1. A DIDACTIC TRAINING FOR REGIONAL CENTER PSYCHIATRISTS
EFFICIENT PRACTICES FOR TREATING THE DEVELOPMENTAL DISABLED WITH MENTAL ILLNESS
A DIDACTIC TRAINING FOR REGIONAL CENTER PSYCHIATRISTS
PRESENTED BY:
ALMA FAMILY SERVICES
Carlos Muralles, M.D.
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

2. DEVELOPMENTAL DISABILITIES (DD): DEFINITION
Diverse cluster of individuals with chronic barriers related to mental and/or physical conditions with severe impairment in their level of functioning. The areas must common affected is with their daily life activities such as independent living, mobility, self care and direction, language- communication, socio-economical self assistance, learning and relational- interaction with others.
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

3. HISTORY OF DD Derogatory Connotations
Past Forms Society Dealt with DD Population
Asylums
18th-19th century: Large organizations providing basic needs
1952: Development of workshops for Special Ed Teachers as well as Day Camps
1960: Elimination of asylums
1970: “The Developmental Disabilities Service and Facilities Construction Act of ”
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

4. CLASSIFICATION: MENTAL RETARDATION
Significant subaverage intellectual functioning: an IQ of 70 or below on an individually administered IQ test
MILD (50 –55 to 70)
MODERATE (35–40) to (50-55)
SEVERE (20-25) to (35-40)
PROFOUND (<20) to 20
M.R. severity NOS (clinically MR unable to be tested)
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

5. CLASSIFICATION: PERVASIVE DD
AUTISM SPECTRUM DISORDERS
RETT’S DISORDER
CHILDHOOD DESINEGRATIVE DISORDER
ASPERGER’S DISORDER
PERVASIVE DEVELOPMENTAL DISORDER NOS
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

6. CLASSIFICATION: NEUROPHYSIOLOGICAL
CEREBRAL PALSY
SEIZURE DISORDERS
HEARING LOSS/DEAF & MUTE
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

7. CONCOMITANT FACTORS LEARNING D/O  FEEDING AND EATING D/O
MOTOR SKILL D/O  TIC D/O
COMMUNICATION D/O  ELIMINATION D/O
ATTENTION DEFICIT D/O  OTHER DISORDERS OF INFANCY,
DISRUPTIVE BEHAVIOR D/O CHILDHOOD OR ADOLESCENCE
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

8. ETIOLOGY UNKNOWN. Efforts to track the disorders are inconclusive
Believed that both genetic and environmental factors play a role
Some disorders are more common with the existence of certain medical conditions
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

9. EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES
The risk of DD in a child increases 4-15 x’s if one of the parent’s has traits or suffers from the same condition
MENTAL RETARDATION:
Familial Pattern: None; this is due to its heterogeneous etiology
Prevalence: 1% of the population
Ethnic, cultural and linguistic background: Reflected in standardized test
Ratio in Gender: Male to Female : 1.5:1
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

10. EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES
MENTAL RETARDATION (cont..)
MILD: “Educable”; 85% of MR population
MODERATE: “Trainable”; 10% of MR population
SEVERE: 3-4% of MR population
PROFOUND: 1-2% of MR population
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

11. EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES
AUTISTIC DISORDER
Familial Pattern: among siblings of individuals w/ DO: 5%
Median Prevalence Rate: 5 cases per 10,000 individuals
(*note: cases range from 2-20 cases / 10,000 individuals)
Ethnic, cultural and linguistic background: None that is specific
Male to female ratio: 4-5:1
Females more likely to exhibit profound MR
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

12. EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES
RETT’S DISORDER
Familial Patterns: Similar to AD; 5% correlation for individuals who have a sibling with d/o
Higher association with Severe and Profound MR
Prevalence: less common than AD
Ratio in Gender: Almost exclusively in females
(1 in every 10,000-20,000 females
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

13. EPIDEMIOLOGY: FAMILIAL, CULTURAL AND GENDER PATTERNS AND FEATURES
CHILDHOOD DISINTEGRATIVE DISORDER
Termed as “Heller’s Sx”, “Dementia Infantillis”, “Disintegrative Psychosis”
Familial Pattern: No information
Prevalence: Very rare and much less than AD
Conditions appear to be underdiagnosed
Ratio in Gender: Equal (+0)
ASPERGER’S SYNDROME
Familial Pattern: Depressive D/O and AD among siblings of individuals with AS
Prevalence: Unknown
Ratio in Gender: Male to Female: 5:1
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

14. Reflected I standardized test 1.5:1 Mild: 85% Moderate: 10%
CONDITION
FAMILIAL PATTERN
PREVALENCE
CULTURAL/ETHNIC
GENDER RATIO
(M to F)
DEGREE
M.R.
None
1-3%
Reflected I standardized test
1.5:1
Mild: 85%
Moderate: 10%
Profound: 1-2%
AUTISTIC D/O
5% (among siblings)
5 per 10,000
No specific criteria
4-5:1
No criteria
RETT’S D/O
5% (as in AD)
Less common than AD
Almost exclusively in females
CHILDHOOD D.D.
No information
Rare; Less than AD
(+0)
equal
ASPERGER’S D/O
Depressive D/O and AD among siblings
Unknown
5:1
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

15. SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS
SYMPTOMS OF AUTISM
Impairment in social interaction
Non use of nonverbal bx
No development of age appropriate peer relationship
Lack of spontaneous interest or seeking to share enjoyment
No social or emotional reciprocity
Impairment in communication
Delay or total lack of development of spoken language
Inability to initiate or sustain conversation
Idiosyncratic language
Lack of play or social activities
Restricted, repetitive and stereotyped play
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

16. SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS
SYMPTOMS OF RETT’S DISORDER
Initial Developmental Hx:
Normal prenatal and perinatal development
0-5 months: Normal psychomotor development
Normal circumference at birth
Onset of Sx After Normal Development
5-48 months: Deceleration of head growth
Loss of previously acquired purposeful hand skill & development of stereotyped hand movements
Loss of social engagement
Poor coordinated gait or trunk movements
Impaired excessive & receptive language
Severe psychomotor retardation
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

17. SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS
SYMPTOMS OF CHILDHOOD DISINTEGRATIVE DISORDER
Regression in various areas of functioning after age 2
Verbal/Non-verbal, language, social, play and adaptive bx
is normal
After age 2 (-10 yrs):
Loss of clinically and qualitative former acquired skills:
Bowel or bladder control
Motor skills
Expressive or receptive language
Social and adaptive bx’s
Play
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

18. SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS
SYMPTOMS OF ASPERGER’S DISORDER
Qualitative Impairment in social interaction
Impairment in the use of nonverbal bx
Failure to develop peer relationships
Lack of spontaneity or emotional reciprocity
Restricted repetitive and stereotyped patterns of bx
Disturbance causes clinical interference with social occupation and functioning
No clinical significant delay in language
No delay in cognitive development, self help skills or adaptive
behavior
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

19. SYMPTOMS AND DX FEATURES OF DD AND PSYCHIATRIC CONDITIONS
SYMPTOMS OF PERVASIVE DEVELOPMENTAL DISORDER N.O.S.
Severe and pervasive Impairment in the development of reciprocal social interaction
Associated with impairment in either verbal or nonverbal communication
Presence of stereotyped behaviors, interests, and activities
Does not meet criteria for
Pervasive Development D/O, Schizophrenia, Schizotypal P.D., Avoidant Personality D/O or “atypical autism”
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

20. CONCOMITANT FACTORS LEARNING DISORDERS MOTOR SKILLS DISORDERS
READING DISORDER
MATHEMATICS DISORDER
DISORDER OF WRITTEN EXPRESSION
LEARNING DISORDER NOS
MOTOR SKILLS DISORDERS
Development Coordination Disorder
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

21. CONCOMITANT FACTORS COMMUNICATION DISORDERS ATTENTION DEFICIT DISORDER
Language Disorder
Mixed Receptive Expressive Language Disorder
Phonological Disorder
Stuttering
Communication Disorder NOS
ATTENTION DEFICIT DISORDER
Hyperactive Type
Combined Type
Predominantly Inattentive Type
Predominantly Hyper-Impulsive Type
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

22. CONCOMITANT FACTORS DISRUPTIVE BEHAVIOR DISORDER CONDUCT DISORDER
Childhood-Onset Type
Adolescent-Onset Type
Unspecified Type
OPPOSITIONAL DEFIANT DISORDER
DISRUPTIVE BEHAVIOR DISORDER NOS
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

23. CONCOMITANT FACTORS FEEDING AND EATING DISORDERS TIC DISORDERS
Pica
Rumination Disorder
Feeding Disorder of Infancy or Early Childhood
TIC DISORDERS
Tourette’s Disorder
Chronic Motor or Vocal Tic Disorder
Transient Tic Disorder
ELMINATION DISORDERS
Encopresis: With or Without Constipation and Overflow Incontinence
Enuresis: Not Due to a General Medical Condition: Nocturnal Only; Diurnal Only; Nocturnal & Diurnal
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

24. OTHER DISORDERS OF INFANCY, CHILDHOOD OR ADOLESCENCE
SEPARATION ANXIETY DISORDER
SELECTIVE MUTISM
REACTIVE ATTACHMENT DISORDER
Infancy: Inhibited or Disinhibited Type
Early Childhood: Inhibited or Disinhibited Type
STEREOTYPIC MOVEMENT DISORDER
With or Without Self Injured Behaviors
DISORDER OF INFANCY, CHILDHOOD OR ADOLESCENCE NOS
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

25. SENSORY IMPAIRMENT OR DEPRIVATION
HEARING LOSS
DEAF
MUTISM
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

26. MENTAL DISORDER AND DD DUE TO GENERAL MEDICAL CONDITION
CATATONIC DISORDERS DUE TO GENERAL MEDICAL CONDITION
PERSONALITY CHANGE DUE TO GENERAL MEDICAL CONDITION
Labile Type
Disinhibited Type
Aggressive Type
Apathetic Type
Combined Type
Unspecified Type
Other Type
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

27. PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS
CEREBRAL PALSY (CP)
DEFINITION
An abnormality of motor function (the ability to move and control movements) that is acquired at an early age, usually less than a year of age, and is due to a brain lesion that is non-progressive.
Result of abnormalities that occur in utero
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

28. PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS
CEREBRAL PALSY (CP)
CHARACTERISTIC SYMPTOMS
Spastic paresis of the limbs (both children and adults)
Choreoathetoid movement disorder: Chorea & Athetosis
Unequal size of hands and feet
Frequent MR
Seizure disorder
Impairment of senses
Visual: Strabismus, Myopia Blindness
Auditory: Deafness
Vocal Dysarthria
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

29. PERVASIVE DEVELOPMENTAL DISORDER DUE TO NEUROLOGICAL DISORDERS
CEREBRAL PALSY (CP)
VARIETIES OF CELERBRAL PALSY
SPASTIC (70%)
Subcategories
Diplegic (25%): paresis of both legs; suffers from seizures and MR
Hemiplegic (50%): paresis of arms and legs; suffers from seizures and MR
Quadriplegic (75%): paresis of all limbs; suffers from seizures and MR
EXTRAPYRAMIDAL (15%):
Choreoathetosis and involuntary writhing of the face/tongue, hands and feet punctuated by jerking momvemnts; 10% Seizure D/O and MR
MIXED FORMS OF CP (15%)
Combination of spastic para paresis and choreoathetosis
Highest incidence (95%0 of seizure and MR
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

30. SEIZURE DISORDERS CLASSIFICATION PARTIAL OR FOCAL SEIZURES
1. Partial Seizures with Elementary Symptomatology
Also called “motor seizures”
Rhymic jerking
Possible development of focal status or secondary generalization
Post-ictal monoparesis
Tod’s Hemiparesis
Possible sensory sx (auditory, visual or olfactory hallucinations)
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

31. SEIZURE DISORDERS CLASSIFICATION PARTIAL OR FOCAL SEIZURES
2. Partial Seizures with Complex Symptomatology
Also called “Psychomotor and Temporal Lobe Seizure D”
Characterized by automatisms
Never occurs without accompanying loss of awareness
Includes: swallowing, kissing, lip smacking, fumbling, scratching, etc.
Utter or mutter brief phrases unintelligibly
May suffer from visual hallucinations (macropsia and micropsia), delusions, déjà-vu dream like states, mind-body dissociations
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

32. SEIZURE DISORDERS CLASSIFICATION GENERAL SEIZURE DISORDERS
Absences or Petit Mal
Occurs in 1-10 second lapses; almost all cases are accompanied by automatisms
Blinking occurs rhythmically at 3 Hz
Children’s mental and physical activity is affected (although they do not have retrograde amnesia and maintain tone and bladder control)
Following the ictus, there is no confusion, agitation or sleepiness
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

33. SEIZURE DISORDERS CLASSIFICATION TONIC-CLONIC OR GRAND MAL
Causes massive motor activity and profound postical residua
Pt’s may experience prodrome of malaise or mood change
Tonic Phase: Pt’s loose consciousness; eyes roll upward, neck, trunk and limbs all extend backwards
Clonic Phase: Limbs, neck and trunk are wracked by violent jerks
Postictal period may include confusion, disorientation, irrationality, agitation, amnesia and cognitive impairment…may last for several hours
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

34. ADDIONAL ASSOCIATED FEATURES AND DISORDERS: PHYSICAL & GENERAL FINDINGS
PHYSICAL FINDINGS
MEDICAL CONDITION
NEURO
CONDITION
M.R.
M.R
None; ONLY if assoc with specific syndrome
Increase w/ severity in visual, auditory & cardiovascular
Increases w/ severity (i.e., seizures)
N/A
AUTISM
Nonspecified
More prominent when assoc w/ other neuro-med condtion
Nonspecified; 25% seizure
d/o present
Most cases are assoc with MR
RETT’S
Assoc w/ seizure d/o
Severe / profound
ASPERGER
No cognitive or language delay in 1st yrs; motor clumsiness; over-activity & inattention are frequent
Generally none; some mild noted in school years
CHILD-
HOOD DD
Metachomatic, leukodystrophy, Schilder’s
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

35. ADDITIONAL ASSOCIATED FEATURES AND DISORDERS: LABORATORY FINDINGS
MENTAL RETARDATION
Other than psychological testing (WAIS-III=Wechsler Adult Intelligence Scale & WISC-III=Wechsler Intelligence Scale for Children) there ARE NO lab findings uniquely assoc w/ MR
AUTISTIC DISORDER
Reports of groups differences in measures of serotonergic activity exist; these are not diagnostic criteria for AD; No specific pattern noted in EEG
RETT’S DISORDER
NO specific findings associated; Increased frequencies of EEG and seizure d/o may exist; Abnormalities in brain imaging have existed
CHILDHOOD DISENTEGRATIVE
Increased frequencies of EEG abnormalities and seizure d/o; Lab findings reflect any assoc general med conditions
ASPERGER’S D/O
Lab findings reflect any assoc general med conditions
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

36. COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE
POOR IMPULSE CONTROL
Frequently related to poor tolerance to frustration
This is often manifested by:
Outburst of anger
Explosive violent and aggressive bx towards others
If more impaired/severe DD, increased likelihood of self injurious bx
Lack of communication skills may predispose individual to disruptive, aggressive or impulsive bx
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

37. COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE
RANGE OF BEHAVIORAL SX
Hyperactivity
Short attention span
Temper tantrums (mostly seen in young population)
ODD RESPONSES TO CONDUCT
Talking to self to keep conduct w/out ability to confirm auditory hallucinations
Close imaginary friends
Confabulation without being delusional
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

38. COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE
SPEECH
Mode of speech and associations are usually repetitive, echolalic and perseverant with the same theme or statement
Tone may be loud, without being irritated or demonstrating any aggressive behavior
ODD RESPONSES TO INTERNAL STIMULI
High threshold for pain and fever (Autistic D/O)
Oversensitivity to loud sounds or being touched
Reactions to light and odors
Fascination with certain moving objects
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

39. COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE
ABNORMALITIES IN EATING PATTERNS
Hyperphagos
Limiting diet to select foods
Pica
Nocturnal eating
ABNORMALITIES WITH SLEEPING HABITS
Recurrent awakening at night w/ unusual bx’s (i.e. rocking in Autistic D/O)
Recurrent naps during the day
Awakening at night with nightmares
Insomnia or hyperinsomnia
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

40. COMMON DENOMINATORS/FEATURES FOUND TO CO-EXIST IN DD POPULATION IN MY PROFESSIONAL EXPERIENCE
FEAR RESPONSES
Lack of or over response to danger/harmless objects
SELF-INJURIOUS BEHAVIORS
Head-banging (autistic), finger/hand/wrist-biting
MOOD CHANGES
Higher level of functioning indiv have tendency to become depressed or dysphoric
Some develop vegetative or autonomic sx
Concomitant factors often lead to demoralization, low self-esteem and deficit in social skills
Excitement is often shown by incongruent affect: weeping or giggling
Intrusive bx or hyperactivity is often seen w/out having a diagnosis of Bipolar D/O
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

41. COURSE OF THE CONDITIONS
MENTAL RETARDATION
Influence of course is underlined by: medical condition and environmental factors
Mild MR:
If dx earlier, manifested by failure in academic learning tasks
May be appropriate to train
May be able to acquire good adaptive skills
Diagnosis required bf age 18 months
Etiology and associations with syndromes may help for early detection (i.e. Down Syndrome)
Mild MR of unknown origin is recognized later
More severe MR resulting from acquired cause will develop more abruptly (i.e. encephalitis)
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

42. COURSE OF THE CONDITIONS
AUTISTIC DISORDER
Follows a continuous course
Language skills and intellectual level are strongest factors for prognosis
School aged children and adolescents:
Developmental gain in some areas (increased interest in social functioning)
Some deteriorate behaviorally during adolescence; others improve
A small % of these individuals live and work independently
1/3 achieve partial independence
Even the highest functioning adults exhibit problems in social interactions and communication along with markedly restricted interest in activities
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

43. COURSE OF THE CONDITIONS
RETT’S DISORDER
Duration is lifelong
Loss of skills is persistently progressive
Communicative bx difficulties remain constant throughout life
Recovery is very limited
Gains (if any) will be in social interaction during adolescence
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

44. COURSE OF THE CONDITIONS
CHILDHOOD DISINTEGRATIVE DISORDER
Disorder follows continuous course
Duration is lifelong
Social, communicative and bx difficulties remain constant throughout life
ASPERGER’S DISORDER
Most cases are lifelong
Motor difficulties will be more apparent in the context of school
Some adults may have problems with empathy and modulations of social interaction
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

45. DIFFERENTIAL DIAGNOSIS
MENTAL RETARDATION
Learning D/O
Communication D/O
Pervasive Developmental D/O
Dementia
Borderline Intellectual Functioning (IQ Range: 71-84)
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

46. DIFFERENTIAL DIAGNOSIS
AUTISTIC DISORDER
Other Pervasive Developmental D/O (Rett’s D/O)
Childhood Disintegrative D/O
Asperger’s D/O
Schizophrenia
Selective Mutism
Expressive Language D/O
Mixed Receptive-Expressive Language D/O
Stereotype Movement D/O
Mental Retardation
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

47. DIFFERENTIAL DIAGNOSIS
RETT’S DISORDER
Autistic D/O
Childhood Disintegrative D/O
Asperger’s D/O
CHILDHOOD DISINTEGRATIVE DISORDER
Other Pervasive Developmental D/O
Rett’s D/O
Demential
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

48. DIFFERENTIAL DIAGNOSIS
ASPERGER’S DISORDER
Pervasive Developmental D/O
Schizophrenia
Autistic D/O
Rett’s D/O
Childhood Disintegrative D/O
Obsessive-Compulsive D/O
Schizoid Personality D/O
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

49. DIFFERENTIAL DIAGNOSIS: SIMILARITIES FOUND
MENTAL RETARDATION
AUTISTIC
D/O
RETT’S
CHILD-HOOD D.D.
ASPERGER’S D/O
Childhood DD X
Autistic D/O
Rett’s D/O
Pervasive DD
Other Pervasive DD
Schizophrenia
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

50. ASSESSING THE CHIEF COMPLAINT
W H Y N O W ?
PRECIPIATATING FACTORS
Change of routine
Moving environment
Separation from parents
Death in the family
Traumatic event
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

51. ASSESSING THE CHIEF COMPLAINT
MEDICAL EVENTS
Current medical condition/illness
Substance use: past and present
Any recent medication prescribed
NON-COMPLIANCE WITH TREATMENT
Abruptly halt with medication
Change of psychotropic medication
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

52. ASSESSING THE CHIEF COMPLAINT
HISTORY OF CHIEF COMPLAINT
Data base
Onset of Symptoms
Description of chronological symptoms and events
Awareness/suspicion of precipitant factor
Psychiatric History
Hospitalizations
Medications: past & recent
Best response to medication
Side effects from other medication
Change of Psychosocial Environment
Current Mental Status Examination
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

53. DYNAMIC FORMULATION
Summary of current data base with summary of chronological symptoms and its evolution with specific rationalization for specific criteria and specific diagnosis.
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

54. CONCLUSIVE CRITERIA FOR DIAGNOSIS ACCORDING TO DSM-IV-TR
RULE IN (R/I) With specific Code
RULE OUT (R/O) in a specific amount of time
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

55. TREATMENT PLAN AND RECOMMENDATIONS
IN-PATIENT TREATMENT
Voluntary
Involuntary
OUT-PATIENT TREATMENT
Individual Psychotherapy
Supportive & Short-term
Cognitive-Behavioral
Family Interventions (Educational & Support Groups)
PSYCHOPHARMACOTHERAPY
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

56. PSYCHOPHARMACOTHERAPY
INDICATIONS FOR ANTIPSYCHOTICS
Primary treatment of psychotic conditions
POSITIVE SYMPTOMS
Hallucinations, delusions, incoherence, disorganized/catatonic bx
NEGATIVE SYMPTOMS
Flat affect, alogia abolition, anhedonia
Bizarre or erratic bx
Agitation, aggressive/assaultive bx
Odd response to sensory stimuli
Stereotypical motor movement, repetitive self-stimulatory bx
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

57. ANTIPSYCHOTIC DRUGS (TYPICAL, TRADITIONAL)
ALIPHATIC CHLORPROMAZINE:
THORAZINE
PIPERAZINE:
FLUPHENAZINE=PROLIXIN (HCL-DECANOATE)
TRIFLUOPENRAZINE= STELAZINE
PHERPHENAZINE=TRILAFON
PIPERIDINE:
THIORIDAZINE= MELLARIL
MESORIDAZINE
THIOXANTHENES:
THIOTHIXENE= NAVANE
DIBENZOXAPINES:
MOLINDONE= MOBAN
BUTYROPHENONES:
HALDOPERIDOL= HALDOL
BENZYMIDES:
SULPIRIDE
RAWLPHIA ALKALOID:
RESERPINE
CLOZARIL:
CLOZAPINE
ZYPREXA:
OLANZEPINE
SEROQUEL:
QUETIAPINE
RESPERIDAL:
RISPERIDONE
GEODON:
ZIPRASIDONE
ABILIFY:
ARIPIPRAZOLD
INVEGA:
PALIPERIDOL
ANTI-PSYCHOTIC DRUGS (TYPICAL TRADITIONAL)
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

58. PSYCHOPHARMACOTHERAPY
INDICATIONS FOR ANTIDEPRESSANTS
Abnormalities in appetite and eating disorders
Anorexia or limiting diet to a few foods
Anergia
Anxiety
Dysphoria
Irritability
Phobias
O.C.D.
Enuresis
Sleeping Disorders; insomnia, Nightmares
Recurrent awakening at night
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

59. TRICYCLIC & TETRACYCLICS: TOFRANIL= IMPIPRAMINE
ANTI-DEPRESSANTS
TRICYCLIC & TETRACYCLICS:
TOFRANIL= IMPIPRAMINE
SURMONRIL= TRIMIPRAMINE
PAMELOR= NORTRIPTYLINE
ASENDIN= AMOXEPIN
LUDIOMIL= MAPROTILINE
UNICYCLIC ANTIDEPRESSANTS:
BUPROPION= WELBUTRIN
TRIAZOLOPYRIDINE DERIVATIVES:
TRAZADONE/ALPRAXZOLAM
SSRI:
FLUOXETINE
PAROXETINE
CITALOPRAM
ESCITALOPRAM
SERTRALINE
FLUVOXAMINE
SNRI:
VENLAFAXINE, DULOXATIN, SYMBIAX
NDRI:
BUPROPION
MULTI MODE:
MIRTAZAPINE
SARI:
NEFAZODONE
MONOAMINE OXIDASE INHIBITORS:
PHENELZINE
HYDRAZINE
NARDIL
PARNATE
COMBINTION:
FLUOXETINE/OLANZEPINE
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

60. PSYCHOPHARMACOTHERAPY
INDICATIONS OF MOOD STABALIZERS
Mood disorders
Mood swings
Irritability
Poor impulse control disorders
Aggressive/assaultive behaviors
Agitation
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

61. PSYCHOPHARMACOTHERAPY
MOOD STABLIZERS
PRIMARY
ADJUNCTIVE
LITHIUM
THYROXINE
DIVALPROEX
CLONAZEPAM
CARBAMAZEPINE
LORAZEPAM
ECT (BILATERAL)
PSYCHOTHERAPY
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

62. REFRACTORY BILPOLAR PATIENTS: RATIONAL OPTIONS WITH LITTLE OR NO DATA
MOOD STABILIZERS
REFRACTORY BILPOLAR PATIENTS: RATIONAL OPTIONS WITH LITTLE OR NO DATA
ANTICONVULSANTS
HORMONES
1. GABAPENTIN
1. ESTROGEN/PROGESTERONE
2. LAMOTRIGINE
3. TOPIRAMATE
4. TIAGABINE
5. ACETAZOLAMIDE
ADRENERGIC BLOCKING AGENTS
PRECURSORS
1. CLONIDINE
1. TRYPTOPHAN
2. PROPRANOLOL
2. CHOLINE
3. GUANFACINE
CALCIUM CHANNEL BLOCKERS
VERAPAMIL
2. NIFEDIPINE
3. NIMODIPINE
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

63. PSYCHOPHARMACOTHERAPY
INDICATIONS FOR ANTICONVULSANTS
Seizure Disorder: Tonic, Clonic, Motor or Focal Mood Disorders
Aggressive Disorder
Poor Impulse Control Disorder
Self Injurious Behavior
Explosive Behaviors
Assaultive Behaviors
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

64. CLORAZEPATE DIPOTASSIUM PHENYTOIN DIAZEPAM PHENYTOIN SODIUM
ANTICONVULSANTS
ACETAZOLAMIDE SODIUM
OXCARBAZEPINE
CARBAMAZEPINE
PHENOBARBITAL
CLONAZEPAM
PHENOBARBITAL SODIUM
CLORAZEPATE DIPOTASSIUM
PHENYTOIN
DIAZEPAM
PHENYTOIN SODIUM
DIVALPROEX SODIUM
PHENYTOIN SODIUM (EXTENDED)
ETHOSUXIMIDE
PRIMIDONE
FOSPHENYTOIN SODIUM
TIAGABINE HYDROCHLORIDE
GABAPENTIN
VALPORATE SODIUM
LAMOTRIGINE
VALPROIC ACID
LEVETIRACETAM
ZONISAMIDE
MAGNESIUM SULFATE
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

65. PSYCHOPHARMACOTHERAPY
INDICATIONS FOR ANXIOLITICS
Muscle Relaxants
Anesthetics
Anticonvulsants
Hypnotic agents
Anti-Anxiety agents
Automic symptoms agents
Anti-hypertensive agents
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

66. PSYCHOPHARMACOTHERAPY
ANXIOLITCS: BENZODIAZEPINES
DIAZAPAM:
VALIUM
CLORODIZAEPOXIDE:
LIBRIUM
FLURAZEPAM:
DALMANE
PRAZEPAM:
CENTRAX
CLORAZEPATE:
TRANXENE
TEMAZEPAM:
RESTORIL
CLONAZEPAM:
KLONOPIN
LORAZEPAM:
ATIVAN
ALPRAZOLAM:
XANAX
OXAZEPAM:
SERAX
TRAIZOLAM:
HALCION
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

67. PSYCHOPHARMACOTHERAPY
ANXIOLITICS: HYPNOTICS BENZODIAZEPINES
ESTAZOLAM:
PROSOM
QUAZEPAM:
DORAL
ZOLPIDEM:
AMBIEN
ZALEPION:
SONATA
ANXIOLITICS: OTHER ANTI-ANXIETY AGENTS
BUSPIRONE:
BUSPAR
HYDROXYZINE:
ATARAX, VISTARIL
DIPHENEHYDRAMINE:
BENADRYL
PROPRANONOL:
INDERAL
ATENOLOL:
TENORMIN
CLONIDINE:
CATAPRES
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

68. PSYCHOPHARMACOTHERAPY
INDICATORS FOR STIMULANTS
Appetite Suppressants
Sleeplessness Agents
Paradoxical ADD Agents
None responsive depression
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

69. PSYCHOPHARMACOTHERAPY
PSYCHO-STIMULANTS
AMPHETATIVE DERIVATIVES
METHYLPHENIDATE
METHYLPHENIDATE SR
DESTROANPHETAMINE
PEMOLINE
ALPHA AND B ALPHA
MODAFINIL
RITALIN
CONCERTA
METADATE
DEXEDRINE
CYLERT
ADDERALL
PROVIGIL
ANTI-DEPRESANTS
ATOMOXETIN HCL
BUIPROPION
STRATERRA
WELLBUTRIN
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

70. PSYCHOPHARMACOTHERAPY
INDICATION OF OTHER MEDICATIONS
NARCOTIC ANTAGONIST
Naltrexone (trexan): Self Injurious behavior
BETA BLOCKERS: PROPANOLOL
Explosive and range behavior, phobias
CALCIUM BLOCKERS
Aggressive behavior, depression
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

71. INTERVIEWING TECHNIQUES
SCREENING FOR DEVELOPMENTAL AND HEALTH CONDITIONS
Aim is to identify the existence and probabilities of an exhibiting delay or abnormal development in the early stages (in children) or current stages (in adults)
Such screening will detect biological problems (PKU-Fragil X syndrome, Sickle Cell A. etc.)
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

72. INTERVIEWING TECHNIQUES
DIAGNOSTIC ASSESMENT FOR DD
The aim is to conclusively determine whether an individual has an existing delay, disability and/OR special needs
This will identify the individual and family strengths as well as possible strategies for intervention
Diagnostic assessment should be based on multiple types of data obtained from multiple sources and team players or disciplines
DIAGNOSTIC ASSESMENT FOR INDIVIDUAL PROGRAM PLANNING
This is done only after a decision is reached for early intervention
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

73. PROCESS OF INTERVIEWING FOR DD
ACKNOWLEDGEMENT
Acknowledgement of prior assessments and test results
Referral
PARENTAL/CARE GIVER PARTICIPATION
Tone of working relationship
OBSERVATION
Formal or informal observations
SETTING
Free from stress; appealing environment for Pt
Can be formal or informal
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

74. PROCESS OF INTERVIEWING FOR DD
GROUND-WORK FOR INTERVENTION
Address directly the affected individual and caregiver
This is done according to the appropriate level of functioning; may be done conjointly or individually
The willingness for either individual or conjoint assessment must be considered
Confidentiality issues must also be considered
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.

75. PROCESS OF INTERVIEWING FOR DD
INTERVENTION
To proceed with the interview process, I:
Introduce myself or other participant(s) involved with the interview
Explain the purpose of the interview
Explain the need of Consent of Information with the involved caregiver and/or individual
Explain the expected outcome, impression and possible diagnosis with the the caregiver and individual at the end of collecting data
Discuss possible alternatives of tx and resources available
Explain the pros/cons, risks and non risks of interventions
Carlos A. Muralles, M.D.
Carlos A. Muralles, M.D.