EPILEPSY AND MENTAL DISORDERS IN CHILDREN AND ADOLESCENTS – DIFFERENTIAL DIAGNOSTICS

Rad se bavi razlikama između epilepsije i mentalnih poremećaja u djece i adolescenata kad je simptomatologija tih bolesti slična. Pokušavaju se dati smjernice za što točniju dijagnostiku, jer je ona preduvjet ispravnom liječenju. Kao najvažnije dijagnostičko sredstvo i dalje se smatra dobro uzeta anamneza te timski rad dječjeg psihijatra i neuropedijatra.The paper deals with differences between manifestations of epileptic and mental disorders in children and adolescents in cases when they exhibit similar symptoms. Since the treatment outcome depends almost entirely on the accurate diagnosis, the paper sets out guidelines and main points of differentiation between these phenomena. Detailed anamnesis along with close cooperation between the child psychiatrist and the neuro-pediatrician are considered the cornerstones of the diagnostic procedure

PHARMACOTHERAPY IN CHILDREN WITH LEARNING DISABILITIES

Dijagnoza poremećaja učenja vrlo je općenita, pa stoga i neprecizna, jer se pod njom može skrivati široki spektar raznih dijagnostičkih kategorija iz područja dječje i adolescentne psihijatrije. Primjeri su ADHD, specifične smetnje učenja, poremećaj ponašanja, mentalna retardacija, depresivni poremećaj, reakcija na stres i poremećaj prilagodbe, neurotski poremećaj, somatoformni poremećaj, poremećaj privrženosti i drugo. Zbog toga je nužno točno postaviti dijagnozu te u dogovoru s roditeljima, djetetom i školom razraditi plan svladavanja nastavnog programa, a prema potrebi početi i psihoterapiju. Ako spomenuti postupci nisu dostatni, možda će biti opravdano uključiti i medikamentoznu terapiju. Najčešći razlog poremećaju učenja je ADHD (F 90), a lijek izbora su psihostimulansi (npr. metilfenidat, dekstroamfetamin, pemolin). Posljednjih godina u terapiji ADHD-a na raspolaganju je i nestimulans atomoksetin – selektivni inhibitor ponovne pohrane noradrenalina. Za sada ne postoji medikamentozna terapija koja bi bila učinkovita kod specifičnih smetnji učenja (F 81). Ako se iza poremećaja učenja skriva neki psihijatrijski poremećaj, kao npr. neurotski, psihotični, afektivni i dr., uz psihoterapiju se ciljano može davati i lijek za tu bolest (npr. anksiolitik, neuroleptik, antidepresiv, itd.). U nekim kombiniranim slučajevima (npr. ADHD i depresivni poremećaj itd.) uz npr. psihostimulanse može se istodobno uključiti i dodatna psihijatrijska medikacija (npr. antidepresiv). Primjena psihijatrijskih lijekova kod djece vrlo je osjetljiv postupak, koji zahtijeva stalno praćenje učinkovitosti terapije, prilagođavanje doze i otkrivanje eventualnih nuspojava.Diagnosis of learning disabilities is a general entity and as such is imprecise since it includes a broad spectrum of various diagnostic criteria in the field of child and adolescent psychiatry. For example, it includes ADHD, specific learning disorders, conduct disorders, mental retardation, depressive disorders, stress disorder and adjustment disorders, neurotic and somatoform disorders, attachment disorders etc. For that reason it is crucial to establish a precise diagnosis, make an adequate schooling plan in cooperation with parents, child and school, and start psychotherapy if necessary. If such procedures are not sufficient, medicament therapy may be considered. The most common reason for learning disabilities is ADHD (F90), and in such cases the drugs of choice are psychostimulants (e.g. methylphenidate, dextroamphetamine, pemolin). In the past few years a non-stimulant drug used in the treatment of ADHD is atomoxetine – selective norepinephrine reuptake inhibitor. At present there is no medical therapy that would be effective in the treatment of specific learning disorders (F81). If there are other psychiatric disorders with ADHD, such as neurosis, psychotic disorder, affective disorder or other, in addition to psychotherapy a specific, targeted drug can be used (e.g. anxiolitic, neuroleptic, antidepressant etc.). In cases of two or more psychiatric disorders (e.g. ADHD and depressive disorder) in addition to psychostimulants other medication can be used simultaneously (e.g. antidepressant). Prescription and usage of psychiatric drugs in children is a very delicate process, which demands continuous monitoring of therapy effectiveness, adjustment of dosage and detection of possible side effects

EPILEPSY AND MENTAL DISORDERS IN CHILDREN AND ADOLESCENTS – DIFFERENTIAL DIAGNOSTICS

Rad se bavi razlikama između epilepsije i mentalnih poremećaja u djece i adolescenata kad je simptomatologija tih bolesti slična. Pokušavaju se dati smjernice za što točniju dijagnostiku, jer je ona preduvjet ispravnom liječenju. Kao najvažnije dijagnostičko sredstvo i dalje se smatra dobro uzeta anamneza te timski rad dječjeg psihijatra i neuropedijatra.The paper deals with differences between manifestations of epileptic and mental disorders in children and adolescents in cases when they exhibit similar symptoms. Since the treatment outcome depends almost entirely on the accurate diagnosis, the paper sets out guidelines and main points of differentiation between these phenomena. Detailed anamnesis along with close cooperation between the child psychiatrist and the neuro-pediatrician are considered the cornerstones of the diagnostic procedure

Holistic approach in the treatment of a boy with Tourette’s disorder

Touretteov poremećaj (TP) neurorazvojni je poremećaj s kombiniranim motoričkim i vokalnim tikovima. Etiologija bolesti nije jasna, ali rezultati istraživanja upućuju na važnost genetičkih faktora. U radu je opisan slučaj holističkog pristupa u liječenju desetogodišnjeg dječaka s Touretteovim poremećajem. Primijenjena farmakoterapija bila je usmjerena na komorbidna stanja, a ne na same tikove. Remisija je uslijedila nakon godinu dana liječenja.Tourette’s disorder is a neurodevelopmental disorder with combined motor and vocal tics. The etiology of the disease is not clear, but results suggest the role of genetic factors. The paper describes a case of a holistic approach in the treatment of a ten-year-old boy with Tourette’s disorder. The pharmacotherapy applied was focused on comorbid conditions, and not on the tics. Remission followed after one year of treatment

Trichotillomania and comorbidity in adolescents: two case reports

Trihotilomanija je relativno rijedak poremećaj. U Dijagnostičkom i statističkom priručniku mentalnih poremećaja (DSM-V, 2013.) svrstan je u skupinu s opsesivno-kompulzivnim i njemu srodnim poremećajima. Trihilomanija ima i karakteristike poremećaja impulsa i navika. Prvi simptomi trihilomanije najčešće se pojavljuju u adolescenciji. Klinička slika u djece i adolescenata često je komplicirana postojanjem komorbiditeta. Najčešće opisivani komorbiditet su anksioznost i depresija iz područja osjećaja i raspoloženja, a rjeđi su tikovi, hiperkinetski i opsesivno-kompulzivni poremećaj, različiti oblici regresivnog ponašanja i neki drugi. Prikazana su dva bolesnika kod kojih je prepoznavanje poremećaja bilo otežano time što djeca i adolescenti nerado priznaju trihilomaniju, a daljnje liječenje bilo je dijelom multidisciplinarno i u mnogo čemu je ovisilo o komorbiditetu. U prvom prikazu etiopatogeneza je najvećim dijelom emocionalna. U drugom prikazu prateći poremećaj je iz skupine neurorazvojnih poremećaja. Odabir psihoterapijske tehnike i širi pristup liječenju u cijelosti su ovisili o komorbiditetu i zahtjevali su suradnju dječjeg psihijatra sa stručnjacima iz drugih područja pedijatrijske medicine. Mislimo da istraživanja ovog poremećaja treba ustrajno i dalje usmjeravati otkrivanju izravne i druge povezanosti trihilomanije i komorbiditeta, kako bi se omogućilo što primjerenije i učinkovitije prepoznavanje i liječenje ovog poremećaja.Trichotillomania (TTM) is a relatively rare disorder. In recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013), TTM is classifi ed in the group including obsessive-compulsive and related disorders. TTM also has some characteristics of the disorders of impulses and habits. Initially, TTM symptoms usually occur during adolescence. The clinical picture in children and adolescentsis often complicated by the presence of comorbidity. In children and adolescents, the most common comorbidity is in the domain of aff ect, specifi cally depression and anxiety. Rarely described comorbidities are tics, hyperkinetic disorder, obsessive-compulsive disorder, various forms of regressive behavior, and some others. In the two cases reported, recognizing TTM was impeded. Specifi cally, children and adolescentsreluctantly acknowledge TTM, so recognizing and further treatment was in many ways multidisciplinary and depended on the comorbidity. In the fi rst case, the etiopathogenesis is mostly emotional. In the second case, the associated disorder is from the group of neurodevelopmental disorders. The choice of psychotherapeutic techniques and broader approach to the treatment entirely depended on the comorbidity and also required cooperation of experts from other areas of pediatric medicine. We believe that research should persistently be focused on discovering direct and other relationships of TTM and comorbidity in order to allow for the most appropriate and eff ective recognizing and treatment of this disorder

Correlations between attention deficit/hyperactivity disorder, obsessive-compulsive disorder and tics in children and adolescents: case report

Povezanost poremećaja nedostatka pozornosti s hiperaktivnošću (ADHD), opsesivno-kompulzivnog poremećaja (OKP) i tikova primarno se opisuje kroz genetičke, neurobiološke, neurokognitivne i neurokemijske supstrate smanjene inhibicije motoričkog odgovora. Komorbiditet ovih poremećaja u djece i adolescenata nije rijetkost. U predškolskoj dobi u našeg 14-godišnjeg pacijenta dijagnosticirani su ADHD i tikovi, a potom u desetoj godini i OKP. Poremećaji su dijagnosticirani prema kriterijima iz DSM-IV. i uporabom polustrukturiranih intervjua koji se na njemu temelje. U multimodalnom pristupu liječenju provodili smo kognitivno-bihevioralne psihoterapijske tehnike, psihoedukaciju i potporu roditelja, terapiju senzorne integracije uz potporu terapijskog psa, neurofeedback te smo primijenili medikamentoznu terapiju (metilfenidat, fluvoxamin), grupnu terapiju usmjerenu poboljšanju socijalnih vještina, izražavanju i razumijevanju emocija i individualizirani pristup u školi uz pomoć osobnog asistenta. U raspravi smo opisali složenost u liječenju kliničke slike komplicirane komorbiditetom i emocionalnim distresom te poznate i moguće poveznice ovih poremećaja. Liječenje ADHD-a zahtijeva multimodalni pristup i suradnju stručnjaka različitih profila. Između ostalog, pravodobno prepoznavanje udruženih simptoma i znakova drugih psihijatrijskih poremećaja i sagledavanje njihovih poveznica bitno je za sprječavanje razvoja složenije kliničke slike i određivanje terapijskih smjernica. Potrebna su daljnja istraživanja.The relationship between the attention deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD) and tics is primarily discussed through genetic, neurobiological, neurocognitive and neurochemical substrates of reduced impulse control. The comorbidity of these disorders in children and adolescents is not a rarity. In our 14-year-old patient, ADHD and simple motor tics were diagnosed at pre-school age and OCD at the age of 10. We diagnosed these disorders by DSM-IV criteria and semi-structured interviews based on it. In a multimodal treatment we used techniques from cognitive behavioural psychotherapy, psychoeducation and parental support, sensory integration therapy with a assistance dog, neurofeedback, medication therapy (methylphenidate, fluvoxamine), group therapy aimed at enhancing social skills and expressing emotions, individualized approach to learning in school with a personal assistant. We discuss the complexity of treatment of clinical presentation complicated by comorbidity and emotional distress, and some known and possible links between these disorders. Treatment of ADHD demands multimodal approach and cooperation of different professionals. Among other things, timely recognition of associated symptoms and other psychiatric disorders and their linkage is very important to prevent intensification of symptoms and signs of the disorder and to determine therapeutic guidelines. Further investigation is needed