Month: July 2019

What is Organic (Affective) Mood Disorders?

Affective disorders are observed in almost all endocrine diseases, and especially in patients who are treated with hormonal drugs during their withdrawal.

Causes of Organic (Affective) Mood Disorders

A frequent cause are endocrine disease (hyperthyroidism, Cushing’s disease – Cushing, thyroidectomy, premenstrual and menopausal syndromes), hormonal drugs in patients with bronchial asthma, rheumatoid arthritis, overdosage and poisoning vitamins and antihypertensives, craniocerebral trauma, tumors of the frontal lobes.

Symptoms of Organic (Affective) Mood Disorders

Affective disorders are manifested in the form of depression, mania, bipolar or mixed disorders. Indirectly, the organic background can be identified by a combination of these disorders with a decrease in activity up to a reduction in energy potential, asthenia, a change in craving (endocrine psycho-syndrome), as well as symptoms of cognitive deficit. In history you can find episodes of organic delirium. Manic episodes occur with euphoria and unproductive euphoria (moria), dysphoria is characteristic in the structure of depressions, daily mood swings are absent or distorted. By evening, mania can be exhausted, and in case of depression, asthenia increases in the evening. In bipolar disorders, affect is associated with the course of the underlying pathology, and seasonality is not characteristic.

Diagnosis of Organic (Affective) Mood Disorders

Based on the identification of the underlying disease and atypia of affective disorders. Affective disorders can usually be manic, depressive, bipolar, or mixed.

Differential diagnostics

Disorders should be differentiated from affective residual disorders due to dependence on psychoactive substances, with endogenous affective disorders, symptoms of frontal atrophy.

Affective residual disorders due to the use of psychoactive substances can be identified by history, the frequent presence of typical psychosis (delirium and affective disorders during abstinence) in history, a combination of affective disorders with a pseudo-paralysis clinic or Korsakov’s disorders.

Endogenous affective disorders are characterized by typical daily and seasonal dynamics, lack of organic neurological symptoms, although secondary endocrine disorders are possible (delayed menstruation, involution).

Symptoms of frontal atrophy are characterized by a combination of affective disorders with the symptoms of E. Robertson (see Pick’s disease).

Treatment of Organic (Affective) Mood Disorders

When treating organic affective disorders, it should be borne in mind that patients may react abnormally to psychoactive substances, that is, the trap should be cautious. In the treatment of depression should prefer Prozac, Lerivon and Zoloft. For the prevention of bipolar disorders – difenin, carbamazepine and depakin. For the treatment of manic states – carbamazepine, beta-blockers, tranquilizers and small doses of teasercine. All this therapy is considered symptomatic, attention should be paid to the treatment of the underlying disease. Of nootropics, phenibut and pantogams should be preferred, since other nootropics can increase anxiety and anxiety.

What is Inorganic Enuresis?

It is characterized by involuntary urination during the day and / or night, which does not correspond to the child’s mental age. Not due to the lack of control over the function of the bladder due to neurological disorders, epileptic seizures, structural abnormalities of the urinary tract.

Causes of Inorganic Enuresis

Bladder control develops gradually, it is influenced by features of the neuromuscular system, cognitive functions, and, possibly, genetic factors. Violations of one of these components may contribute to the development of enuresis. Children suffering from enuresis are approximately twice as likely to have developmental delays. 75% of children with inorganic enuresis have close relatives suffering from enuresis, which confirms the role of genetic factors. Most children suffering from enuresis have an anatomically normal bladder, but it is functionally small. Psychological stress can increase enuresis. A big role is played by the birth of a sibling, the beginning of schooling, the breakup of a family, and the transfer to a new place of residence.

Prevalence

Enuresis affects more men than women, at any age. The disease occurs in 7% of boys and 3% of girls aged 5 years, 3% of boys and 2% of girls aged 10 and 1% of boys and is almost completely absent in girls aged 18 years. Daytime enuresis is less common than nocturnal, in about 2% of 5-year-olds. Unlike nocturnal, daytime enuresis occurs more often in girls. Mental disorders are present only in 20% of children with inorganic enuresis, most often they occur in girls or in children with day and night enuresis. In recent years, descriptions of rare forms of epilepsy appear more and more often in the literature: an epileptic variant of enuresis in children (5-12 years old).

Symptoms of Inorganic Enuresis

Inorganic enuresis can be observed from birth – “primary” (80%), or occur after a period of more than 1 year, acquired bladder control – “secondary”. Late onset is usually observed at the age of 5-7 years. Enuresis can be monosymptomatic or combined with other emotional or behavioral disorders, and is the primary diagnosis if involuntary urination is observed several times a week, or if other symptoms show a temporary connection with enuresis. Enuresis is not associated with any particular sleep phase or night time, more often it is observed in a random order. Sometimes it occurs when it is difficult to go from a slow phase of sleep to a fast one. Emotional and social problems that arise as a result of enuresis include low self-esteem, a sense of inferiority, social constraints, stiffness and family conflicts.

Diagnosis of Inorganic Enuresis

The minimum chronological age for diagnosis should be 5 years, and the minimum mental age should be 4 years.

• Involuntary or arbitrary urination in bed or clothing can be observed during the day (F98.0) or overnight (F98.01) or observed during the night and day (F98.02).
• At least two episodes per month for children aged 5-6 years and one event per month for older children.
• The disorder is not associated with a physical illness (diabetes, urinary tract infections, seizures, mental retardation, schizophrenia and other mental illnesses).
• The duration of the disorder is at least 3 months.

Differential diagnostics

It is necessary to exclude the possible organic causes of enuresis. Organic factors are most often found in children who have daytime and nocturnal enuresis, combined with frequent urination and an urgent need to empty the bladder. They include: 1) disorders of the genitourinary system – structural, neurological, infectious (uropathy, cystitis, hidden spina bifida, etc.); 2) organic disorders causing polyuria – diabetes mellitus or diabetes insipidus; 3) disorders of consciousness and sleep (intoxication, somnambulism, epileptic seizures), 4) side effects of treatment with certain antipsychotic drugs (thioridazine, etc.).

Treatment of Inorganic Enuresis

Due to the etiology of the disorder, various methods are used in treatment.

Hygiene requirements include training in using the toilet, limiting fluid intake 2 hours before bedtime, and sometimes a night waking to use the toilet.

Behavioral therapy. In the classic version – conditioning by a signal (bell, beep) the time of the onset of involuntary urination. The effect is observed in more than 50% of cases. This therapy uses hardware methods. It is reasonable to combine this treatment option with praise or reward for longer periods of abstinence.

Drug treatment

The use of Melipramine is recommended. Against the background of its administration, in 30% of patients, enuresis completely stops, and in 85% it weakens.

However, the effect is not always lasting. There are reports of the effectiveness of the use of Driptan (the active substance is oxybutrin), which has a direct antispasmodic effect on the bladder and a peripheral M-cholinolytic effect with a decrease in the hypertonus of the parasympathetic nervous system. Doses 5 – 25 mg / day.

Traditional variants of psychotherapy for enuresis in some cases are not effective.

What is Undifferentiated Somatoform Disorder?

Undifferentiated somatoform disorder. This category should be used in cases where somatic complaints are multiple, variable and long-lasting, but at the same time, a complete and typical clinical picture of a somatized disorder is not detected. For example, the assertive and dramatic nature of the complaint may be absent, the latter may be relatively small in number, or there may be no violation of social and family functioning. The grounds for the assumption of psychological conditioning may or may not be present, but there should be no somatic basis for a psychiatric diagnosis.

Symptoms of Undifferentiated Somatoform Disorder

Symptoms resembling somatic disease, however, constant complaints despite excessive detail, vague, inaccurate and inconsistent in time. Somatic is framed by emotional instability, anxiety, low mood, not reaching the level of depression, decay of physical and mental strength, besides, irritability, a feeling of internal tension and dissatisfaction are often present. An exacerbation of the disease is provoked not by physical exertion or by changing weather conditions, but by emotionally significant stressful situations.

Diagnosis of Undifferentiated Somatoform Disorder

Criteria:

• The presence of multiple, changing somatic symptoms in the absence of any somatic diseases that could explain these symptoms.
• Constant concern about the symptom leads to prolonged suffering and repeated (3 or more) consultations and examinations in the outpatient clinic, and if counseling is unavailable for any reason, repeated visits to representatives of paramedicine.
• Persistent refusal to accept a medical opinion on the absence of sufficient somatic causes of the existing symptoms or only a short-term agreement with it (up to several weeks).

Undifferentiated somatoform disorder can be diagnosed, when the minimum duration of symptoms is reduced to 6 months, criteria 1 and 3 are fully satisfied, criterion 2 can only be partially met

Important differentiation with the following disorders:

• Somatic disorders. It is most difficult to differentiate somatoform disorder from some somatic diseases, such as multiple sclerosis, systemic lupus erythematosus, etc., beginning with nonspecific, transient manifestations. Here, the doctor needs to distinguish from a variety of clinical symptoms those that are characteristic of these diseases. Thus, multiple sclerosis often begins with transient motor, sensory (paresthesia) and visual disturbances. Hyperparathyroidism can be manifested by osteoporosis (loosening and tooth loss), and systemic lupus erythematosus often begins with polyarthritis, which is gradually joined by polyserositis.
  However, one should take into account the probability of the emergence of an independent somatic disorder in such patients, which is not lower than that of ordinary people at the same age. Particular attention in case of change of emphasis in the complaints of patients or their stability, when you need to continue surveys.
• Affective (depressive) and anxiety disorders. Depression and anxiety of varying degrees are often accompanied by somatized disorders, but they should not be described separately unless they are sufficiently pronounced and stable to justify their own diagnosis. The appearance of multiple somatic symptoms after the age of 40 years may indicate a manifestation of primary depressive disorder.
• Hypochondriacal Disorder. With somatisation disorder, the focus is on the symptoms themselves and their individual manifestation, while in hypochondriacal disorder, attention is directed more to the presence of the intended progressive and serious disease process, as well as its disabling consequences. In hypochondriacal disorder, the patient more often asks for examination in order to confirm the nature of the alleged disease, while a patient with somatisation disorder asks for treatment in order to remove the existing symptoms. With somatisation disorder, there is usually excessive use of drugs, whereas patients with hypochondriacal disorder are afraid of drugs, their side effects, and seek support and relief from frequent visits to various doctors.
• Delusional disorders (such as schizophrenia with somatic delusions and depressive disorders with hypochondriacal ideas). Freakish features of ideas, combined with a smaller number of them and the more constant nature of somatic symptoms, are most typical of delusional disorders.

Longer (from 2 years) and more intense symptoms are diagnosed as somatoform disorder.

Treatment of Undifferentiated Somatoform Disorder

The main role in the treatment belongs to psychotherapy. Pharmacotherapy aims to create psychotherapy opportunities and is carried out to correct the accompanying symptoms. The choice of drugs in each case is determined by the characteristics of the symptoms and associated manifestations. The following groups of drugs are used for pharmacotherapy: drugs of the first choice are antidepressants (tricyclic and SSRI groups); second choice drugs are beta blockers and mood stabilizers; In the initial stages of treatment, a combination of antidepressant with benzodiazepine is possible; antipsychotics with sedative effect are also used as reserve medicines for severe anxiety, which can not be stopped by benzodiazepines. In addition, the treatment of somatoform disorders must be supplemented with vasoactive, nootropic drugs and vegetal stabilizers.

What is a Disruption of Activity and Attention?

Previously called minimal brain dysfunction (MMD), hyperkinetic syndrome, minimal brain damage. This is one of the most common childhood behavioral disorders, many of which remain in adulthood.

Prevalence

The disorder is more common in boys. The relative prevalence among boys and girls from 3: 1 to 9: 1, depending on the criteria of diagnosis. Currently, the prevalence among schoolchildren is from 3 to 20%. In 30-70% of cases, the syndromes of the disorder turn into adulthood. Hyperactivity in adolescence in many decreases, even if other disorders remain, but the risk of asocial psychopathy, alcoholism and drug addiction is high.

Causes Disruption of Activity and Attention

Previously, the hyperkinetic disorder was associated with intrauterine or postnatal brain damage (“minimal brain damage”). Identified genetic predisposition to this disorder. For identical twins, concordance is higher than for dvuiaytsovyh. 20-30% of parents of patients suffered or suffer from impaired activity and attention. Congenital tendency to hyperactivity increases under the influence of certain social factors, since this behavior is more common in children living in adverse social conditions. Parents of patients are more likely to have alcoholism, asocial psychopathy, and affective disorders in the general population. The alleged causes of the disorder are associated with food allergies, prolonged lead intoxication and exposure to food additives, but these hypotheses are not supported by convincing evidence. A strong relationship was found between activity and attention disorders and insensitivity to thyroid hormones – a rare condition, based on a mutation of the thyroid hormone beta-receptor gene.

Symptoms Disruption of Activity and Attention

The diagnostic criteria for a disorder have changed somewhat over the years. Symptomatology almost always manifests itself to 5-7 years. The average age of a doctor is 8-10 years.

Major manifestations include:

• Violations of attention. Inability to maintain attention, decreased selective attention, inability to concentrate on the subject for a long time, frequent forgetting of what needs to be done; increased distractibility, irritability. Such children are fussy, restless. Even more attention is reduced in unusual situations when you need to act on your own. Some children cannot even watch their favorite TV shows to the end.
• Impulsivity. In the form of scruffy fulfillment of school tasks, despite the efforts to do them correctly; frequent shouts from a place, noisy tricks during classes; “Getting into” the conversation or work of others; impatience in line; inability to lose (as a result of this, frequent fights with children). With age, manifestations of impulsivity can change. At an early age, it is urinary and fecal incontinence; at school – excessive activity and extreme impatience; in adolescence – hooligan antics and antisocial behavior (theft, drug use, etc.). However, the older the child, the more impulsive is more pronounced and more noticeable to others.
• Hyperactivity. This is an optional feature. In some children, motor activity can be reduced. However, motor activity is qualitatively and quantitatively different from the age norm. In preschool and early school age, such children continuously and impulsively run, crawl, jump up, and are very fussy. To puberty, hyperactivity often decreases. Children without hyperactivity are less aggressive and hostile to others, but they are more likely to experience partial developmental delays, including school skills.

Additional signs

• Violations of coordination are noted in 50-60% in the form of the impossibility of subtle movements (tying shoelaces, using scissors, coloring, letters); imbalances, visual and spatial coordination (inability to play sports, cycling, ball games).
• Emotional disturbances in the form of imbalance, temper, intolerance to failure. There is a delay in emotional development.
• Relations with others. In mental development, children with impaired activity and attention lag behind peers, but strive to be leaders. It is difficult to be friends with them. These are extraverted children, they are looking for friends, but they quickly lose them. Therefore, they often communicate with more “complaisant” younger ones. Relationships with adults are difficult. They are not affected by punishment, affection, or praise. From the point of view of parents and educators, it is precisely “bad manners” and “bad behavior” that are the main reason for going to doctors.
• Partial developmental delays. Despite normal IQ, school performance in many children is low. The reasons are inattention, lack of perseverance, intolerance to failure. Partial delays in the development of writing, reading, and counting are characteristic. The main symptom is the mismatch of a high intellectual level and poor performance in school. The criterion of partial delay is considered to be a backlog of skills by at least 2 years. However, it is necessary to exclude other causes of failure: perceptual disorders, psychological and social causes, low intelligence and inadequate teaching.
• Behavioral disorders. Not always observed. Not all children with behavioral disorders may have impaired activity and attention.
• Bedwetting. Disorders of falling asleep and drowsiness in the morning.

Disorders of activity and attention can be divided into 3 types: with a predominance of inattention; with a predominance of hyperactivity; mixed.

Diagnostics Disorders of Activity and Attention

It is necessary to have inattention or hyperactivity and impulsivity (or all manifestations at the same time) that do not correspond to the age norm.

Features of behavior:

• appear up to 8 years;
• are found in at least two areas of activity – school, home, work, games, clinic;
• are not caused by anxious, psychotic, affective, dissociative disorders and psychopathies;
• cause significant psychological discomfort and maladaptation.

Inattention:

• Inability to focus on details, errors of inattention.
• Inability to maintain attention.
• Inability to listen to the speech addressed.
• Inability to complete tasks.
• Low organizational skills.
• Negative attitude to tasks requiring mental stress.
• Loss of items needed to complete the task.
• Distractibility to extraneous irritants.
• Forgetfulness. (Of the listed symptoms, at least six should be stored for more than 6 months.)

Hyperactivity and impulsivity (of the following symptoms, at least four should last at least 6 months.):

• hyperactivity: the child is fussy, restless. Jumps up without permission. Running aimlessly, fidgeting, climbing. Cannot rest, play quiet games;
• impulsiveness: cries out the answer without listening to the question. Cannot wait in line.

Differential diagnosis

For the diagnosis you need: a detailed history of life. Information must be found out with everyone who knows the child (parents, carers, teachers). Detailed family history (presence of alcoholism, hyperactivity disorder, ticks in parents or relatives). Data on the current behavior of the child.

Information is required on the child’s academic performance and behavior in the educational institution. There are currently no informative psychological tests to diagnose this disorder.

Disorders of activity and attention do not have clear pathognomonic signs. This disorder can be suspected on the basis of an anamnesis and psychological testing, taking into account diagnostic criteria. For a final diagnosis, a trial appointment of psychostimulants is shown.

The phenomena of hyperactivity and inattention can be symptoms of anxiety or depressive disorders, mood disorders. The diagnosis of these disorders is made in the presence of their diagnostic criteria. The presence of an acute onset of hyperkinetic disorder at school age can be a manifestation of a reactive (psychogenic or organic) disorder, manic state, schizophrenia, neurological disease.

Treatment Disorders of Activity and Attention

Drug treatment is effective in 75-80% of cases, with the correct diagnosis. Its effect is more symptomatic. Suppressing symptoms of hyperactivity disorder and impaired attention facilitates the child’s intellectual and social development. Drug treatment obeys several principles: only long-term therapy ending in adolescence is effective. The selection of the drug and dose proceed from the objective effect, and not the patient’s sensations. If the treatment is effective, then it is necessary to take trial breaks at certain intervals to determine whether the child can do without drugs. The first breaks are preferably arranged during the holidays, when the psychological load on the child is less.

Pharmacological agents used to treat this disorder are CNS stimulants. The mechanism of their action is not fully known. However, psychostimulants not only calm the baby, but also affect other symptoms. The ability to concentrate increases, emotional stability, sensitivity to parents and peers appear, and social relations are being established. Mental development can dramatically improve. Amphetamines (dexamphetamine (Dexedrine), methamphetamine), methylphenidate (Ritalin), pemoline (Ziller) are currently used. Individual sensitivity to them is different. If one of the drugs is ineffective, switch to another. The advantage of amphetamines is the long duration of action and the presence of prolonged forms. Methylphenidate is usually taken 2-3 times a day. It often has a sedative effect. The intervals between doses are usually 2.5-6 hours. Prolonged forms of amphetamines take 1 time per day. Doses of psychostimulants: methylphenidate – 10-60 mg / day .; methamphetamine – 5-40 mg / day .; pemoline – 56.25-75 mg / day. Treatment begins usually with low doses with a gradual increase. Physical dependence usually does not develop. In rare cases, the development of tolerance is transferred to another drug. Methylphenidate is not recommended for children under 6 years of age, dexamphetamine for children under 3 years of age. Pemoline is prescribed for the ineffectiveness of amphetamines and methylphenidate, but its effect may be delayed for 3-4 weeks. Side effects include decreased appetite, irritability, epigastric pain, headache, and insomnia. Pemoline – an increase in the activity of liver enzymes, possible jaundice. Psychostimulants increase heart rate, blood pressure. Some studies indicate a negative effect of drugs on growth and body weight, but these are temporary violations.

If psychostimulants are ineffective, imipramine hydrochloride (tofranil) is recommended in doses of 10 to 200 mg / day .; other antidepressants (desipramine, amfebutamon, phenelzine, fluoxetine) and some antipsychotics (chlorprotixen, thioridazine, sonapax). Antipsychotics do not contribute to the social adaptation of the child, therefore, indications for their appointment are limited. They should be used in the presence of severe aggressiveness, uncontrollability, or when other therapy and psychotherapy are ineffective.

Psychotherapy

A positive effect allows psychological assistance to children and their families. Rational psychotherapy is advisable with explaining to the child the reasons for his failures in life; behavioral therapy with teaching parents reward and punishment methods. Reducing psychological tension in the family and at school, creating a favorable environment for the child contribute to the effectiveness of treatment. However, as a method of radical treatment of disorders of activity and attention, psychotherapy is ineffective.

Monitoring the condition of the child should be established from the beginning of treatment and carried out in several directions – the study of behavior, school performance, social relationships.