Dissociative Disorders / Disruptive and Conduct Disorders Flashcards

Question

transient depersonalization/derealization is MC in pt with ?

Answer 1

- hx of seizures or migraines - psychedelic drugs, medications - head injury

Answer 2

1. acute or chronic trauma 2. substance abuse 3. psychiatric disorders - ⅓ to ½ of individuals with DDD report **chronic trauma/stressor exposure** ***equally common** in men and women*

Answer 3

1. _Depression_ 2. _anxiety_ 3. OCD 4. avoidant or borderline personality disorder

Answer 4

- Possible serotonergic involvement - response to traumatic stress - ego defense mechanism in the face of major negative life events

Answer 5

1. The presence of persistent or _recurrent_ experiences of depersonalization, derealization, or both: - **Depersonalization** - experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions - **Derealization** - Experiences of unreality or detachment with respect to surroundings 2. During the depersonalization/derealization, _reality testing remains intact_ 3. causes distress or functional impairment 4. not due to substance/medication or a medical condition 5. not better explained by another mental disorder

Answer 6

1. Other Psych Disorders - Secondary to panic attacks, phobias, PTSD, acute stress disorder, schizophrenia - Depersonalization/derealization can also be manifestations of other dissociative disorders 2. Medical Conditions - Seizures, brain tumors, postconcussive syndrome, migraines - Vertigo, Meniere’s disease 3. Substance Use - Marijuana, cocaine, other psychostimulants

Answer 7

1. Often **refractory to treatment** 2. Psychotherapy - mixed results - _Stress management_ strategies and _relaxation techniques_ may be of use 3. Pharmacotherapy - _SSRIs_ may be helpful - Still often have sporadic response

Answer 8

Dissociative Identity Disorder

Answer 9

women often diagnosed in 20s-30s

Answer 10

1. **PTSD** (79-100%) 2. Depression (83-96%) 3. substance abuse (83-96%) 4. personality disorders 5. somatoform disorders

Answer 11

**childhood trauma** (89-97%) - Typically physical or sexual abuse - no strong evidence to support genetics

Answer 12

1. Presence of ***_two or more_ distinct identities or personality states,*** each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and itself - “**being possessed**” by an alternate self 2. **Amnesia** _must_ occur 3. causes distress and/or functional impairment 4. *not* part of normal cultural or religious practices - Ex. an “imaginary friend” is not considered indicative of a separate personality state alone 4. not due to substance abuse or medical condition Ex. alcohol intoxication, complex partial seizures, etc.

Answer 13

1. **PTSD Symptoms** - Intrusive thoughts, hyperarousal, avoidance, numbing symptoms 2. **Affective Symptoms** Depression, dysphoria, or anhedonia, mood lability, suicidal thoughts, self-harm, helplessness or hopelessness 3. **Somatic Symptoms** Pseudoneurological symptoms (seizures), pain symptoms (abdominal, MSK, pelvic, HA), psychophysiological (asthma/SOB, menstrual disorders, IBS, GERD, Memory difficulties) 4. **Obsessive/Compulsive Symptoms** Ruminations about trauma, obsessive/compulsive behaviors (counting, singing, arranging/organizing, washing, checking)

Answer 14

1. **Asking about memory problems/amnesia** - Have you had any periods where you felt like you “lost” a few hours/days/weeks and cannot recall what happened? - Do you have trouble remembering major events in your past that others have told you about, which you feel like you should be able to recall? 2. **Noting objective evidence of different selves** - Referring to self in first-person plural (“we,” “our”) - Referring to self in the third person (“she,” “his”) - Making depersonalized self-references (“the body,” “the son”) - Referring to parts of themselves by their roles or moods (“the angry one,” “the wife”)

Answer 15

1. Other dissociative disorders 2. Substance use/abuse 3. Other Psych Disorders - often also meet criteria! - Mood disorders, anxiety disorders, PTSD - Personality disorders - Somatic symptom disorders - Factitious disorders/malingering 4. Medical Disorders - especially neurological / seizure

Answer 16

1. **_Psychotherapy - mainstay_** - Cognitive therapy - helps address cognitive distortions that contribute to formation and persistence of multiple selves - Hypnosis - can alleviate self-destructive impulses and improve symptoms - Family/Group therapy - adjunctive; helps improve social support - Expressive/occupational therapy - helps patient express feelings and give structured, focused activities 2. Pharmacotherapy - aimed at ***managing major symptoms*** - SSRIs, TCAs, MAOIs, antipsychotics - BZDs, beta-blockers, clonidine, anticonvulsants - sedation - Prazosin - PTSD-related nightmares - Useful during latency between start of tx and clinical onset of action 3. ECT - for refractory mood disorders

Answer 17

Impulse Control Disorders

Answer 18

Impulse Control Disorders

Answer 19

Impulse Control Disorders

Answer 20

1. Pyromania 2. Kleptomania 3. Pathologic Gambling 4. Trichotillomania 5. Intermittent Explosive Disorder

Answer 21

1. Pathological Gambling - ~3% 2. Kleptomania - ~0.6% 3. Trichotillomania - ~0.6% 4. Pyromania - thought to be rare

Answer 22

→ Symptoms often worsen in times of significant stress → _Early life events_ - poor behavior modeled by parents, violence in home → May have serotonergic or limbic system abnormalities

Answer 23

1. Persistent and recurrent **maladaptive gambling behaviors** 2. **5+** of the following: - *Preoccupation* with gambling - Need to gamble with *increasing amounts of money* to get desired excitement - Repeated *unsuccessful efforts* to reduce or stop gambling - *Restless or irritable* when trying to reduce or stop gambling - Gambles to *improve mood* or escape from problems - After losing money, *returns another day* to win the money back - *Lies* to others to conceal the extent of gambling - Has committed *illegal acts* to finance gambling - Jeopardizes or *loses relationships*, jobs, or opportunities because of gambling - *Relies on others* to provide money to relieve a situation caused by gambling

Answer 24

Trichotillomania Tension or anxiety immediately before, or when resisting the urge Pleasure, gratification, or relief when pulling hair

Answer 25

kleptomania Tension or anxiety immediately before stealing, or when resisting the urge Pleasure, gratification, or relief when stealing Stealing is not due to anger or psychosis

Answer 26

1. Recurrent, deliberate, purposeful fire setting on multiple occasions 2. Tension or anxiety immediately before setting fire, or when resisting the urge 3. Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their aftermath 4. Fascination with, interest in, curiosity about, or attraction to fire 5. Fire setting is not for monetary gain, expression of ideology, to conceal criminal activity, as an act of anger, to improve one’s living circumstances, because of psychosis, or due to impaired judgement * must cause significant distress or functional impairment * must not be better accounted for by another psychiatric or medical condition

Answer 27

1. psychotherapy 2. tx of comorbid psych disorders

Answer 28

SSRIs, Lithium

Answer 29

Early intervention programs (i.e., adolescence)

Answer 30

SSRIs, opiate antagonists (Naloxone, Naltrexone)

Answer 31

Clomipramine (Anafranil) SSRIs not strongly shown to be beneficial

Answer 32

Intermittent Explosive Disorder (IED)

Answer 33

Patients show genuine regret or self-reproach No generalized impulsivity or aggressiveness

Answer 34

males often starts in adolescence

Answer 35

1. pyromania 2. other impulse control disorders 3. substance use 4. mood and anxiety disorders

Answer 36

1. genetic predisposition 2. exposure to abuse/violence as a child 3. narcissistic defense mechanism - Also see decreased serotonergic activity - Increased rates of brain inflammation, hx of *T. gondii* infection

Answer 37

1. Presence of ***recurrent behavioral outbursts*** representing a failure to control aggressive impulses, as manifested by either of the following: - _Verbal or physical aggression_ towards property, animals, or other individuals, occurring twice weekly on average for a period of 3 months; the aggression *does not* result in damage or destruction of property or physical injury - 3+ behavioral outbursts involving _damage/destruction of property or physical injury_ against animals or other individuals occurring within a 12-month period 2. The magnitude of aggressiveness during the outbursts is grossly out of proportion to the provocation or any precipitating stressors. 3. The aggressive outbursts are not premeditated and are not committed to achieve a tangible objective 4. Chronological age is **at least 6 years** (or equivalent developmental level). 5. Syndrome causes distress, functional impairment, or financial/legal consequences 6. Syndrome is not due to substance abuse or medical condition - Ex. alcohol intoxication, dementia, DMDD, etc.

Answer 38

1. Substance use/abuse 2. Other Psych Disorders - Psychosis - impaired reality testing - Antisocial or borderline personality disorder - aggression will linger between outbursts - Conduct disorder - persistent, repetitive aggression rather than episodic outbursts 3. Medical Disorders - especially dementia/delirium

Answer 39

1. Combination psychotherapy and pharmacotherapy preferred 2. Psychotherapy is helpful, but often difficult - Problems setting limits with therapists - Patients can become defensive and have outbursts in therapy - _Group and family therapy often helpful_ 3. Pharmacotherapy - Serotonergic drugs - SSRIs, trazodone, buspirone - Anticonvulsants/mood stabilizers - lithium, carbamazepine, valproate/divalproex, phenytoin, gabapentin may be helpful - Adjunct therapy - antipsychotics, beta blockers, calcium channel blockers

Answer 40

1. Enduring pattern of negativistic, hostile, disobedient behavior - Frequently argue with adults and authority figures - Often angry, resentful, easily annoyed 2. Inability to take responsibility for mistakes - Places blame on others for their own transgressions or omissions 3. Commonly have problems with peer relationships and in school - Symptoms may initially only manifest in one setting, and later show in others 4. Typically do not display much physical aggression or violent behavior - May display verbal aggression - Reactive (ex. in response to rules) rather than proactive (ex. bullying) - Overt (ex. shouting) rather than covert (ex. spreading rumors)

Answer 41

1. Angry/Irritable - often lose their tempers; easily annoyed; feel angry most of the time 2. Argumentative/Defiant - habitually argue with authority figures; actively refuse to comply with requests; intentionally break rules; purposely annoy others 3. Vindictive - in addition to clashing with authority, tend to engage in vengeful and spiteful behavior

Answer 42

more common in males before puberty; equal post-puberty begins as young as 3, average age at onset is 6; identified by age 14

Answer 43

pyromania, other impulse control disorders, substance use, mood and anxiety disorders

Answer 44

family discord, single parent, low socioeconomic status, maternal depression, inattentive parents

Answer 45

irritable temperament; childhood trauma; chronic incapacity (illness, mental retardation); parenting style that reinforces defiant behavior like tantrums

Answer 46

Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least **6 months** as evidenced by **4+ symptoms** from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling: 1. _Angry/Irritable Mood_ - Often loses temper - Often touchy or easily annoyed - Often angry and resentful 2. _Vindictiveness_ - Has been spiteful or vindictive at least twice within the past 6 months 3. _Argumentative/Defiant Behavior_ - Often argues with authority figures or, for children and adolescents, with adults - Often actively defies or refuses to comply with rules or requests from authority figures - Often deliberately annoys others - Often blames others for his or her mistakes or misbehavior 4. _Pt < 5 y/o_ - Behavior should _occur on most days_ for a period of at least 6 months 5. _Pt 5+ y/o_ - Behavior should _occur at least once per week_ for at least 6 months, unless otherwise noted - Also consider if the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture 6. Behavior causes distress or functional impairment 7. Behavior is not due to substance use or another psychiatric disorder

Answer 47

Mild - Symptoms are confined to only one setting Moderate - Some symptoms are present in at least two settings Severe - Some symptoms are present in three or more settings

Answer 48

1. Normal developmental behavior - Consider behavior of other patients of the same age! 2. Substance use/abuse 3. Other Psych Disorders - Adjustment Disorder - occurs temporarily, in response to a stressor - Disruptive Mood Disregulation Disorder - less disregard for rules/authority specifically, behavior is not deliberately antagonistic, patients show remorse after outbursts - Conduct Disorder - more likely to have physical aggression Note - ODD can progress to conduct disorder as the patient ages!

Answer 49

1. **_Psychotherapy - first-line therapy_** - Family therapy - train parents to reinforce desired behavior and diminish attention/not reinforce oppositional or negative behavior - Individual therapy - role play positive behavior, help work on self esteem to improve ability to deal with conflict and disappointment 3. Pharmacotherapy Only as indicated for any comorbid conditions

Answer 50

1. 25% - few/absent symptoms of ODD by late adolescence and early adulthood 2. 50% - still display partial or full symptoms of ODD 3. 25% - progress to Conduct Disorder - Especially patients with predominantly angry/irritable or vindictive types due to higher levels of aggression May also develop mood or anxiety disorders, ADHD, learning delays if inadequately treated

Answer 51

Conduct Disorder Physical aggression or threats of harm to people Destruction of their own property or that of others Theft or acts of deceit Frequent violation of age-appropriate rules

Answer 52

psychosocial factors 1. Childhood maltreatment 2. Harsh or punitive parenting 3. Family discord 4. Lack of appropriate parental supervision 5. Lack of social competence 6. Low socioeconomic level

Answer 53

4-12x more common in males typically starts in adolescence

Answer 54

ADHD, substance use, anxiety disorders (including PTSD), mood disorders, learning disorders

Answer 55

impulsivity, poor parental supervision, harsh/punitive parental discipline, low IQ, poor school performance; regular alcohol use

Answer 56

Pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as determined by **3+ of the following 15 criteria** in the **past 12 months** (at least 1 in the past 6 months): 1. Aggression to People and Animals 2. Destruction of Property 3. Deceitfulness or Theft 4. Serious Violations of Rules 5. Behavior causes functional impairment 6. Not better explained by other disorders (e.g., antisocial personality disorder)

Answer 57

* Childhood-onset type - At least one symptom present prior to age 10 * Adolescent-onset type - No symptoms present prior to age 10 * Unspecified onset - Unable to clarify age at onset of symptoms

Answer 58

1. Mild - Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others - Ex. lying, truancy, staying out after dark without permission, other rule breaking 2. Moderate - The number of conduct problems and the effect on others are intermediate between those specified in “mild” and those in “severe” - Ex. stealing without confronting a victim, vandalism 3. Severe - Many conduct problems in excess of those required to make the dx, or conduct problems cause considerable harm to others - Ex. forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering

Answer 59

1. lack of remorse/guilt - Lack of concern about consequences 2. callous (no empathy) - unconcerned about the feelings of others. 3. unconcerned about performance - Blames others 4. shallow or deficient affect - Does not express feelings

Answer 60

1. Substance use/abuse 2. Other Psych Disorders - Adjustment Disorder - occurs temporarily, in response to a stressor - ADHD - Aggression and violation of others’ rights and well being is minimal to absent - Disruptive Mood Dysregulation Disorder - less physical aggression and disregard for the rights of others - Oppositional Defiant Disorder - less physical aggression and disregard for the rights of others Note - ODD can progress to conduct disorder as the patient ages! 3. Medical Disorders - especially neurological injury/disease

Answer 61

ADHD ⅓ to ½ of all children with ADHD have comorbid ODD!

Answer 62

1. Psychotherapy - early, sustained intervention can significantly reduce negative behavior and improve long-term outcomes! - Recommend therapy as early as kindergarten in children with symptoms or at high risk of developing conduct disorder - Therapy helps more with overt symptoms (aggression) than covert symptoms (lying, stealing) - Reinforcement of positive, prosocial behaviors 2. Pharmacotherapy - Atypical antipsychotics - may help reduce aggressive behavior - Risperidone (Risperdal) has shown particular promise - SSRIs - can help with impulsivity, irritability, and mood lability - Anticonvulsants - may help with aggression; mixed results - Treatment of comorbid conditions, such as ADHD, if present