WYONG WEEK 7 - 31/05/12 Adolescent Development & Medicine

-Shaveen Normal Adolescent development -Carmen Adolescent Medicine

Week 7 SDS Adolescent Development

Introduction:
Adolescence is the transition from childhood to adulthood. No defined age range. Considered to be from puberty until 18 years of age. Involves biological, psychological and social changes.

Definitions:
Adrenarche: Is the activation of the adrenal cortex for the production of adrenal androgens Occurs before the onset of puberty. Maturational increase in adrenal androgen production six years of age in both girls and boys. Unrelated to the hypothalamic-pituitary-gonadal axis. Change in the pattern of adrenal secretory response to adrenocorticotropic hormone (ACTH), resulting in increases in dehydroepiandrosterone sulfate (DHEA-S), marker of Adrenarche. Stimulus for Adrenarche unknown. Androgens contribute to development of sebaceous glands and pubic hair (pubarche), and possibly to bone mineralization. Gonadarche is the activation of the gonads by the pituitary hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH) Pubarche is the appearance of pubic hair Thelarche is the appearance of breast tissue Menarche is the age of onset of the first menstrual period

Spermarche is the age at first ejaculation (heralded by nocturnal sperm emissions and appearance of sperm in the urine)

Pubertal Stages:
Tanner stages:
Descriptions of the development of secondary sexual characteristics. Breast changes in females, pubic hair changes in both males and females, and genital changes in males.

Tanner staging for pubic hair, breast, and genitalia consists of five categories, with stage one representing prepuberty and stage five representing adult development.
Leukorrhoea in girls 6-12 months before menarche. (thin white, non-foul smelling vaginal discharge)

Timing of pubertal maturation influences on self-esteem, behaviour, growth, and weight. Eg: Early maturation => Short and fat in adulthood.

Tanner Stages:

Tanner staging Boys

Tanner staging - Girls

Peak Height velocity:

o 17-18% adult height occurs through puberty. Axial and appendicular (trunk and limbs). o Limbs before trunk.

o Growth spurt varies by gender. 2 years earlier during puberty in girls.

o When evaluating growth look at whole year changes.

Sequence of Puberty:

Weight Changes:
o Based on gender, timing and stage of pubertal maturation. o Early puberty slight decrease in fat. Increases at the end. o Adolescent girls have a greater proportion of body fat, upper arms, thighs, and upper back.

o <16y.o. weight gain is fat free. >16y.o. weight gain is fat mass.

Physiology of Pubertal Maturation:

Variable but most follow a predictable path through pubertal maturation. Girls:
Earliest = thelarche (breast/areolar development). Some have pubarche first. Menarche occurs 2.6 years after onset of puberty. If thelarche first then likely to have increased BMI. If pubarche first then 3X more likely for maternal preeclampsia. Several factors influence onset of puberty and menarche. Genetics, overall health, social environment (stress, non biologically related brother), environmental exposures (endocrine disruptors).

Physiology of Pubertal Maturation:

o Boys:
Earliest = increase in testicular volume (3ml or more).
This happens before penile growth and pubic hair appearance. Male equivalent of menarche considered as appearance of sperm in urine. Occurs after peak height velocity is reached. Prader orchidometer measures testicular volume. Penile length measured from pubic ramus to tip of glans (compress suprapubic fat and gentle traction). Height Spurt occurs when testicular volume is 12-15 ml after a delay around 18 months.

Body fat, leptin and onset of puberty:

Earlier onset of puberty thought to be linked increasing obesity. Leptin thought to be hormone triggering onset and progression of puberty. Produced in adipocytes. Increased body fat => increased serum leptin.

Leptin influences maturation of GnRH. In males serum leptin falls after onset of puberty returns to baseline 30 to 40 months after. In females leptin rises throughout puberty. Varied leptin levels depending on serum free testosterone, free oestrogen, sum of skinfolds.

Genetics:
Common genetic variants associated with variation in menarche age. Such as genes associated with height. GPR54 important as loss of function causes autosomal recessive idiopathic hypogonadotrophic hypogondasim. Too much function of this gene can lead to precocious puberty.

Perils of Puberty:
Anaemia:
Anaemia and iron deficiency common in adolescent girls. Haemoglobin and Ferritin concentrations both increase with advancing pubertal stage in males. This doesnt happen in females. Not solely due to intake. Gender difference probably due to biological differences (androgens), menstrual bleeding and decreased intake.

Perils of Puberty:
Gynecomastia:
50% of boys aged 13, persists for 6 to 18 months. Persistent Gynecomastia - >2cm palpable tissue during first year. Mechanism: imbalance of oestrogen to testosterone stimulation. Increased oestrogen production. Decreased testosterone production. Increased breast tissue sensitiveness to oestrogen. Causes include: idiopathic pubertal Gynecomastia, hypogondasim, testicular tumors and hyperthyroidism.

Perils of Puberty:
Acne:
Follicular occlusion and inflammation of pilosebaceous duct caused by androgen stimulation. Blackhead (non-inflammatory - wide opening and oxidation of keratinous material) vs. Whitehead (inflammatory small opening, closed comedone, often ruptures into dermis.) Moderate or severe acne in early puberty be wary of endocronoligcal disorders with excess androgen such as nonclassical congenital adrenal hyperplasia.

Perils of Puberty:
Psychological Changes:
Early adolescence: Concrete thinking, develop moral concepts, sexual identity. Early emotional separation from parents. Strong peer identification. Early exploratory behaviours (eg. Smoking). Mid adolescence: Abstract thinking, bulletproof, increasing verbal dexterity, develop fervent ideology, continued emotional separation from parents, heterosexual peer interest, early vocational plans. Late adolescence: Complex abstract thinking, difference between law and morality, increased impulse control, further personal identity development, further development or rejection of ideologies. Social autonomy, develop intimate relationships, further education/employment, financial independence. Puberty does not affect cognitive ability but timing may affect psychosocial functioning. Depression 2x more in girls during adolescence. With progression of puberty bys develop positive self-image and mood, girl experience diminished perceived physical appearance. Girls maturing early and boys maturing late have psychopathology. Early maturing girls have disruptive behaviour (attention deficit, hyperactivity, oppositional and/or conduct disorders) and have older friends (more likely to succumb to peer pressure). Late maturing boys have internalising behaviours and emotional reliance on others.

Perils of Puberty:
Musculoskeletal injuries:
Periods of high peak velocity => greater risk of damage to epiphyseal growth plates.
Sprains or strains from limited range of movement (increased muscle mass and asynchronous growth).

Overuse injuries Osgood-Schlatter disease (inflammation of tibial tubercle apophysis leading to avulsion).

Gynaecological consequences:
Associated with maturation of hypothalamic-pituitary ovarian axis. DUB in adolescents (80% caused by Anovulation) Unopposed oestrogen on endometrium => sustained proliferative phase

Perils of Puberty:
Myopia:
Mostly (distant images out of focus) during puberty, caused by growth in axial diameter of eye.

Scoliosis:
Accelerated progression of scoliosis due to growth in axial skeleton.

STD:
Adolescents are a high risk group. Increased risk if younger age of intercourse, increased lifetime partners understanding. Biological factors such as age of menarche and gynaecological maturation (change from columnar to sqaumous cells- enhances Chlamydia infection).

References:
Up to date normal puberty. www.uptodate.com Lissauer Illustrated textbook of Paediatrics

Youth Health Adolescent medicine

Areas which are going to cover briefly in this presentation:

At risk groups Bulimia Depression Alcohol Schizophrenia Self harm Anorexia Suicide Substance abuse Anxiety disorder Sexual activity

The FACTS!!!
During adolescence Dramatic growth & development of nerve pathways in the brain Changes in both brain structure & function Areas responsible for regulating behaviours are not fully developed till mid 20s These areas a vulnerable to alcohol & drugs Unable to accurately assess outcomes/cons

At Risk youth include:

Aboriginal and Torres Strait Islander Socio-economically disadvantaged geographically & socially isolated remote and rural areas Culturally/linguistically diverse - newly arrived or refugee Approaching transition periods Homeless or at risk of homelessness Domestic and family violence exposure Experiencing family conflict &/or family breakdown Young carers Sexual, physical &/or emotional abuse and neglect Victims of crime

Make transitions easier for young people

Adolescence features a number of transition points. moving from one environment to another move between primary school and secondary school; move between formal education and employment; and the move from living at home to independent housing.
other transition points: young people who are transitioning from care into independent living; from the juvenile justice system to the community; from life in rural areas to metropolitan areas; from child health facilities to adult health facilities; or from a supported school environment to further education or employment. Transition points => increased stress and risk & increased risk of damaging or negative outcomes

Prevalence of conditions per 1000 adolescents

Musculoskeletal Skin conditions Mental health Diabetes T1 Diabetes T2 Respiratory conditions 41 32 120 2 2 150
100 4 1.5

Asthma Epilepsy Cerebral palsy

 17 % smoke tobacco 23 % have used an illicit drug in the last 12 months 31 % drank alcohol once a month or more at a level that puts them at risk of short-term alcohol-related harm 11 % drank at a level that puts them at risk of long-term alcohol related harm 25 % of young people are overweight or obese 63 % of young people said they had a long-term medical condition (lasting 6 months or more) Mental health disorders accounted for almost 50 % of the total disease burden among young people in 2003 sexually transmitted infection, almost doubled in young women between 2001 and 2005 (chlamydia) Melanoma is the skin cancer with the highest incidence rate among young people

Statistics of 12-24s

NSW Statistics
1.14 million young people are aged 12-24 in NSW, 31% of all young people in Australia (ABS, Census 2006a). 36,600 or 3.2% of young people aged 12-24 in NSW identified as indigenous. 22% experience major health problems, Young people have specific health problems and developmental needs that differ from those of children or adults. The major causes of ill-health in adolescents in NSW are mostly psychosocial rather than biological and therefore potentially preventable.

 Young men were 34 times as likely as young females to be hospitalised for transport accidents, falls and assault Young women were 3 times as likely to be hospitalised for intentional self-harm

Indigenous Australians young 13-19 year olds

were 2.6 x as likely to be obese as non-Aboriginal teenagers in 200405 Had 40% higher prevalence of mental and behavioural problems than non-Aboriginal teenagers overall hospitalisation rate was 30 per cent higher than for other teenagers rate of assaults related hospitalisation were 5 times higher unemployment was >2x as high as other young people in 2006 (22.4 per cent compared to 9.9 per cent) Year 12 completion rates among 19 year olds were half that of non indigenous (37 per cent compared with 74 per cent) in 2006 In the juvenile justice system, the supervision rate for Aboriginal teenagers was 13 times that of other teenagers

Eating Disorders

Thirty years ago the average model was 8% thinner than the average woman. Now the average model is 23% thinner than the average woman.

 1 in 4 teenage girls may suffer from the symptoms of an eating disorder 23% are currently dieting 15% reported binge eating associated with loss of control 8.2% reported self induced vomiting 2.4% using diet pills 52% of adolescents begin dieting before age 14 Up to 90% of eating disorders occur in women (anorexia, bulimia) In a study of children aged 8 10, 50% of the girls and 33% of boys were unhappy with their size In Australia 1 in every 100 females has anorexia nervosa. 3 in every 100 females has bulimia nervosa.

ANOREXIA
Loss of at least 15% body weight or failure to put on appropriate amount of weight with normal growth, going to extremes to avoid eating, possibly excessive exercise, obsession with food and preparation symptoms of depression or anxiet. Biopsychosocial illness due to social factors? Cases being dx as young as 11 yo Average age of onset is 17 years 1/3 most prevalent common chronic illness for young females (asthma =1 & obesity =2) It is 10 x more prevalent than T1DM 0.5%-3.7% of adolescents meet criteria 7 new cases per 100,000 per annum Male: female ratio of 1:6 upto 1:10 64% of normal wt women & 23% of men are dieting

Mortality from anorexia

20% after 20 years of disease 5x greater risk than average population

Average duration of disorder = 5 years At risk groups include: First degree relatives are 10x more risk

Early physical clues may include: Loss of periods or failure to begin menstruating in young girls Weight loss without evidence of any other illness that would explain weight loss. Early psychological clues may include: An obsessive concern about body weight and shape and dieting An unrealistic perception about being fat An extreme fear of getting fat or gaining weight or of eating. Early behavioural clues may include: Cutting out foods once enjoyed Excessive exercise Vomiting and using laxatives (purging) as part of a pursuit of thinness Avoiding sharing meal times with others because of food anxieties.

Early signs

Anorexia: Long term effects

Brain atrophy Effect on conigition Cardiac arrhythmias Growth retardation Infertility Osteopaenia leading to osteoposoris Renal and hepatic function impaired Neurogenic bowel with subsequent rectal prolapse

Diagnosing Anorexia
A Psychological or Mental Health Assessment may include:

Questions about current or past depression Questions about your moods and thoughts Feelings about your weight, body and looks Anxiety about eating General perception of how life is going otherwise, and in particular, your perceptions about changes to your routines in relation to past activities, school or social life Exercise routines, other activities, socialising, alcohol /drug use Relationships at home, school and work Coping patterns and support available to you.

Aims of treatment
The aims of treatment for anorexia nervosa include to: Prevent death by restoring nutrition Correct dysfunctional behaviours and thinking Treat depression and obsessional thinking Prevent or reduce absences from work or school Resume normal psychological and physical development Restore autonomy and prevent relapse and disablement Support family or partner where needed.

Treatments available
Supportive psychotherapy Psycho-education CBT Interpersonl therapy Psycodynamic oriented psychotherapy Narrative therapy Family therapy Motivational enhancement therapy Medication SSRIs preferred

Bulimia Nervosa
Feeling out of control around food, binge-eating of calorie-rich foods, compensating by excessive exercise, self-induced vomiting or laxative abuse: may be underweight, normal wight or overweight. 2% of women, 15-40 yo 15 new cases per 100, 000 per year. by definition, its sufferers are not underweight, and do not suffer this extreme of physical consequences

Factors that could contribute to Bulimia

Culture Families Life changes or stressful events Personality traits Biology

What happens?
Overwhelming fear of getting fat. Alternate between binging & making themselves sick They purge because they feel guilty, fear of putting on weight, laxatives, diet pills, over exercising. Vicious circle Likely to have low self-esteem

Spotting the Signs

Regular changes in weight An obsessive attitude towards food and eating Large amounts of money being spent on food Disappearing soon after eating (usually visiting the toilet to vomit) Episodes of over-eating Periods of starvation Depression and anxiety Distorted opinions about body weight and shape Isolation. Someone with bulimia may show signs of throwing up, such as: Swollen cheeks or jaw area Calluses or scrapes on the knuckles (if using fingers to induce vomiting) Teeth that look clear Broken blood vessels in the eyes

Treatment for bulimia

Psychological support Medications SSRIs Re-establish healthy attitudes towards eating - CBT - Interpersonal therapy - Counselling Aim to improve attitudes towards food & eating, improve self-esteem

Causes of adolescent deaths

60% 10% 9% 16% injury & poisoning cancer nervous system other causes

15-24 yrs Cause of Death 2004-06

External causes Transport accident Intentional self harm Accidental poisoning Accidental drowning Assault Falls Other Drug induced deaths Neoplasm Total deaths of which suicide %Males 33.5 21.6 5.0 2.0 1.8 1.4 10.0 5.3 6.6 955 266 deaths % Females 25.2 15.4 5.0 0.6 2.3 0.6 9.1 7.2 12.9 389

Suicide
In 2009, 1.5% of all deaths were attributed to suicide. One of the leading causes of death other than MVA Rural remote rates 2X higher than city rates Prevalent in adolescence 15-19yo Rates 40% higher in indigenous communities Studies found that 23.5% to 49% of teenagers have thoughts of suicide at some time.

Adolescents with increased risk of suicide:

Depression Conduct problems Personality disorder Substance abuse Anxiety Psychosis Bipolar disorder

Etiology of suicide
Individual factors Mental illness Family-related risk factors Social risk factors Enviromental risk factors

Individual factors
Male highest rates in 20s to 30s Psychological & emotional problems Sexual orientation Physical health problems Stressful life events

Sobering thought?
12% of 13-17yo have thought about suicide, while 4.2% had actually made a suicide attempt.

Mental Illness
About 45% of adult Australians will experience a mental illness at some stage in their lives. 1 in 5 Australians will experience a mental disorder in any 12 month period. 5% of Australians experience anxiety so crippling that it affects every aspect of their life. The greatest number of people with a mental illness are within the 18-24 year age group. Schizophrenia first presents in mid to late teens Depression is one of the most common health conditions in you people & increases in adolescence.

One in 10 young Australians had long-term mental health or behavioural problems Mental disorders were the leading contributor to the total burden of disease among young Australians. There is Increased occurrence of mental illness in step/blended families, low income & sole parent families.

Depression
Risk of death is 1.4 x more than average 160,000 young people aged 16-24 years live with depression 1 in 5 experience depression by adulthood Depression can lead to other problems eg binge drinking, smoking, drugs, low self esteem, risk taking.

Increased risk of depression - If one or both parents have depression - Have other illnesses eg epilepsy, cancer, diabetes
Mood disorders (depression and anxiety) were the most common problem for females, while problems of psychological development were most common among males

Risk factors for Depression

Biomedical factors Chronic illness (e.g., diabetes) Female sex Hormonal changes during puberty Parental depression or family history of depression Presence of specific serotonin-transporter gene variants Use of certain medications (e.g., isotretinoin [Accutane]) Psychosocial factors Childhood neglect or abuse (physical, emotional, or sexual) General stressors including socioeconomic deprivations Loss of a loved one, parent, or romantic relationship Other factors Anxiety disorder Attention-deficit/hyperactivity, conduct, or learning disorders Cigarette smoking History of depression

Depression checklist For more than two weeks, have you: 1. Felt sad, down, miserable or irritable most of the time? 2. Lost interest or pleasure in all or nearly all of your usual activities? If you answered YES to either of those questions, please complete the symptom checklist below. Behaviours: -stopped going out -not getting things done at school or work -withdrawn form close family and friends -relying on alcohol & sedatives -stopped doing things you enjoy -unable to concentrate

Thoughts: Im a failure Its all my fault Im worthless Life is not worth living Nothing good every happens to me

Feelings -overwhelmed -unhappy, depressed -irritable -frustrated -no confidence -guilty -indecisive -disappointed -miserable -sad

Physical Tired all the time Sick and run down Headaches and muscle pains Churning gut Cant sleep Poor appeptite/wt loss

Assessment as per DSM IV

Key symptoms: - persistent sadness or low mood -marked loss of interest or pleasure at least one of these, most days, most of the time for at least 2 weeks if any of the above present, ask about? - Disturbed sleep, - changes in appetite, - changes in weight - fatigue or loss of energy - agitation or slowing of movements - poor concentreation or indecisivemenss - feeling s of worthlessness or guilt - suicidal thoughts or acts

Depression Rx - Medications
There are four groups of medications most likely to be used for depression: Antidepressants Antipsychotics Mood stabilisers Augmenting agents.

Depression Rx ECT
appropriately prescribed ECT has an important role in treating certain psychiatric conditions, particularly: Psychotic depression Severe melancholic depression-high risk of suicide, too ill to eat, drink or take medications medications are of no benefit Severe mania Severe post-natal depression. some short-term side-effects, generally ECT is a relatively safe

Depression Rx -Transcranial Magnetic Stimulation (TMS)

evidence in favour of this treatment is not yet in, but it is a major area of research It may be a possible alternative to ECT. No clear evidence about its utility is expected for a number of years.

Depression - Psychological treatments

in non-melancholic depression psychological therapy may be the sole or major treatment (without medication being used). Mindfulness therapy Cognitive Behaviour Therapy (CBT) Interpersonal Therapy (IPT) Psychotherapies Counselling Narrative Therapy.

Lifestyle changes that can treat depression (sometimes) Exercise Nutrition Sleep Social support Stress reduction

Things to do: Ruling out medical causes Mental health specialist Psychotherapy Contributing factors of depression Relationships Setting healthy boundaries, saying no. Handling lifes problems Individual or group sessions

Self-help & alternative therapies

useful for some types of depression, either alone or in conjunction with physical treatments (such as antidepressants) or psychological treatments. Self-help and alternative therapies that may be useful for depression include: Acupuncture Relaxation Alcohol and drug avoidance Bibliotherapy St John's wort Yoga Massage therapy Meditation Good nutrition Exercise Omega-3 Light therapy Aromatherapy

Substance abuse Two categories of substance use disorders:

1. 2. Substance dependence, Substance abuse DSM-IV-TR, defines Substance dependence: refers to a person with a problematic pattern of drug use, involving three of these features: Tolerance the need for increasing amounts of the drug in order to achieve intoxication Withdrawal the person experiences unpleasant symptoms when they dont use the drug Lack of success in cutting down or controlling their use of the drug Spending a lot of time trying to get hold of the drug or recovering from its effects Giving up various social activities, work or recreational activities because of drug use.

DSM-IV-TR defines substance abuse as: 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) 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) Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) 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)

Use of illicit drugs

Amphetamines Pain killers used inappropriately Leads to a range of problems from psychological to behavioural effects. 23% aged 15-24 had used illicit drugs in 12mths

Drugs used by 15-24s

18% 9% 4% 4% marijuana/cannabis ecstasy meth/amphetamines pharmaceuticals

Experimentation begins with marijuana & moves onto harder drugs In 2005-06 there were 11,700 hospitalisations due to drug use. 60% for young women for self harm 78 deaths per year from drugs

Hospitalisation due to drug use

(a) Includes a combination of principal diagnosis codes from Chapter V and external causes codes from Chapter XX of the 10th Revision of the International Classification of Diseases, Australian modification (ICD-10-AM). (b) Principal diagnosis. (c) Hospital separations per 100,000 population.

ALCOHOL

Alcohol
Irresponsible use of alcohol can lead to: - Addiction - Binge drinking or drinking too much on a single occasion - Drink driving - Unsafe sex - Impaired brain development - Injury or death
- Alcohol increases the rate of teen dating violence

Young people take more risks when drinking: - Fighting or brawling - Drowning - Drug overdose - self-harm - suicide

Common effects of binging: Hangovers, headaches bowel CNS psychological problems Nausea vomiting high risk injury assault/ sexual assault Shakiness road accidents Fights violence

Over 90% of australian teenagers over 14 yrs have tried alcohol at least once. Half of over 14 yo drink at least weekly Survey 14-17 yo regular weekly use M19.8% Occasional use, past year M44.3% Never a full glass M 29.2

F17.1% F51.6% F27.0

 In 14-17 yo, 85% of alcohol consumption is @ risky or high risk levels for acute harm. 13% drove when drinking 4.4% had memory lapses Access - @ private parties 67.8% for males, 70.2% for females Parents are most common source for yr 7-12 student for alcohol

RISKY/HIGH RISK DRINKING AT LEAST ONCE A WEEK - 2007

(a) Risk of harm over the short term. 'Risky drinking' is seven or more standard drinks in one day for males and five or more for females. 'High risk drinking' is eleven or more standard drinks in one day for males and seven or more for females. (b) Estimate for males has a relative standard error of 25% to 50% and should be used with caution.

13.6% of all drivers involved in fatal crashes where young drivers (15-20) Adjudications for dangerous driving offences:

Injury and death from transport accidents 2005-06

Injury and death from transport accidents 2005-06

15,100 hospitalisations for transport accidents in 15-24 yo Males 720 per 100,000 36% were motorcyclists Females 318 per 100,000 In M/F teenage passenger had the highest hospitalisation rates in 15-19s DEATHS 418 in 15-24 yo

Anxiety

Types of anxiety
Panic disorder eg panic attacks
Sweating, SOB, pounding heart, dry mouth, think you are dying/losing control/about to collapse PTSD burst of anxiety after expeirencing a traumatic event OCD unwanted thoughts & fears that cause anxiety & behaviours/rituals GAD involves uncontrollable and unrealistic worry about everyday situations such as school, work, relationships or health Phobias

Anxiety disorder
Anxiety can be a symptom of a medical or substance abuse problem.
1 in 25 teenagers experience anxiety in any 12mths GAD long lasting anxiety not focussed on any one object or situation

Panic disorder
Brief attacks of intense terror & apprehension S&S: tremblin, shaking, confusion, dizziness, nausea, diff breathing. Triggered by stress, fear, exercise, unknown cause

Phobic disorders
Largest category Triggered by a specific stimulus or situation 5%-12% of population are sufferers Some anticipate terrifying consequences from encountering object of fear.

Some causes of an anxiety disorder might be: genetics (a history of anxiety in your family) disturbance of brain activity a stressful event like: a family break-up abuse ongoing bullying at school a death a relationship break up family conflict.

Schizophrenia
Affects approx 1 in 100, -inappropriate unusual or bizarre thoughts & emotions - disordered thoughts - Delusions - Hallucinations - Problems with feelings, behaviours, motivation & speech

Dx by DSM IV criteria: 1. Two or more of the following, Delusions, hallucinations, disorganised speech grossly disorganised behaviour negative symptoms: 2. Social or occupational dysfunction: 3. Significant duration: Continuous signs for at least six months. including at least one month of symptoms If disturbance are present > a month but <six months, the diagnosis of schizophreniform disorder is applied. Psychotic symptoms lasting less than a month may be diagnosed as brief psychotic disorder,

 The first-line psychiatric treatment for schizophrenia is antipsychotic medication,which can reduce the positive symptoms of psychosis in about 714 days. Antipsychotics, however, fail to significantly ameliorate the negative symptoms and cognitive dysfunction. Long term use decreases the risk of relapse.

which antipsychotic? based on benefits, risks, and costs & side effects For people who are unwilling or unable to take medication regularly, long-acting depot preparations of antipsychotics may be used to achieve control. Psychosocial treatment includes: family therapy, assertive community treatment supported employment, cognitive remediation skills training, cognitive behavioral therapy (CBT) token economic interventions, and psychosocial interventions for substance use and weight management.

Prognosis
Schizophrenia has great human and economic costs. decreased life expectancy of 1215 years, increased rate of suicide Schizophrenia is a major cause of disability, with active psychosis ranked as the third-most-disabling condition after quadriplegia and dementia and ahead of paraplegia and blindness In people with a first episode of psychosis a : good long-term outcome occurs in 42%, an intermediate outcome in 35% and a poor outcome in 27%.

Sexual activity
Only 63% of sexually active teens use condoms 25% of STI each year occur in 15-24 yo Chlamydia is most prevalent Teenage pregnancy accounts for 1/5 of unplanned pregnancies each year.

Teenage and Sexual Behaviour

78% of all teenagers engaged in some form of sexual activity >25% of year 10 students have had sexual intercourse. > 50% of year 12 students have had sexual intercourse. > 33% of year 10 students have had oral sex > 55% of year 12 students have had oral sex. 38% of females have had unwanted sex, 19% for males. Nearly 25% of sexually active teens surveyed reported been drunk during their last sexual encounter that figure rose to 34% for males. Just under 50% of the students surveyed had experienced oral sex. 28% had oral sex with 3 or more people. 6% of males and 7% of females reported having same sex attractions

Safe Sex Practices 31% of teenagers did not use a condom the last time they had intercourse. Over 50% those who use the pill for contraception dont use condoms. 50% of all teenage pregnancies occur within the first six months of sexual activity. 30% of sexually active teenagers report having 3 or more sexual partners in the last 12 months. Over 75% of teenagers are confident to talk to their partner about contraception. 48% were confident to talk to their parents about sex and contraception

Self harm
Self-harm refers to people deliberately hurting or mutilating their bodies without necessarily wanting to die. It often begins in the teenage years. reasons why? may be a way of telling other people about their distress asking for help, a way of coping with stress or emotional pain, a symptom of a mental illness like depression. could suggests that you are thinking about suicide Not everyone who self-harms is suicidal

What types of behaviour suggest self-harm?

Cutting part of the body, commonly the arms, wrists, or thighs overdoses of prescribed or illegal drugs or other substances Using cigarettes or lighters to burn the skin

Other 'risk taking' behaviour can lead to harm train surfing, driving cars at high speed, illegal drug use, deliberately unsafe sex. Some people are more susceptible to self-harm than others experienced emotional, physical or sexual abuse, have had a stressful and highly critical family environment, or have a mental illness such as depression. What can you do if you self-harm? talk to someone get medical assistance if you need it counselling can help - ways of coping.

Finally ,

THE END!