1. COMORBIDITY By Larry B. Silver, M.D.

2. THERE IS A CONTINUUM OF NEUROLOGICALLY-BASED DISORDERS THAT ARE OFTEN FOUND TOGETHER If any one of the disorders on this continuum is found, there is up to a 50 percent possibility that one or more of the disorders on this continuum will be found. If any one of the disorders on this continuum is found, there is up to a 50 percent possibility that one or more of the disorders on this continuum will be found. Thus, if any disorder on this continuum is found, it is important to explore for the other possible disorders. Thus, if any disorder on this continuum is found, it is important to explore for the other possible disorders.

3. THE CONTINUUM CORTEX-BASED DISORDERS CORTEX-BASED DISORDERS –Learning, Motor, Language Disorders –Organization, Executive Function Disorders ATTENTION-DEFICIT/HYPERACTIVITY DISORDER ATTENTION-DEFICIT/HYPERACTIVITY DISORDER EMOTIONAL “REGULATORY” DISORDERS EMOTIONAL “REGULATORY” DISORDERS –Anxiety Disorders –Depression –Anger-Control Disorders –Obsessive-Compulsive Disorder TIC DISORDERS TIC DISORDERS ??? BIPOLAR DISORDER ??? BIPOLAR DISORDER

4. DIAGNOSTIC CLUES THAT BEHAVIORS ARE NEUROLOGICALLY-BASED THERE IS A CHRONIC AND A PERVASIVE HISTORY OF THE CLINICAL PROBLEMS. THERE IS A CHRONIC AND A PERVASIVE HISTORY OF THE CLINICAL PROBLEMS. THERE OFTEN IS A FAMILY HISTORY OF THE CLINICAL PROBLEMS

5. CORTICAL-BASED DISORDERS CORTICAL-BASED DISORDERS LEARNING DISABILITIES LEARNING DISABILITIES LANGUAGE DISABILITIES LANGUAGE DISABILITIES MOTOR DISABILITIES MOTOR DISABILITIES

6. ATTENTION DEFICIT HYPERACTIVTY DISORDER ATTENTION DEFICIT HYPERACTIVTY DISORDER

7. EMOTIONAL REGULATORY DISORDERS ANXIETY DISORDERS ANXIETY DISORDERS DEPRESSION DEPRESSION ANGER CONTROL DISORDERS ANGER CONTROL DISORDERS OBSESSIVE-COMPULSIVE DISORDER OBSESSIVE-COMPULSIVE DISORDER

8. ANXIETY DISORDERS GENERALIZED ANXIETY DISORDER GENERALIZED ANXIETY DISORDER PANIC DISORDER PANIC DISORDER PHOBIAS PHOBIAS OBSESSIVE-COMPULSIVE DISORDER OBSESSIVE-COMPULSIVE DISORDER

9. DEPRESSION MAJOR DEPRESSIVE DISORDERS MAJOR DEPRESSIVE DISORDERS –Present two or more weeks DYSTHYMIC DISORDER DYSTHYMIC DISORDER –Present for two or more years

10. INTERMITTENT EXPLOSIVE DISORDER Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors. The aggressive episodes are not better accounted for by another mental disorder. The aggressive episodes are not better accounted for by another mental disorder.

11. OBSESSIVE-COMPULSIVE DISORDER: OBSESSIONS OBSESSIONS ARE UNWANTED THOUGHTS, IMAGES, OR IMPULSES THAT THE INDIVIDUAL REALIZES ARE SENSELESS OR UNNECESSARY, INTRUDE INTO ONE’S CONSCIOUSNESS INVOLUNTARILY, AND CAUSE FUNCTIONAL IMPAIRMENT AND DISTRESS OBSESSIONS ARE UNWANTED THOUGHTS, IMAGES, OR IMPULSES THAT THE INDIVIDUAL REALIZES ARE SENSELESS OR UNNECESSARY, INTRUDE INTO ONE’S CONSCIOUSNESS INVOLUNTARILY, AND CAUSE FUNCTIONAL IMPAIRMENT AND DISTRESS

12. OBSESSIVE-COMPULSIVE DISORDER: COMPULSIONS COMPULSIONS ARE ACTIONS THAT ARE RESPONSES TO A PERCEIVED INTERNAL OBLIGATION TO FOLLOW CERTAIN RITUALS OR RULES. COMPULSIONS CAN BE MOTIVATED DIRECTLY BY OBSESSIONS OR EFFORTS TO WARD OFF CERTAIN THOUGHTS, IMPULSES, OR FEARS. COMPULSIONS ARE ACTIONS THAT ARE RESPONSES TO A PERCEIVED INTERNAL OBLIGATION TO FOLLOW CERTAIN RITUALS OR RULES. COMPULSIONS CAN BE MOTIVATED DIRECTLY BY OBSESSIONS OR EFFORTS TO WARD OFF CERTAIN THOUGHTS, IMPULSES, OR FEARS.

13. COMMON BEHAVIORS WITH OBSESSIVE-COMPULSIVE DISORDER Counting or repeating behavior Counting or repeating behavior Checking or questioning behavior Checking or questioning behavior Collecting or hoarding behavior Collecting or hoarding behavior Arranging and organizing behavior Arranging and organizing behavior Cleaning and/or washing behavior Cleaning and/or washing behavior “Preening” behaviors (nail biting, cuticle picking, hair pulling, picking at sores) “Preening” behaviors (nail biting, cuticle picking, hair pulling, picking at sores)

14. TREATMENT FOR REGULATORY DISORDERS THE “SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) THE “SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) Trade NameGeneric Name Prozac fluoxetine Prozac fluoxetine Paxil paroxetine Paxil paroxetine Zoloft sertraline Zoloft sertraline Luvox fluvoxamine Luvox fluvoxamine Celexa citalopram Celexa citalopram

15. THE TIC DISORDERS THE TIC DISORDERS

16. TRANSIENT TIC DISORDERS TRANSIENT TIC DISORDERS CHRONIC TIC DISORDERS CHRONIC TIC DISORDERS –Chronic Motor Tic Disorder –Chronic Vocal Tic Disorder TOURETTE’S DISORDER TOURETTE’S DISORDER

17. TREATMENT FOR TIC DISORDERS TRADE NAME GENERIC NAME TRADE NAME GENERIC NAME Catapres clonidine Catapres clonidine Haldol haloperidol Haldol haloperidol Tenex guanafacine Tenex guanafacine Orap pimozide Orap pimozide

18. BIPOLAR DISORDER BIPOLAR DISORDER

19. BIPOLAR DISORDER A CLINICAL COURSE THAT IS CHARACTERIZED BY THE OCCURRENCE OF ONE OR MORE MANIC EPISODES OR MIXED EPISODES. OFTEN THE INDIVIDUAL HAS ALSO HAD ONE OR MORE MAJOR DEPRESSIVE EPISODES

20. TYPES OF BIPOLAR DISORDER BIPOLAR I:SINGLE MANIC EPISODE BIPOLAR I:SINGLE MANIC EPISODE BIPOLAR II: RECURRENT MAJOR DEPRESSIVE EPISODES WITH HYPOMANIC EPISODES BIPOLAR II: RECURRENT MAJOR DEPRESSIVE EPISODES WITH HYPOMANIC EPISODES

21. BIPOLAR DISORDER IN CHILDREN AND ADOLESCENTS OFTEN MORE RAPID CYCLING THAN WITH ADULTS OFTEN MORE RAPID CYCLING THAN WITH ADULTS CYCLES INCLUDE: CYCLES INCLUDE: –DEPRESSION TO HYPOMANIC OR MANIC –CALM TO IRRITIBILITY TO RAGE

22. TREATMENT FOR BIPOLAR DISORDER FOR MANIC AND RAGE BEHAVIORS: FOR MANIC AND RAGE BEHAVIORS: –ANTI-CONVULSANT MEDICATIONS –ATYPICAL ANTIPSYCHOTIC MEDICATIONS FOR DEPRESSION: FOR DEPRESSION: –A NON-SSRI MEDICATION –MOST COMMONLY USED: WELLBUTRIN

23. ANTICONVULSANT MEDICATIONS DEPAKOTE DEPAKOTE TEGRETAL TEGRETAL NEURONTIN NEURONTIN LAMICTAL LAMICTAL TRILEPTAL TRILEPTAL GABRITRAL GABRITRAL (LITHIUM) (LITHIUM)

24. ATYPICAL ANTIPSYCHOTIC MEDICATIONS RESPERDAL RESPERDAL ZYPREXIA ZYPREXIA GEODON GEODON SEROQUIL SEROQUIL ABILIFY ABILIFY

25. SIGNIFICANCE OF THE CONCEPT OF A CONTINUUM OF NEUROLOGICALLY-BASED DISORDERS

26. IF ONE DIAGNOSIS IS FOUND, THE OTHER DIAGNOSES MUST BE LOOKED FOR. IF ONE DIAGNOSIS IS FOUND, THE OTHER DIAGNOSES MUST BE LOOKED FOR. UNLESS ALL DIAGNOSES ARE ADDRESSED, THE CLINICAL OUTCOME MAY BE LESS THEN DESIRED. UNLESS ALL DIAGNOSES ARE ADDRESSED, THE CLINICAL OUTCOME MAY BE LESS THEN DESIRED.