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Behavioral dynamics > Dissociative Disorders / Disruptive and Conduct Disorders > Flashcards

Dissociative Disorders / Disruptive and Conduct Disorders Flashcards

1
Q

segregation of any group of mental processes from the rest of someone’s psychological activity

A

dissociation

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2
Q

what is
An unconscious defense mechanism
Often associated with psychological trauma
May be transient or chronic, sudden or gradual

A

Dissociation

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3
Q

5 Core Symptoms of Dissociative Disorders

A
  1. Amnesia
  2. depersonalization
  3. derealization
  4. identity confusion
  5. identity alternation
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4
Q

Recurrent gaps or other defects in memory

A

amnesia
May vary from several minutes to years

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5
Q

Sense of detachment or disconnection from one’s self

A

depersonalization

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6
Q

a pt states feeling like a stranger in one’s own body, or like part of your body does not belong to you
Feeling detached from emotions, or like a “robot” or on “autopilot”
what symptom are they experiencing

A

depersonalization

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7
Q

Sense of disconnection from familiar people or one’s surroundings
Close relatives or friends, one’s home or workplace may seem unreal or unfamiliar

A

derealization

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8
Q

Inner struggle about one’s sense of self/identity
what symptom is being described?

A

Identity confusion

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9
Q

pt comes in saying “I don’t know who I am anymore,” “I don’t know which me is the real me”
what symptom are they experiencing

A

identity confusion

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10
Q

Sense of acting like a different person some of the time

A

identity alternation

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11
Q

what are some signs of a pt experiencing identity alternation

A
  1. May use different names in different situations
  2. May have items one doesn’t recognize/cannot recall acquiring
  3. May have a learned skill without recollection of learning that ability
  4. Uncontrolled mood/behavior changes
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12
Q

what are the Dissociative Disorders - DSM-V Categories?

A
  1. Dissociative Amnesia
  2. Depersonalization/Derealization Disorder
  3. Dissociative Identity Disorder
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13
Q

potentially reversible memory impairment that primarily affects autobiographical memory

A

Dissociative Amnesia
- Cannot recall personal information
- Typically affects memories of a traumatic or stressful nature, but can also impact other memories

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14
Q

sudden unexpected travel or wandering in a dissociated state, with subsequent

A

Dissociative Fugue

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15
Q

what is the Subtype of dissociative amnesia in DSM-V

A

Dissociative Fugue

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16
Q

dissociative amnesia is MC seen in who?

A

late adolescence/early adulthood
No specific gender

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17
Q

Comorbidities of dissociative amnesia

A
  1. MDD (up to 60%)
  2. bipolar
  3. substance abuse
  4. other anxiety disorders
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18
Q

what is the criteria for diagnosing dissociative amnesia

A
  1. Inability to recall important autobiographical information, usually of a traumatic or stressful nature, inconsistent with ordinary forgetting
    - May be localized/selective amnesia for a specific event
    - May be generalized amnesia for identity and life history
  2. causes significant distress or impairment in functioning
  3. Syndrome is not
    - Due to substance use or medical / organic brain condition
    - Better explained by other mental disorder
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19
Q

criteria for dissociative fugue

A

same as dissociative amnesia PLUS
apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or other important autobiographical information

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20
Q

5 types of dissociative amnesia

A
  1. localized amnesia
  2. continuous amnesia
  3. generalized amnesia
  4. selective amnesia
  5. systematized amnesia
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21
Q

Differential Diagnoses for dissociative amnesia

A
  1. Ordinary Forgetfulness
  2. Medical Disorders
    - Age-Related Cognitive Decline
    - Dementia/Delirium
    - Neurological Disorders
  3. Substance Use/Abuse
  4. Medication Side Effects
  5. Other Psychiatric Disorders
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22
Q

tx for dissociative amnesia

A
  1. psychotherapy
    - phase-oriented - standard of care
    - Cognitive therapy - address cognitive distortions based in trauma
    - Hypnosis - may help reduce intensity of symptoms and facilitate recall of dissociated memories
    - Group therapy - may provide support for individuals with experiences like combat-related PTSD, childhood abuse

no pharm tx

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23
Q

what pharmacotherapies have been used to facilitate interviews and help recall dissociated information for dissociative amnesia

A
  1. BZDs
  2. barbiturates
  3. amphetamines
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24
Q

prevalence of depersonalization/derealization disorder

A
  1. Transient depersonalization/derealization, last 12 months - up to 20%
  2. Lifetime, DDD - about 1-3%
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25
Q

transient depersonalization/derealization is MC in pt with ?

A
  • hx of seizures or migraines
  • psychedelic drugs, medications
  • head injury
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26
Q

risk factors for depersonalization/derealization disorder

A
  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

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27
Q

comorbidities for depersonalizaton/derealization disorder

A
  1. Depression
  2. anxiety
  3. OCD
  4. avoidant or borderline personality disorder
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28
Q

etiology of depersonalization/derealization disorder

A
  • Possible serotonergic involvement
  • response to traumatic stress
  • ego defense mechanism in the face of major negative life events
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29
Q

criteria for depersonalizaton/derealization disorder

A
  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
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30
Q

ddx for depersonalization/derealization disorder

A
  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
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31
Q

tx for depersonalization/derealization disorder

A
  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
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32
Q
  • Characterized by the presence of two or more “selves” or “personalities” with distinct memories, thoughts, opinions, and goals
  • Previously referred to as multiple personality disorder
A

Dissociative Identity Disorder

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33
Q

dissociative identity disorder is 5-9x as common in who?

A

women
often diagnosed in 20s-30s

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34
Q

comorbidities of dissociative identity

A
  1. PTSD (79-100%)
  2. Depression (83-96%)
  3. substance abuse (83-96%)
  4. personality disorders
  5. somatoform disorders
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35
Q

etiology of dissociative identity disorder

A

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

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36
Q

criteria for dissociative identity disorder

A
  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
  5. not due to substance abuse or medical condition
    Ex. alcohol intoxication, complex partial seizures, etc.
37
Q

what are other common symptoms of dissociative identity disorder

A
  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)
38
Q

how do you make the diagnosis of dissociative identity disorder

A
  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”)
39
Q

ddx for dissociative identity disorder

A
  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
40
Q

tx for dissociative identity disorder

A
  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
41
Q

Umbrella term for conditions related to difficulty controlling a temptation or impulse

A

Impulse Control Disorders

42
Q

Characterized by inability to resist the impulse, desire, or drive to perform a particular act that is obviously harmful to self, others, or both

A

Impulse Control Disorders

43
Q

Act is preceded by mounting tension and/or anticipatory pleasure
Completing action results in immediate gratification and relief
Action is followed by remorse, guilt, self-reproach, dread
Individuals are often secretive about activity

A

Impulse Control Disorders

44
Q

main examples of Impulse Control Disorders

A
  1. Pyromania
  2. Kleptomania
  3. Pathologic Gambling
  4. Trichotillomania
  5. Intermittent Explosive Disorder
45
Q

which impulse control disorder example is the MC

A
  1. Pathological Gambling - ~3%
  2. Kleptomania - ~0.6%
  3. Trichotillomania - ~0.6%
  4. Pyromania - thought to be rare
46
Q

Kleptomania and trichotillomania are more common in who

A

females

47
Q

⅔ of pathological gamblers are what gender

A

males

48
Q

90% of pyromaniacs are what gender?

A

males

49
Q

etiology of impulse control disorders

A

→ 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

50
Q

common symptoms of pathologic gambling

A
  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
51
Q

Recurrent hair pulling resulting in noticeable hair loss

A

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

52
Q

Recurrent theft of items not needed for personal use or monetary value

A

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

53
Q

common symptoms of pyromania

A
  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
54
Q

tx for all impulse control disorders

A
  1. psychotherapy
  2. tx of comorbid psych disorders
55
Q

tx for kleptomania

A

SSRIs, Lithium

56
Q

tx for pyromania

A

Early intervention programs (i.e., adolescence)

57
Q

tx for pathologic gambling

A

SSRIs, opiate antagonists (Naloxone, Naltrexone)

58
Q

tx for trichotillomania

A

Clomipramine (Anafranil)
SSRIs not strongly shown to be beneficial

59
Q

Discrete episodes of losing control of aggressive impulses
Can result in serious assault, property destruction
Aggressiveness is grossly out of proportion for any stressor which may have precipitated the episode

A

Intermittent
Explosive Disorder (IED)

60
Q

between IED episodes, what happens?

A

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

61
Q

IED is MC in what gender

A

males
often starts in adolescence

62
Q

comorbidities of IED

A
  1. pyromania
  2. other impulse control disorders
  3. substance use
  4. mood and anxiety disorders
63
Q

etiology of IED

A
  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
64
Q

criteria for IED

A
  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.
65
Q

ddx for IED

A
  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
66
Q

tx for IED

A
  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
67
Q

what is oppositional defiant disorder (ODD)

A
  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)
68
Q

Three major subtypes of ODD

A
  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
69
Q

ODD is MC in who?

A

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

70
Q

comorbidities of ODD

A

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

71
Q

risk factors of ODD

A

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

72
Q

etiology of ODD

A

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

73
Q

criteria for ODD

A

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

74
Q

how do you categorize the severity of ODD

A

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

75
Q

ddx for ODD

A
  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!

76
Q

tx for ODD

A
  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
  2. Pharmacotherapy
    Only as indicated for any comorbid conditions
77
Q

what is the overall course of ODD

A
  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

78
Q

Enduring set of behaviors in a child or adolescent that evolves over time, usually characterized by aggression and violation of the rights of others

A

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

79
Q

conduct disorder is associated with what certain factors?

A

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

80
Q

conduct disorder is MC in who?

A

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

81
Q

comorbidities for conduct disorder

A

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

82
Q

risk factors for conduct disorder

A

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

83
Q

criteria for conduct disorder

A

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)

84
Q

onset for conduct disorder

A
  • 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
85
Q

severity of conduct disorder

A
  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
86
Q

(Conduct disorder)
with limited prosocial emotions - must display 2+ of the following traits persistently for over 1 year, in multiple relationships and settings (need multiple information sources to verify):

A
  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
87
Q

ddx for conduct disorder

A
  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
88
Q

characterized by poor impulse control, and often associated with learning difficulties, leading to poorer self-esteem and frustration

A

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

89
Q

tx for conduct disorder

A
  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

Behavioral dynamics (19 decks)

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