Osler Institute Child & Adolescent Psychiatry Review
Drug interactions are ubiquitous
• Only rarely an absolute contraindication
Drug-drug interactions in • Only one of many factors involved in
prescribing decisions
psychopharmacology
• More critical examples include: lithium,
Shauna P. Reinblatt, MD nortriptyline, monoamine oxidase
Johns Hopkins University inhibitors, pimozide, carbamazepine,
ketoconazole
Examples of particular
Other relevant factors
relevance
• Age • Unexplained mental status changes
• Gender • Clinical deterioration
• Hepatic or renal disease
• Refractoriness to standard treatment
• Smoking
• Extreme or erratic drug plasma levels
• Alcohol use
• Diet and nutritional status • Issues with drug absorption, serum protein
• Compliance
binding, altered elimination
• Genetic polymorphisms
Useful drug interactions Categories of drug interactions
• Naloxone (Narcan) for opiate overdose • Idiosyncratic – rare, unpredictable,
• Flumazenil (Romazicon) for unexpected from pharmacokinetic and
benzodiazepine overdose pharmacodynamic properties
• Bethanechol (Urecholine) for • Pharmacodynamic
anticholinergic side effects (urinary
retention) • Pharmacokinetic
• Anticholinergics for antipsychotic induced
extrapyramidal symptoms
Reinblatt_Clinical Psychopharmocolgy 1
Osler Institute Child & Adolescent Psychiatry Review
Pharmacodynamic Pharmacodynamic examples
• Known direct effects at biologically active • CNS depression from alcohol,
receptor sites that do not involve an benzodiazepines and/or barbiturates
alteration in drug plasma levels • Cardiac conduction delays from quinidine-
• May be additive, synergistic, or like effects ie low potency antipsychotics
antagonistic and tricyclic antidepressants
• Anticholinergic toxicity from drugs sharing
antimuscarinic properties
Pharmacodynamic examples Pharmacokinetic interactions
• Hypotension with alpha-1-adrenergic • Involve a change in the plasma level
blockade and/or tissue distribution of drugs, rather
– Antidepressants – trazodone, imipramine than their pharmacological activity.
– Low potency and atypical antipsychotics – • Mediated by effects on
clozapine, olanzapine – Absorption
– Interference with dopamine agonist or – Distribution
precursor for Parkinson’s disease or – Metabolism
hyperprolactinemia by an antipsychotic – Excretion
Children compared with adults Absorption issues
• Greater hepatic capacity • Accelerated gastric emptying
• More glomerular filtration – Metaclopramide (Reglan)
• Less fatty tissue • Diminished gastrointestinal motility
• Therefore more rapid elimination of – TCA’s, morphine, canabis
stimulants, antipsychotics, TCAs, lithium • Binding to other drugs
• Shorter half-life of meds in children – Cholestyramine (Questran), charcoal, kaolin-
pectin, non-absorbable fats
• Higher mg/kg dosing is usually required
Reinblatt_Clinical Psychopharmocolgy 2
Osler Institute Child & Adolescent Psychiatry Review
Absorption issues Distribution issues
• Altered gastric pH • Regional blood flow
– Aluminum hydroxide, magnesium hydroxide, • Lipophilicity
sodium bicarbonate, potentially altering the
non-polar, un-ionized fraction of drug • Amount of drug bound to tissue and
available for absoption plasma proteins
• inhibition of gastric or intestinal enzymes • Adipose to lean body mass ratio
resulting in elevated concentration of
substrate
– Monoamine oxidase – tyramine
Competition for protein-binding
Minimal protein binding
sites
• Most psychotropic drugs are highly • Lithium
protein-bound at 80% to 90% to albumin, • Gabapentin
alpha-1-acid glycoproteins, or lipoproteins • Topiramate
• Effects usually have no practical • Oxcarbazine
significance because of offset by rapid
redistribution to sites of metabolism • venlafaxine
Effects on transport to tissue Interference with metabolism
• Amino acids competing with l-dopa for • Phase I
protein carrier across blood-brain barrier – Oxidation, reduction, hydrolysis
• Phase II
– Glucuronidation and acetylation resulting in
highly polar, water-soluble metabolites
suitable for renal excretion
Reinblatt_Clinical Psychopharmocolgy 3
Osler Institute Child & Adolescent Psychiatry Review
Exceptions Metabolic enzymes
• Benzodiazepines (lorazepam, oxazepam, • Cytochrome P450 isoenzymes
temazepam, and clonazepam undergo – Inducing agents produce gradual decline of
only Phase II substrate level
– Inhibitors produce abrupt elevations over
• Lithium, gabapentin, and amantadine are hours to days of blood levels and levels fall
excreted by the kidneys without hepatic rapidly upon discontinuation
biotransformation • Flavin-containing monoxygenases
(FMOs), N-acetyltransferase,
glucuronyltransferases,
methyltransferases, and sufotransferases
Renal excretion Cytochrome P450 isoenzymes
• Lithium interactions • Over 30
• Emergency management • Located in the endoplasmic reticulum of
– Enhanced excretion of weak bases such as hepatocytes and GI tract and brain
PCP and amphetamines by acidification of • 1A2
urine with ammonium chloride
• 2C
– Enhanced excretion of weak acids such as
tricyclic antidepressants and barbiturates with • 2D6
acetazolamide • 2A3/4
2D6 polymorphisms 1A2 substrates
• 2D6 • Acetaminophen, aminophylline, caffeine,
– 7-10%Caucasians are poor clozapine, haloperidol, olanzapine,
metabolizers phenacetin, procarcinogens, ropinirole,
– 1-3% A-A or Asian tertiary tricyclic antidepressants,
theophylline
– Have higher baseline concentrations of
substrate, lower concentration of
metabolites, and little effect from
inhibitors or inducers
Reinblatt_Clinical Psychopharmocolgy 4
Osler Institute Child & Adolescent Psychiatry Review
1A2 2C
• Inhibitors • Substrates
– Fluoroquinolones (Cipro), fluvoxamine, – Barbiturates, diazepam, NSAIDS, propranolol,
grapefruit juice tertiary TCA’s, THC, tolbutamide, warfarin
• Inducers • Inhibitors
– Fluoxetine, fluvoxamine, ketoconazole,
– Cigarette smoking, omeprazole (Prilosec), omeprazole, oxcarbazepine, sertraline
charbroiled meats
• Inducers
– rifampin
2D6 Substrates 2D6 Inhibitors
• Amoxetine (Strattera), beta-blockers • Antimalarials, bupropion, duloxetine,
(lipophilic), codeine, donepezil (Aricept), fluoxetine, methadone, moclobemide,
dextromethorphan, encainide, flecainide, paroxetine, phenothiazines, protease
haloperidol, hydroxycodone, inhibitors (ritonavir), quinidine, sertraline,
phenothiazines, risperidone, aripiprazole, TCAs, yohimbine
SSRIs, TCAs, tramadol (Ultram)
• Inducers ?
3A3/4 Substrates 3A3/4
• Alprazolam, amiodarone, aripiprazole, • Inhibitors
buspirone, calcium channel blockers, – Ketoconazole, verapamil, cimetidine,
carbamazepine, clozapine, cyclosporine, fluvoxamine, grapefruit juice, erythromycin,
diazepam, disopyramide, estradiol, nefazodone
lidocaine, lovastatin, loratadine,
• Inducers
methadone, midazolam, quetiapine,
sildenafil, simvastatin, tertiary TCAs, – Carbamazepine, oxcarbazepine,
triazolam, warfarin, zaleplon (Sonata), phenobarbital, phenytoin, rifampin, St. John’s
ziprasodone, zolpidem (Ambien) wort
Reinblatt_Clinical Psychopharmocolgy 5
Osler Institute Child & Adolescent Psychiatry Review
PSYCHOTROPIC SIDE
Developmental Considerations
EFFECTS
• Developmental Issues • Increased renal clearance
• Medications • Hormonal changes during puberty
• Contraindications • Increased hepatic metabolism
• Interactions
• Side effects
• Important notes
Stimulants: Stimulants
• ADHD in children and adolescents • Contraindications:
• ADHD in adults (Adderall) – Hypersensitivity
• Narcolepsy – Cardiac abnormalities
– Active psychosis
– MAOI treatment
Others off label…
– glaucoma
Side Effects
• Irritability, dysphoria, GI distubance, • Concerns re: clonidine and
insomnia, increased heart rate, decreased methylphenidate? …
appetite, ?tics
• Sudden death risk (Adderall)-Risks when
personal or family history of cardiac
problems esp long QTc.
Reinblatt_Clinical Psychopharmocolgy 6
Osler Institute Child & Adolescent Psychiatry Review
Atomoxetine
• Rebound • Indicated kids 6 years and over for ADHD
• Headache • Contraindication: Narrow Angle Glaucoma
• Irritability • Somnolence, fatigue, decreased appetite,
• Tics weight loss
• Warnings: hepatic injury and suicidality
Tricyclic antidepressants
• Indications: ADHD, OCD, Enuresis • Sudden cardiac death in children with
• Contraindication: MAOI desipramine- 7 cases. (Ref; Varley,
• Relative: Pregnancy, cardiac problems, CK(2001) Pediatric Drugs 3(8) 613.
thyroid conditions Several of the children had family history
of cardiac problems
Alpha Adrenergic Agents –
TCAs and Cardiac Monitoring
Clonidine and Guanfacine
• Baseline EKG and blood pressure, pulse • ADHD, Tourettes, tics (all off label)
and repeat with increased dose and every • Contraindication: cardiac problems, renal
three months. or liver disease
• Side effects: Sedation, hypotension,
dizziness, abdominal pain
Reinblatt_Clinical Psychopharmocolgy 7
Osler Institute Child & Adolescent Psychiatry Review
Mood stabilizers Lithium
• Lithium • Indication: Acute mania nad prophylaxis
• Valproate over 12 yrs
• Carbamazepine • Side effects: weight gain, psoriasis,
• Lamotrigine enuresis, polyuria, polydipsia,
hypothyroidism.
• Gabapentin
• Narrow therapeutic window.
• Topiramate
• Ebstein’s abnormality in pregnancy
• Toxicity symptoms…coarse tremor
Lithium Lithium
• Increased lithium level • Increased antithyroid effect
– Thiazide diuretics, ACE inhibitors, NSAIDS • Check calcium (PTH)
(except sulindac, aspirin), metronidazole, • Neurotoxicity (rare)
spectinomycin, tetracycline – Antipsychotics, calcium channel blockers,
carbamazepine, methyldopa
• Decreased lithium level
• Prolonged neuromuscular blockade
– Aminophylline, theophylline, acetazolamide,
– Succinylcholine, pancuronium
sodium bicarbonate, sodium chloride, osmotic
diuretics (mannitol, urea) • Serotonin syndrome (rare)
– SSRIs, serotonergic TCAs, tramadol, venlafaxine
Valproate
• Informed consent re: medication • Indications in adults: migraines, partial
interactions, ex. No NSAIDs, careful seizures, mania or mixed episodes
hydration, inform of new medications. • Side Effects: nausea, sedation, inc.
appetite, hair loss, black box warnings for
hepatotoxity and pancreatitis
• Polycystic ovary disease
Reinblatt_Clinical Psychopharmocolgy 8
Osler Institute Child & Adolescent Psychiatry Review
Valproate Valproate
• Increased valproate levels • Inhibited metabolism of co-administered
– Aspirin (increased unbound levels), agents
cimetidine, erythromycin, ibuprofen, – Lorazepam, oxazepam, tempazepam,
phenothiazines diazepam, LAMOTRIGINE, carbamazepine,
phenobarbital, tolbutamide, warfarin, AZT
• Decreased valproate levels
– Carbamazepine, phenobarbital, phenytoin,
rifampin
Carbamazepine Carbamazepine
• No indication in children, in adults • Increased carbamazepine levels
indicated for acute manic and mixed – Valproate (active CBZ-E metabolite), P450
episodes 3A4 inhibitors, antifungals, macrolide
antibiotics, calcium channel blockers,
• Cytochrome P450 interactions and
fluvoxamine, grapefruit juice, isoniazid,
autoinduction nefazodone, protease inhibitors
• Hyponatremia
• Black box agranulocytosis
Carbamazepine
• Decreased carbamazepine levels • Carbamazepine– autoinduction after
– Carbamazepine (autoinduction), several weeks
phenobarbital, phenytoin, primidone
– Hyponatremia
• Induced metabolism of co-administered
agents
– Anticonvulsants (phenytoin, lamotrigine,
valproate), antidepressants, antipsychotics,
benzodiazepines, cyclosporine,
glucocorticoids, methadone, oral
contraceptives, warfarin
Reinblatt_Clinical Psychopharmocolgy 9
Osler Institute Child & Adolescent Psychiatry Review
Effects of P450 inhibition Effects of P450 inhibition
• Antihistamines (astemizole, loratidine) 3A4 • Codeine
• Antipsychotics – Metabolized by 2D6 into active (morphine)
– 1A2 clozapine, olanzapine, haloperidol metabolite
– 2D6 risperidone, phenothiazines • Secondary TCAs
– 3A4 quetiapine – Metabolized by 2D6
• Benzodiazepines • Tertiary TCAs
– 2C diazepam
– Metabolized by 1A2, 2C, 2D6, 3A4
– 3A4 triazolam
2D6 Serotonin syndrome
• Most inhibition • Myoclonus
– Fluoxetine, paroxetine, duloxetine • Hyperreflexia
• Moderate inhibition • Nausea
– Sertraline • Hyperthermia
• Autonomic instability
• Negligible inhibition
• Agitation
– Citalopram, escitalopram
• Delirium
• Coma
Serotonin Syndrome TCA interactions
• Monoamine oxidase inhibitors • Increased TCA levels
– Methylphenidate, SSRIs
– Remember Demerol
• Decreased TCA levels
• Lithium – Carbamazepine, phenobarbital, phenytoin
• Serotonergic agents • Prolonged cardiac conduction
– Type I antiarrhythmics, low potency antipsychotics,
CCBs
• Hypotension
– Antihypertensives, antipsychotics, trazodone
Reinblatt_Clinical Psychopharmocolgy 10
Osler Institute Child & Adolescent Psychiatry Review
Antipsychotic interactions Antipsychotic interactions
• Increased antipsychotic levels • Decreased absorption - antacids
– Inhibitors of 1A2, 2D6, 3A4 including • Prolonged cardiac conduction
fluoxetine, paroxetine, fluvoxamine, – CCBs, TCAs, P450 inhibitors
nefazodone, bupropion, duloxetine, • Hypotension – TCAs, trazodone
fluoroquinolones, macrolides, antifungals • Anticholinergic toxicity
• Decreased antipsychotic levels • Interference with dopaminergic effects
– Lipophilic betablockers, carbamazepine, • Additive risk of myelosuppression
phenobarbital, phenytoin – Carbamazepine, AZT with clozapine
Antipsychotic interactions Antipsychotic interactions
• Pimozide (Orap) 3A4 • Quetiapine and ziprasidone are 3A4
– Dangerous arrhythmia potential substrates
• Clozapine, olanzapine, haloperidol 1A2 – Concentration increased by erythromycin
– Inhibited by Luvox, Cipro – Concentration decreased by carbamazepine
– Induced by omeprazole, cigarette smoking • Aripiprazole substrate of 3A4 and 2D6
• Phenothiazines are both substrates and – Increased by fluoxetine
inhibitors of 2D6 – Decreased by carbamazepine
Neuroleptic Malignant Concerns with Atypical
Syndrome Antipsychotics
• CPK elevation • Metabolic syndrome
• Neuroleptics • EPS
• Autonomic instability • Tardive dyskinesia
• Delirium • Hyperprolactinemia
• Febrile • Cardiac
• Dantrolene
Reinblatt_Clinical Psychopharmocolgy 11
Osler Institute Child & Adolescent Psychiatry Review
Cardiac Anxiolytic pharmacodynamics
• Montior baseline and when raise • Additive CNS depressant effects
mediation. – Barbiturates
• Caution with QTC> =450! – Antihistamines
– TCAs
or high HR – Antipsychotics
Or elevated PR or QRS – Antiepileptic drugs
– Hypnotics – zolpidem, zaleplon, Lunesta
Monitor – alcohol
Anxiolytic pharmacokinetics Anxiolytic pharmacokinetics
• Antacids may delay absorption • 3A3/4 inhibitors – macrolides, antifungals,
• Phase I inducers (CBZ, PHB) may lower nefazodone, fluvoxamine, grapefruit juice
blood levels except lorazepam, oxazepam, may increase levels of alprazolam,
and temazepam triazolam and midalozam
• Valproate inhibits glucuronide conjugation • 2C inhibitors – omeprazole, ketoconazole,
increasing levels of lorazepam, oxazepam, fluoxetine, fluvoxamine, sertraline, may
and temazepam increase levels of diazepam
St. John’s wort induces 3A4 Methylphenidate
• Cyclosporine • Inhibits metabolism of
• Antiretrovirals
• Anticoagulants – SSRIs
• Theophyllinge
• Digoxin – TCAs
• Oral contraceptives
– anticonvulsants
Reinblatt_Clinical Psychopharmocolgy 12
Osler Institute Child & Adolescent Psychiatry Review
Modafinil (Provigil) Atomoxetine (Strattera)
• Induces 3A4 • Substrate of 2D6
• May lower level and effectiveness of oral • Metabolism is inhibited by fluoxetine,
contraceptives paroxetine, bupropion
Cholinesterase inhibitors Codeine
• Rivastigmine (Exelon) has no P450 aspect • Substrate of 2D6 which converts it into its
active form (morphine). Diminished
• Galantamine (Rasadyne) and donepezil analgesic effect if co-administered with
(Aricept) are substrates for 2D6 and 3A4 2D6 inhibitor
but do not induce or inhibit P450
Disulfiram (Antabuse) SSRIs
• Inhibits any array of enzymes interfering • Indications:
with the metabolism of a variety of drugs – MDD- Fluoxetine
– OCD: Clomipramine, Fluoxetine, Flv,
sertraline
– SIDE EFFECTS: include GI, headache, and
behavioral activation
– Suicidality black box warning- extended til mid
20’s re: increased risk of suicidality 4X vs. 2X
in placebo in pooled data
Reinblatt_Clinical Psychopharmocolgy 13
This page was intentionally left blank.
Osler Institute Child & Adolescent Psychiatry Review
Adjustment Disorder def.
• An adjustment disorder is a psychological response to
an identifiable stressor or stressors that results in the
development of clinically significant emotional or
behavioral symptoms.
ADJUSTMENT DISORDERS • The symptoms must develop within 3 months after the
onset of the stressor(s).
• Clinical significance of the reaction is determined by
either marked distress in excess of what would be
Shauna P. Reinblatt, MD expected given the nature of the stressor or by
significant impairment in social, occupational, or
academic functioning.
• A normal or expectable reaction to a stressor can
qualify as an adjustment disorder if the reaction is
sufficiently severe to cause significant impairment.
• The stressor may be single or multiple, recurrent or • The DSM-IV also recognizes that the patient’s
continuous, minor or severe, common or unique – in vulnerability is as important to symptom
short, the stressor need only be a psychosocial event
that precedes the symptoms and that the patient and/or
production as is the exact stressor
therapist views as stressful and responsible for the • The disturbance must be something other than
symptoms. “one instance of a pattern of overreaction to
• The maladaptive reaction must be severe enough to stress” or an exacerbation of another mental
impair school (or work) performance, hinder social illness.
activities or interpersonal relationships, and/or be in
“excess of a normal and expectable reaction to the • Adjustment disorder = age independent, defined
stressor(s).” primarily by its symptom picture rather than by
age
Classification Classification
• Adjustment disorder is a specific diagnosis, not a • DSM-III (1980) renamed this category
nebulous category. adjustment disorder and required that specific
objective criteria be met to make the
• The current DSM-IV diagnosis is a refinement of a diagnosis. The DSM-III also defined 8
number of similar diagnoses developed over the years
and called reactive, transient, situational, and adjustment subtypes based upon symptom patterns,
disorders. excluded very minor symptom pictures as
well as psychotic reactions (reclassified as
• The Group for the Advancement of Psychiatry brief psychotic reactions), and removed the
Committee on Child Psychiatry (GAP) in 1966 used developmental stage (age) requirement.
reactive disorder to describe a generally (but not With minor variations, this is the classification
exclusively) transient disorder caused by an emotionally
traumatic event that reflected a conscious conflict in place today in DSM-IV.
between the child and his or her environment. The
DSM-II (1968) described a set of “transient situational
disturbances” .
Schwartz_Reinblatt_Adjustment
Disorders 1
Osler Institute Child & Adolescent Psychiatry Review
DSM-IV diagnostic criteria for
Caveats
adjustment disorders
• One of the most telling problems lies not with the • 1. The development of emotional or behavioral symptoms in
severity of the stressor but with its chronicity. response to an identifiable stressor(s) occurring within 3
months of the onset of the stressor(s).
• If a stressor is continuously present or frequently • 2. Symptoms are clinically significant as evidenced by the
recurrent, does the disturbance become something other following:
than an adjustment disorder after 6 months? • • Marked distress that is in excess of what would be
• Those patients with chronic symptoms due to ongoing expected from exposure to the stressor
stress who also do not meet criteria for another • • Significant impairment in social or occupational
diagnosis fit poorly within this nosology. (academic) functioning
• In addition, sometimes it is exceptionally difficult in the • 3. The stress-related disturbance does not meet the criteria
clinical situation to differentiate between a parent-child for another specific Axis I disorder and is not merely an
problem or uncomplicated bereavement and an exacerbation of a preexisting Axis I or Axis II disorder.
adjustment disorder. -- the severity of both stressors • 4. The symptoms do not represent bereavement.
and symptoms is continuous rather than discrete. • 5. Once the stressor (or its consequences) has terminated,
the symptoms do not persist for more than an additional 6
months
Types
• Adjustment disorders are coded based on the subtype,
• • Acute: if the disturbance last fewer than which is selected according to the predominant
6 months symptoms. The specific stressors(s) can be specified
on Axis IV.
• • 309.0 With depressed mood
• • 309.24 With anxiety
• • Chronic: if the disturbance lasts for 6 • • 309.28 With mixed anxiety and depressed mood
months or longer • • 309.3 With disturbance of conduct
• • 309.4 With mixed disturbance of emotions and
conduct
• • 309.9 Unspecified
With depressed mood -
• Differential diagnosis includes major • This diagnosis requires a predominance of
symptoms of depressed mood, tearfulness, and
depression, dysthymia, bipolar disorder feelings of hopelessness.
(depressed), uncomplicated bereavement, • The differential diagnosis is broad in that it
mood disorder 2e GMC. includes not only key mood disorders but also
• Considered by some to be the most uncomplicated bereavement, which can be
viewed as a variant of adjustment disorder –
common subtype among adults, serious depressive symptoms in response to the
• also common among children loss of a loved one that, however, are an
expected reaction to such a severe stress.
Schwartz_Reinblatt_Adjustment
Disorders 2
Osler Institute Child & Adolescent Psychiatry Review
With anxiety-
• Axis II disorders of the borderline and • differential diagnosis=
histrionic types, particularly in adolescents, – generalized anxiety disorder,
are likely to present with depressive – panic disorder,
symptoms and develop in an individual – post traumatic stress disorder
from a turbulent environment. – anxiety disorder 2e GMC
With disturbance of conduct
• Sx= nervousness, worry, and jitteriness. • Differential diagnosis includes conduct disorder,
oppositional-defiant disorder; child or adolescent
• Subsyndromal levels of anxiety are common antisocial behavior (V-code).
among children and certainly compose a major • This subtype requires the violation of the rights of others
portion of the differential diagnosis. Differential (eg, vandalism and fighting), and conduct-disordered
behavior such as truancy, reckless driving, and
of this subtype includes generalized anxiety defaulting on legal responsibilities.
disorder, panic disorder, PTSD, ASD, and • It is particularly common in adolescents but can also
anxiety disorder 2e GMC. occur in children. The primary differential, of course, is
with conduct disorder and oppositional defiant disorder
• With mixed anxiety and depressed but needs also to include the lesser degree of
mood - differential diagnosis includes mood and misbehavior found in the V Code category of childhood
anxiety disorders. or adolescent antisocial behavior. Limited evidence
suggests a poor prognosis in children who react to stress
with this behavior pattern.
With mixed disturbance of Prevalence
• . Between 2% and 8% in community samples of children and
emotions and conduct adolescents and the elderly.
• Differential diagnosis includes disruptive behavioral • It has been diagnosed in up to 12% of general hospital inpatients
disorders. The most likely differential is with the who are referred for a mental health consultation, in 10%-30% of
those in mental health outpatient settings, and in as many as 50%
combination of a conduct disorder and a full emotional in special populations that have experienced a specific stressor
disorder of some type. (eg, following cardiac surgery).
• Includes emotional and conduct manifestations. It is • Individuals from disadvantaged life circumstances experience a
presumably uncommon in adults but will find occasional high rate of stressors and may be at increased risk for the
use with children and adolescents. The most common disorder. (DSM-IV-TR, pg.681) The New York Longitudinal Study
pattern seems to be disordered behavior with a of Temperament notes that adjustment disorder was the primary
depressed mood, although other combinations are diagnosis in 40 of the 45 children in their study who developed a
possible. Few data are available about this condition. mental illness prior to 13 years of age. The majority of cases
occurred in the 3-5 age group, and mild cases predominated.
Although the number of afflicted children was small, the findings
• Unspecified - "wastebasket." This may include such are particularly significant since their sample flowed from a healthy
things as massive denial of illness, markedly regressed population that during the course of the study developed illness,
behavior, or a preoccupation with fantasies rather than from a self-selected population of psychiatric patients.
Thus their figure compares the relative frequency of children in the
general population who develop an adjustment disorder to those
who develop other mental illness.
Schwartz_Reinblatt_Adjustment
Disorders 3
Osler Institute Child & Adolescent Psychiatry Review
Etiology Course
• By definition, the disorder begins within 3 months of
• Vulnerability of the child is the most onset of a stressor and lasts no longer than 6 months
important factor in the development of an after the stressor has ceased.
• If the stressor is an acute event, the disturbance is
adjustment disorder. usually immediate and the duration relatively brief.
• • Type of stressor • If the stressor persists, the disorder may also persist.
The persistence of adjustment disorder or progression to
other, more severe mental disorders (eg, major
depressive disorder) may be more likely in children and
adolescents than in adults. This increased risk may be
attributable to the presence of co-morbid conditions (eg,
attention-deficit/hyperactivity disorder) or to the
possibility that the adjustment disorder actually
represented a subclinical prodrome manifestation of the
more severe mental disorder.
Three DSM-IV Disorders in
• Thirty percent of children with a significant new medical
diagnosis have one form of adjustment reaction Response to Stressors
• Adjustment disorders are likely most common childhood • Adjustment disorder
psychiatric diagnosis after conduct disorders. • 1. Described as the development of clinically significant,
• It is one of the most common psychiatric diagnoses for emotional or behavioral symptoms in response to an
patients hospitalized for medical or surgical problems, with as identifiable psychosocial stressor, (personal misfortune)
much as 30 %... within three months of the onset of the stress.
• • This condition is most frequently diagnosed in
adolescence but occurs at any age. • a. The stressor may be of any degree of intensity and
the degree of dysfunction does not appear to be related
• • Older studies suggest that 30% of children who suffer a directly to what the stressor is.
chronic medical illness develop psychological symptoms.
Thirty-three percent of children newly diagnosed with insulin- • b. The symptoms must, by definition, resolve within six
dependent diabetes are noted to develop an adjustment months of termination of the stressor.
disorder within the first three months. (Kovacs 1985) • g. Chronic stressors which may lead to chronic
• In community disasters over one-third of individuals display adjustment disorders include medical conditions that are
symptoms of adjustment disorders. ongoing and chronically disabling or a stressor of
enduring consequences, such as financial or emotional
difficulties resulting from their parent’s divorce.
Differential
• B. Post-traumatic stress disorders • Adjustment disorder with depressed mood
• 1. The differential diagnosis is between major
• • Require an extreme stressor for the depression, dysthymia or bipolar disorder,
diagnosis to be made, with fear of death depressed phase, or uncomplicated
etc. bereavement.
• C. Acute stress disorders • • Vegetative signs are not as prominent in
children and adolescents, specifically motor
• • Like the post-traumatic stress disorder retardation or weight loss or change.
requires an extreme stressor: extreme = • • Guilt is more typical in depressive disorders
fear of death etc. than in adjustment reaction.
Schwartz_Reinblatt_Adjustment
Disorders 4
Osler Institute Child & Adolescent Psychiatry Review
Bereavement Bipolar disorder
• Viewed by some as a variant of adjustment disorder, • There is often a familial loading [might also be present in
although the diagnosis of adjustment disorder is not to major depression].
be made in this circumstance.
• The children tend not to be normal between cycles.
Bereavement is generally diagnosed when the reaction
is an expectable response to the death of a loved one. • Pre-pubertal children may have school phobia and
The diagnosis of adjustment disorder, on the other hand, evidence of impaired concentration
may be made when the reaction is in excess of, or more • Adolescents appear irritable, aggressive, have increased
prolonged than, that normally expected. activity, loud speech, and suicidality; Unreasonable or
• Serious depressive symptoms as an expected reaction unpredictable explosive behavior In children, the loss of
to loss do not qualify for adjustment disorder. self-esteem and the presence of guilt is probably the
most helpful distinctions.
Other adjustment disorder
characteristics
• 1. In making the differential, assess whether symptoms • Some events which may lead to adjustment disorder:
reflect a consistent pattern of behavior over time, the Almost any event can lead to an adjustment disorder.
quality of the family relationships, and the presence of a Some of those that are notable include:
precipitating condition.
• • Foster placements
• 2. The differential diagnosis of adjustment disorders
also includes certain personality disorders, specifically • • Divorce of parents or break-up of family
borderline and hysterical personality. • • Menarche in female, onset of spermarch in male
• Look for specific ego deficits such as poor reality testing, • • Rejection in an interpersonal relationship
and inadequate development of age-appropriate defense
mechanisms. [These should be chronic and without the • • Parental problems and arguments within the
evidence of a specific stressor.] family
• • Birth of a new sibling
Miscellaneous Information Re:
Pharmacotherapy
Adjustment Disorders
• Drugs may be useful in treating the specific • Children tend to develop guilt for a personal illness. This
is most likely in children who have had no previous
symptoms; brief periods. All drug categories are experience with a serious illness or with younger children
applicable but particularly the antianxiety and who are likely to assume that the illness is a punishment.
Providing a child with explanations for the cause of an
antidepressant medications. Antipsychotic illness lessens the chance of this occurring.
medications may be useful for severe anxiety • The birth of a child with congenital defects presents the
and decompensation, and psychostimulant family with a crisis similar to a premature birth. Conflicts
may develop around the appearance of the baby and
medication may work for withdrawn or inhibited related social stigma.
states or children with comorbid ADHD. • Families experiencing early death of an infant would
benefit from interventions such as support groups, visual
and physical contact with the infant, ongoing
psychosocial follow-ups, and routine autopsy.
Schwartz_Reinblatt_Adjustment
Disorders 5
Osler Institute Child & Adolescent Psychiatry Review
• Even though some cases remit without intervention,
• Adolescents experience a greater amount of anxiety adjustment disorder is not a minor condition requiring no
compared to younger children related to medical treatment. It is painful for the patient and the patient’s
procedures and chemotherapy. A lack of protest family, likely to worsen if the illness and its underlying
regarding a procedure is not always synonymous with causes are not addressed, and often responsive to
the lack of distress. In children, the thing that helps most vigorous and appropriate treatment.
in coping with pain experience is the presence of a
parent. • Treatment begins with a thorough evaluation, including a
search for physical causes for any physical symptoms
• • Hospitalizations occurring from the 12th to 48th present. Because adjustment disorder can mimic so
month age are associated with later difficulty in adaptive many different psychiatric disorders, such other
functioning. conditions must be sought in the hope of finding a
• • Factors associated with increased risk for specific treatment for the child’s difficulties.
psychological morbidity in children following the death of • The next step is to remove the stressor, if possible.
a sibling include (a) loss that occurred when a child was
under 5 years of age or during early adolescence; (b) • The core of treatment typically centers around both
unanticipated death or deaths from suicide or homicide; working with the child individually to address his or her
and (c) lack of adequate family or community support. concerns and working with the family about many of the
same issues. The conceptual approach and techniques
• Increased risk of morbidity also include the loss of a used, of course, depend in part on the age of the child
mother for girls fewer than 11 years of age and loss of a and the therapist’s assessment
father for adolescent boys.
• Treatment generally should be brief and focused, with an
emphasis on the child’s adjustments to the difficulties he
or she has experienced. The stressor must not be
ignored, particularly if chronic; rather, the child should be
allowed (or encouraged) to express fear, dismay,
resentment, and anger.
• Avoid, except temporarily and for very well-determined
reasons, fostering regression or the hope of a magical
recovery. A supportive, problem-solving approach often
works well and individual therapy becomes
indispensable when the family is destructive or has few
resources upon which to draw.
• Because the family is bound up in so many of the
stressors faced by these children, family therapy is an
equally essential mode of intervention. The family should
be involved in any efforts at behavioral management and
environmental manipulation, if they can participate
constructively.
• Limited research in this area; treatment relies on clinical
judgment.
Schwartz_Reinblatt_Adjustment
Disorders 6
This page was intentionally left blank.
Osler Institute Child & Adolescent Psychiatry Review
Psychotherapy
Individual Psychotherapy in
• Individual
Children and Adolescents
• Group
• Family
Shauna Pencer Reinblatt, MD
Johns Hopkins University
Goals of Psychotherapy Focus of Treatment
• Reduction in Psychiatric symptoms • Cognitive functions: Thought disorders
• Treatment of underlying cause of • Affective functions: Emotional /Mood
symptoms problems
• Behavior functions: Compulsions
Psychodynamic psychotherapy Play therapy
• Unconscious conflict • Drawings
• Unbalanced id/ ego/superego • Toys
• Defense mechanisms • Psychodynamic, short term
• Transference/ countertransference
Reinblatt_Individual Psychotherapy 1
Osler Institute Child & Adolescent Psychiatry Review
Psychic Determinism Psychoanalytic treatment
• Individuals are unaware of unconscious • Role of unconscious factors affecting
factors that determine their emotions, current relationships and behavior
moods and behavior • Helps the individual to deal better with the
• We are all unconsciously controlled realities of adult life
Transference
• Patient unconsciously reenacts the past
significant relationship
Interpretation of Transference Countertransference
• Feelings, Emotions, Thoughts are • Psychiatrist develops Counter transference
encouraged in Therapy • Patient reminds the psychiatrist about someone
from his past
• Transference: Unconscious
• Countertransference is monitored internally by
• Interpretation makes it conscious for the the psychiatrist
patient and leads to recovery • Awareness of Countertransference prevents
Psychiatrist’s anti-therapeutic behavior/
response
Resistance Methodology: Psychoanalysis
• Patient’s attempt to oppose gaining insight • Typically, the patient comes four or five
and change times a week
• Represents a compromise between forces • Lies on a couch
of recovery and pathology • Not suitable for children and Adolescents
• Late for appointment • Fantasies, dreams, and fears reveal
• Silent in Sessions clinical data
• Non compliance
Reinblatt_Individual Psychotherapy 2
Osler Institute Child & Adolescent Psychiatry Review
Window to Unconscious “Defenses”:
Uncomfortable Unconscious material or Opposing forces prevent expression of
drives come out in indirect way: “Wishes”
Slip of tongue Denial
Fantasies Projection
Dreams.
Tripartite Structural Model of
Id
Freud
Id • Unconscious
Ego • Discharges tension
Superego • Aggressive drive
• Libidinal or sexual drive
Ego Superego
• Unconscious + Conscious • Policeman of psyche
• Unconscious contains Defenses • Moral Conscience: internalization of
• Conscious integrates information, parental or societal values
executes action and makes decision • Ego ideal: role model
Reinblatt_Individual Psychotherapy 3
Osler Institute Child & Adolescent Psychiatry Review
Ego Psychology Defenses
• Id has sexual and aggressive drives which • Part of Ego
want expression, but ego and superego • Defenses protect ego from sexual and
opposes their expression aggressive drives from id.
• Conflict produces anxiety
• Anxiety produces a defense
• Defenses lead to formation of psychiatric
symptoms
Defense: Repression Defense: Displacement
• Freud • Feelings, emotions are redirected to
• Expels unacceptable drives, wishes or another target
fantasies from conscious awareness • Angry at boss hits a dog on the street
• It produces distress “Conflict model”
• Explains Neurotic symptoms i.e. anxiety,
depression and Hysterical Neurosis (Loss
of strength in one arm)
Object Relations Theory Rapprochement
• Previous relationships leave mental • Between 16 to 24 months of age
representations of self and others • Realizes more separateness from the
• Drives emerge in context of a relationship mother
• Infant-mother relationship • Increased sense of vulnerability to
• Interpersonal relationships are internalized separations from mother
as self-object representations of
relationships • Checks back frequently with the mother
Reinblatt_Individual Psychotherapy 4