→ SUICIDAL THREATS, ATTEMPTS, AND

SUICIDE COMPETITION ARE ASSOCIATED WITH

PREVIOUSLY LEARNED ASSOCIATIONS OR
 THE HUMAN ACT OF SELF INFLICTED, SELF RESPONSES TO CRISES
INTENTIONED CESSATION OF LIFE → SUICIDAL ACT FUNCTIONS AS BOTH REWARD
AND PUNISHMENT
SUICIDAL IDEATION
• THOUGHTS , FANTASIES,RUMINATIONS AND
PREOCCUPATION ABOUT DEATH, SELF HARM
AND SELF INFLICTED DEATH
• ?DO YOU EVER FEEL THAT LIFE IS NOT WORTH
LIVING
• ?DO YOU EVER HAVE THOUGHTS ABOUT NOT
WANTING TO LIVE ANYMORE
• ?DO YOU EVER WISH YOU WERE DEAD
• ?IS DEATH SOMETHING THAT YOU HAVE
THOUGHT ABOUT RECENTLY
• ?DO YOU EVER THINK ABOUT ENDING YOUR
LIFE

SUICIDAL INTENT
• PATIENT’S EXPECTATION AND COMMITMENT
TO DIE BY SUICIDE

EPIDEMIOLOGY
 AGE ADJUSTED SUICIDE RANGE GLOBALLY
o 1.1/100,000 TO 51.6/100,000 (WHO
2002)
 INCREASING SUICIDE – MEXICO, BRAZIL,INDIA
 USA SUICIDE DEATHS 40% HIGHER THAN DURKHEIM
HOMICIDE DEATHS CATEGORIES OF SUICIDE IN TERMS OF THE INDIVIDUALS
 DEVELOPED COUNTRIES-ONE OF THE THREE RELATIONSHIP TO SOCIETY:
LEADING CAUSES OF DEATH IN PEOPLE BET.15 1. ALTRUISTIC SUICIDE- RIGID OBEDIENCE TO
TO 24 CUSTOMS OR RULES OF A SOCIETY
-HARAKIRI,SUTTEE (ALTRUISTIC
 IN NORTH AMERICA 2/3 OF THOSE WHO
SUICIDE)
COMMIT SUICIDE HAD CONTACT WITH HEALTH
2. EGOISTIC SUICIDE- NO CONNECTION TO HIS
CARE PROFESSIONAL
SOCIETY
3. ANOMIC SUICIDE- RELATIONSHIP BET. AN
THEORIES OF SUICIDE
INDIVIDUAL AND HIS SOCIETY IS SEVERED OR
1. PSYCHOANALYTIC THEORY
ABRUPTLY CHANGED
 FREUD
→ SUICIDE WAS INTRAPSYCHIC
BARRIERS TO DETECTION AND PREVENTION
→ UNCONSCIOUS HOSTILITY TOWARD
1. STIGMA AND SECRECY- SINFUL ,
INTROJECTED LOVE OBJECT
SHAMEFUL,WEAK
 MENNINGER
FEELINGS OF ISOLATION, SELF CONTEMPT
→ HOSTILE DRIVE COMPOSED OF WISH TO
SELF DEPRECIATION
COMMIT SUICIDE,WISH TO BE KILLED,WISH TO
SHAME AND GUILT
DIE
SECRECY AND SILENCE
 SNEIDMAN
2. FAILURE TO SEEK HELP
→ PSYCHOLOGICAL CHARACTERISTICS RELATED TO
3. LACK OF SUICIDE KNOWLEDGE AND AWARENESS
SUICIDE
AMONG HEALTH PROFESSIONALS
a. ACUTE SUICIDAL CRISIS IS A
4. SUICIDE IS A RARE EVENT
DANGEROUS PERIOD OF SHORT
→ SUICIDAL IDEATION- 100X MORE COMMON
DURATION
THAN COMPLETED SUICIDES, 6X MORE
b. AMBIVALENCE MAY BE
COMMON THAN SUICIDE ATTEMPTS
PARAMOUNT: AN INDIVBIDUAL
→ SUICIDE ATTEMPTS- 20X MORE COMMON
CAN MAKE PLANS FOR SUICIDE &
THAN COMPLETED SUICIDES
ENTERTAIN FANTASIES OF RESCUE
c. DYADIC EVENT
ASSESSMENT OF SUICIDALITY
1. DEMOGRAPHIC DATA
2. BEHAVIORAL/ COGNITIVE
→ SUICIDE RATES INCREASES WITH INCREASING
 FREDERICK AND RESNICK AGE (YOUNG ADULTS AND ELDERLY)

Page 1 of 14
 → HIGHER COMPLETED SUICIDE RATES IN MEN
o LESS WILLING TO SEEK AND ACCEPT HELP
o MORE IMPULSIVE
o LESS SOCIALLY EMBEDDED
o CHOOSE MORE LETHAL MEANS
o HIGHER SUBSTANCE ABUSE PROBLEMS
→ WOMEN HIGHER SUICIDE IF WITH-
o INTIMATE PARTNER ABUSE
o DOMESTIC ABUSE
o POSTPARTUM DEPRESSION/PSYCHOSIS
o RIGID ROLE EXPECTATION
2. CLINICAL CHARACTERISTICS
A. PRECIPITATING FACTOR
B. CRISIS- DEGREE OF ANXIETY, TENSION,
ANGER OR DEPRESSION
C.COPING STRATEGIES
D. SIGNIFICANT OTHERS
E. SOCIAL AND PERSONAL RESOURCES
F. PAST SUICIDE ATTEMPTS
G. PAST PSYCHIATRIC HISTORY
H. CURRENT PSYCHIATRIC/MEDICAL HISTORY
I. LIFESTYLE
J. SUICIDE PLAN
CHARACTERISTICS OF PAST ATTEMPTS
• INCREASE FUTURE SUICIDE RISK
1. PRESENCE OF LONG STANDING MEDICAL
ILLNESS
2. PRESENCE OF PSYCHIATRIC ILLNESS
3. LOW LEVELS OF SOCIAL COHESION
4. SERIOUS ATTEMPT WITH ADVERSE
CONSEQUENCES
5. HIGH INTENT
6. USE OF HIGHLY LETHAL MEANS
7. MEASURES TAKEN TO AVOID DISCOVERY
PSYCHIATRIC SYMPTOMS ASSOCIATED WITH
INCREASED SUICIDE RISK
• DEPRESSION
• SEVERE ANXIETY
• PANIC ATTACKS
• HOPELESSNESS
• COMMAND HALLUCINATIONS
• IMPULSIVITY
• AGGRESSION
• SEVERE ANHEDONIA
• DYSPHORIA
• SHAME OR HUMILIATION
• DECREASED SELF ESTEEM
• VIOLENCE TOWARDS OTHERS
• AGITATION
• AKATHISIA
• ANGER/ INSOMNIA
PSYCHIATRIC DIAGNOSIS
1. MOOD DISORDER
→ CONFER 20X RISK; 50% SUICIDE DEATHS HAS
MDD
2. PSYCHOTIC DISORDERS
→ SCHIZOPHRENIA 10X RISK
→ ABOUT 10% SUICIDE DEATHS
3. ANXIETY DISORDERS
→ 6 TO 10X SUICIDE RISK
→ 15 TO 20% OF SUICIDE ASSO. WITH PANIC
ATTACKS AND ALCOHOL USE
4. ALCOHOL AND SUBSTANCE ABUSE DISORDER
→ 6X RISK; 25 TO 50% OF DEATHS BY SUICIDE
SUBSTANCE USE DISORDERS
RISK FACTORS FOR SUICIDE:
 RECENT OR IMPENDING PERSONAL LOSS
 PRESENCE OF OTHER PSYCHIATRIC DISORDERS
 DISRUPTION OF INTERPERSONAL RELATIONSHIP
 PRESENCE OF DEPRESSIVE EPISODE
MEDICAL DISORDER AND SUICIDE RISK
• CHRONIC DISEASE – HIV,CA,PUD,SLE,
HEMODIALYSIS,COPD
• NEUROLOGICAL DISORDER WITH:
PAIN,FUNCTIONAL AND COGNITIVE
IMPAIRMENT, LOSS OF SIGHT OR
HEARING,DISFIGUREMENT, INC. DEPENDENCE
ON OTHERS
PRESENCE OF PSYCHIATRIC
DISORDER/SYMPTOM
PROTECTIVE FACTORS FOR SUICIDE
1. ABSENCE OF A MENTAL DISORDER
2. EMPLOYMENT
3. CHILDREN IN THE HOME
4. SENSE OF RESPONSIBILITY TO FAMILY
5. PREGNANCY
6. STRONG RELIGIOUS BELIEF
7. HIGH LIFE SATISFACTION
8. INTACT REALITY TESTING
9. POSITIVE COPING SKILLS
10. POSITIVE PROBLEM SOLVING SKILLS
11. POSITIVE SOCIAL SUPPORT
12. POSITIVE THERAPEUTIC RELATIONSHIP
ASSESSMENT OF SUICIDE PLAN
1. LETHALITY- METHOD OF CHOICE, CIRCUMSTANCES
AND HOW CLOSE TO DEATH HE CAME
2. INTENTION- ASSESS MOTIVATION AND FANTASY
3. POST GESTURE ATTITUDE
SUICIDE PLAN
1. METHOD –CHOICE OF HIGHER LETHALITY
METHOD IS ASSOCIATED WITH HIGHER SUICIDE
RISK
2. AVAILABILITY OF MEANS
3. PATIENT’S BELIEF ABOUT THE LETHALITY OF
THE METHOD
4. CHANCE OF RESCUE
5. STEPS TAKEN TO ENACT PLAN
6. PREPAREDNESS FOR DEATH
MANAGEMENT
• BASIC PRINCIPLES
1. SAFETY AND SECURITY
2. SUPPORT
3. TARGETED INTERVENTION
Page 2 of 14
 o SERIOUS MENTAL DISORDER ORGANIC VS FUNCTIONAL
o PSYCHOSOCIAL STRESSORS • FEATURES SUGGESTIVE TO ORGANIC CAUSES
o MALADAPTIVE PATTERNS OF 1. ACUTE ONSET
THOUGHT,EMOTION OR BEHAVIOR 2. FIRST EPISODE
3. GERIATRIC AGE
4. CURRENT MEDICAL ILLNESS OR INJURY
5. SIGNIFICANT SUBSTANCE ABUSE
6. NONAUDITORY DISTURBANCES OF PERCEPTION
PSYCHIATRIC EMERGENCY ORGANIC IF:
(ADULTS) 7. NEUROLOGICAL SYMPTOMS - DECREASED
→ LOC,SEIZURES, HEAD INJURY,CHANGE IN
HEADACHE PATTERN, CHANGE IN VISION
DEFINITION → CLASSIC MENTAL STATUS SIGNS –
• DISTURBANCE IN THOUGHTS, FEELINGS, OR DIMINISHED ALERTNESS, DISORIENTATION,
ACTION FOR WHICH IMMEDIATE THERAPEUTIC MEMORY IMPAIRMENT, IMPAIRMENT IN
INTERVENTION IS NECESSARY CONCENTRATION, ATTENTION,
DYSCALCULIA,CONSTRUCTIONAL APRAXIA
Emergency if:
• Threat to: INTERVIEW SITUATIONS
• patient’s own bodily integrity by assault, self (PSYCHOSIS)
mutilation, drug ingestion • WITHDRAWAL FROM OBJECTIVE REALITY
• Somebody else’s bodily integrity • PARANOIA
• Patient’s own functional and psychological • COMMAND HALLUCINATIONS
integrity- ability to perceive reality, feel • LIMIT POTENTIAL FOR AGITATION OR
appropriately, make judgments REGRESSION
• Psychological and functional integrity of the
family or social unit ACUTE PSYCHOTIC STATES
1. IMPAIRMENT OF IMPULSE CONTROL
EPIDEMIOLOGY CAPACITY TO RESTRAIN RAPIDLY
• FEMALES = MALES ? ORGANIC OR NOT(ACUTE ALCOHOL
• SINGLE> MARRIED INTOXICATION)
• 20% SUICIDAL;10% VIOLENT NE/PE
• 40% HOSPITALIZED IMMEDIATE TRANQUILIZATION- EXCEPTION
• NIGHT HOURS SEDATING DRUG IM OR IV
2. IMPAIRMENT IN PERCEPTION
EVALUATION ?ORGANICITY
1. MAKE INITIAL DIAGNOSIS DRUG INTOXICATION
2. IDENTIFY PRECIPITATING FACTORS AND DRUG WITHDRAWAL
IMMEDIATE NEEDS DEMENTIA
3. BEGIN TREATMENT OR REFER THE PATIENT 3. IMPAIRMENT IN THINKING
SCHIZOPHRENIC DISINTEGRATION:
DIAGNOSIS A. AGITATED, DISORGANIZED THINKING
• PSYCHIATRIC INTERVIEW- HISTORY WITH MSE B.WITHDRAWN/ISOLATED/MUTE
• PE AND ANCILLARY TESTS C.INCREASED SYMPTOMS
• REQUEST FOR OLD RECORDS ANXIETY, DEPRESSION, MANIA
• MULTILINGUAL STAFF
RELATIVES NOT ADVISED AS TRANSLATORS ACUTE PSYCHOTIC STATE
• MANIA
SUMMARY OF EMERGENCY EVALUATION – QUALITY OF MANIC EPISODE
• IS IT SAFE FOR THE PATIENT TO BE IN THE ER? – FIRST RECOGNIZED MANIC EPISODE
• IS THE PROBLEM ORGANIC OR FUNCTIONAL OR – PATIENT’S PHYSICAL CONDITION
A COMBINATION? – IS PATIENT ON LITHIUM MAINTENANCE
• IS THE PATIENT PSYCHOTIC? – ?CONTENT OF THOUGHT
• IS THE PATIENT SUICIDAL OR HOMICIDAL?
• TO WHAT DEGREE IS THE PATIENT CAPABLE OF INTERVIEW SITUATIONS
SELF CARE? (VIOLENT PATIENTS)

PATIENT SAFETY • PREDICTORS OF VIOLENCE

• EMERGENCY ROOM’S PHYSICAL LAYOUT 1. EXCESSIVE ALCOHOL INTAKE
• STAFFING PATTERNS AND COMMUNICATION 2. HISTORY OF VIOLENT ACTS
• PATIENT POPULATION 3. HISTORY OF CHILDHOOD ABUSE
• EMOTIONAL SAFETY

Page 3 of 14
SIGNS OF IMPENDING VIOLENCE
1. VERY RECENT ACTS OF VIOLENCE
2. VERBAL OR PHYSICAL THREATS
3. CARRYING OBJECTS THAT CAN BE USED AS
WEAPONS
4. PROGRESSIVE PSYCHOMOTOR AGITATION
5. ALCOHOL OR DRUG OVERDOSE
6. COMMAND VIOLENT AUDITORY
HALLUCINATIONS
7. ORGANIC MENTAL DISORDER
8. PATIENTS WITH CATATONIC EXCITEMENT
9. PATIENTS WITH MANIA
10. AGITATED WITH AGITATED DEPRESSION
ASSESSMENT OF RISK OF VIOLENCE
• CONSIDER VIOLENT IDEATION,
WISH,INTENTION,PLAN,AVAILABILITY OF
MEANS,IMPLEMENTATION OF PLAN, WISH TO
HELP
• CONSIDER DEMOGRAPHICS
• CONSIDER PAST HISTORY
• CONSIDER OVERT STRESSORS
PRINCIPLES
• DEAL WITH THE HEALTHY EGO
• ESTABLISH CONTROLS
• HALOPERIDOL IM 2 TO 10 MG Q 45MIN.
• RISPERIDONE QUICKLET
• IV DIAZEPAM
SUBSTANCE USE RELATED DISORDERS
CRITERIA FOR SUBSTANCE ABUSE
A. A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by one (or more) of the following,
occurring within a 12-month period:
1. recurrent substance use resulting in a failure
to fulfill major role obligations at work,
school, or home (e.g., repeated absences or
poor work performance related to substance
use; substance-related absences,
suspensions, or expulsions from school;
neglect of children or household)
2. recurrent substance use in situations in which
it is physically hazardous (e.g., driving an
automobile or operating a machine when
impaired by substance use)
3. recurrent substance-related legal problems
(e.g., arrests for substance-related disorderly
conduct)
4. continued substance use despite having
persistent or recurrent social or interpersonal
problems caused or exacerbated by the
effects of the substance (e.g., arguments with
spouse about consequences of intoxication,
physical fights)
B. The symptoms have never met the criteria for
Substance Dependence for this class of
substance.
DSM-IV-TR Diagnostic Criteria for Substance
Dependence
A maladaptive pattern of substance use, leading to
clinically significant impairment or distress, as
manifested by three (or more) of the following,
occurring at any time in the same 12-month period:
1. tolerance, as defined by either of the
following:
a. a need for markedly increased
amounts of the substance to achieve
intoxication or desired effect
b. markedly diminished effect with
continued use of the same amount of
the substance
2. withdrawal, as manifested by either of the
following:
a. the characteristic withdrawal
syndrome for the substance (refer to
Criteria A and B of the criteria sets for
Withdrawal from the specific
substances)
b. the same (or a closely related)
substance is taken to relieve or avoid
withdrawal symptoms
3. the substance is often taken in larger amounts
or over a longer period than was intended
4. there is a persistent desire or unsuccessful
efforts to cut down or control substance use
5. a great deal of time is spent in activities
necessary to obtain the substance (e.g., visiting
multiple doctors or driving long distances), use
the substance (e.g., chain-smoking), or recover
from its effects
6. important social, occupational, or recreational
activities are given up or reduced because of
substance use
7. the substance use is continued despite
knowledge of having a persistent or recurrent
physical or psychological problem that is likely
to have been caused or exacerbated by the
substance (e.g., current cocaine use despite
recognition of cocaine-induced depression, or
continued drinking despite recognition that an
ulcer was made worse by alcohol
consumption)
Specify if:
With Physiological Dependence: evidence of
tolerance or withdrawal (i.e., either Item 1 or 2 is
present)
Without Physiological Dependence: no evidence of
tolerance or withdrawal (i.e., neither Item 1 nor 2 is
present)
Page 4 of 14

ALCOHOL RELATED DISORDERS
IMPACT ON LIFE
• DECREASE LIFE SPAN BY 10 YEARS TO 15
• 22,OOO DEATHS/YEAR
• 2 MILLION NON FATAL INJURIES
• BEER –HALF OF ALCOHOL CONSUMPTION
• LIQUOR -1/3
• 50% HOMICIDES;25% SUICIDES
EPIDEMIOLOGY FOR ALCOHOL RELATED DISORDERS
• ALL SOCIOECONOMIC CLASS
• 70% OF ADULTS WITH COLLEGE DEGREES ARE
CURRENT DRINKERS; 40% WITH LESS
EDUCATION
• BINGE ALCOHOL USE SIMILAR ACROSS
DIFFERENT LEVELS OF EDUCATION
• MEN > WOMEN
CO MORBID DISORDERS
• ANTISOCIAL PERSONALITY DISORDER
• DEPRESSION- 30 T0 40% (WOMEN)
• ANXIETY DISORDER
• SUICIDE
ETIOLOGY
• 60% GENETIC
• CHILDHOOD HISTORY OF ADHD, CONDUCT
DISORDER
• EEG,EVOKED POTENTIAL (P300)
• IDENTICAL TWIN/ADOPTIVE STUDIES
• 40% ENVIRONMENTAL
• PSYCHOLOGICAL THEORY
• REDUCE TENSION
• INC. FEELINGS OF POWER
• DEC.PSYCHOLOGICAL PAIN
• PSYCHODYNAMIC THEORY
• DECREASE UNCONSCIOUS STRESS LEVEL
• FIXATED TO ORAL STAGE
• BEHAVIORAL THEORY
• EXPECTATIONS ABT. REWARDING EFFECTS OF
DRINKING
ALCOHOL
• SINGLE DRINK EQUAL TO 12 G ALCOHOL
• 12 OUNCES OF BEER
• METABOLISM IN ONE HOUR 15 TO 20 MG/DL
• Stomach absorption;SI
• Pyloric valve closure
• Peak blood conc.45 to 60 min. after ingestion
• Food delays absorption
• Rapid drinking decrease time to peak
concentration
• MELLANBY EFFECT
METABOLISM
• ALCOHOL-ACETALDEHYDE (ALCDH)ACETIC
ACID (ALDDH)
• 90% OXIDIZED IN THE LIVER;10% ECRETED
UNCHANGED INKIDNEYS AND LUNGS
• CHRONIC ALCOHOLISM –UPREGULATION OF
ENZYMES
• WOMEN,ASIANS,LOWER ENZYMES
EFFECTS ON THE BRAIN
• NO SINGLE MOLECULAR TARGET
• “INTERCALATION IN MEMBRANES OF
NEURONS”-FLUIDITY, STIFFNESS
• RECEPTORS ENHANCED BY ALCOHOL-
5HT3,GABA A,NIC. ACH
• INHITED RECEPTORS- GLUTAMATE,CALCIUM
CHANNEL
BEHAVIORAL EFFECTS
• 0.05%- THOUGHT,JUDGMENT&RESTRAINT
LOOSENED
• 0.1%-CLUMSY MOTOR ACTS
• 0.2%-DEPRESSED MOTOR AREA,CONTROL OF
EMOTIONAL BEHAVIOR
• 0.3%CONFUSION,
• STUPOROUS
• 0.4 TO 0.5%-COMA
• > RESPIRATORY DEPRESSION
• SLEEP
• DECREASE REM,DEC.DEEP SLEEP, SLEEP
FRAGMENTATION
PHYSIOLOGICAL EFFECTS
• FATTY LIVER
• ALCOHOLIC HEPATITIS
• HEPATIC CIRRHOSIS
• ESOPHAGITIS
• GASTRITIS
• ACHLORHYDRIA
Page 5 of 14
 • GASTRIC ULCER
• PANCREATIC CANCER
• FAILED NUTRIENT ABSORPTION
• HYPERTENSION
• INC. RISK MI,CVD
• INC. RESTING CO,HR,O2 CONSUMPTION
• INC.
HEAD,NECK,ESOPHAGEAL,STOMACH,HEPATIC,C
OLONIC,LUNG CANCER
• HYPOGLYCEMIA
• MYOPATHY
ALCOHOL RELATED DISORDERS
Alcohol use disorders
Alcohol dependence
Alcohol abuse
Alcohol-induced disorders
Alcohol intoxication
Alcohol withdrawal
Specify if:
With perceptual disturbances
Alcohol intoxication delirium
Alcohol withdrawal delirium
Alcohol-induced persisting dementia
Alcohol-induced persisting amnestic disorder
Alcohol-induced psychotic disorder, with
delusions
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-induced psychotic disorder, with
hallucinations
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-induced mood disorder
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-induced anxiety disorder
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-induced sexual dysfunction
Specify if:
With onset during intoxication
Alcohol-induced sleep disorder
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol disorder not otherwise specified
DSM-IV-TR Diagnostic Criteria for Alcohol Intoxication
A. Recent ingestion of alcohol.
B. Clinically significant maladaptive behavioral
or psychological changes (e.g.,
inappropriate sexual or aggressive
behavior, mood lability, impaired
judgment, impaired social or occupational
functioning) that developed during, or
shortly after, alcohol ingestion.
C. One (or more) of the following signs,
developing during, or shortly after, alcohol
use:
1. slurred speech
2. incoordination
3. unsteady gait
4. nystagmus
5. impairment in attention or memory
6. stupor or coma
D. The symptoms are not due to a general
medical condition and are not better
accounted for by another mental disorder.
DSM-IV-TR Diagnostic Criteria for Alcohol Withdrawal
A. Cessation of (or reduction in) alcohol use
that has been heavy and prolonged.
B. Two (or more) of the following, developing
within several hours to a few days after
Criterion A:
1. autonomic hyperactivity (e.g.,
sweating or pulse rate greater than
100)
2. increased hand tremor
3. insomnia
4. nausea or vomiting
5. transient visual, tactile, or auditory
hallucinations or illusions
6. psychomotor agitation
7. anxiety
8. grand mal seizures
C. The symptoms in Criterion B cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning.
D. The symptoms are not due to a general
medical condition and are not better
accounted for by another mental disorder.
Specify if:
With perceptual disturbances
Page 6 of 14
Impairment Likely to be Seen at Different Blood NEUROLOGICAL AND MEDICAL COMPLICATIONS OF
Alcohol Concentrations ALCOHOL USE
Level Likely Impairment Alcohol intoxication
20-30 mg/dL Slowed motor Acute intoxication
performance and Pathological intoxication (atypical, complicated, unusual)
decreased thinking ability Blackouts
30-80 mg/dL Increases in motor and Alcohol withdrawal syndromes
cognitive problems Tremulousness (the shakes or the jitters)
80-200 mg/dL Increases in Alcoholic hallucinosis (horrors)
Withdrawal seizures (rum fits)
incoordination and
Delirium tremens (shakes)
judgment errors
Nutritional diseases of the nervous system secondary to alcohol
Mood lability
abuse
Deterioration in cognition Wernicke-Korsakoff syndrome
200-300 mg/dL Nystagmus, marked Cerebellar degeneration
slurring of speech, and Peripheral neuropathy
alcoholic blackouts Optic neuropathy (tobacco-alcohol amblyopia)
>300 mg/dL Impaired vital signs and Pellagra
possible death Alcoholic diseases of uncertain pathogenesis
Central pontine myelinolysis
Marchiafava-Bignami disease
Fetal alcohol syndrome
Myopathy
Alcoholic dementia
Alcoholic cerebral atrophy
Systemic diseases due to alcohol with secondary neurological
complications
Liver disease
Hepatic encephalopathy
Acquired (non-Wilsonian) chronic hepatocerebral degeneration
Gastrointestinal diseases
Malabsorption syndromes
Postgastrectomy syndromes
Possible pancreatic encephalopathy
Cardiovascular diseases
Cardiomyopathy with potential cardiogenic emboli and
cerebrovascular disease
Arrhythmias and abnormal blood pressure leading to
cerebrovascular disease
Hematological disorders
Anemia, leukopenia, thrombocytopenia (could possibly lead to
• LP hemorrhagic cerebrovascular disease)
• RF Infectious disease, especially meningitis (especially pneumococcal
Brain PET metabolic images in a normal control subject and meningococcal)
and an alcoholic subject tested 2 weeks after the last Hypothermia and hyperthermia
use of alcohol. Notice the decreased cortical metabolic Hypotension and hypertension
activity in the alcoholic person. Respiratory depression and associated hypoxia
Toxic encephalopathies, including alcohol and other substances
Electrolyte imbalances leading to acute confusional states and,
SUBTYPES OF ALCOHOL DEPENDENCE
rarely, local neurological signs and symptoms
• TYPE A- MILD DEPENDENCE, Late onset
Hypoglycemia
• Antisocial alcoholism
Hyperglycemia
• Developmentally cumulative Hyponatremia
• TYPE B-SEVERE DEPENDENCE, early onset Hypercalcemia
• Negative effect alcoholism Hypomagnesemia
• Developmentally limited alcoholism Hypophosphatemia
Increased incidence of trauma
Epidural, subdural, and intracerebral hematoma
Spinal cord injury
Posttraumatic seizure disorders
Compressive neuropathies and brachial plexus injuries (Saturday
night palsies)
Posttraumatic symptomatic hydrocephalus (normal pressure
hydrocephalus)
Muscle crush injuries and compartmental syndromes

Page 7 of 14
CAFFEINE RELATED DISORDERS
• A CUP- 100 TO 150 MG
• TEA – 30 TO 100 MG
• CHOCOLATE BAR- 25 T0 35 MG
• SOFT DRINKS- 25 TO 50 MG
• DECAF- 2 TO 4 MG
• COMORBID USE OF SEDATIVE AND HYPNOTIC
NEUROPHARMACOLOGY
• HALF LIFE 3 TO 10 HOURS
• TIME OF PEAK CONC. 30 TO 60 MG
• ANTAGONIST OF ADENOSINE RECEPTORS
• INHIBIT Gi protein inc. cAMP in neurons
• Dopamine and NE
• Global cerebral vasoconstriction
• ?rebound, coronary artery
CAFFEINE-RELATED DISORDERS
Caffeine-induced disorders
Caffeine intoxication
Caffeine-induced anxiety disorder
Specify if:
With onset during intoxication
Caffeine-induced sleep disorder
Specify if:
With onset during intoxication
Caffeine-related disorder not otherwise specified
DIAGNOSTIC CRITERIA FOR CAFFEINE INTOXICATION
A. Recent consumption of caffeine, usually in
excess of 250 mg (e.g., more than 2–3 cups of
brewed coffee).
B. Five (or more) of the following signs, developing
during, or shortly after, caffeine use:
1. restlessness
2. nervousness
3. excitement
4. insomnia
5. flushed face
6. diuresis
7. gastrointestinal disturbance
8. muscle twitching
9. rambling flow of thought and speech
10. tachycardia or cardiac arrhythmia
11. periods of inexhaustibility
12. psychomotor agitation
C. The symptoms in Criterion B cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning.
D. The symptoms are not due to a general medical
condition and are not better accounted for by
another mental disorder (e.g., an Anxiety
Disorder).
CRITERIA FOR CAFFEINE WITHDRAWAL
A. Prolonged daily use of caffeine.
B. Abrupt cessation of caffeine use, or reduction in
the amount of caffeine used, closely followed
by headache and one (or more) of the following
symptoms:
1. marked fatigue or drowsiness
2. marked anxiety or depression
3. nausea or vomiting
C. The symptoms in Criterion B cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning.
D. The symptoms are not due to the direct
physiological effects of a general medical
condition (e.g., migraine, viral illness) and are
not better accounted for by another mental
disorder.
AMPHETAMINE RELATED DISORDERS(STIMULANT)
 METAMPHETAMINE
 METHYLPHENIDATE
 EPHEDRINE
 PSEUDOEPHEDRINE
 PHENYLPROPANOLAMINE
 PHENTERMINE
 MODAFINIL
NEUROPHARMACOLOGY
• RELEASE DOPAMINE
• VENTRAL TEGMENTAL
AREACEREBRALCORTEX AND LIMBIC AREA
• DESIGNER AMPHETAMINE
• DA,NE,SEROTONIN
DIAGNOSTIC CRITERIA FOR AMPHETAMINE
INTOXICATION
A. Recent use of amphetamine or a related
substance (e.g., methylphenidate).
B. Clinically significant maladaptive behavioral or
psychological changes (e.g., euphoria or
affective blunting; changes in sociability;
hypervigilance; interpersonal sensitivity;
anxiety, tension, or anger; stereotyped
behaviors; impaired judgment; or impaired
social or occupational functioning) that
developed during, or shortly after, use of
amphetamine or a related substance.
C. Two (or more) of the following, developing
during, or shortly after, use of amphetamine or
a related substance:
1. tachycardia or bradycardia
2. apillary dilation
3. elevated or lowered blood pressure
4. perspiration or chills
5. nausea or vomiting
6. evidence of weight loss
7. psychomotor agitation or retardation
8. muscular weakness, respiratory
depression, chest pain, or cardiac
arrhythmias
9. confusion, seizures, dyskinesias,
dystonias, or coma
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 D. The symptoms are not due to a general medical
condition and are not better accounted for by NEUROBIOLOGY
another mental disorder. • TETRAHYDROCANNABINOL
• G PROTEIN LINKED RECEPTOR (Gi)
Specify if: • Monoamine and gaba
With perceptual disturbances • Euphoria peak in 30 min then 2 to 4 hrs
• ? Reward center
DIAGNOSTIC CRITERIA FOR AMPHETAMINE • Amotivational syndrome,cognitive impairment
WITHDRAWAL
DIAGNOSTIC CRITERIA FOR CANNABIS INTOXICATION
A. Cessation of (or reduction in) amphetamine (or
a related substance) use that has been heavy A. Recent use of cannabis.
and prolonged. B. Clinically significant maladaptive behavioral or
B. Dysphoric mood and two (or more) of the psychological changes (e.g., impaired motor
following physiological changes, developing coordination, euphoria, anxiety, sensation of
within a few hours to several days after slowed time, impaired judgment, social
Criterion A: withdrawal) that developed during, or shortly
1. fatigue after, cannabis use.
2. vivid, unpleasant dreams C. Two (or more) of the following signs,
3. insomnia or hypersomnia developing within 2 hours of cannabis use:
4. increased appetite 1. conjunctival injection
5. psychomotor retardation or agitation 2. increased appetite
C. The symptoms in Criterion B cause clinically 3. dry mouth
significant distress or impairment in social, 4. tachycardia
occupational, or other important areas of D. The symptoms are not due to a general medical
functioning. condition and are not better accounted for by
D. The symptoms are not due to a general medical another mental disorder.
condition and are not better accounted for by
another mental disorder. Specify if:
With perceptual disturbances
CANNABIS RELATED DISORDER
NICOTINE RELATED DISORDER
NEUROBIOLOGY
• LUNG CANCER, EMPHYSEMA,
CARDIOVASCULAR DISEASE
• SECONDHAND SMOKE
• SCHIZOPHRENIA-REDUCE SENSITIVITY TO
OUTSIDE STIMULI;INCREASE CONCENTRATION
• AGONIST OF NICOTINIC ACH RECEPTORS
• BRAIN 15 SEC. HALF LIFE 2HOURS
• ACTIVATE THE REWARD CENTER
• INCREASE NE,E, VASOPRESSIN,
ENDORPHIN,ACTH AND CORTISOL
Marijuana (Cannabis sataiva)
DIAGNOSTIC CRITERIA FOR NICOTINE WITHDRAWAL

A. Daily use of nicotine for at least several weeks.

Autoradiography of cannabinoid receptor distribution in a
sagittal section of rat brain. Binding of tritiated ligand is
dense in the hippocampus (Hipp), the globus pallidus (GP),
the entopeduncular nucleus (EP), the substantia nigra pars
reticulata (SNr), and the cerebellum (Cer). Binding is
moderate in the cerebral cortex (Cx) and the caudate
putamen (CP) and sparse in the brainstem (Br St) and spinal
cord.
B. Abrupt cessation of nicotine use, or reduction in
the amount of nicotine used, followed within 24
hours by four (or more) of the following signs:
1. dysphoric or depressed mood
2. insomnia
3. irritability, frustration, or anger
4. anxiety
5. difficulty concentrating
6. restlessness
7. decreased heart rate
8. increased appetite or weight gain
C. The symptoms in Criterion B cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning.

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 D. The symptoms are not due to a general medical PERVASIVE DEVELOPMENTAL DISORDERS
condition and are not better accounted for by
another mental disorder. • AUTISTIC DISORDER
• RETT’S DISORDER
• ASPERGER’S DISORDER
• DISINTEGRATIVE DISORDER

• IMPAIRED RECIPROCAL SOCIAL INTERACTIONS

CHILD PHYCHIATRY • ABERRANT LANGUAGE DEVELOPMENT
• RESTRICTED BEHAVIORAL REPERTOIRE
• PRESENT BY AGE 3 YRS.
CHILD PSYCHIATRIC EVALUATION
AUTISTIC DISORDER
Identifying data • AVERAGE AGE OF DIAGNOSIS 3.1 YEARS
Identified patient and family members • 4 TO 5X> BOYS
Source of referral • GENETIC CHROMOSOMES
Informants • 2,4,7, 15 19
History • TWIN STUDIES
Chief complaint • PERINATAL COMPLICATIONS
History of present illness • FRAGILE X SYNDROME-1%
Developmental history and milestones • TUBEROUS SCLEROSIS- 2%
Psychiatric history • MENTAL RETARDATION-70%
Medical history, including immunizations • GRAND MAL-4 TO 32%
Family social history and parents' marital status • HYPOPLASIA OF CEREBELLUM
Educational history and current school functioning • POLYMICROGYRIA
Peer relationship history • ?IMMUNOLOGICAL INCOMPATIBILITY
Current family functioning • INCREASED BRAIN VOLUME IN O,P,T LOBES
Family psychiatric and medical histories • ? INC. NEUROGENESIS
Current physical examination • ? DEC. DEATH
Mental status examination • ?INC. NONNEURONAL TISSUE
Neuropsychiatric examination (when applicable) • DECREASE PURKINJE CELLS
Developmental, psychological, and educational testing • HIGH PLASMA SEROTONIN INV. PROPORTIONAL
Formulation and summary TO 5HIAA CONC. IN CSF
DSM-IV-TR diagnosis • SYMTOM DECREASE AS RATIO OF HIAA TO
Recommendations and treatment plan HOMOVANILIC ACID IN CSF INCREASE

MENTAL STATUS EXAMINATION FOR CHILDREN DIAGNOSTIC CRITERIA FOR AUTISTIC DISORDER

1. Physical appearance A. A total of six (or more) items from (1), (2),
2. Parent and child interaction and (3), with at least two from (1), and one
3. Separation and reunion each from (2) and (3):
4. Orientation to time, place, and person 1. qualitative impairment in social
5. Speech and language interaction, as manifested by at
6. Mood least two of the following:
7. Affect a. marked impairment in the
8. Thought process and content use of multiple nonverbal
9. Social relatedness behaviors such as eye-to-eye
10. Motor behavior gaze, facial expression, body
11. Cognition postures, and gestures to
12. Memory regulate social interaction
13. Judgment and insight b. failure to develop peer
relationships appropriate to
developmental level
c. a lack of spontaneous
seeking to share enjoyment,
interests, or achievements
with other people (e.g., by a
Test item from the Benton Visual Retention Test. The most lack of showing, bringing, or
frequently used testing condition involves the presentation of
pointing out objects of
each geometric figure for 10 seconds, after which the patient
attempts to draw the figure from memory. interest)

Page 10 of 14
 d. lack of social or emotional
reciprocity
2. qualitative impairments in
communication as manifested by at
least one of the following:
a. delay in, or total lack of, the
development of spoken
language (not accompanied
by an attempt to
compensate through
alternative modes of
communication such as
gesture or mime)
b. in individuals with adequate
speech, marked impairment
in the ability to initiate or
sustain a conversation with
others
c. stereotyped and repetitive
use of language or
idiosyncratic language
d. lack of varied, spontaneous
make-believe play or social
imitative play appropriate to
developmental level
3. restricted repetitive and
stereotyped patterns of behavior,
interests, and activities, as
manifested by at least one of the
following:
a. encompassing preoccupation
with one or more
stereotyped and restricted
patterns of interest that is
abnormal either in intensity
or focus
b. apparently inflexible
adherence to specific,
nonfunctional routines or
rituals
c. stereotyped and repetitive
motor mannerisms (e.g.,
hand or finger flapping or
twisting, or complex whole-
body movements)
d. persistent preoccupation
with parts of objects
B. Delays or abnormal functioning in at least
one of the following areas, with onset prior
to age 3 years: (1) social interaction, (2)
language as used in social communication,
or (3) symbolic or imaginative play.
C. The disturbance is not better accounted for
by Rett's disorder or childhood
disintegrative disorder.
QUALITATIVE IMPAIRMENT IN SOCIAL INTERACTION
• ABSENT SOCIAL SMILE, ANTICIPATORY
POSTURE, POOR EYE CONTACT
• CANT DIFFERENTIATE IMPORTANT PERSONS
• POOR ABILITY TO PLAY, MAKE FRIENDS
• MORE SKILLED IN VISUO-SPATIAL TASKS THAN
IN VERBAL REASONING
• CANT INFER FEELINGS, LACK EMPATHY
DISTURBANCE IN COMMUNICATION AND LANGUAGE
• MINIMAL BABBLING
• EMIT NOISES
• SPEAK BY PROVIDING INFORMATION
• PRONOUN REVERSALS
• SAY MORE THAN THEY UNDERSTAND,
ECHOLALIA
AUTISTIC CHILDREN
• INSTABILITY OF MOOD AND AFFECT
• ABNORMAL RESPONSE TO SENSORY STIMULI
• ENJOY VESTIBULAR STIMULATION
• ENJOY MUSIC
• HYPERKINESIS
• SELF INJURIOUS BEHAVIOR
• SHORT ATTENTION SPAN
• POOR ABILITY TO FOCUS ON A TASK
• ENURESIS
• SPLINTER FUNCTION
• ISLETS OF PRECOCITY
STEREOTYPED BEHAVIOR
• ABSENT EXPLORATORY PLAY
• NO IMITATIVE PLAY
• PLAY RIGID AND MONOTONOUS
• RESISTANT TO CHANGE
• RITUALS AND COMPULSIVE PHENOMENA
OFTEN
TREATMENT
• EDUCATIONAL AND BEHAVIORAL
INTERVENTIONS
• DRUGS- ATYPICAL ANTIPSYCHOTICS FOR
AGGRESSIVE AND SELF INJURIOUS BEHAVIOR
• (RISPERIDONE,OLANZAPINE,QUETIAPINE,CLOZA
PINE)
• IRRITABILITY- ESCITALOPRAM
• METHYLPHENIDATE- HYPERACTIVITY
RETT’S DISORDER
• FEMALES >MALES
• PROGRESSIVE ENCEPHALOPATHY-
MICROCEPHALY
LOSS OF PURPOSEFUL HAND
MOVEMENT
LOSS OF SPEECH
PSYCHOMOTOR RETARDATION
ATAXIA
DISORGANIZED BREATHING
EPILEPTIFORM DISCHARGES
Page 11 of 14
DIAGNOSTIC CRITERIA FOR RETT’S DISORDER DIAGNOSTIC CRITERIA FOR CHILDHOOD
DISINTEGRATIVE DISORDER
A. All of the following:
1. apparently normal prenatal and A. Apparently normal development for at least
perinatal development the first 2 years after birth as manifested by
2. apparently normal psychomotor the presence of age-appropriate verbal and
development through the first 5 nonverbal communication, social
months after birth relationships, play, and adaptive behavior.
3. normal head circumference at birth B. Clinically significant loss of previously
B. Onset of all of the following after the period acquired skills (before age 10 years) in at
of normal development: least two of the following areas:
1. deceleration of head growth 1. expressive or receptive language
between ages 5 and 48 months 2. social skills or adaptive behavior
2. loss of previously acquired 3. bowel or bladder control
purposeful hand skills between ages 4. play
5 and 30 months with the 5. motor skills
subsequent development of C. Abnormalities of functioning in at least two
stereotyped hand movements (e.g., of the following areas:
hand wringing or hand washing) 1. qualitative impairment in social
3. loss of social engagement early in interaction (e.g., impairment in
the course (although often social nonverbal behaviors, failure to
interaction develops later) develop peer relationships, lack of
4. appearance of poorly coordinated social or emotional reciprocity)
gait or trunk movements 2. qualitative impairments in
5. severely impaired expressive and communication (e.g., delay or lack of
receptive language development spoken language, inability to initiate
with severe psychomotor or sustain a conversation,
retardation stereotyped and repetitive use of
language, lack of varied make-
believe play)
DIFFERENTIAL DIAGNOSIS 3. restricted, repetitive, and
stereotyped patterns of behavior,
AUTISTIC DISORDER RETT’S DISORDER interests, and activities, including
• HAND • HAND MOTIONS motor stereotypies and mannerisms
MANNERISMS ALWAYS PRESENT
D. The disturbance is not better accounted for
INCONSTANT • POOR
by another specific pervasive
• NORMAL GROSS COORDINATION ,
MOTOR ATAXIA AND developmental disorder or by
FUNCTION APRAXIA schizophrenia.
• USE ABERRANT • VERBAL ABILITY
LANGUAGE LOST COMPLETELY DIAGNOSTIC CRITERIA FOR ASPERGER’S DISORDER
• RESPIRATORY
IRREGULARITY A. Qualitative impairment in social interaction,
• SEIZURES APPEAR as manifested by at least two of the
EARLY following:
1. marked impairment in the use of
multiple nonverbal behaviors such
as eye-to-eye gaze, facial expression,
CHILDHOOD DISINTEGRATIVE DISORDER body postures, and gestures to
(HELLER’S SYNDROME) regulate social interaction
• 4-8 MALES: 1 FEMALE
2. failure to develop peer relationships
• ONSET BETWEEN 3 TO 4YEARS
appropriate to developmental level
• ASSOCIATED WITH SEIZURES AND TUBEROUS
SCLEROSIS 3. a lack of spontaneous seeking to
• ONSET INSIDIOUS, OR ABRUPT share enjoyment, interests, or
• ANXIETY COMMON achievements with other people
(e.g., by a lack of showing, bringing,
or pointing out objects of interest to
other people)

Page 12 of 14
 4. lack of social or emotional
reciprocity
B. Restricted repetitive and stereotyped
patterns of behavior, interests, and
activities, as manifested by at least one of
the following:
1. encompassing preoccupation with
one or more stereotyped and
restricted patterns of interest that is
abnormal either in intensity or focus
2. apparently inflexible adherence to
specific, nonfunctional routines or
rituals
3. stereotyped and repetitive motor
mannerisms (e.g., hand or finger
flapping or twisting, or complex
whole-body movements)
4. persistent preoccupation with parts
of objects
C. The disturbance causes clinically significant
impairment in social, occupational, or other
important areas of functioning.
D. There is no clinically significant general
delay in language (e.g., single words used by
age 2 years, communicative phrases used
by age 3 years).
E. There is no clinically significant delay in
cognitive development or in the
development of age-appropriate self-help
skills, adaptive behavior (other than in
social interaction), and curiosity about the
environment in childhood.
F. Criteria are not met for another specific
pervasive developmental disorder or
schizophrenia.
ATTENTION DEFICIT HYPERACTIVITY DISORDER
• MALES > FEMALES
• RELATIVES WITH INCREASED INCIDENCE
OFDISRUPTIVE BEHAVIOR DISORDER,ANXIETY
DISORDERS, DEPRESSIVE DISORDERS, LEARNING
DISORDERS
• PARENTS- HYPERKINETIC,
SOCIOPATHY,ALCOHOL USE DISORDER,
CONVERSION
ETIOLOGY
• CNS NORMAL STRUCTURE
• GENETIC FACTORS
• ? PRENATAL INFECTION DURING FIRST
TRIMESTER
• SOFT NEUROLOGICAL SIGNS
• ABNORMAL NE & DOPAMINE
• ABNORMAL FEEDBACK TO THE LOCUS
CERULEUS
• NON SPECIFIC EEG ABNORMALITY
• LOWER CBF AND METABOLISM IN THE FRONTAL
LOBE
• NON INHIBITION BY THE FRONTAL LOBE
• EMOTIONAL DEPRIVATION
• INCREASED DOPAMINE TRANSPORTER BINDING
DENSITIES IN THE STRIATUM
DIAGNOSTIC CRITERIA FOR ADHD
A. Either (1) or (2):
1. six (or more) of the following
symptoms of inattention have
persisted for at least 6 months to a
degree that is maladaptive and
inconsistent with developmental
level:
Inattention
a. often fails to give close
attention to details or makes
careless mistakes in
schoolwork, work, or other
activities
b. often has difficulty sustaining
attention in tasks or play
activities
c. often does not seem to listen
when spoken to directly
d. often does not follow
through on instructions and
fails to finish schoolwork,
chores, or duties in the
workplace (not due to
oppositional behavior or
failure to understand
instructions)
e. often has difficulty
organizing tasks and
activities
f. often avoids, dislikes, or is
reluctant to engage in tasks
that require sustained
mental effort (such as
schoolwork or homework)
g. often loses things necessary
for tasks or activities (e.g.,
toys, school assignments,
pencils, books, or tools)
h. is often easily distracted by
extraneous stimuli
i. is often forgetful in daily
activities
2. six (or more) of the following
symptoms of hyperactivity-
impulsivity have persisted for at
least 6 months to a degree that is
maladaptive and inconsistent with
developmental level:
Hyperactivity

Page 13 of 14
 a. often fidgets with hands or
feet or squirms in seat
b. often leaves seat in
classroom or in other
situations in which remaining
seated is expected
c. often runs about or climbs
excessively in situations in
which it is inappropriate (in
adolescents or adults, may
be limited to subjective
feelings of restlessness)
d. often has difficulty playing or
engaging in leisure activities
quietly
e. is often “on the go― or
often acts as if “driven by
a motor―
f. often talks excessively
Impulsivity
g. often blurts out answers
before questions have been
completed
h. often has difficulty awaiting
turn
i. often interrupts or intrudes
on others (e.g., butts into
conversations or games)
B. Some hyperactive-impulsive or inattentive
symptoms that caused impairment were
present before age 7 years.
C. Some impairment from the symptoms is
present in two or more settings (e.g., at
school [or work] and at home).
D. There must be clear evidence of clinically
significant impairment in social, academic,
or occupational functioning.
E. The symptoms do not occur exclusively
during the course of a pervasive
developmental disorder, schizophrenia, or
other psychotic disorder and are not better
accounted for by another mental disorder
(e.g., mood disorder, anxiety disorder,
dissociative disorder, or a personality
disorder).
Code based on type:
Attention-deficit/hyperactivity disorder,
combined type: if both Criteria A1 and A2 are met
for the past 6 months
Attention-deficit/hyperactivity disorder,
predominantly inattentive type: if Criterion A1 is
met but Criterion A2 is not met for the past 6
months
Attention-deficit/hyperactivity disorder,
predominantly hyperactive-impulsive type: if
Criterion A2 is met but Criterion A1 is not met for
the past 6 months
Coding note: For individuals (especially
adolescents and adults) who currently have
symptoms that no longer meet full criteria, “in
partial remission― should be specified.
• SHORT ATTENTION SPAN
• EASY DISTRACTIBILITY
• EXPLOSIVE
• IRRITABLE
• EMOTIONALLY LABILE
• MOOD AND PERFORMANCE UNRELIABLE
• IMPAIRMENT IN TWO SETTINGS
• HYPERACTIVITY
• PERCEPTUAL MOTOR IMPAIRMENT
• GENERAL COORDINATION DEFICIT
• ATTENTION DEFICIT
• IMPULSIVITY
• MEMORY AND THINKING DEFICITS
• SPECIFIC LEARNING DISABILITIES
COURSE AND PROGNOSIS
• 50 -50
• OVERACTIVITY FIRST TO REMIT
• DISTRACTIBILITY LAST
• REMISSION UNLIKELY BEFORE 12 YEARS
• AGE OF REMISSION 12-20 YEARS
• PERSISTENCE- FAMILY DISORDER, NEGATIVE
LIFE EVENTS,COMORBID CONDUCT DISORDER,
DEPRESSION, ANXIETY DISORDER
• PARTIAL REMISSION-ANTISOCIAL
BEHAVIOR,SUBSATNCE USE DISORDER MOOD
DISORDER
TREATMENT
• METHYLPHENIDATE-DOPAMINE AGONIST
• GIVEN IN THE MORNING
• OLDER THAN 6
• SUPPRESS GROWTH
• HEADACHES,STOMACHACHE, NAUSEA AND
INSOMNIA
• DEXTROAMPHETAMINE
• ATOMOXETINE-NE UPTAKE INHIBITOR

God bless!
06-29-11
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