain where it binds to DA transporters

[11C]methylphenidate

methylphenidate

PET studies of the Site of Action of

Methylphenidate in the Human Brain

11C

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[11C]Cocaine

[11C]Methylphenidate

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80

% P

ea

k

"High"

Time (min)

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80

"High"% P

ea

k

NH3C

CO2CH3

O

O

HN CO2CH3

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Time is always…. everything

Caudate nucleus

(Attention Network)

Nucleus accumbens

(Motivation Network)

Substantia nigraVentral tegmental area

Hypothalamus

Four dopamine Pathways

Frontal

Cortex

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Pre- and Perinatal Risk Factors for ADHD (Biederman & Colleagues)

Odds Ratio (ADHD versus Control)

Parental CD

Parental ADHD

Parental IQ

Age at Birth

SES

Low Birth Weight

Drug Exposure

Alcohol Exposure

Cigarette Exposure

Results from Logistic Regression ModelResults from Logistic Regression Model

Psychosocial Adversity

0 2 4 6 8 101

Dopamine Deficit Hypothesis of ADHDDopamine Deficit Hypothesis of ADHD

SNVTA

DRD2

DAT

Dopamine Receptor D4 (DRD4)

Dopamine Receptor D2 (DRD2)

Wender, (1971); Levy (1990)10Gabriella

Brain Structure & Function

� Differences in brain maturation, structure, function (particularly abnormalities in frontostriatal circuitry):

� Prefrontal cortex

� Basal ganglia

� Cerebellum

� These areas of the brain are associated with executive function abilities:

� Attention, spatial working memory, and short-term memory

� Response inhibition and set shifting

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What Are Executive Functions?

• “a neuropsychological concept referring to the cognitive processes required

– to plan and direct activities, including task initiation

– and follow through, working memory, sustained attention, performance monitoring, inhibition of impulses, and goal-directed persistence.”(Dawson & Guare, 2004, p. vii)

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Executive Function

• Capacity to separate action and reward.

• Normal development allows increasingly complex, prolonged separation of action and reward.

• Allows us to execute goal-directed behavior across time.

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Executive Functions

• Inhibit – Control impulses, appropriately stop own behavior at proper time

• Shift – Move freely between tasks, transition, flexible in problem solving

• Emotional Control – Modulate emotional responses appropriately

• Initiate – Independently begin a task or activity, generate ideas

• Working Memory – Hold info in mind for purpose of completing a task

• Plan / Organize – Anticipate future events, set goals, carry out tasks in systematic manner

• Org of Materials – Keep workspace / materials in orderly manner

• Monitor – Keep track of own behavior and effect, assess performance during or after task to ensure goal attainment

ADHD Affects

All Executive Functions

Impaired EF Observed Behavior

Attention inattention, distractibility

Sustained effort “not trying”, poor follow-through

Modulation of impulse poor self-control, risk-taking

Organization disorganized locker/backpack, schedule

Social skills may not play well with others, loses friends

Self-observation unaware of behavior, emotions, effectiveness,

others

Emotional self-control poor frustration tolerance, lack of empathy

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Focus for ADHD

• ADHD Inattentive Type – brain produces an

abundance of slow brain waves and less fast

wave activity

• Slow waves – day dreamy, tuned out,

distracted

• Faster waves (SMR) – calm, alert focused,

thinking intensely

Focus of EEG Biofeedback Therapy

• Reduce activity (amplitude) of low frequency

brain waves

– Delta, Theta and Alpha waves

• Increase activity (amplitude) of higher

frequency brain waves

– Beta, SMR waves

• Vehicle for administering rewards and inhibits

of rewards is a video game

Inattention Hyperactivity

Impulsivity

What Is ADHD?

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• Predominantly inattentive type

(formerly called ADD)

• Predominantly hyperactive/impulsive

type

• Combined type

Prevalence & Impact

• 50% of children referred to mental health clinics

are referred for ADHD-related problems

• Prevalence rate of 6-10%

• More prevalent in males than females

– Male:female ratio is 3:1 in epidemiological

samples

� www.cdc.gov19Gabriella

Gender differences

children and adults

Childhood

Underdiagnosis in girls

Adulthood

M>>F

M=F

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DSM -5 - 22 Chapters

1. Neurodevelopmental Disorders

2. Schizophrenia Spectrum & Other Psychotic Disorders

3. Bipolar & Related Disorders4. Depressive Disorders5. Anxiety Disorders6. Obs-Compulsive & Related 7. Trauma- & Stressor-Related 8. Dissociative Disorders9. Somatic Symptom Disorders10.Feeding & Eating Disorders11.Elimination Disorders12.Sleep/Wake Disorders

13. Sexual Dysfunctions14. Gender Dysphoria15. Disruptive, Impulse-Control

& Conduct Disorders16. Substance Related &

Addictive Disorders17. Neurocognitive Disorders18. Personality Disorders19. Paraphilic Disorders20. Other Mental Disorders21. Medication-induced

Movement…Med Effects22. Other Conditions (v codes)

RO

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ADHD IS NOT OUTGROWN

Fayyad J Br J Psychiatry. 2007 May;190:402-9; Kooij JJS Psychol Med. 2005 Jun;35(6):817-27; Kessler RC

J Occup Environ Med. 2005 Jun;47(6):565-72.; Kessler RC Am J Psychiatry. 2006 Apr;163(4):716-23.

?

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Impairment in adult ADHD

In clinical as well as epidemiological samples compared to NCs:

• Learning problems (60%)

• Less graduated

• Lower education

• Lower income

• Less employed, more sickness leave

• More job changes (longest job 5 yrs)

• More often arrested, divorced and more social problems

• More driving accidents, teenage pregnancies, suicide attempts

• Higher (mental) health care costs

Biederman 2006; Kooij 2001, 2005; Barkley 2002; Manor, 201023Gabriella

How can we help to Gabriella?

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Stimulants:

Mechanism of Action

• Reuptake inhibition of NE & DA

– increased release of presynaptic NE/DA

• Amphetamine promotes

– passive diffusion of NE and DA into synaptic cleft

– NE and DA from cytoplasmic pools

• Amphetamine & Methylphenidate are mild inhibitors of MAO

v vStoragevesicle

DA Transporter

Cytoplasmic DA

Methylphenidate blocks

reuptake

Presynaptic NeuronPresynaptic Neuron

SynapseSynapse

Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501–513

Amphetamine blocks

reuptake

Amphetamine blocks

Mechanism of Action of Stimulants

References

1. ADHD & Specific Learning Disabilities in DSM-5, Rosemary Tannock, http://portal.idc.ac.il/he/main/research/documents/4_tannock_herzliya_dsm5.pdf.

2. ADHD and the School Age Child, James Hedrick, http://webcache.googleusercontent.com/search?q=cache:7i7k-e4M7fYJ:www.kysna.com/KSNA_Srp_2012/handouts/ADHD%2520J%2520Hedrick.ppt+&cd=1&hl=hu&ct=clnk&gl=hu

3. ADHD in Adults: Separating the Wheat from the Chaff, James Chandler, http://webcache.googleusercontent.com/search?q=cache:E4WOoVIvmd8J:www.klis.com/chandler/office/talks%2520for%2520gps/ADHD%2520in%2520Adults%2520for%2520powerpoint.ppt+&cd=1&hl=hu&ct=clnk&gl=hu

4. ADHD Through The Life Cycle, Humberto Nagera, http://webcache.googleusercontent.com/search?q=cache:GxB3G53WiL8J:www.thecjc.org/ppoint/ppoint/ADHD.ppt+&cd=2&hl=hu&ct=clnk&gl=hu

5. ADHD Two Attentions One Deficit , Oren Mason, http://webcache.googleusercontent.com/search?q=cache:BfpnPhycQ1AJ:www.oaisd.org/downloads/specialneedslinks/2attentions1deficit02122014_20140206_093247_1.ppt+&cd=1&hl=hu&ct=clnk&gl=hu

6. Adult ADHD, Delicia Garner, http://www.uky.edu/~hadleyr/PA2007/Garner.ppt

7. Attention-Deficit/Hyperactivity Disorder (ADHD), Andrea Chronis-Tuscano, http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/FoodAdvisoryCommittee/UCM272307.ppt

8. Attention Deficit Hyperactivity Disorder, A Window into Disability as Variability, http://webcache.googleusercontent.com/search?q=cache:GOFshF9U-kEJ:isites.harvard.edu/fs/docs/icb.topic835372.files/ADHDpresentation(sampleLS).ppt+&cd=1&hl=hu&ct=clnk&gl=hu

9. Attention-Deficit/Hyperactivity Disorder, Dispelling Myths is Good Medicine , Karen J. Kraus, http://www.fresno.ucsf.edu/newsroom/public_education/borders_adhd_kraus%20.ppt

10. Attention Deficit Hyperactivity Disorder (ADHD), Tips for Understanding and Managing ADHD in the Home , Brett L. Patterson, http://www.oumedicine.com/docs/ad-psychiatry-workfiles/attention-deficit-hyperactivity-disorder-(adhd).ppt?sfvrsn=2

11. Attention Deficit Hyperactivity Disorder: What Educators Need To Know, Annie Schave, https://www.msu.edu/~schavean/CEP841.ADHD.finalproject.ppt

12. Being a Good Diagnostician: Changes in Diagnosis, Rhoda Olkin, http://media-library.uofthenet.info/2013/06/DSM-5-handout-updated-6-14-13.ppt

13. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, Mark L. Wolraich, http://webcache.googleusercontent.com/search?q=cache:G4HNeanphSgJ:www2.aap.org/pcorss/webinars/pco/ADHD%2520Webinar_Wolraich.ppt+&cd=1&hl=hu&ct=clnk&gl=hu

14. Child psychiatry and DSM-5, Natalie Grizenko http://www.douglas.qc.ca/uploads/File/011113_Le%20DSM-5%20et%20la%20pedopsychiatrie_Natalie%20Grizenko.pdf

15. Diagnosis and Management of ADHD, P. Hill, http://www.nhshighland.scot.nhs.uk/Services/Documents/Medicines%20in%20Schools/Diagnosis%20and%20Management%20of%20ADHD.ppt

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References

1. Diagnostic and Statistical Manual Of Mental Disorders, Changing from DSM-IV to DSM-5, Steve Franklin, Shelly Justison, Kathleen McMullan, http://stevefranklinmsw.com/DSM-5Final.ppt

2. Evaluation of the Dopamine Hypothesis of ADHD with PET Brain Imaging, James M. Swanson http://webcache.googleusercontent.com/search?q=cache:ovRkKUA46CAJ:vmsstreamer1.fnal.gov/VMS_Site_03/Lectures/Colloquium/presentations/100428Swanson.PPT+&cd=1&hl=hu&ct=clnk&gl=hu

3. Diagnostic Assessment, Treatment, and Lifespan Clinic for ADHD, J.J. Sandra Kooij, http://www.psichiatria.it/wp-content/uploads/2013/01/Brescia-Assessment-and-Treatment-and-Lifespan-clinic-2014.ppt

4. Hyperactivity and Attention Disorders in Children, Miriam K. Pizzani http://webcache.googleusercontent.com/search?q=cache:Snnuev7cZK4J:fbcrichmond.org/physician/ADHD.ppt+&cd=1&hl=hu&ct=clnk&gl=hu

5. Is it ADHD or just inattention? http://webcache.googleusercontent.com/search?q=cache:0fEaqeaFeUMJ:support.childmind.org/site/DocServer/2012_SUFK_Talk_ADHD.ppt%3FdocID%3D502+&cd=1&hl=hu&ct=clnk&gl=hu

6. Pharmacological Treatment of Child & Adolescent ADHD, http://www.gpscbc.ca/system/files/LS2G.%20Medications-%20ADHD%20v1.3.ppt

7. Subtypes of ADHD Related to Substance Use Disorders (SUD): Results from the MGH Longitudinal Study of Boys with ADHD, Timothy E. Wilens, http://archives.drugabuse.gov/meetings/apa/ppt/wilens.ppt

8. The Diagnosis and Treatment of ADHD, Jess P. Shatkin, http://webcache.googleusercontent.com/search?q=cache:AtRg8XKbAaYJ:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/cap_resources_for_medical_student_educators/ADHD.ppt+&cd=1&hl=hu&ct=clnk&gl=hu

9. ‘Teaching the Tornado’: Strategies for Working With the Disorganized, Inattentive, Overactive Student, Jim Wright, http://webcache.googleusercontent.com/search?q=cache:D4bmjzY5KeIJ:www.jimwrightonline.com/ppt/mspa08/ADHD_Intro.ppt+&cd=3&hl=hu&ct=clnk&gl=hu

10. The complete picture, http://webcache.googleusercontent.com/search?q=cache:w4imEt7Fpe8J:parentsunitedwi.org/parentsunited/ResourceFiles/ADHD%2520Presentation%2520Handouts.ppt+&cd=1&hl=hu&ct=clnk&gl=hu

11. The Integrative Approach to ADHD or Do 4 million children really need Ritalin?, Sanford Newmark, http://webcache.googleusercontent.com/search?q=cache:XyFGRqrZqBMJ:https://www2.aap.org/sections/chim/ADHD-CHIM.ppt+&cd=1&hl=hu&ct=clnk&gl=hu

12. The Unrecognized Role of Emotions in ADHD, Thomas E. Brown http://www.powershow.com/view1/755af-ZDc1Z/The_Unrecognized_Role_of_Emotions_in_ADHD_Implications_for_Social_Interaction_powerpoint_ppt_presentation

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