Trauma and Stress-Related Disorders

Trauma and Stress-Related Disorders

• Trauma is from exposure to a traumatic or significantly stressful event
• Stressful events can impact someone's conscience, mood, and well-being, even if the event doesn't qualify as PTSD
• PTSD, prisoners of war, and abuse survivors are examples of people that may need help alleviating stress
• People with stressful jobs, marriages, or children with disabilities might need stress alleviation
• In children, trauma and stress-related disorders are marked by pathological responses to severe stressors
• Pathological responses are negative responses, not the proper way of grieving
• Diagnoses related to stress disorders in children/adolescents include reactive attachment disorder
• Reactive attachment disorder presents as emotionally withdrawn children may have difficulty connecting with others and wont seek out comfort
• Reactive attachment disorder was present in many adopted children from Eastern Europe (Poland, Russia)
• Children with reactive attachment disorder were ripped from drug-addicted mothers at birth and may have spent time in orphanages
• These children may have reactive attachment disorder because they disconnect and don't want to get close to avoid getting hurt
• These children are very withdrawn and sometimes confrontational
• Refugee and adopted children may have reactive attachment disorder at first, eases with therapy and time
• The opposite of reactive attachment disorder is disinhibited social engagement disorder (DSED)
• DSED can be caused by the same reasons as reactive attachment disorder
• DSED causes children to be overly familiar with adults and have no fear
• Children with DSED are very familiar with adults, have no fear, and will go with anyone, making them susceptible to kidnapping
• DSED is common in kids who were neglected, left alone, or didn't have parental influence, causing them to seek connections with everyone
• Reactive attachment involves closing off, while disinhibited attachment involves latching on to anyone to avoid being alone
• For reactive/disinhibited attachment disorders to be diagnosed, significant neglect or inadequate caregiving must have occurred
• A child may have reactive/disinhibited attachment disorders despite family intactness and socioeconomic status if parents aren't connected
• Inadequate caregiving is caused by emotional numbness, lack of parental instinct, or work obligations
• Kids in orphanages and unfavorable conditions may have reactive/disinhibited attachment disorders because of early neglect/abuse
• Early neglect or abuse is a trigger, especially between ages 0-10 during crucial development years.
• Kids institutionalized in Romania in the 80s had many with attachment issues after dictators outlawed birth control, leading to overwhelming orphanages
• By 16-18, the orphaned children were kicked out with no safeguards, leading to homelessness, drug addiction, and sex work
• Lack of stable caregiving disrupts normal attachment processes necessary to learn relationships, interaction, and trust
• Children are "revolving door" inpatient psych patients, going from ward to ward and becoming at ease in institutions
• Some people cannot adjust outside of institutions, just like those in prison for many years
• Children raised in institutions could be angry, have psych disorders, and be inpatient into their teens meaning they are unable to adapt
• Children raised in institutions have difficulties forming relationships as well are at high risk of trauma conditions

Clinical Features of Trauma

• Frequent changes in caregivers or foster care also cause attachment difficulties
• Lack of stability contributes to higher rates of attachment disorders, especially in foster care
• When assessing psychosocial or developmental history, determine whether child grew up in a stable home
• Clinical features of reactive attachment disorder includes persistent emotional withdrawal, and minimal social/emotional responsiveness
• Children with Reactive attachment disorder prefer to be alone as they don't trust others, may present as cold, antisocial
• This may not be a true conduct disorder or sociopathy, but deep-seated trauma that prevents them from getting close
• Limited positive affect (AFFECT) and a lot of times, conscripted affect where a child expresses their emotions making them seem cold and antisocial
• Episodes of unexplained sadness, irritability, or fearfulness during interactions
• Children also become fearful and run away as an escape or form disinhibited social engagement disorder
• DSED leads to a lot of issues because of an inappropriate willingness to interact with people
• The behavior might lead to problems and can lead to a dangerous course in life
• Strangers in the park who offer to play are more likely to be joined because the child does not want to be alone
• Children display overly familiar verbal and physical behavior with adults
• Kids might joke with adults inappropriately and have playdates organized with no initiation
• The above issues can cause the child to be isolated and avoided by others
• There is a reduced check-in with caregivers when in unfamiliar environments
• Children might run off in public and not check to see if their parents are present
• The willingness to leave with unfamiliar adults without hesitation
• DSM-5 requires symptoms to present before the age of five for diagnosis
• Also rule out Autism Spectrum Disorder, intellectual disability and Intellectual disability when diagnosing
• Children with an intellectual disability presented as a disinhibited kid because they may not understand right from wrong
• Treatment involves stable, nurturing caregiving, foster parents, and attachment-based therapies
• Parent-child interaction therapy and play therapy effective for emotional regulation, especially in children five and younger

Major Depressive Disorder (MDD) and Suicidality

• Medication only helps the associated symptoms and focus on anxiety, aggression and first line of treatment is SSRIs (though off-label)
• Prozac is the most well-studied SSRI, Lexapro is also technically approved, treat based on symptoms
• Address the underlying reason to avoid just medicating symptoms.
• Major Depressive Disorder presents depression in children as irritability, somatic complaints, and social withdrawal
• Children have trouble processing and expressing emotions, leading to anger
• It affects ~2-3% of children, rising to ~5-8% in adolescents after puberty
• Prevalence of depression is higher in females after puberty
• Family history is a risk factor, check for suicides and relation to the victim
• Other risk factors are chronic medical conditions, disabilities, parental loss, and divorce
• Divorce is a trigger, especially if not handled well
• Monitor a decline in academic performance as MDD increases in severity
• Check the student's standing since a drastic drop indicates a higher level of dedication
• Withdrawal and trouble concentrating can impact performance in school
• Irritable mood, psychomotor agitation, and angry mood swings are more common than sadness in children with MDD
• Ahedonia and somatic symptoms are a sign of depression
• It is important to check school history as well to see where they are having the most success, and where they might not be able to hold up
• A child’s complaints may not relay feelings of depression
• Instead, they say things like they have a stomach ache, they have a headache, and or just “don’t feel right”
• Always assess children like children.
• Using assessment tools like the Beck Depression Inventory to diagnose appropriately
• Cognitive behavioral therapy, Cognitive behavioral therapy, changing the negative thoughts into something more productive, into things that aren’t hurtful
• First line of treatment in medicating is SSRIs but could also be SNRIs (off-label)
• Fluorescentine, LesaPro and Prozac are FDA approved medications for depression.
• People with depression can be treated, so be sure to diagnose them
• Dysthymia, a persistent depressed or irritable mood, requires symptoms for at least a year
• Psychothymia is related and tied to similar symptoms of those with bipolar disorder
• Dysthymia is associated with low self-esteem and pessimism and can isolate people socially
• Prior suicide attempts are a major risk factor
• If a patient indicates that they have tried to commit suicide before, but it was nothing more than trying something superficial such as cutting their arm with a bread knife be sure to get as much information as needed
• Determine what the severity of the situation came to
• It’s also important to take a look at the family history as suicide attempts could be hereditary
• Determine if there’s access to lethal means in the patients household
• If they do make a bodily harm threat to a building perform a SAFE ACT
• To look at prevention of suicide in children one must also look at bullying , abuse, stress, break ups, and if they had to move
• Norquil contracts with some of the schools in Nassau and Suffolk to assist in helping children through the process
• Parental education , parental therapy

Bipolar Disorder and Disruptive Mood Dysregulation Disorder (DMDD)

• Bipolar disorder in youth presents as chronic mood instability and irritability, but the cases that need professional help are rare
• The mood instability and irritability aren't as cyclical as adults
• Diagnosis of bipolar disorder in children is challenging and can result in misdiagnosis like ADHD, oppositional-defiant disorder or conduct disorder
• It can also be early-onset bipolar with diagnostic challenges
• Bipolar in children may manifest as ultra-rapid cyclones, occurring more quickly than in adults, even within the same day.
• Bipolar includes full, elevated, irritable moods lasting a week, grandiosity, decreased need for sleep (2-3 hours), and hyper-sexuality.
• Can also include hypermania, with a milder form lasting at least four days
• The only FDA-approved way to treat bipolar disorder in children is lithium for the following: elevated or irritable mood lasts a week, grandiosity, decreased need for sleep (2-3 hours), and hyper-sexuality
• Depakote can be prescribed, but it is not FDA approved
• Baseline blood testing is required for levels and kidney health
• Over the last 15 years, most people now need dialysis
• Lithium is also good for suicidality and if they are chronically suicidal then lithium can help
• Lithymil can take 25 weeks to reach full effectiveness
• Other options alongside lithium for atypical antipsychotics are Abilify and Risperdal, sometimes Seroquil for those with more anxiety
• DMDD includes severe irritability and frequent temper outbursts, with constant anger (more than ODD which is more annoyed)
• DMDD includes frequent severe temper outbursts that happen three or more times per week and it lasts for 12 months or longer
• It only has to be at at home but has to be at least between two or more settings
• It is caused by deep-seated depression, emotional component, aversion to authority
• Mood stabilizers help the mood if they really do have problems regularly and then there are disruptive behaviors of childhood adolescence

Additional Information regarding ODD, Conduct disorder and managing all of the above

• If people have ODD then the best way to reinforce them is with positive reinforcements
• ODD is associated with authority, being told no, and things like that
• Management must be CBT for emotional regulation and when you start to include stimulants
• People with DMDD are those who have anger outbursts and then they are just angry
• Unlike ODD ODD doesn't really have that emotional component it would just be mostly an aversion to authority
• Conduct disorder is associated with aggressiveness to people and animals, destruction of property and deceitfulness
• If you have conduct disorder then it will carry over to being thrown into prison or even on death row
• Conduct disorder needs multi systemic therapy, community based interventions, group and family therapies
• Is not guaranteed to cure but maintainable with abilify/risperidone, just really depends on their situations
• Lower ages for stimulants would be like H5 and above, you can start them really young
• DLPA-2 is the clonidine and the gloxine for impulsivity, and atypical for hyperactivity
• Risperidone and Abilify, we kind of went over this already
• First line would be SSRIs for irritability and mood symptoms
• Risperidone and abilify help those with hyperaggression
• Do mood stabilizers for emotional regulation
• Atypical antipsychotics as first-line adjuncts

Treating Mental Health conditions with Medications

• Treatment depends on diagnosis and how well that assessment was, it's imperative to treat it correctly
• Trauma focused CBT remains first and primary treatment
• Medication that is uses as adjunctively for managing symptoms and when the stress is severe
• If going down to medication rout, the first line should be SSRIs (sertraline, fluoxetine is Prozac)
• The indications are PTSD symptoms, depressive symptoms, anxiety, and prozac
• Prozac isn't particularly studied like a lot of other medications with child and adolescent psychiatry because its unethical
• Prozac is indicated in even eating disorders, more well studied and it can regulate mood and anxiety with the increase of serotonin and or serotonin
• Side effects of any medication you should tell a patient is GI upset
• Prozac is more stimulating one of the other ones
• Prozac may be moved taken at night if it does make you tired (take lyosopro and zoloft)
• Major side effects include Gl upset like nausea, diarrhea, and stomach discomfort, usually subsides in a couple of weeks
• You must educate patients, and you can become suicidal, and you can have thoughts about hurting yourself
• SSRI use among the public had suicide rates go up but its all about educating patients
• If you start and you stop and you are at the starting rate it will resolve quickly
• Fluoxetine has the strongest evidence of youth PTSD, or they all said
• In medical do the life threatening conditions, stabalize that first to the mood
• And then you can all Proaz too, or if you can all be low-dose
• Clonidine is used for hyperarousal symptoms and its to slow them down
• Alpha-2 agonists are like buffers for children that are on edge, emotional dysregulation, sleep
• Regular chlonodine as a sleep aid may be used, not cafefine
• In the mechanism of Ashton reduces noreprhine over activity
• Clonodine helps ADHD as well, and you have to tell the patients they should be on the medication for 2 weeks and there wont a result or a side effect or improvement
• Both of them are both cardia medications too, base of which
• Fluoxetine or Lexipro should be used during pregnancy (SSRIs)
• Fluoxitience is FDA approved for 8 and older
• If the patient is 12 years or younger then you may want to use lexipro, but it is just a starting point
• There would be some GI, Headache, insomnia

Additional Medication side effects

• The most severe black box is icnreased suiciditiy, in young kids 35 years old and younger Adjunct medication called viliffy came out it also works for patients with treatment resistance depression
• Could do 2 milligrams to potentiate the SSRI
• Side effects, we all learn about with treatment you will get Atypical
• Weight gain, metabolic syndrome, sedation
• Bupropion and Valbutrin is for depression with comorbid ADHD for this
• Side effect are lower for seziere disorders and people may become really hungry
• If the patient cant sleep or cant eat, then metazapine might help/remeron
• So if you are at risk for going into Mania then you should stabalize the mood first
• Idealy use lithium for monotherapy
• Lmethral and lithium are most of the time used
• A side effect of lithium it tremmors, weight gain, polyuria
• Lithium level is suppose to be 0.6-1.2 also monitor kidneys and thyroid
• Depakote is good for the acute and to help and enhance GABA Side effects of depakote are weight gain, sedation, liver damage All those levels should be recorded
• If a patient is has metabolic problems it my might not be for Abilify
• The patient keeps getting the prolactin elevated in that side effect then you want to change out risperidone
• Use stimulants if the patient has ADHD or other co-morbidities, if use can trigger manias
• Stimulates must be used with norepineephrine