COMORBIDITYCOMORBIDITY

ByBy

Larry B. Silver, M.D.Larry B. Silver, M.D.

THERE IS A CONTINUUM OF THERE IS A CONTINUUM OF NEUROLOGICALLY-BASED NEUROLOGICALLY-BASED DISORDERS THAT ARE OFTEN DISORDERS THAT ARE OFTEN FOUND TOGETHERFOUND TOGETHER• If any one of the disorders on this If any one of the disorders on this

continuum is found, there is up to a 50 continuum is found, there is up to a 50 percent possibility that one or more of percent possibility that one or more of the disorders on this continuum will be the disorders on this continuum will be found.found.

• Thus, if any disorder on this continuum Thus, if any disorder on this continuum is found, it is important to explore for is found, it is important to explore for the other possible disorders.the other possible disorders.

THE CONTINUUMTHE CONTINUUM

• CORTEX-BASED DISORDERSCORTEX-BASED DISORDERS– Learning, Motor, Language DisordersLearning, Motor, Language Disorders– Organization, Executive Function DisordersOrganization, Executive Function Disorders

• ATTENTION-DEFICIT/HYPERACTIVITY DISORDERATTENTION-DEFICIT/HYPERACTIVITY DISORDER• EMOTIONAL “REGULATORY” DISORDERSEMOTIONAL “REGULATORY” DISORDERS

– Anxiety DisordersAnxiety Disorders– DepressionDepression– Anger-Control DisordersAnger-Control Disorders– Obsessive-Compulsive DisorderObsessive-Compulsive Disorder

• TIC DISORDERSTIC DISORDERS• ??? BIPOLAR DISORDER??? BIPOLAR DISORDER

DIAGNOSTIC CLUES THAT DIAGNOSTIC CLUES THAT BEHAVIORS ARE BEHAVIORS ARE

NEUROLOGICALLY-BASEDNEUROLOGICALLY-BASED

THERE IS A THERE IS A CHRONIC CHRONIC AND A AND A PERVASIVEPERVASIVE HISTORY OF THE HISTORY OF THE CLINICAL PROBLEMS. CLINICAL PROBLEMS.

THERE OFTEN IS A THERE OFTEN IS A FAMILY HISTORYFAMILY HISTORY OF OF THE THE CLINICAL PROBLEMSCLINICAL PROBLEMS

CORTICAL-BASED CORTICAL-BASED DISORDERSDISORDERS

• LEARNING DISABILITIESLEARNING DISABILITIES

• LANGUAGE DISABILITIESLANGUAGE DISABILITIES

• MOTOR DISABILITIESMOTOR DISABILITIES

ATTENTION DEFICIT ATTENTION DEFICIT HYPERACTIVTY DISORDERHYPERACTIVTY DISORDER

EMOTIONAL REGULATORY EMOTIONAL REGULATORY DISORDERS DISORDERS

• ANXIETY DISORDERSANXIETY DISORDERS

• DEPRESSIONDEPRESSION

• ANGER CONTROL DISORDERSANGER CONTROL DISORDERS

• OBSESSIVE-COMPULSIVE DISORDEROBSESSIVE-COMPULSIVE DISORDER

ANXIETY DISORDERSANXIETY DISORDERS

• GENERALIZED ANXIETY DISORDERGENERALIZED ANXIETY DISORDER

• PANIC DISORDERPANIC DISORDER

• PHOBIASPHOBIAS

• OBSESSIVE-COMPULSIVE DISORDEROBSESSIVE-COMPULSIVE DISORDER

DEPRESSIONDEPRESSION

• MAJOR DEPRESSIVE DISORDERSMAJOR DEPRESSIVE DISORDERS– Present two or more weeksPresent two or more weeks

• DYSTHYMIC DISORDERDYSTHYMIC DISORDER– Present for two or more yearsPresent for two or more years

INTERMITTENT EXPLOSIVE INTERMITTENT EXPLOSIVE DISORDERDISORDER

• Several discrete episodes of failure to resist Several discrete episodes of failure to resist aggressive impulses that result in serious aggressive impulses that result in serious assaultive acts or destruction of property.assaultive acts or destruction of property.

• The degree of aggressiveness expressed The degree of aggressiveness expressed during the episodes is grossly out of during the episodes is grossly out of proportion to any precipitating psychosocial proportion to any precipitating psychosocial stressors.stressors.

• The aggressive episodes are not better The aggressive episodes are not better accounted for by another mental disorder.accounted for by another mental disorder.

OBSESSIVE-COMPULSIVE OBSESSIVE-COMPULSIVE DISORDER: DISORDER:

OBSESSIONSOBSESSIONS• OBSESSIONS ARE UNWANTED OBSESSIONS ARE UNWANTED

THOUGHTS, IMAGES, OR IMPULSES THOUGHTS, IMAGES, OR IMPULSES THAT THE INDIVIDUAL REALIZES ARE THAT THE INDIVIDUAL REALIZES ARE SENSELESS OR UNNECESSARY, SENSELESS OR UNNECESSARY, INTRUDE INTO ONE’S INTRUDE INTO ONE’S CONSCIOUSNESS INVOLUNTARILY, CONSCIOUSNESS INVOLUNTARILY, AND CAUSE FUNCTIONAL AND CAUSE FUNCTIONAL IMPAIRMENT AND DISTRESSIMPAIRMENT AND DISTRESS

OBSESSIVE-COMPULSIVE OBSESSIVE-COMPULSIVE DISORDER: COMPULSIONSDISORDER: COMPULSIONS

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

COMMON BEHAVIORS WITHCOMMON BEHAVIORS WITH OBSESSIVE-COMPULSIVE OBSESSIVE-COMPULSIVE

DISORDERDISORDER• Counting or repeating behaviorCounting or repeating behavior

• Checking or questioning behaviorChecking or questioning behavior

• Collecting or hoarding behaviorCollecting or hoarding behavior

• Arranging and organizing behaviorArranging and organizing behavior

• Cleaning and/or washing behaviorCleaning and/or washing behavior

• ““Preening” behaviors (nail biting, Preening” behaviors (nail biting, cuticle picking, hair pulling, picking at cuticle picking, hair pulling, picking at sores)sores)

TREATMENT FOR REGULATORYTREATMENT FOR REGULATORY DISORDERS DISORDERS

• THE “SELECTIVE SEROTONIN REUPTAKE THE “SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)INHIBITORS (SSRIs)

Trade NameTrade Name Generic NameGeneric Name

ProzacProzac fluoxetine fluoxetine

PaxilPaxil paroxetine paroxetine

ZoloftZoloft sertraline sertraline

LuvoxLuvox fluvoxamine fluvoxamine

CelexaCelexa citalopram citalopram

THE TIC DISORDERSTHE TIC DISORDERS

THE TIC DISORDERSTHE TIC DISORDERS

• TRANSIENT TIC DISORDERSTRANSIENT TIC DISORDERS

• CHRONIC TIC DISORDERSCHRONIC TIC DISORDERS– Chronic Motor Tic DisorderChronic Motor Tic Disorder– Chronic Vocal Tic DisorderChronic Vocal Tic Disorder

• TOURETTE’S DISORDERTOURETTE’S DISORDER

TREATMENT FOR TIC TREATMENT FOR TIC DISORDERSDISORDERS

TRADE NAMETRADE NAME GENERIC NAMEGENERIC NAME

CatapresCatapres clonidine clonidine

HaldolHaldol haloperidolhaloperidol

TenexTenex guanafacine guanafacine

OrapOrap pimozide pimozide

BIPOLAR DISORDERBIPOLAR DISORDER

BIPOLAR DISORDERBIPOLAR DISORDER

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

TYPES OF BIPOLAR TYPES OF BIPOLAR DISORDERDISORDER

• BIPOLAR I:BIPOLAR I: SINGLE MANIC EPISODESINGLE MANIC EPISODE

• BIPOLAR II: RECURRENT MAJOR BIPOLAR II: RECURRENT MAJOR DEPRESSIVE EPISODES DEPRESSIVE EPISODES

WITH HYPOMANIC WITH HYPOMANIC EPISODES EPISODES

BIPOLAR DISORDER IN BIPOLAR DISORDER IN CHILDREN CHILDREN AND AND ADOLESCENTSADOLESCENTS

• OFTEN MORE RAPID CYCLING THAN OFTEN MORE RAPID CYCLING THAN WITH ADULTSWITH ADULTS

• CYCLES INCLUDE:CYCLES INCLUDE:– DEPRESSION TO HYPOMANIC OR MANICDEPRESSION TO HYPOMANIC OR MANIC– CALM TO IRRITIBILITY TO RAGECALM TO IRRITIBILITY TO RAGE

TREATMENT FOR BIPOLAR TREATMENT FOR BIPOLAR DISORDERDISORDER

• FOR MANIC AND RAGE BEHAVIORS:FOR MANIC AND RAGE BEHAVIORS:– ANTI-CONVULSANT MEDICATIONSANTI-CONVULSANT MEDICATIONS– ATYPICAL ANTIPSYCHOTIC MEDICATIONSATYPICAL ANTIPSYCHOTIC MEDICATIONS

• FOR DEPRESSION:FOR DEPRESSION:– A NON-SSRI MEDICATIONA NON-SSRI MEDICATION– MOST COMMONLY USED: WELLBUTRINMOST COMMONLY USED: WELLBUTRIN

ANTICONVULSANT ANTICONVULSANT MEDICATIONSMEDICATIONS

•DEPAKOTEDEPAKOTE

•TEGRETALTEGRETAL

•NEURONTINNEURONTIN

•LAMICTALLAMICTAL

•TRILEPTALTRILEPTAL

•GABRITRALGABRITRAL

•(LITHIUM)(LITHIUM)

ATYPICAL ANTIPSYCHOTIC ATYPICAL ANTIPSYCHOTIC MEDICATIONS MEDICATIONS

•RESPERDALRESPERDAL

•ZYPREXIAZYPREXIA

•GEODONGEODON

•SEROQUILSEROQUIL

•ABILIFYABILIFY

SIGNIFICANCE OF THE SIGNIFICANCE OF THE CONCEPTCONCEPT OF A CONTINUUM OF OF A CONTINUUM OF NEUROLOGICALLY-BASED NEUROLOGICALLY-BASED

DISORDERS DISORDERS

• IF ONE DIAGNOSIS IS FOUND, THE IF ONE DIAGNOSIS IS FOUND, THE OTHER DIAGNOSES MUST BE OTHER DIAGNOSES MUST BE LOOKED FOR.LOOKED FOR.

• UNLESS ALL DIAGNOSES ARE UNLESS ALL DIAGNOSES ARE ADDRESSED, THE CLINICAL ADDRESSED, THE CLINICAL OUTCOME MAY BE LESS THEN OUTCOME MAY BE LESS THEN DESIRED.DESIRED.