Eating disorders 

High comorbidity with body dysmorphic disorder and OCD.

• In PEDATRICS 50th percentile
•  In adults, use BMI [a screening tool. Higher than 30 is predisposition for many diseases. OBESE].
• BMI -Correlates to measures of body fat -- Under 17.5 significant risk for anorexia associated health problems

SELF imposed starvation : BMI < 17%

• Refusal to maintain body weight at or above that expected for age & height (<85% of Ideal Body Weight).
• Intense fear of gaining weight or becoming fat despite being severely underweight
•  Distortion in the way one’s body size is experienced and denial of seriousness of low weight.
• Amenorrhea from ↓LH and FSH in post-menarcheal females (absence of 3 or more consecutive menstrual cycles)

• restricting - eating very little and not regularly engaging in binge eating or purging behavior.  often substantially increasing exercise 
• binge eating/purging (less frequent) - excessive caloric intake. Then vomits or uses diuretics/laxatives

•  Vital signs: emaciated, hypotension, bradycardia, skin/hair changes (lanugo), dry skin, salivary gland hypertrophy, amenorrhea
• Labs: CBC: leukocytosis, leukopenia, anemia; hypokalemia, ↑BUN (pre-renal dehydration), hypothyroid, arrhythmias

• hospitalization for < 75% expected body weight to stabilize medically
• psychotherapy: CBT
• pharmacotherapy: if depression SSRI, atypical anti-psychotics (may help with weight gain as well)

• recurrent episodes of binge eating - objectively a large amount of food, individual feels "out of control" and eats to point of discomfort
• recurent compensatory mechanisms to avoid weight gain - self induced vomiting, laxative use, fasting, excessive exercise 

1. purging-self-induced vomiting, misuse of laxatives, enemas or diuretics
2. non-purging-using compensatory behaviors like excessive exercising or fasting 

• Recurrent episodes of Binge eating for at least a period of 2 days/week for 6 MONTHS
• Characterized by the consumption of a larger amount of food in 2 hours than the average person would consume
• Binge eating episodes are associated with 3 or more of the following:

1.     Eating faster than normal
2.     Eating until feeling uncomfortably full
3.     Eating to excesssssssss
4.     Eating even though not hungry
5.     Eating alone out of embarassment with feelings of disgust, guilt, or depression after the episode

• psychotherapy: CBT
• pharmacotherapy:fluoxetine shown to reduce binge-purge cycle

• Binge eating: gastric dilation and rupture; obesity
•  Vomiting:

·       Esophageal rupture
·       Parotiditis with hyperamylasemia
·       hypokalemic, hypochloremic metabolic alkalosis (with cardiac arrhythmias)

• Laxative use

·       Constipation (from dependence)
·       Dehydration

• Cardiovascular – just know that it can cause arrhythmias

·       Orthostatic hypotension (starvation)
·       Bradycardia (starvation)
·       Prolonged QT and T-wave abnormalities on EKG (purging behaviors)
·       Mitral valve prolapse (diminished muscle mass)
·       Cardiomyopathy (Ipecac toxicity)

• Cell counts

·       Low WBC (starvation and stress)
·       Anemia (starvation)

• Fluid and electrolytes

·       Dehydration (starvation, purging)
·       *Decreased albumin (starvation)
·       Peripheral edema and effusions (starvation)
·       Electrolyte disturbances (purging)

• Dermatologic

·       Hair loss (stress, starvation)
·       Dull hair (decreased fat)
·       *Lanugo hair (starvation)-a fine, pale hair appearing in the setting of protein-calorie malnutrition

·       Dry skin (decreased fat)
·       Calloused or scarred knuckles (purging)
·       Acrocyanosis (starvation)-blueness of hands and feet

• Dental (purging)
•  Re-feeding syndrome: when treating severely underweight (<75% of IBW), watch for this. State caused by sudden carbohydrate intaked severely depleting body phosphate stores (hypophosphatemia) resulting in rhabdomyolysis, delerium, seizures and eventual cardiovascular collapse. Look for signs of CHF, AMS, and signs of edema

amenorrhea

bone health (decrease in peak bone mineral density)

•  *Hypokalemia: Serum potassium < 3.2 mmol/L
• *Hypochloremia: Serum chloride < 88 mmol/L
• *Cardiac arrhythmias, including prolonged QTc interval
• Syncope
• Intractable vomiting
• Hematemesis
• Failure to respond to outpatient treatment
• Severity of psychiatric comorbidities (Major depression, anxiety disorders, substance abuse disorders)

• stimulants - increase risk of cardiac arrest, risk of abuse to lose more weight. also reduce appetite
• buproprion (wellbutrin) decrease seizure threshold which can increase risk of seizures
• TCA's - increase risk of cardiac dysfunction

depressant and functions by releasing dopamine 

overstimulation of the reward d/t to brain "soaked in dopamine" produces euphoric effects

substance dependence

1. compulsive use

2. inability to control use

3. continued use despite consequences

• Has not met criteria for dependence, but results in impairment
• Maladaptive pattern of substance use, characterized by one (or more) of the following symptoms in a 12 month period
• 1.     Recurrent substance use leads to failure of major obligations (home, school, work)
• 2.     Repeated substance use in situations in which it is physically hazardous
• 3.     Recurrent substance-related legal problems
• 4.     Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

• Physical: physiologic changes that occur with drug abuse and result with withdrawal on termination
• Psychological: craving or desire for substance independent of withdrawal symptoms
• Maladaptive pattern of substance use, characterized by 3 (or more) of following symptoms in a 12-month period:

• 1.     ***TOLERANCE***: need for more or diminished effect. 

  o   As a person continues to abuse drugs, the brain adapts to the overwhelming surges of dopamine by:

  §  Producing less dopamine

  §  Reducing the number of dopamine receptors in the reward circuit 

  2.     ***WITHDRAWAL*** 

  o   2 or more of the following developing within a few hours to a few days of reduction in heavy or prolonged alcohol use

  ·       Sweating or rapid pulse 

  ·       Increased hand tremor 

  ·       Insomnia 

  ·       Nausea or vomiting 

  ·       Physical agitation 

  ·       Anxiety 

  ·       Transient visual, tactile, or auditory hallucinations or illusions 

  ·       Grand mal seizures

  o   Delirium tremens is severe form of withdrawal 2-3 days after stopping: delirium, tremors, seizures, visual hallucinations

  3.     Substance taken in larger amounts or over a longer period than intended

  4.     Persistent desire or unsuccessful efforts to cut down or control substance use

  5.     Great deal of time spent obtaining, using, or recovering from effects of the substance

  6.     Important social, occupational, or recreational activities are given up or reduced 

  7.     Substance use continued despite knowledge of having a persistent or recurrent physical or psychological problem that was likely caused or exacerbated by the substance

• Addictive substances and behaviors like nicotine, food, caffeine, and perhaps sex and gambling act by a final common pathway influencing neurons of the ventral striatum/nucleus accumbens.
•  this structure is a target of the mesolimbic dopamine pathway that mediates reward system function.
•  Rewards like feeding, sex, exercise produce associate memories linked to the rewards that reinforce the probability of rewarding behavior. 
• Drugs, via direct synaptic effects, produce similar powerful associated memories strongly reinforcing behavior associated with drug use.

• happens when tolerance and withdrawal symptoms develop
• There is persistent desire to cut down/ control intake without success
• Compared with control subjects, the relatives of alcoholics are more likely to have higher rates of depression and antisocial PD.

• Early signs→  acne rosacea, palmar erythema, painless hepatomegaly (from fatty infiltration)
• Advanced signs→ cirrhosis, jaundice, ascites, testicular atrophy, gynecomastia, Dupuytren contracture
• Cirrhosis can lead to: variceal bleeding, hepatocellular carcinoma, hepatic encephalopathy
• Increased risk for pneumonia, TB, HTN, cardiomyopathy, GI cancers

• Blood alcohol levels confirm alcohol in the blood and provide rough estimate of tolerance (higher levels without intoxication indicate higher tolerance)
• Elevated MCV
• Elevated glutamic oxaloacetic transaminase
• Elevated glutamic-pyruvic transaminase
• May have evidence of rib fractures on CXR

• Wernicke- Korsakoff’s syndrome (Wernicke’s encephalopathy) due to thiamine deficiency

• alcoholic hallucinations
• alcohol induced dementia
• peripheral neuropathy
• alcohol induced depression
• Suicide

• Supportive and withdrawal of the alcohol source
• Intensive care if complicated by respiratory compromise
• Vitamin supplementation with folate 1mg QD and 100mg thiamine QD for all patients
• If early signs of Wernicke's give thiamine before glucose→ glucose depletes thiamine stores. So rule this out before considering hypoglycemia treatment!!!
• Magnesium replacement

• slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention/memory, stupor/coma
•  clinically significant maladaptive behavioral or psychological changes (inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning)
• dx has to be differentiated from other medical/neuro states like diabetichypoglycemia, medication toxicity with ethylene lycol, lithium, and phenytoin; medication intoxication with benzos or barbituates.                     
• Dx by blood alcohol level

• the presence of symptoms after a prolonged period of heavy alcohol use is stopped. 
• tremor (especially of the hands), tachycardia, HTN, sweating, GI sx (N/V), insomnia, sensory disturbances like perceptual distortions and hallucinations, psychomotor agitation, anxiety; may have grand mal seizures.    

• delirium tremens: delirium (perceptual disturbances, confusion, disorientation, agitation etc), autonomic hyperarousal, fever.
• Typically presents 2-3 days after alcohol cessation and can                                                persist for few days to weeks
• Tx: IV benzos, supportive care

• when alcohol is determined to be the cause of deficits in memory, aphasia, apraxia, agnosia, impaired executive functions

• AKA korsakoff's syndrome 
• often irriversible 
• development of memory impairement in learning new memories or recalling old information w/ hx of alcohol dependence 
• confabulation (making up information to fill gaps in memory) is common

• two goals: sobriety & tx of comorbid psychopathology
• AA program has 12 steps & effective way to recover
• tx of assoc. depression should be done if persistent > 2-4 weeks after sobriety - intoxicated pts may appear severely depressed & display sucidal thoughts or behavior which resolve when sobriety achieved 
• tx of anxiety should be done if persistent after 1 mo of sobriety
• Inpatient and residential rehab programs: team approach aimed at recovery

•        Group therapy: allows patients to see their problems mirrored in and confronted by others

  ·       Family therapy: allows patient to examine role of family in the alcoholism

• Disulfram (Antabuse) inhibits alcohol dehydrogenase causing acetaldehyde to build up in the body causing adverse side effects like flushing, n/v, hypotension and palpitations making the patient more inclined not to drink. Very dangerous if pt continues to drink or relapses on this medication. Starting dose is 250mg QD
• Naltrexone (Revia) opiate antagonist to reduce cravings of alcohol intake by reducing the “high” feeling of alcohol. Starting dose is 50mg QD; is okay to take if relapse occurs
• both of these meds are used for maintenance therapy and do not prevent withdrawal
• Benzos are used in acute detoxification to prevent life-threatening complications of withdrawal

• All are cross tolerant with each other and alcohol; include barbiturates and benzos(most widely prescribed and available)
• phenomenon that occurs when someone who is tolerant to the effects of a certain drug also develops a tolerance to another drug.
• Barbituate and benzodiazepines can produce a life-threatening withdrawal syndrome

• quantitative and qualitative urine/serum tox screen for barbiturates, benzos
• minor withdrawal sx : restlessness, apprehension, anxiety
• more severe withdrawal: coarse tremors, weakness, N/V, sweating, hyperreflexia, ohTN, seizures
• Dependence evident by 3 or more withdrawal s/s

• Inpt detox done in more high risk cases (comorbid psych dz, prior treatment failure, lack of support etc)
•  Benzos/barbiturates can be given on a scheduled dose and slowly tapered off in controlled manner
• Withdrawal from short acting drugs is more severe than that of long acting drugs which is prolonged
• Barbiturate withdrawal more severe than benzos- hyperpyrexia, seizures, death happens more easily
• If alcohol abuse occurring also, can do phenobarbital challenge test to see how tolerant the patient is to know how much drug to give and taper to reduce withdrawal problems
• Treatment: detox and therapy/rehab

• History: most users take drugs IV; initial rush followed by psychomotor retardation, drowsiness, inactivity and impaired concentration
• Flushing, and intensely pleasurable bodily sensation that resembles orgasm, followed by sense of well being, then coming down

• after immediate administration pupillary constriction, respiratory depression, slurred spech, hypotension, bradycardia, hypothermia
• N/V, constipation common after opiate use 

• dependent addicts use 3+ times a day
• withdrawal happens 10 hours after last dose and lasts 7-10 days with short acting opiates and 2-3 weeks with long acting 

• can be highly uncomfortable but is rarely medically complicated or life threating 
• mild withdrawal - dysphoric mood, anxiety, & restlessness, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, tachycardia, fever, diarrhea, insomnia, yawning
• more severe withdrawal - N/V, muscle aches, seizures (in meriperidine withdrawal), abdominal cramps, HTN, hot and cold flashes, severe anxiety 

• opiate addicts often have comorbid substance use disorder, antisocial or borderline personality disorder and mood disorders.
• Addicts more prone to commit crimes because of $$$ of opiates
• Addiction associated with high mortality rates from OD, accidents and suicide
• Higher risk for medical problems from poor nutrition and dirty needles
• Medical problems: hepatitis, HIV, endocarditis, pneumonia, cellulitis

• Methadone- weak mu opiate receptor agonist with longer half-life so less intoxicating/withdrawal effects
• Buprenorphine (Buprenex)- mu and k opioid receptor antagonist approved for outpatient detox

• Naloxone(Narcan)-opioid antagonist
• Clonidine- centrally acting alpha 2 agonist that decreases central noradrenergic output used to treat the autonomic sx but doesn’t curb the craving; risk of hypotension limits use in outpatient setting
• Promethazine (for nausea), quinine (for muscle aches) and dicyclomine (for abd. cramping)
• Long term rehab involves Narcotics anonymous and methadone administration 60-100mg QD in approved clinics

• psychoactive & sympathomimetic effects
• cocaine - adrenergic agonist that blocks re-uptake of NE at storage site (nerve terminal). Rapid onset of action & short half life, requiring frequent dosing
• amphetamine - gets into n. terminal & causes release of NE. longer half life so taken less frequently 

• CNS stimulant abuse (cocaine, amphetamines)
• can use anti-depressants affecting catecholamine function like buproprion (atypical antidepressant), better than SSRI's for cocaine depression

• Maladaptive behavioral changes (ex: euphoria or hypervigilance)
• tachy/bradycardia
• pupil dilation (constriction in opioid use)
• Hyper or hypotension
• Perspiration or chills
• n/v
• tactile hallucinations(coke bugs)
• psychomotor agitation/retardation
• confusion/seizures/dyskinesias,coma
• muscle weakness, resp depression, CP, cardiac dysrhythmias
• agitation, impaired judgment
• transient psychosis-paranoia, visual hallucinations

• fatigue, depression, nightmares, HA, sweating, muscle cramps, hunger
• sx peak in 2-4 days

self limited, no inpatient detox required

antipsychotics can be used to treat agitation 

main goal is rehab

doesn't require treatment 

sx are self-limited

• Ecstacy (MDMA) → stimulant/ hallucinogenic properties and enhances desire for intimacy;long term use associated w decreased serotonin in the brain
• Methamphetamine → psychostimulant neurotoxic to dopamine and serotonin axons; highest use in young adults
• GHB →  low doses used by bodybuilders and those seeking increased muscle mass as it promotes the release of GH, high doses used to get high and can cause rep arrest
• Ketamine →a dissociative anesthetic that is hallucingenic
• Rohypnol→ a benzo that has strong amnestic properties, and is frequent culprit in drugging others for purpose of theft or sexual assault. hypnotic, sedative, anticonvulsant, anxiolytic, and skeletal muscle relaxant drug
•  LSD→ hallucinogenic

• CNS: Induces feelings of pleasure, improved performance and vigilance, relaxation, perceived improvement of mood and curbing hunger
• Peripheral: Increase BP/rate, decreased coronary blood flow (induces vasoconstriction), increased bowel motor activity

toxic to heart, lungs

is carcinogenic

• nicotine patch
• buproprion (dopa/NE reuptake inhibitor)
• varenicline (Chantix-N receptor parital agonist, most effective) - less euphoria than nicotine . + dopamine reward

somatoform disorders

(not willfully produced by the individual)

• a medical condition, other psychiatric illness, or the effects of a stubstance (ie alcohol or a medication) will not explain the entirety patient's symptoms
• the patiend does not meet the criteria for malingering or factitious disorder
• at least one primary area of the patients life (ie work or social functioning) is significantly disrupted by thes ymptoms or the symptoms cause a lot of distress 

• somatization disorder

•  Long hx of going to doctor (even multiple physicians) for unexplainable symptoms. No medical disorder ever found
• Pattern of symptoms prior to 30 years old
• More common in females.
• May seek disability b/c of their conviction that they are severely and chronically medically ill
•  Vague physical complaints involving many organ systems
• 50% have a comorbid mental disorder

GI tract

reproductive tract

neurologic symptoms

pain

•  Must have reported at least 4 occurrences of pain in different areas of the body

o   2 symptoms involving digestion/GI (other than pain)
o   1 symptom involving sexual function  (other than pain)
o   1 symptom imitating disease of CNS [pseudoneurologic] (other than pain)

• CBT is the best tx 
• anti-depressants may help if they have co-morbid depression

hypochondriasis

duration of disturbance @ least 6 months

anxiety, panic attacks, depression, & chronic fatigue

poor insight 

CBT is the most useful of the psychotherapies 

can use SSRI's if comorbid anxiety and/or depression

•   If a slight physical anomaly is present, the person’s concern is markedly excessive.
• Patient feels self-conscious and fears humiliation
• Patients can go to great lengths to hide or correct their perceived anomaly
• Visits to dermatologist or plastic surgeon are common

• serotonin-modulating drugs (fluoxetine, clomipramine) are efficacious in majority of cases
• SSRI

• Often patient will seek hospital admission under different names and by feigning different illnesses.
• When (or if) confronted with their ruse, they usually become angry and sign out.
• Patients usually familiar with the disease process and they are feigning, however, true disease processes must be ruled out

had a serious illness in childhood (they get used to the attention and are comfortable in this role), they have a sick relative 

• Parent abusing the child by seeking unneeded medical attention for the child.
• Parent may fake symptoms of illness in child by:

·       adding blood to the child's urine/stool
·       withholding food
·       falsifying fevers
·       secretly giving child drugs to make the child throw up or have    

      diarrhea

·       adding toxic materials that will create difficult diagnosis

• The parent is usually female and appears very helpful at the hospital. Appears very devoted and caring.

• collaberate w/ medical staff to avoid unnecessary procedures
• once dx is confirmed, approach pt in non-threatening manner
• psychotherapy (individual, family) suggested 
• SSRI useful in reducing impulsive tendencies seen in acting-out factitious disorder

• patients tend to express vague, poorly defined complaints and claim that these symptoms cause great distress and impaired functioning
• Injuries often found to be self inflicted
• History reveals multiple undiagnosed illnesses or previous injuries and even tampering with laboratory results
• Patients uncooperative and refuse to accept clean bill of health
• Symptoms typically improve when the objective has been met or the ruse has been exposed

• ADHD usually persists through a person's lifetime. Not limited to children
• ADHD seems to run in families 
• hypothesized d/t deficient dopamine availability

• Syndrome characterized by persistent inattention, hyperactivity and impulsivity compared with what is expected for a child at a particular developmental level.  
• The 3 subtypes are hyperactive impulsive, inattentive, and combined (most children demonstrate combined type). 
• To meet criteria 6 of the listed symptoms must persist for 6 months    -- pg 33

• Can Manifest as Hyperactivity and Impulsivity or as Inattentiveness
• Most children manifest sxs of both attention deficit and hyperactivity
• Secondary sxs:  emotional immaturity, poor social skills, sometimes motor incoordination, disruptive behaviors
• Between 2-20% of children of school age may be affected.
• 2-5X more common in boys than girls with the firstborn son most commonly affected

• staying up late
• waking up early
• spending most of the waking hours in various hyperactive and impulse activities

• appear not to follow directions
• forget important school supplies
• fail to complete homework or in class assignments
• attempts to blurt out answers to teachers' questions before called on 

• Inattention-fails to pay close attention to details, easily distracted, difficulty persisting to task completion
• Hyperactivity and impulsivity-fidgety, squirmy, talking excessively, interrupting

• Meets symptom criteria
• Some inattention or hyperactivity-impulse symptoms causing impairment are present before age 7 years
• Some impairment from symptoms present in two or more settings (e.g., home, school or work, social)
• Clear evidence of clinically significant impairment in social, academic, or occupational functioning

BPD

oppositional defiant d/o (unwillingness to comply w/ demands, but not out of difficulty of attention)

anxiety

depression

substance use disorders

conduct disorder

ODD

learning disabilities

•   Emotional suppor

1. behavioral management program
2. positive reinforcement
3. firm limit setting
4. techniques for reducing stimulation (like 1 playmate at a time, short/focused tasks)

•  educational assessment (school underperformance) d/t learning disability

1. oppositional defiant disorder (MC)
2.  conduct disorder
3. mood disorder
4. anxiety
5. neuro issues: epilepsy or tourette syndrome

• Medications with combination of behavioral modifications is the best TX

1. Psychostimulants: these are controlled substances that increase dopamine and norepinephrine
2.   First line: methylphenidate (concerta, Ritalin, Quillivant XR)
3.   dextroamphetamine
4.     lisdexamfetamine (vyvanse)
5.  Adderall (amphetamine and dextroamphetamine)
6. Side effects of sleep difficulty, stomach aches, headaches, appetite reduction, growth retardation, weight loss, drowsiness, irritability, nervousness, excessive starring

•  Non-stimulants

1. atomoxetine (Strattera) is a non-stimulant SNRI. Not methamphetamine based so non habit forming
2.  clonidine (α2 agonist)
3. guanfacine (Intuniv-α2 agonist)
4. Wellbutrin-first resort if non-stimulant is desired and patient has a co-occurring mood disorder

• A persistent pattern of behavior that includes the following

1. defiance of authority 
2. violating the rights of others or society's norms
3. aggressive behavior towards persons, snimals, or property

• Overlap with ADHD, substance abuse, learning disabilities, neuropsychiatric disorders, mood disorders and family dysfunction
• May come from homes with domestic violence, child abuse, drug abuse, shifting parental figures, and poverty
• Of the children with conduct disorder, 25-40% go on to have antisocial personality disorder.

• Diagnosis is established on the basis of a pattern of behavior that involves violation of the basic rights of others or of social norms and at least 3 acts of the following types
• Aggression to people and animals

1. Bullies/threatens
2. Intimidates others often initiates physical fights
3. Has used a weapon that could cause serious physical harm to others (bat, brick, knife or gun)
4. Physically cruel to people or animals
5. Steals from a victim while confronting them (e.g. assault)
6.  Forces someone into sexual activity

• Destruction of property

1. fire setting
2. Deliberately destroys other's property

• Deceitfulness, lying, or stealing

1. has broken into someone else's building, house, or car
2.  lies to obtain goods, or favors or to avoid obligations
3.  steals items without confronting a victim (e.g. shoplifting, but without breaking and entering)

• Serious violations of rules 

1.  often stays out at night despite parental objections
2. runs away from home
3. often truant from school

•  Efforts to stabilize the environment and improve functioning in the home [Family therapy] (particularly parental functioning and disciplinary techniques)
• ID learning disabilities and place in optimal school environment
•  Juvenile justice system involvement is common in cases where conduct disorder behaviors lead to illegal activities, theft or assault

Medication Treatment of Conduct Disorders:

• Risperdol (most common)
•  Haloperidol
• Lithium
• Olazapine
• ^^^All used to treat aggressivity and mood
• SSRI-Prozac, Paxil, Zoloft (reduces impulsivity and mood lability/ irritability.)
• Stimulants (dextroamphetamine, methylphenidate), bupropion, clonidine, Lithium, and valproic acid can be used to treat aggressive/assaultive behavior

 3 empirically supported treatments

• 1.     Parent management training
• 2.     Problem solving skills training
• 3.     Multi-systemic therapy: used increasingly as an intervention for youth with conduct disorders and involvement in the legal system. It is an intensive home based model of care that seeks to stabilize and improve the home environment and to strengthen the support system and coping skills of the individual and family
•  Parent-child interaction therapy

• Generally begins before age 8 and affects 16-22% of children
• Will remit in 25%, but may progress to conduct disorder
• High comorbidity with substance abuse disorders, mood disorders and ADHD

Age-inappropriate, stubborn, hostile, and defiant behavior, including:

• losing temper
• arguing with adults
• active defiance or refusal to comply
• deliberately annoying others
• blaming others for mistakes or misbehavior
• being “touchy” or easily annoyed
• anger and resentfulness
• spitefulness or vindictiveness
• 4 of the above must be present
• the dx includes at least 6 months of negativism, hostile, and defiant behavior

• family intervention using training skills in child management for the parents/caregivers
• individual psychotherapy focusing on behavioral modification and problem solving skills
• treat comorbid psychiatric disorder with meds as needed 
• PG 37!!