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    Autism Spectrum Disorder,

    ADHD, ODD and sluggish

    cognitive tempo

    DSM 5Dr. See King Emilio Quinto

    Psiquiatra. CBT PhD. M.A. Terapia familiar y logoterapia.

    CBT Training for children and adolescents Beck Institute.

    USA:

    Miembro Internacional de APAProfesor asociado os rado de si uiatra USAC

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    Speaker: JanssenCilag, Astra Zeneca,Glaxo, Elli Lilly,

    Organon, Pfizer,Abbott, Laprin,Asofarma, ABL.

    Research: AstraZeneca, Elli Lilly,UCSF, UCLA.

    Declaraciones de inters tico.

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    Agenda.

    Descripcin de los criterios de inclusinpropuestos.

    Razones para el cambio.

    Referencias bibliogrficas.

    Casos clnicos.

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    A 09 Autism Spectrum

    Disorder Must meet criteria A, B, C, and D:

    A. Persistent deficits in socialcommunication and social interactionacross contexts, not accounted for bygeneral developmental delays, and

    manifest by all 3 of the following:

    1. Deficits in social-emotionalreciprocity; ranging from abnormal social

    approach and failure of normal back and

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    A 09 Autism Spectrum

    Disorder B. Restricted, repetitive patterns of

    behavior, interests, or activities asmanifested by at least two of the

    following: 1. Stereotyped or repetitive speech,

    motor movements, or use of objects;

    (such as simple motor stereotypies,echolalia, repetitive use of objects, oridiosyncratic phrases).

    2. Excessive adherence to routines,

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    A 09 Autism Spectrum

    Disorder C. Symptoms must be present in early

    childhood (but may not become fullymanifest until social demands exceed

    limited capacities) D. Symptoms together limit and

    impair everyday functioning.

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    A 09 Autism Spectrum

    Disorder: Razones de

    cambio. New name for category, autism spectrum

    disorder, which includes autistic disorder(autism), Aspergers disorder, childhood

    disintegrative disorder, and pervasivedevelopmental disorder not otherwisespecified.

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    A 09 Autism Spectrum

    Disorder: Razones de

    cambio. Differentiation of autism spectrum

    disorder from typical development andother "nonspectrum" disorders is done

    reliably and with validity; whiledistinctions among disorders have beenfound to be inconsistent over time,variable across sites and often associatedwith severity, language level or intelligencerather than features of the disorder.

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    A 09 Autism Spectrum

    Disorder: Razones de

    cambio. Because autism is defined by a common

    set of behaviors, it is best represented asa single diagnostic category that is

    adapted to the individuals clinicalpresentation by inclusion of clinicalspecifiers (e.g., severity, verbal abilities andothers) and associated features (e.g.,known genetic disorders, epilepsy,intellectual disability and others.) A singlespectrum disorder is a better reflection

    of the state of knowledge about

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    A 09 Autism Spectrum

    Disorder Razones de

    cambio. Three domains become two:

    1) Social/communication deficits

    2) Fixated interests and repetitivebehaviors

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    A 09 Autism Spectrum

    Disorder Deficits in communication and social

    behaviors are inseparable and moreaccurately considered as a single set of

    symptoms with contextual andenvironmental specificities

    Delays in language are not unique nor

    universal in ASD and are more accuratelyconsidered as a factor that influences theclinical symptoms of ASD, rather thandefining the ASD diagnosis

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    A 09 Autism Spectrum

    Disorder Requiring both criteria to be completely

    fulfilled improves specificity of diagnosiswithout impairing sensitivity

    Providing examples for subdomains for arange of chronological ages and languagelevels increases sensitivity across severity

    levels from mild to more severe, whilemaintaining specificity with just twodomains

    Decision based on literature review,

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    Several social/communication criteriawere merged and streamlined to clarifydiagnostic requirements.

    In DSM-IV, multiple criteria assess samesymptom and therefore carry excessiveweight in making diagnosis

    Merging social and communicationdomains requires new approach tocriteria

    Secondary data analyses were conducted

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    Severity Level for

    ASD

    Social Communication Restricted interests &

    repetitive behaviors

    Level 3

    Requiring very substantial

    support

    Severe deficits in verbal

    and nonverbal social

    communication skills

    cause severe impairments

    in functioning; very limitedinitiation of social

    interactions and minimal

    response to social

    overtures from others.

    Preoccupations, fixated

    rituals and/or repetitive

    behaviors markedly

    interfere with functioning

    in all spheres. Markeddistress when rituals or

    routines are interrupted;

    very difficult to redirect

    from fixated interest or

    returns to it quickly.

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    Severity Level for ASD Social Communication Restricted interests &

    repetitive behaviors

    Level 2

    Requiring substantial

    support

    Marked deficits in verbal

    and nonverbal social

    communication skills;

    social impairments

    apparent even withsupports in place; limited

    initiation of social

    interactions and reduced

    or abnormal response to

    social overtures fromothers.

    RRBs and/or

    preoccupations or fixated

    interests appear frequently

    enough to be obvious to

    the casual observer andinterfere with functioning

    in a variety of contexts.

    Distress or frustration is

    apparent when RRBs are

    interrupted; difficult toredirect from fixated

    interest.

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    Severity Level for ASD Social Communication Restricted interests &

    repetitive behaviors

    Level 1

    Requiring support

    Without supports in place,

    deficits in social

    communication causenoticeable impairments.

    Has difficulty initiating

    social interactions and

    demonstrates clear

    examples of atypical or

    unsuccessful responses to

    social overtures of

    others. May appear to

    have decreased interest in

    social interactions.

    Rituals and repetitive

    behaviors (RRBs) cause

    significant interferencewith functioning in one or

    more contexts. Resists

    attempts by others to

    interrupt RRBs or to be

    redirected from fixated

    interest.

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    A 10 Attention

    Deficit/HyperactivityDisorder

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder The disorder consists of a characteristic

    pattern of behavior and cognitivefunctioning that is present in different

    settings where it gives rise to social andeducational or work performancedifficulties. The manifestations of thedisorder and the difficulties that theycause are subject to gradual change beingtypically more marked during times whenthe person is studying or working and

    lessening during vacation.

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder Superimposed on these short-term

    changes are trends that may signal somedeterioration or improvement with many

    symptoms becoming less common inadolescence. Although irritable outburstsare common, abrupt changes in moodlasting for days or longer are notcharacteristic of ADHD and will usuallybe a manifestation of some other distinctdisorder.

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder In children and young adolescents, the

    diagnosis should be based on informationobtained from parents and teachers.

    When direct teacher reports cannot beobtained, weight should be given toinformation provided to parents byteachers that describe the childs behaviorand performance at school. Examinationof the patient in the clinicians office mayor may not be informative. For older

    adolescents and adults, confirmatory

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder A. Either (1) and/or (2).

    1. Inattention: Six (or more) of thefollowing symptoms have persisted for at

    least 6 months to a degree that isinconsistent with developmental level andthat impact directly on social and

    academic/occupational activities. Note:for older adolescents and adults (ages 17and older), only 4 symptoms are required.The symptoms are not due too ositional behavior, defiance, hostilit ,

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder (c) Often does not seem to listen when

    spoken to directly (mind seemselsewhere, even in the absence of any

    obvious distraction). (d) Frequently does not follow through

    on instructions (starts tasks but quickly

    loses focus and is easily sidetracked, failsto finish schoolwork, household chores,or tasks in the workplace).

    (e) Often has difficulty organizing tasks

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder (g) Frequently loses objects necessary

    for tasks or activities (e.g., schoolassignments, pencils, books, tools, wallets,

    keys, paperwork, eyeglasses, or mobiletelephones).

    (h) Is often easily distractedby

    extraneous stimuli. (for older adolescentsand adults may include unrelatedthoughts.).

    (i) Is often forgetful in daily activities,

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder 2. Hyperactivity and Impulsivity: Six

    (or more) of the following symptomshave persisted for at least 6 months to a

    degree that is inconsistent withdevelopmental level and that impactdirectly on social andacademic/occupational activities. Note:for older adolescents and adults (ages 17and older), only 4 symptoms are required.The symptoms are not due to

    oppositional behavior, defiance, hostility,

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder (c) Often runs about or climbs on

    furniture and moves excessively ininappropriate situations. In adolescents or

    adults, may be limited to feeling restlessor confined.

    (d) Is often excessively loudor noisy

    during play, leisure, or social activities. (e) Is often on the go,acting as if

    driven by a motor. Is uncomfortable

    being still for an extended time, as in

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder (g) Often blurts out an answerbefore a

    question has been completed. Olderadolescents or adults may complete

    peoples sentences and jump the gun inconversations.

    (h) Has difficulty waiting his or her

    turn or waiting in line. (i) Often interrupts or intrudes on

    others (frequently butts into

    conversations, games, or activities; may

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder (k) Is often impatient, as shown byfeeling restless when waiting for othersand wanting to move faster than others,

    wanting people to get to the point,speeding while driving, and cutting intotraffic to go faster than others.

    (l) Is uncomfortable doing thingsslowly and systematicallyand oftenrushes through activities or tasks.

    (m) Finds it difficult to resist

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder B. Several noticeable inattentive orhyperactive-impulsive symptoms werepresent by age 12.

    C. The symptoms are apparent in twoor more settings (e.g., at home, school orwork, with friends or relatives, or in other

    activities). D. There must be clear evidence that the

    symptoms interfere with or reduce the

    quality of social, academic, or

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    A 10 Attention

    Deficit/Hyperactivity

    Disorder E. The symptoms do not occurexclusively during the course ofschizophrenia or another psychotic

    disorder and are not better accountedfor by another mental disorder (e.g.,mood disorder, anxiety disorder,dissociative disorder, or a personalitydisorder).

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    Specify Based on Current

    Presentation Combined Presentation: If both

    Criterion A1 (Inattention) and CriterionA2 (Hyperactivity-Impulsivity) are met for

    the past 6 months. Predominately Inattentive

    Presentation: If Criterion A1

    (Inattention) is met but Criterion A2(Hyperactivity-Impulsivity) is not met and3 or more symptoms from Criterion A2have been present for the past 6 months.

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    Q 00 Oppositional Defiant

    Disorder

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    Q 00 Oppositional Defiant

    Disorder A. A persistent pattern of angry and

    irritable mood along with defiant andvindictive behavior as evidenced by four

    (or more) of the following symptomsbeing displayed with one or more personsother than siblings.

    Angry/Irritable Mood 1. Loses temper

    2. Is touchy or easily annoyed by others.

    3. Is an r and resentful

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    Q 00 Oppositional Defiant

    Disorder Defiant/Headstrong Behavior

    4. Argues with adults

    5. Actively defies or refuses to complywith adults request or rules

    6. Deliberately annoys people

    7. Blames others for his or her mistakesor misbehavior

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    Q 00 Oppositional Defiant

    Disorder Vindictiveness

    8. Has been spiteful or vindictive at leasttwice within the past six months

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    Q 00 Oppositional Defiant

    Disorder B. (NOTE: UNDER CONSIDERATION)

    The persistence and frequency of thesebehaviors should be used to distinguish a

    behavior that is within normal limits froma behavior that is symptomatic todetermine if they should be considered asymptom of the disorder. For childrenunder 5 years of age, the behavior mustoccur on most days for a period of atleast six months unless otherwise noted

    (see symptom #8). For individuals 5 years

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    Q 00 Oppositional Defiant

    Disorder C. The disturbance in behavior causes

    clinically significant impairment in social,educational, or vocational activities.

    D. The behaviors may be confined to onlyone setting or in more severe casespresent in multiple settings.

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    Recomendaciones y razonespara el cambio 1. Do not make major changes to

    the symptoms or structure of the

    ODD criteria.

    2. Remove exclusionary criteria forConduct Disorder.

    3. Organize symptoms in the

    criteria for ODD to distinguishemotional and behavioral

    symptoms.

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    Recomendaciones y razonespara el cambio 4. Develop a severity index based on

    the cross-situation pervasiveness of

    the symptoms.

    Under consideration: Provideobjective and standard definitions of

    frequency for ODD symptom

    threshold.

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    0 - Absent: Shows fewer than twosymptoms

    1 - Subthreshold: Shows at least two

    but fewer than four symptoms orsymptoms do not cause significantimpairment in any setting 2 -

    Mild: Shows at least four symptoms butsymptoms are confined to only onesetting (e.g., at home, at school, at work,with peers)

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    Sluggish cognitive tempo

    Is an unformalized descriptive term whichis used to better identify what appears tobe a homogeneous sub-subgroup within

    the formal subgroup "ADHDpredominantly inattentive(ADHD-I orADHD-PI).

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    SCT

    Have the opposite symptoms of thosewith classic ADHD: instead of beinghyperactive, extroverted, obtrusive, and

    risk takers, those with SCT are drifting,introspective and daydreamy, and feel as if"in the fog" (although in excited states, anSCT patient behaves very similarly to a

    traditional ADHD patient).

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    SCT

    A key behavioral characteristic of thosewith SCT symptoms is that they are morelikely to appear to be lacking motivation.

    They lack energy to deal with mundanetasks and will consequently seek thingsthat are mentally stimulating because oftheir underaroused state, an intense

    craving for emotional and intellectualstimulation.

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    SCT

    Currently the American PsychiatricAssociation (APA) is working on creatingthe DSM-5. In the published preliminary

    draft revisions, APA writes that moreresearch is needed to assess the "sluggishcognitive tempo" construct

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    Caso clnico.

    Nace en Praga 1883. Fue un escritor checo de idioma alemn.

    Su obra es considerada una de las ms

    influyentes de la literatura universal en elltimo siglo,1 a pesar de no ser muyextensa: fue autor de tres novelas(El

    proceso, El castillo yAmrica), una novelacorta(La metamorfosis) y un ciertonmero de parbolas y relatos breves.

    http://es.wikipedia.org/wiki/Franz_Kafkahttp://es.wikipedia.org/wiki/Franz_Kafka
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    Caso clnico

    Padre autoritario, madre pasiva. Era el mayor de seis hermanos. Dos de

    ellos, Georg y Heinrich, fallecieron a los

    quince y seis meses de edad. Por cuya muerte se sinti culpable en

    cierto sentido al vincularla con sus deseos

    de que desapareciesen motivados por suscelos.

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    Caso clnico.

    En sus relaciones sociales, albergabatemor de ser percibido de manerarepulsiva tanto fsica como mentalmente.

    Muy al contrario, impresionaba a losdems con su aspecto infantil, pulcro yaustero, su conducta tranquila y fra, y sugran inteligencia, adems de su particular

    sentido del humor. Desde 1905 se veobligado a frecuentar los sanatorios comoresultado de su debilidad fsica.

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    Caso clnico

    Entre 1913 y 1917 mantuvo una relacinde dimensiones muy complejas conFelice Bauer, que dio origen a una

    correspondencia de ms de 500 cartas ytarjetas postales.

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    Caso clnico

    En sus diarios y cartas se quejafrecuentemente de insomnio y dolores decabeza. Fue un partidario de la dieta

    vegetariana y del naturismo. Se dice queconsuma grandes cantidades de leche sinpasteurizar, lo que pudo ser el factordesencadenante de su tuberculosis, en

    1917, en sus cuadernos ntimos l hablade "demonios", "derrumbamiento","embates", "desamparo", "persecucin",

    "soledad", "asalto a las ltimas fronteras

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    Caso clnico

    Slo public algunas historias cortasdurante toda su vida, una pequea partede su trabajo, por lo que su obra pas

    prcticamente inadvertida hasta despusde su muerte. Con anterioridad a sufallecimiento, dio instrucciones a su amigoy albacea Max Brod de que destruyera

    todos sus manuscritos.

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    Caso clnico

    En su obra, a menudo el protagonista seenfrenta a un mundo complejo, que sebasa en reglas desconocidas, las cuales

    nunca llega a comprender. El adjetivokafkiano se utiliza precisamente a menudopara describir situaciones similares

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    Caso clnico

    Frank Kafka.

    20 id A 0 49Vi t H II 15

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    20 avenida A 0-49 Vista Hermosa II zona 15Guatemala ciudad.

    [email protected] Telfonos:(502) 23690709 y(502)23693238

    www.clinicahumanamente.com

    Cursos y seminarios.

    Entrenamiento intensivo clnico.

    Atencin psiquitrica. Publicaciones.

    Investigaciones.

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