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Psychiatric Principles > Final: ICDs and sexual disorders > Flashcards

Final: ICDs and sexual disorders Flashcards

1
Q

Describe the Addiction cycle

A
  1. Preoccupation/anticipation
  2. Binge intoxication
  3. Withdrawal Negative Affect
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2
Q

Detail the impulse control disorder cycle

A
  1. tension/arousal
  2. Impulsive act
  3. Pleausre/relief
  4. Regret/guilt and self-reproach
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3
Q

DDx Intermittent explosive disorder (rage)

A

Ddx: ASPD, CD, dissociative disorder

*no psychotic sx

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4
Q

DSM IV cx Intermittent Explosive Disorder

A
  1. Discrete episodes of aggressive behavior resulting in assaultive acts or destruction of property w/o cause
  2. Aggressiveness out of proportion to precipitating psychosocial stressors
  3. Behavior not accounted for by another mental disorder
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5
Q

Tx Intermittent Explosive disorder

A

Meds: anything acting like GABA
SSRI, Mood stabilizers (lithium, depakote), BZs (caution), anticonvulsants (good), antipsychotics

Behavior modification (desensitization)

Restraints may be necessary (in patient)

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6
Q

Background of Conduct disorder

A

> 7 yo (similar sx to ADHD)
Child and Adolescent onset types
Mild/moderate/severe categories
Risk factors: parental rejection or neglect, difficult infant temperament, harsh discipline, physical or sexual abuse, unstable family role models, familial psychopathology

One of the most common peds psych disorders (1-10%)
*want to dx early to prevent antisocial behavior

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7
Q

DSMIV criteria for Conduct Disorder

A

A) Major rights of other or societal norms are violated
Aggression to people and animals (bully, use weapon, cruel)
Behavior causes sig impairment in social, academic or occupational functioning
If >18yo, does not meet cx for ASPD

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8
Q

Tx of Conduct disorder

A

a) individual and group therapy
b) parental group therapy
c) Meds: ADHD drugs, antidepressants, mood stabilizers, antipsychotics

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9
Q

Background of Oppositional Defiant disorder and keep distinguishers bw ODD and CD (conduct disorder)

A
  • Recurrent pattern of negativistic, defiant, disobedient and hostile behavior toward authority figures
  • More common in disruptive households; can be a/w ADHD
  • Preschool defiance is normal, but if sx increase, need to assess
  • usually before 8yo, 2-16%, may lead into childhood CD but sx less severe than CD

CD dx takes precedence over ODD
Familial link to mood disorders (ODD, CD, ADHD, ASPD, substance abuse)
Tx: behavioral modification, family therapy

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10
Q

DSM IV criteria ODD

A

[A] Negativistic, hostile and defiant behavior >6 mth with 4+ of the following:

1) Often loses temper
2) Often argues with adults
3) Defies adults requests or rules
4) Deliberately annoys people
5) Blames others for their behavior
6) Easily annoyed
7) Often angry or resentful
8) often spiteful or vindictive

[B] Sig impairment in social, academic or occupational

[C] Not psychotic or mood disorder

[D] Criteria not met for CD and if they are >18 yo, criteria not met for ASPD

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11
Q

Etiology of Kleptomania

A

May be linked to OCD, can co-occur in mood and addictive disorders; rare occurrence; not shop lifting or ordinary theft

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12
Q

DSMIV criteria Kleptomania

A

A) Recurrent impulse to steal objects NOT needed for personal use or for their monetary value

B) Increase tension before the act of stealing

C) Pleasure, gratification or relief at the time of committing the theft

D) Stealing is not to express anger and is not in response to delusion or hallucination

E) Stealing NOT accounted for CD, mania or ASPD

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13
Q

Tx for Kleptomania

A

Behavioral modification

No clear indication for medications (look for psych co-morbidities0

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14
Q

DSMIV criteria for Pyromania

A
  1. Deliberate and purposeful fire setting on more than one occasion
  2. Build up of tension before setting the fire
  3. Fascination, curiosity, interest in fire and its contents
  4. Pleasure, gratification or relief when setting fires or when witnessing or participating in the aftermath
  5. Fire setting not done for monetary gain
  6. Not accounted for by CD, mania or ASPD
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15
Q

Tx of Pyromania

A
  1. Psychotherapy (determine primary cause)
  2. No clear need for meds (trial SSRI, mood stabilizer, anxiolytics)

*so rare that hard to know best meds

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16
Q

Co-morbidities and related disorders with Pathological Gambling

A

Stress related physiological comorbidities

Increased rates of mood d/o, ADHD, Substance abuse, other ICDs and Cluster B personality d/o

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17
Q

DSM IV dx pathological gambling

A

A) Persistent and recurrent maladaptive gambling behavior as indicated by FIVE+ of the ten

  1. Preoccupation with gambling (planning, reliving winnings)
  2. Desired excitement achieved w/ increased amt of money gambled
  3. Unable to stop or cutback
  4. Restless or irritable when trying to cut down
  5. May serve to escape problems or relieve dysphoric mood
  6. After losing money comes back to gamble to get even: chasing losses
  7. Lies to family, therapists and other
  8. Commits illegal acts – forgery, fraud, theft and embezzlement
  9. Has jeopardized relationships, employment or career
  10. Relies on others to provide money to relieve desperate financial situation

b) behavior not better accounted for by manic episode

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18
Q

Tx of pathological gambling

A

Psychotherapy: moderate benefit
Behavioral modification, CBT to address erroneous beliefs, role of chance

Group support
Gamblers anonymous (12 step)
Group therapy

Medication: mild to moderate benefit

  • tx OCD, anxiety or mood disorder sx (SSRI, anxioloytics, mood stabilizers)
  • some promise with opiate antagonists (NALTREXONE)
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19
Q

DSMIV criteria Trichotillomania

A
  1. Recurrent PULLING OUT OF HAIR resulting in NOTICEABLE hair loss
  2. INCREASED TENSION before pulling out hair
  3. Pleasure, gratification or RELIEF when pulling out hair
  4. Not accounted for by another condition (psych or derm)
  5. Causes SIGNIFICANT DISTRESS in social occupational and other areas of functioning
20
Q

Tx of Trichotillomania

A
  1. Behavior modification; desensitization (give stress stimulus and don’t allow to pull hair out)
  2. Meds have mixed results: SSRIs, Mood stabilizers and Anxiolytics
    - - Fluoxetine (Prozac) is the most studied
    - -Chlomipramine (anafranil) shows promise
21
Q

What are the various paraphilias and their potential for a degree of victimization (* = degree of victimization)

A
  1. Fetishism
  2. Transvestic Fetishism
  3. Exhibitionism *
  4. Voyeurism *
  5. Frotteurism **
  6. Masochism**
  7. Sadism ***
  8. Pedophilia ***
22
Q

Define Paraphilias and the DSMIV criteria

A

Def: deviation from what are considered normal sexual interests and behaviors

DSMIV: Recurrent, intense, sexually arousing fantasies, urges or behaviors involving either

1) nonhuman objects
2) The suffering/humiliation of self or partner
3) children or non-consenting persons
* occurs over at least 6 mth and
* causes sig distress or impairment in social or other functioning

23
Q

Etiology of Paraphilias

A

a) Means to release sexual energy or frustration (act is followed by arousal and orgasm achieved by masturbation)
b) often concealed, a/w guilt/shame, financial or legal problems and maybe uncooperative to tx (online material is problematic)
c) Psychoanalytical theory (Freud) suggests result form unsuccessful negotiating in normal development during phases of courtship – urges are repressed then re-expressed as paraphilias
d) Classical conditioning of sexual arousal to objects and subsequent negative reinforcement due to unpleasant normal sexual activity (women don’t condition to these stimuli)

24
Q

Exhibitionism: what is it and DSMIV criteria? Long version

A

“Indecent exposure” “flashing” (usually M to F)

DSMIV

  1. Over period of at least 6 mth, pt have recurrent intense sexually arousing fantasies, sexual urges or behaviors that involve exposing their genitals to unsuspecting strangers
  2. The fantasies, sexual urges or behaviors cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

Evokes shock or fear in victim: derive pleasure from rxn and excitement increases with risk of being discovered

25
DSMIV exhibitionism: short version
1. 6 mth, recurrent sexual fantasies, urges or behaviors involving exposing genitals 2. These cause impairment
26
DSMIV criteria Voyeurism
1. 6 mth, recurrent intense sexual fantasies/urges/behaviors involving act of observing an unsuspecting person who is naked, undressing, or engaging in sexual activity 2. Impairment note: pt derive sexual gratification from seeing sex organs and acts; scopophilia synonym for voyeurism (usually unmarried M in 20-30s who masturbate during activity; excitement increases with risk of being discovered)
27
DSMIV criteria Frotteurism
1. 6 mth, urge/behavior to rub against and touching non consenting person 2. Impairment * usually in crowded situation; often attempt is made to rub ones genitals against the other person * milder variations include accidental touching, inappropriate grabbing, “copping a feel”
28
Fetishism: DSM IV criteria
1. 6 mth, recurrent intense, sexually arousing fantasies, urges, behaviors involving NONLIVING OBJECT 1. Impairment 3. Not limited to female clothing used in cross dressing or devices designated for purpose of tactile genital stimulation * object invariable used for masturbation: ex women’s undergarments, high heels, silk, leather, fur, body parts * considered relatively harmless
29
DSM IV criteria Transvestic Fetishism “Cross dressing”
1. 6 m, heterosexual M pt has recurrent, intense, sexually arousing fantasies, urges or behaviors involving cross dressing 2. Impairment notes: * majority are heterosexual MARRIED M who derive sexual pleasure from dressing in women’s clothing * different from F impersonators or homosexuals who occasionally dress in W clothing; need to differentiate from gender dysphoria
30
DSMIV criteria Masochism
1. 6 mth, pt have recurrent intense sexually arousing fantasies, urges or behaviors involving act of being humiliated, beaten, bound or otherwise made to suffer 2. ‘Impairment’ notes: * usually starts early adulthood; lifetime course may be stable or progressive * may include restraint, bondage, paddling, beating, verbal abuse, being urinated or defecated on, forced cross dressing, infantilism, hypoxyphilia * individual may derive pleasure from receiving and inflicting pain = SADOMASOCHISM
31
What is sadomasochism
Individual may derive pleasure from receiving AND inflicting pain
32
DSMIV criteria Sadism
1) 6mth, recurrent, intense, sexually arousing fantasies sexual urges or behaviors involving acts in which PSYCH OR PHYSICAL SUFFERING OF THE VICTIM is sexually exciting to the person 2) Person has acted on urges with NON consenting person or the urges cause marked distress or interpersonal difficulty 2) Impairment notes: - may start in childhood; usually early adulthood - may be a/w ASPD - Mild/moderate or severe (rape, torture, murder)
33
Pedophilia: DSMIV criteria
1. 6 mth urge involving sexual activity with prepubescent child/children (13 y or younger) 2) pt must be >16 yo and at least 5 yr older than the child 3) Impairment 4) specifiers: (a) to whom they are attracted (b) if limited to incest, (c) if limited exclusively attracted to children notes: - Pattern of behavior is variable (undressing, exposing themselves, masturbation, fondling, sexal acts including rape) - May rationalize behavior as educational value, the child derives sexual pleasure, or the child is sexually provocative
34
Tx options for Paraphilias
PSYCHOTHERAPY CBT: addresses rationalization and distorted thinking ‘covert sensitization’ classical conditioning of harmful variation with noxious stimuli (pedophilia and sadism) Social skills training: intimacy dev, communication, sex ed 12 step programs: cognitive restructuring, social support, relinquish control Group therapy: addresses denial, leads to healthy remorse, relapse prevention Individual psychotherapy MEDS (with psychotherapy) SSRIs for milder cases Anti androgens for victim based paraphilias (depo provera, GnRH/LH analogues triptorelin:Trelstar) Mood stabilizers (depakote) and antipsychotics for aggressive behaviors
35
Gender identity disorder DSMIV dx
1. strong and persistent cross gender identification (desire to be other sex) 2. Discomfort with their sex or feel inappropriate in the gender role (aka belief being born wrong sex, desire to remove sex characteristics) 3. NOT CONCURRENT with physical intersex condition 4. Impairment’
36
Etiology of Gender dysphoria (new term for Gender Identity disorder) and what it is/is not?
When gender and sex do not align….. ‘transsexual or transgender individuals” NOT nonconformity to stereotypical sex role behavior.. it is disturbance of sense of IDENTITY… “gender is bw your ears and not bw your legs” * NOT a/w deviant sexual desires (thus NOT a paraphilia)
37
Biological sex/etiology
GENETICally M/F… XX or XY
38
Gender identity definition and PRESUMED etiology
Sense of self as M/F | Etiology: exposure to prenatal sex hormones and genetic influences
39
Sexual Orientation definition and presumed etiology
Persistent and unchanging pref for people of same or opposite sex for love and sexual expression Etiology: exposure to prenatal sex hormones and genetic influences
40
Gender role: definition, Presumed etiology
Expression of ones gender identity in society (ie clothing) | Etiology: Societal expectations
41
Development background GID
Gonad/genital dev 6-7 wk gestation Brain differentiation in 2nd trimester (GID a/w too LITTLE androgen in M, too MUCH in F) *Those with GID may seek hormone tx or sex reassignment surgery
42
DSM IV Sexual disorder NOS (used for hypersexual behavior ie pornography)
DSMIV dx of Sexual disorder NOS is dx for sexual disturbance that does not meet criteria for dysfunction, disorder or paraphilia Current theories based in addiction, impulsivity, compulsivity Key components: 1. loss of control 2. inability to stop 3. Negative consequences
43
Tips for quick sexual disorder NOS (aka hypersexual disorder (pornography)) screen and how to address it
unless seeking tx, probably won’t talk about it with you higher risk STI, secrecy/deception/violation of trust from partner address topic in questions re lifestyle behaviors (sexual risk, STI) PATHOS screen (3+ = refer) 1. Preoccupied (with sexual thoughts) 2. Ashamed (do you hide sexual behavior) 3. Tx (ever sought therapy for sexual behavior) 4. Hurt others (anyone emotionally hurt bc of their sexual behavior) 5. Out of control 6. Sad (feel depressed after sex)
44
Etiology of sex disorder NOS (hypersexual)
cultural isolation, loss of community, childhood abandonment/rejection, abuse, loneliness and unmet needs
45
Tx hypersexual disorder (sexual disorder NOS)
12step Counseling – CBT, psychoanalysis Group or couples counseling to resotre trust Meds possibly: SSRI, mood stabilizer (lithium, valproate), Naltrexone (opiate antagonist), anti-androgens *note: PD meds can induce hypersexuality

Psychiatric Principles (9 decks)

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