Common Mental Disorders

Among Adolescents:
Diagnosis & Management

Eleonor E. Sanchez, M.D.

Child and Adult Psychiatry
Adolescence
Adolescence

Psychological Changes
1. acceleration of cognitive development
2. consolidation of personality formation
Psychological Changes:
Biopsychosocial Factors
1. Biological
A. Hormonal
B. Neurobiological/physiological
2. Psychological
A. Brain Function
B. Psychological tasks
3. Social demands/consequences
Biological
Neurobiological Changes
• Marked changes in the brain
synaptic connections 
“pruning”
• maturational changes in
prefrontal, mesocortical &
limbic areas
Connections that are
reinforced by environment are
retained
Biological
“Raging Hormones” Theory
• Influence in the brain:
low estrogen (e.g. PMS)  depression
high testosterone  aggression & impulsivity

• Association of hormones on development

of psychological problems is less
compared with influence of social factors
Psychological
Changes in Brain Functions

1. Intellectual Abilities
or Way of Thinking
(Piaget: Formal
Operations Stage)
- More abstract
- Ability to construct
“contrary to fact”
propositions
Psychological
Changes in Brain Functions

2. Shifts in the
executive functions
of the brain:
• Motivation
• Attention
• Inhibition
• Emotion
Psychological
Normal Psychological Tasks

1. Satisfactory & realistic body image

2. Independence
3. Satisfying relationships outside the
family
4. Appropriate control & expression of
drives
5. Identity consolidation
Social Demands/Consequences

Peer pressure
Academic demands
More mature responsibility
Conflicts in the family
“Normal” Psychological Problems

Changes in brain functions

Increased sensitivity to
normative stressors of adolescence

Psychological Problems
Mental Disorders
In Adolescence
Mental Disorders in Adolescence

1. Adjustment Disorder
2. Eating Disorders
3. Oppositional Defiant Disorder
4. Conduct Disorder
5. Impulse Control Disorders
Mood Disorders

1. Depressive Disorders
2. Anxiety Disorders
vs. “Normal” Depression of Adolescence &
Anxious Reactions
significant impairment in social and
academic functioning
Adjustment
Disorder
Adjustment Disorders

- most frequently diagnosed in adolescents

- common precipitating stressors:
school problems
parental rejection and divorce
substance abuse
Adjustment Disorders: DSM-IV-TR
A. Emotional & behavioral symptoms in response
to an identifiable stressor occurring within 3
months of the onset of stressor
B. Clinically significant as evidenced by the ff:
1. Marked distress that is in excess of what wld
be expected from exposure to stressor
2. Significant impairment in functioning
Adjustment Disorders: DSM-IV-TR
C. Not meet criteria for another mental disorder
D. Not bereavement
E. Once stressor is terminated, symptoms do not
persist for more than an additional 6 months
Subtypes:
with depressed mood
With anxiety
with mixed anxiety and depressed mood
with disturbance of conduct
with mixed disturbance of emotion & conduct
Adjustment Disorders: Treatment

1. Psychotherapy
2. Crisis Intervention
3. Pharmacotherapy - Benzodiazepine
Body Image
equated to
Self-Concept
Eating
Disorders
Eating Disorders

1. Anorexia Nervosa
2. Bulimia Nervosa
Anorexia
Nervosa
Anorexia Nervosa
DSM-IV-TR
• Refusal to maintain body weight (BM) at or
above a minimally normal weight for age &
height (e.g. weight loss or failure to make expected
weight gain  less than 85% of expected BW)
• Intense fear of gaining weight or becoming fat
even though underweight
Anorexia Nervosa
DSM-IV-TR
C. Disturbance in the way in which one’s BW or
shape is experienced,
undue influence of BW or shape on self-
evaluation,
denial of the seriousness of the current low
BW
Anorexia Nervosa
DSM-IV-TR
D. In postmenarcheal females, amenorrhea, i.e.
absence of at least 3 consecutive menstrual
cycles
Anorexia Nervosa
DSM-IV-TR
Types:
Restricting type: person has not regularly engaged
in binge-eating or purging behavior (i.e. self-
induced vomiting or the misuse of laxatives,
diuretics or enemas)
Binge-eating/purging type: has regularly engaged
in binge-eating or purging behavior
Anorexia Nervosa
Medical Complications
Related to weight loss
Neuroendocrine: reduced thyroid metabolism
Cachexia
Cardiac: arrhythmia, bradycardia
GIT: abdominal pain, delayed gastric emptying
Hematological: leukopenia
Skeletal: osteoporosis
Anorexia Nervosa
Medical Complications
Related to purging
Metabolic: electrolyte imbalance
GIT: gastric & esophageal erosion, pancreatic
inflammation
Dental: Erosion of the enamel
Neuropsychiatric: seizure, mild neuropathies
Anorexia Nervosa
Management
Multimodal, comprehensive treatment approach
Medical and Psychiatric treatment
In-patient or Outpatient
Anorexia Nervosa
Management
The decision to hospitalize is based on the
patient’s medical condition & the amount of
structure needed to ensure patient
cooperation
Patient who are:
20% below expected weight for height
 inpatient program
30% below  psychiatric hospitalization for 2
to 6 months
Anorexia Nervosa
Management
Psychotherapy
1. Individual therapy
2. Family therapy
Anorexia Nervosa
Management
Pharmacotherapy
- case to case basis
• Antidepressant - with comorbid depression
• Cyproheptadine (antihistaminic/antiserotonergic)
- Restricting type
Bulimia
Nervosa
Bulimia Nervosa
Diagnosis: DSM-IV-TR
A. Recurrent episode of binge-eating
(characterized by both of the ff:)
• eating, in a discrete period of time (w/in 2-
hour period) an amount of food that is larger
than most people would eat
• A sense of lack of control over eating during
the episode
Bulimia Nervosa
Diagnosis: DSM-IV-TR
B. Recurrent inappropriate compensatory
behavior in order to prevent weight gain, such
as self-induced vomiting; misuse of laxatives,
diuretics, enemas, or other meds; fasting or
excessive exercise.
Bulimia Nervosa
Diagnosis: DSM-IV-TR
C. Binge eating & compensatory behaviors both
occur, on average, at least twice a week for 3
months.
D. Self-evaluation is unduly influenced by body
shape & weight.
E. Disturbance does not occur exclusively during
episodes of anorexia nervosa.
Bulimia Nervosa
Diagnosis: DSM-IV-TR
Types:
Purging type: regularly engaged in self-induced
vomiting or the misuse of laxatives, diuretics &
enemas
Nonpurging type: has used other compensatory
behaviors, e.g. fasting or excessive exercise,
but NOT self-induced vomiting, use of
laxatives
Bulimia Nervosa
Management
Most patients work well on OUT PATIENT
management
Indications for admission/hospitalization:
3. Suicide
4. Medical complication
Bulimia Nervosa
Management
1. Psychotherapy
a. Individual therapy
b. Family therapy
2. Pharmacotherapy
a. Antidepressant – SSRI, Tricyclics
Independence
Identity
 Oppositional
Defiant Disorder
Oppositional Defiant Disorder
(ODD)
- begin as early as 3 years old and not later than
adolescence
- Boys > girls - prepubertal
male = females among adolescents
- parents overly concerned with issues of power,
control and autonomy
- most do not later meet criteria for Conduct D/O
- most children who develop Conduct D/O have
previous history of ODD
Oppositional Defiant Disorder:
DSM-IV-TR
A. Pattern of negativistic, hostile & defiant behavior
lasting for 6 months with 4 or more of the ff:
Often..
1. Loses temper
2. Argues with adults
3. Actively defies or refuses to comply with
adults’ requests or rules
4. Deliberately annoys people
Oppositional Defiant Disorder:
DSM-IV-TR
Often...
5. Blames others for his mistakes
6. Touchy or easily annoyed by others
7. Angry and resentful
8. Spiteful or vindictive
Oppositional Defiant Disorder:
Treatment
1. Family intervention - teaching child
management skills to parents
2. Individual psychotherapy for the adolescent
Cognitive-Behavioral Therapy
 Control of
Sexual and Aggressive
Drives
Conduct Disorder
Conduct Disorder

- enduring set of behaviors that evolves over time,

characterized by aggression & violation of rights
of others
- associated with ADHD, depression & learning d/o
- age of onset:
boys: 10 - 12 y/o
girls: 14 - 16 y/o
- More common among boys
Conduct Disorder: DSM-IV-TR

A. 3 or more of the ff in the past 12 months, with at

least one criterion present in the past 6 months:
Aggression to people & animals
1. Often bullies, threatens or intimidates others
2. Often initiates physical fights
3. Used a weapon that can cause physical harm
4. Physically cruel to people
Conduct Disorder: DSM-IV-TR

Aggression to people & animals

5. Physically cruel to animals
6. Stole while confronting a victim
7. Forced someone into sexual activity
Destruction of property
8. Engaged in fire setting with intention of
causing damage
9. Deliberately destroyed other’s property
Conduct Disorder: DSM-IV-TR
Deceitfulness or theft
10. Broke into someone else’s house, car
11. Often lies to obtain goods or avoid obligation
12. Stolen nontrivial items w/o confronting victim
Serious violation of rules
13. Often stays out at night despite parental
prohibitions beginning before 13 years old
14. Ran away from home overnight at least twice
15. Often truant from school before age 13
Conduct Disorder: Treatment

Multimodal Treatment
1. Behavioral modification
2. Parental psychiatric evaluation & management
3. Liaison with school for consistency of
management
4. Individual psychotherapy
Conduct Disorder: Treatment

5. Pharmacotherapy - for overt explosive

aggression
a. low dose antipsychotics - Risperidone,
Haloperidol
b. mood stabilizers - Lithium
c. SSRI - Fluoxetine, Sertraline, Paroxetine
 Control of
Sexual and Aggressive
Drives
Impulse Control
Disorders
Impulse Control Disorders

Impulse - disposition to act to decrease heightened

tension
Impulse Control Disorders
1. Intermittent Explosive Disorder
2. Kleptomania
3. Trichotillomania
 Intermittent
Explosive Disorder
Intermittent Explosive Disorder:
DSM-IV-TR
A. Several discrete episodes of failure to resist
aggressive impulses that result in serious
assaultive acts or destruction of property.
B. Degree of aggressiveness expressed during the
episodes is grossly out of proportion to any
precipitating psychosocial stressors.
C. Not accounted for by other mental disorders
Intermittent Explosive Disorder:
Treatment
1. Psychotherapy - individual and group
2. Pharmacotherapy
Mood stabilizers - Lithium, Divalproex, Valproate
Antipsychotic - Haloperidol, Risperidone
SSRI - Fluoxetine, Sertraline
Kleptomania
Kleptomania: DSM-IV-TR

A. Recurrent failure to resist impulses to steal

objects that are not needed for personal use or
for their monetary value.
B. Increasing sense of tension immediately before
committing the theft.
C. The stealing is not committed to express anger
or vengeance and is not in response to a
delusion or hallucination
Kleptomania: Treatment

1. Psychotherapy
2. Behavior Therapy
3. Pharmacotherapy
Mood Stabilizers - Lithium, Valproic Acid
SSRI - Fluoxetine, Sertraline
Trichotillomania
Trichotillomania: DSM-IV-TR

A. Recurrent pulling of one’s hair resulting in

noticeable hair loss.
B. An increasing sense of tension immediately
before pulling out the hair or when attempting to
resist the behavior.
C. Pleasure, gratification or relief when pulling out
the hair.
Trichotillomania: Treatment

1. Liaison with dermatologist

2. Behavior Therapy
3. Hypnotherapy
4. Pharmacotherapy
SSRI – Sertraline, Fluoxetine
Pathologic Gambling
Pathologic Gambling: DSM-IV-TR
A. Persistent & recurrent maladaptive gambling
behavior as indicated by five (or more) of the
following:
1. Preoccupation with gambling
2. Need to gamble w/ increasing amount of money
3. Unsuccessful efforts to control gambling
4. Restless or irritable when attempting to cut down or
stop gambling
Pathologic Gambling: DSM-IV-TR

A. Persistent & recurrent maladaptive gambling

behavior as indicated by five (or more) of the
following:
1. Gambling as a way of escaping from problems or
relieving a dysphoric mood
2. After losing money, returns another day to get even
3. Lies to family or others to conceal extent of
involvement in gambling
Pathologic Gambling: DSM-IV-TR

A. Persistent & recurrent maladaptive gambling

behavior as indicated by five (or more) of the
following:
1. Committed illegal acts e.g. forgery, theft to finance
gambling
2. Significant impairment in job, educational & social
functioning
3. Relies on others to provide money to relieve a
desperate financial situation
Pathologic Gambling: DSM-IV-TR

B. Not better accounted for by a manic episode

Pathologic Gambling: Treatment

1. Individual Psychotherapy
2. Family Therapy
3. Pharmacotherapy?
* Only a few seek therapy. They are usually seen
for a comorbid psychiatric problem or when
bound with legal difficulties
Pyromania
Pyromania: DSM-IV-TR

A. Deliberate & purposeful fire setting on more

than one occasion.
B. Tension or affective arousal before the act.
C. Pleasure, gratification or relief when setting
fires, or when witnessing or participating in its
aftermath.
Pyromania: DSM-IV-TR

A. Not done for monetary gain, as an expression

of sociopolitical ideology, to conceal criminal
activity, to express anger, to improve one’s
living circumstances, in response to a delusion
or hallucination or as a result of impaired
judgment.
B. Not better accounted for by other mental
disorder
Pyromania: Treatment

1. Behavior Therapy
2. Family Therapy
Dealing with Adolescents
 Dealing with Adolescents
1. Understand the issue behind changes and
appropriately address it
2. Differentiate between normal and abnormal
behavior
3. Differentiate between the controllable and the
uncontrollable
4. Validate the feeling but set limits for
unacceptable and destructive behaviors
5. Take time to LISTEN!
Thank you