PSYCH ROTATION Flashcards
ADHD
has to affect them in different areas of their life, in multiple settings: school/work, home, etc.
Manifests in childhood with symptoms of hyperactivity, impulsivity and/or inattention
CAUSE = GENETIC + ENVIRONMENTAL FACTORS
⦁ Increased chance of sibling having ADHD
⦁ Even higher chance of twin having ADHD (not guaranteed to have ADHD though)
Symptoms affect cognitive, academic, behavioral, emotional and social functioning
these patients experience their emotion in a more intense fashion; may seem to be an “inappropriate reaction” to a stress
Now realizing that ADHD can manifest in adults who didn’t show symptoms as a child; instead of school functioning issues, impulsivity/inability to follow through with tasks at work, multiple job changes, unhappiness at work/failure at work; mostly productivity
ADHD = one of the most common disorders of childhood
Having oppositional defiant disorder / conduct disorder = more likely to also have ADHD. Same with kids who have anxiety disorder and learning disabilities
More prevalent in males
ADHD = frequently associated with other psychiatric disorders
NEUROPATHOGENESIS OF ADHD
- brain imaging reveals decreased activation in areas of basal ganglia + anterior frontal lobe
- major NEUROTRANSMITTERS involved in ADHD = ****Dopamine + NE*****
- Most of dopamine sensitive neurons = located in the frontal lobe
- Dopamine system = associated with reward, attention, STM tasks, planning, motivation, taking risks or being impulsive
- Dopamine limits and selects sensory information arriving from the thalamus to the forebrain
The sensory information gets unorganized and unfiltered; it’s difficult for people with ADHD to filter info and store it properly –> so move around a lot, or are doing other things while listening or looking elsewhere but still able to process what’s going on
Too little dopamine (like Parkinson’s) - so need medication that will increase dopamine
FRONTAL LOBE = ability to project future consequences resulting from current actions, and being able to choose between good and bad decisions (or even between better and best choices).
- Frontal lobe also allows for the override + suppression of socially unacceptable responses, and the determination of similarities + differences between things/events
Attention deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by limited attention span and poor impulse control. It is associated with a decrease in frontal lobe volume* or metabolism, but does not result in a lower intelligence level*
- the impulsivity will decrease with behavioral interventions and as the person ages
DIFFERENCE IN BRAIN FUNCTION OF THOSE WITH ADHD
- decreased activation in areas of basal ganglion and anterior frontal lobe
- there is an increase in dopamine transporter activity –> clears dopamine from the synapse too quickly
- Hypoactivity of dopamine, norepinephrine, and epinephrine in the prefrontal cortex
THE BASIS OF TREATMENT OF ADHD WITH METHYLPHENIDATE***
⦁ increases extracellular dopamine + NE in the brain
⦁ changes the areas of function in the frontal lobe
⦁ in patients without ADHD, methylphenidate does NOT have the same effect on the frontal lobe function
CRITERIA FOR DIAGNOSIS
- NEED 6+ SYMPTOMS OF INATTENTION OR 6+ SYMPTOMS OF HYPERACTIVITY/IMPULSIVITY***
- Symptoms must be present of at least 6 MONTHS
- The majority of the time, children have symptoms of BOTH subtypes
- Need 5+ for age 17 or older
- Symptoms should be inappropriate for the given age**
- symptoms negatively impact social + academic or occupational activities
- symptoms developed PRIOR to age 12** = have to have started between ages 6 - 12
- symptoms present in 2+ settings***
- symptoms present for at least 6 months**
- symptoms not better explained by other psych disorders
Patients with ADHD have normal intelligence
Tourette syndrome is a childhood tic disorder often associated with ADHD
ADHD = Classified as
1) Inattentive
2) Hyperactive (overly active + impulsive)
3) Both = MOST COMMON**
ADHD INATTENTIVE SYMPTOMS (9)
⦁ Easily distracted; miss details, frequently switch from one activity to another, forget things. Easily distracted when multiple things are happening simultaneously
⦁ Difficulty maintaining focus on one task or learning something new
⦁ Failure to give close attention to detail; misses details, may make careless mistakes
⦁ Failure to listen** when spoken to directly, Failure to follow instructions
⦁ Difficulty organizing tasks and activities; difficulty completing assignments
⦁ Reluctance to engage in tasks that require sustained mental effort
⦁ Forget things or lose things needed to complete activities and tasks (pencil); (did my hw, but I lost it - very common with ADHD).
⦁ Forgetfulness in daily activities
⦁ Becomes bored with a task after a few minutes, unless doing something enjoyable
ADHD IMPULSIVE-HYPERACTIVITY SYMPTOMS (9)
⦁ Fidgetiness with hands and feet or squirms in seat
⦁ Constantly in motion; may often leave their seat - difficulty remaining seated in class
⦁ Has trouble sitting for long periods (ex: doing homework, dinner, school)
⦁ Difficulty doing quiet tasks or engaging in quiet activities
⦁ Often talks excessively or non-stop = Excessive talking and blurting out answers before questions have been completed
⦁ Excessive running or climbing in inappropriate situations; Dashes around, touching or playing with everything in sight = Restlessness
⦁ Blurts out appropriate or inappropriate comments; shows unrestrained emotions
⦁ Is often “on-the-go” or acts as if “driven by a motor”
⦁ Difficulty awaiting turns (while waiting in line); Impatient
⦁ Interrupting and intruding on others; Interrupts the conversation or activities of others
MEDICAL EVALUATION FOR ADHD
- Parents + Teacher need to fill out form - such as the Vanderbilt form
- Refer for vision + hearing tests* - r/o that kid isn’t just having difficulty seeing or hearing at school
- Complete hx, ROS, and PE to rule out other causes / psych illnesses
- If history suggests, may consider the following
⦁ blood lead level
⦁ TSH
⦁ sleep study
⦁ neurology consult if concern for seizures or other neurologic disorder
Poor sleep quality can lead to ADHD-like symptoms or learning disabilities; so ask about snoring, look in mouth (tonsils), large neck, obesity, etc.
DIAGNOSIS + TREATMENT OF ADHD IN ADULTS
- diagnosis should be made by a mental health professional
- symptoms often continue into adulthood, and can have significant effects on social + occupational functioning
- same meds used for adults + kids with ADHD
often kids with ADHD are able to come off the med as an adult due to decrease in symptoms; unsure if changes in brain development or whether due to adaptation to ADHD over time
ADHD TREATMENT
1) BEHAVIOR MODIFICATION
Cognitive behavioral therapy is the FIRST LINE PSYCHOTHERAPY for patients with attention deficit hyperactivity disorder
⦁ CBT = often targeted at children. Focuses on teaching kids things like better time management and organizational skills (creating structured routines)
- Behavioral Therapy Treatment = has NOT been shown to reduce symptoms in the absence of a concurrent stimulant Rx for a patient that truly has a diagnosis of ADHD
- other alternative treatments, such as cognitive treatment, dietary modification and multivitamins have NOT been shown to be effective in controlled studies
2) SYMPATHOMIMETIC MEDICATIONS (STIMULANTS) = pharmacologic treatment of choice**
⦁ Methylphenidate (Ritalin / Concerta) ⦁ Amphetamine / Dextroamphetamine (Adderall) ⦁ Dexmethylphenidate (Focalin) ⦁ Dextroamphetamine (Dexedrine) ⦁ Lisdexamfetamine (Vyvanse)
Stimulant MOA = blocks dopamine + norepinephrine reuptake ==> increases release of dopamine + norepinephrine in extra-neuronal space
Stimulant Indications = ADHD, Narcolepsy, Excessive Daytime Sleepiness
Stimulant SE ⦁ Anxiety ⦁ Hypertension ⦁ Tachycardia ⦁ Weight loss (decreased appetite) ⦁ Growth delays ⦁ Addiction
Methylphenidate, dexmethylphenidate and amphetamines are equally effective
Have similar side effect profiles
- The fast release of dopamine causes euphoria and can be addictive (methamphetamine), which is why it is imperative to have a slow release of dopamine (ADHD meds)-> helps with focus and attention = what the ADHD stimulant meds do
Dose Titration: know that the initial dose is not necessarily the effective dose, so need to titrate up, and education patient/parents that drug won’t be effective until reach effective dose, but important to start on lower dose initially
- children < 6 = need short acting stimulant
- short acting stimulant can also be used to determine optimal dosing before switching to long acting agent
- long acting stimulant can be used in patients > 6; start at lowest dose, titrate up
3) NONSTIMULANTS
⦁ Atomoxetine (Strattera)
Nonstimulant MOA = SNeRI - selective norepinephrine reuptake inhibitor
- similar efficacy and side effect profile as stimulants, however, side effects occur less often and have a less addictive ability
- for children > 6
- may take 1-2 weeks before see effects*** (unlike stimulants - will know pretty quickly)
- also can’t take “pill holiday” with strattera the way you can with stimulants
- Similar efficacy and SE profile as stimulants, however, SE occur less often with Strattera, and there are less addictive properties
4) Adjunctive Medications
- Bupropion (Wellbutrin)
- Venlafaxine (Effexor)
- Guanfacine (Intuniv)
- Clonidine (Catapres)
Clonidine and guanfacine are α2 agonist medications that are used in combination with central nervous system stimulants for patients with ADHD
CRITERIA FOR INITIATION OF THERAPY
⦁ Complete diagnostic assessment that confirms ADHD
⦁ ≥ 6 years old
⦁ Parental consent
⦁ School is cooperative (if dosing during school hours)
⦁ No previous sensitivity to the chosen medication
⦁ Normal heart rate and BP
⦁ No history of seizure disorder (if so refer to neurology to treat ADHD too)
⦁ Does not have Tourette syndrome, Autism spectrum disorder, anxiety disorder, or substance abuse among household members
if there is a hx of substance abuse in household members, can prescribe a non-stimulant therapy
PRETREATMENT WORK UP
o need a comprehensive medical evaluation (above info) + EKG to r/o arrhythmia
o document pretreatment height / weight / BP / HR
o document the presence of any of the following symptoms PRIOR to treatment
⦁ general appetite
⦁ sleep pattern
⦁ headaches
⦁ abdominal pain
o assess for substance use or abuse
⦁ need treatment for this before starting ADHD meds
EVALUATION AT EACH FOLLOW-UP ⦁ Decreased appetite*** ⦁ Poor growth*** (take summer drug holidays) ⦁ Dizziness (monitor BP) ⦁ Insomnia/Nightmares ⦁ Mood lability (can occur when drug is wearing off - consider switching to longer acting or increasing to BID or TID) ⦁ Rebound ⦁ Tics ⦁ Psychosis ⦁ Diversion and misuse
REASONS FOR TREATMENT FAILURE
- not sticking to medication regimen
- possibility of medication diversion (giving it to another person - selling it)
- are treatment goals / expectations realistic?
- is there a comorbid psychiatric diagnosis?
o Can try another stimulant medication
o if pt fails multiple stimulants or experiences intolerable side effects = try Atomoxetine (Strattera) or a centrally-acting alpha-2 adrenergic (Clonodine - Cataprex) (Guanfacine - Tenex)
DRUG HOLIDAYS
- discontinuation of stimulant medication on weekends or during the summer
- decide on a case by case basis
- not an option for atomoxetine (strattera) or alpha-2 adrenergic agonists because of the extended half life**
MAINTENANCE OF THERAPY
- once on a stable dose - follow up in office every 3-6 months
- continue to monitor weight / BP / HR (SE of decreased appetite, hypertension, tachycardia)
TERMINATION OF THERAPY
- May abruptly discontinue stimulants or atomoxetine (Strattera)***
- for alpha-2 adrenergic agonists + TCAs = should taper off over several weeks*
both Ritalin + Adderall can cause anxiety, weight loss, psychosis and heart problems in at risk pts. High potential for addiction and abuse
DEXTROAMPHETAMINE (DEXEDRINE)
- previously used for OTC diet pill
- among the most effective treatments for ADHD***
- sudden death in ppl that have heart problems or cardiac defects (like ritalin + adderall)
LISDEXAMFETAMINE (VYVANSE)
- is converted to dextroamphetamine after oral ingestion
- is less addictive*** but is still a schedule II drug like rest
- amphetamines cause release of catecholamines (primarily dopamine + NE) from their storage sites in presynaptic nerve terminals
ATOMOXETINE (STRATTERA)
- non-stimulant - was initially the only approved non-stimulant treatment until Intuniv
- non-stimulant - so DOESN’T WORK ON DOPAMINE, only works on NE*** - but therefore also why its less effective than a stimulant
- was initially tested for depression, but didn’t do much
**BBW - INCREASED RISK OF SUICIDAL BEHAVIOR IN PTS < 25 **
- may not be as effective as stimulant meds
- is expensive
Strattera - SE
⦁ dry mouth, insomnia, nausea, decreased appetite, constipation, decreased libido/ED, urinary hesitancy, dizziness, sweating
- RISK OF SUICIDAL IDEATION IN CHILDREN AND ADOLESCENTS*
- so need to weight risk vs benefits, and should be monitored closely for suicidal thinking and behavior
- families/caregivers should be advised of the need for close observation + communication with the provider
GUANFACINE (INTUNIV)
- alpha-2 adrenergic agonist - antihypertensive
- but also approved for treatment of ADHD
***So if patient has ADHD + Hypertension = give Guanfacine (Intuniv)
SE of Guanfacine = can become HYPOTENSIVE**
**Caution with KIDNEY OR LIVER DISEASE **
BUPROPION (WELLBUTRIN)
- alternative treatment for ADHD (as well an antidepressant and to quit smoking) = miscellaneous antidepressant
- SE = anxiety + insomnia
- DON’T give in bulimics - can lower the seizure threshold
- can be used as add on therapy with SSRI to prevent sexual SE
- increases dopamine
ANOREXIA NERVOSA
⦁ Very low weight (< 85% of normal body weight)
⦁ fear of gaining weight
⦁ distorted view of body
- Refusal to maintain a minimally normally body weight - fueling a relentless desire for thinness
- Morbid fear of fatness or gaining weight, even though the patient is underweight
- Depression is the most common psychological disease that coexists with anorexia nervosa.
2 types = Restrictive and Binge / Purge
MC age of onset = mid teens
90% of patients = Women
60% = 15-24y/o
Frequently seen in athletes, dancers, or other conditions requiring thinness
60% incidence of depression
CLINICAL MANIFESTATIONS
- Exhibits behaviors targeted at maintaining a low weight or certain body image
- Excess water intake, food-related obsessions (hoarding, collecting)
RESTRICTIVE TYPE = reduced calorie intake, dieting, fasting, excessive exercise, diet pills
BINGE/PURGE TYPE = primarily engages in self-induced vomiting, diuretic / laxative / enema use
binge/purge anorexia vs bulimia = For those with binge-purge anorexia, what they are doing results in a net intake lower than their output for long enough to become, or maintain, a too-low weight (underweight). For those with bulimia, the net input is enough to maintain or gain weight (normal weight or overweight)
- so people can start out with bulimia and end up with anorexia over time…or vice versa
SIGNS/SYMPTOMS ⦁ dry skin ⦁ cold intolerance / hypothermia (hypothyroidism) ⦁ blue hands / feet ⦁ constipation ⦁ bloating ⦁ delayed puberty ⦁ primary or secondary amenorrhea ⦁ fainting ⦁ orthostatic hypotension ⦁ lanugo hair ⦁ scalp hair loss ⦁ early satiety ⦁ weakness / fatigue ⦁ short stature ⦁ osteopenia / osteoporosis ⦁ breast atrophy ⦁ atrophic vaginitis ⦁ pitting edema ⦁ cardiac murmurs / sinus bradycardia
Decreased bone density due to decreased estrogen levels and
DIAGNOSIS
- BMI = 17.5 kg or weight < 85% of ideal weight
mild anorexia = BMI > 17
moderate anorexia = BMI between 16-17
severe anorexia = BMI between 15-16
extreme anorexia = BMI < 15
PHYSICAL EXAM
- emaciation (abnormally thin / weak)
- hypotension
- bradycardia
- skin / hair changes (ex: lanugo - fine hairs), dry skin, brittle hair
- salivary gland hypertrophy
- amenorrhea (no periods)
- arrhythmias
- osteoporosis
Metatarsal stress fractures are the most common type of fracture seen in patients with severe anorexia nervosa.
o Vital signs - include Orthostatic vitals
o Skin + Extremity evaluation =dryness, bruising, lanugo
o Cardiac Exam = Bradycardia, Arrhythmia, MVP** (heart muscle shrinks but the valves don’t)
o Abdominal Exam
o Neuro Exam - evaluate for other causes of weight loss or vomiting (brain tumor)
LABS
- leukopenia (decreased WBC count)
- anemia
- hypokalemia***
- hyponatremia
- hypochloridemia
- HYPERCAROTENEMIA**
- HYPERCHOLESTEROLEMIA**
- increased BUN (dehydration), decreased GFR
- hypothyroidism
- low levels of FSH, LH, TSH, and prolactin
- metabolic alkalosis –> ketonuria***
due to impaired liver functions, there could be hypercholesterolemia and hypercarotenemia.
Individuals suffering from anorexia nervosa tend to bleed and bruise more easily due to lower levels of platelets.
low creatinine level is seen in individuals suffering from anorexia nervosa due to loss of muscle mass.
TREATMENT
o medical stabilization: hospitalization if < 75% of ideal body weight, or if patients have medical complications; electrolyte imbalances may lead to cardiac abnormalities, dehydration, arrested growth/development, etc
Psychotherapy and nutritional rehabilitation are the first line treatments for anorexia nervosa.
o Psychotherapy = CBT, supervised meals, weight monitoring
o Pharmacotherapy: if depressed = SSRIs, or atypical antipsychotics - Olanzapine (Zyprexa) - (may also help with weight gain)
o Nutrition
- Goal = to regain 90-92% of ideal body weight
- Inpatient treatment varies by facility
+ oral liquid nutrition
+ nasogastric tube feedings
+ gradual caloric increase with “regular” food - but take it easy during first 2 weeks - so don’t get heart failure + pitting edema
ANOREXIA OUTCOME
o 50% = good outcome - return of menses + weight gain
o 25% = intermediate outcome - some weight regained
o 25% = poor outcome
⦁ associated with later age of onset
⦁ longer duration of illness
⦁ lower minimal weight
⦁ Overall mortality rate = 6.6%. 1/5 anorexia deaths are due to suicide
SUMMARY
Anorexia nervosa is an eating disorder characterized by a low weight, fear of gaining weight, a strong desire to be thin, and food restriction. Many people with anorexia see themselves as overweight even though they are underweight. If asked they usually deny they have a problem with low weight. Often they weigh themselves frequently, eat only small amounts, and only eat certain foods. Some will exercise excessively, force themselves to vomit, or use laxatives to produce weight loss. Complications may include osteoporosis, infertility and heart damage, among others. Women will often stop having menstrual periods.
BULIMIA NERVOSA
Bulimia patients (vs anorexia) = patients with bulimia have NORMAL WEIGHT or are OVERWEIGHT
- more common in females
- average onset = late teens
- concerned about body image
- 2 types: Purging and Non-Purging
ASSOCIATED WITH
⦁ OCD
⦁ Depression
⦁ Anxiety
EPIDEMIOLOGY
- occurs in 1-5% of high school girls
- occurs in as high as 10% of college women
Typically occurs in young girls with low self-esteem and who have a strong desire for control
- Are often fixated on food (amount and calorie count)
DSM IV CRITERIA FOR BULIMIA / clinical manifestations
1) Recurrent BINGE EATING: an episode of binge eating is characterized by BOTH of the following
⦁ Recurrent episodes of eating a large amount of food in a small amount of time (2hrs) = (larger amount of food than what most individuals would eat in a similar period of time)
⦁ A sense of a lack of control over eating during the episode
- **Occurs at least weekly x 3 months
2) Recurrent inappropriate COMPENSATORY BEHAVIORS to prevent weight gain
o Purging Type
⦁ self-induced vomiting
⦁ misuse of laxatives, diuretics, enemas, other meds
o Non-Purging Type ⦁ reduced calorie intake ⦁ dieting ⦁ fasting ⦁ excessive exercise ⦁ diet pills / stimulants
3) The binge eating + inappropriate compensatory behaviors both occur, on average, at least 1x per week x 3 months
4) Self evaluation is influenced by body shape and weight
5) the disturbance does not occur exclusively during periods of anorexia nervosa
Usually starts out with them making an unrealistic goal (ex: score 100% on exam) - then goal is not met –> binge eat –> compensatory mechanism to fix / control the binge phase
SIGNS/SYMPTOMS OF BULIMIA NERVOSA
⦁ mouth sores
⦁ pharyngeal trauma
⦁ dental caries / teeth pitting / enamel erosion*
⦁ halitosis
⦁ Russell’s Sign = Calluses on back of knuckles/fingers from sticking hand in mouth to gag
⦁ Heartburn / chest pain
⦁ Transmural esophageal rupture (boerhaave’s) or Mallory Weiss Syndrome from forceful / repetitive vomiting –> hematemesis
⦁ Impulsivity: stealing / alcohol abuse / drugs / tobacco
⦁ Muscle cramps
⦁ weakness
⦁ bloody diarrhea
⦁ bleeding or easy bruising
⦁ irregular periods - menstrual irregularities; may develop amenorrhea
⦁ fainting
⦁ swollen parotid glands** - Bilateral Parotid Sialadenosis - parotid gland hypertrophy
⦁ Hypotension (from dehydration)
⦁ Tachycardia
parotid gland hypertrophy - attempt to increase saliva release in order to buffer acidity from vomiting
-metabolic alkalosis from vomiting
HISTORY
⦁ maximum height + weight
⦁ exercise habits: intensity + hours/week
⦁ stress levels
⦁ habits + behaviors: smoking / alcohol / drugs / sexual activity
⦁ eating attitudes + behaviors
⦁ ROS (review of systems)
PHYSICAL EXAM - BULIMIA
All previous elements +
⦁ Parotid Gland Hypertrophy (if purging type)
⦁ Erosion of teeth enamel (caries) (if purging type)
LABS
- metabolic alkalosis from vomiting*****
- may have hypokalemia (from vomiting)
- may have hypomagnesemia (from vomiting)
- electrolyte imbalance may lead to cardiac arrhythmias
Low levels of Na, K, Mg, Ca, Phosphate
***Biggest concern = HYPOKALEMIA –> can lead to muscle weakness and cardiac arrhythmias –> death
*****AT RISK FOR DEVELOPING DIABETES - purging / food restriction –> starvation state of the body’s cells. unable to process glucose –> further cell starvation
TREATMENT FOR BULIMIA
o CBT** is effective! (not very effective with anorexia, but IS effective for bulimia)
o Pharmacotherapy = high success rate (unlike anorexia)
⦁ SSRIs** = 1st line tx - Fluoxetine (Prozac) - up to 67% reduction in binge eating, and 56% reduction in vomiting - has been shown to reduce binge-purge cycle, but may have CV SE if electrolyte abnormalities are present
⦁ TCAs
⦁ Topiramate (Topamax) - reduced binge eating by 94% and average weight loss of 6.2 kg (seizure med that is also used to treat migraines, and now bulimia)
⦁ Ondansetron (Zofran) - 24mg/day (often food is associated with vomiting - helps prevent nausea/urge to throw up after - Sublingual available - Dwight prefers this)
**do NOT give Wellbutrin (Bupropion) = (miscellaneous antidepressant) - can lower seizure threshold in bulimics
CONVERSION DISORDER
FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER
Neurological dysfunction that is suggestive of a physical disorder, BUT CANNOT CLINICALLY BE EXPLAINED
- cannot be explained by neurological pathophysiology
- physical symptoms that suggest neurological problems**
- sensory impairment: any modality
⦁ paresthesias
⦁ blindness
⦁ paralysis - SUDDEN onset
- SUDDEN termination
- SUDDEN reappearance
Conversion Disorder
- 2-10x more common in women
- age of onset = late childhood to early adulthood (rarely before 10, rarely after 35)
- onset is acute or sudden; symptoms remit after about 2 weeks, but recur about 25% of the time
- mostly affects women, but also affects men in combat
- often misdiagnosed
**Conversion disorder is more common in:
⦁ rural areas
⦁ lower SES
⦁ lower educational levels
“LA BELLE INDIFFERENCE” = a condition in which the person is UNCONCERNED with symptoms caused by a conversion disorder
EXAMPLE OF LA BELLE INDIFFERENCE = A middle-aged woman was referred to the psychiatric emergency room when a rather thorough medical examination could not explain the sudden onset of a complete paralysis below the waist. Additionally, the resident was concerned because her “affect” was rather strange. It seems that, despite what one might normally consider a rather devastatingly traumatic event–the loss of one’s ability to walk or to experience any sensation below the waist–the patient was laughing and joking with the medical resident.
6 CRITERIA FOR CONVERSION DISORDER
1) one or more symptoms or deficits affecting voluntary motor or sensory function that suggests a Neurological or other General Medical Condition
2) Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors
3) the symptom or deficit is not intentionally feigned (not factitious or malingering disorder)
4) the symptom or deficit cannot be fully explained by a general medical condition or by the direct effects of a substance
5) the symptom/deficit causes clinically significant distress or impairment in functioning
6) the symptom or deficit is not limited to pain or sexual dysfunction; does not occur exclusively during course of Somatization Disorder, and is not better accounted for by another mental disorder
CONVERSION DISORDER = severe physical dysfunctioning (paralysis, blindness, etc) without corresponding physical pathology
- affected people are genuinely unaware that they can function normally
- may coincide with other problems, especially somatization disorder
- most prevalent in low SES groups, women, and men under extreme stress (soldiers)
Conversion disorder is a condition where a person loses bodily functions due to excess stress, falls under the scope of somatic symptom disorder.
CAUSES = life stresses or psychological conflict –> incapactiating symptoms
Symptoms may be exaggerated and irrational for us, but they are REAL for the patient
- symptoms cause significant distress or impairment
SYMPTOMS ARE NOT INTENTIONALLY PRODUCED OR FEIGNED
**(NOT due to malingering)**
Patients often have depression, anxiety, schizophrenia or personality disorders
CLINICAL MANIFESTATIONS
- symptoms tend to be episodic and may recur during times of stress
MC in females
Onset = usually in adolescence or young adulthood
o MOTOR DYSFUNCTION ⦁ Paralysis***** ⦁ Aphonia ⦁ Mutism***** ⦁ Seizures ⦁ Gait abnormalities ⦁ Involuntary movements ⦁ Tics ⦁ Weakness ⦁ Swallowing
o SENSORY DYSFUNCTION ⦁ Blindness***** ⦁ Anesthesia ⦁ Paresthesias ⦁ Visual changes ⦁ Deafness
o Patients often have depression, anxiety, schizophrenia or personality disorders**
TREATMENT
⦁ Psychotherapy
- Behavioral therapy = TREATMENT OF CHOICE***
CLUSTER A PERSONALITY DISORDERS
“WEIRD”
⦁ PARANOID - “accusatory”
⦁ SCHIZOID - “aloof”
⦁ SCHIZOTYPAL - “awkward”
- SOCIAL DETACHMENT with unusual behaviors
- WEIRD, ODD, ECCENTRIC BEHAVIOR
"weird" = cluster A "wild" = cluster B "worried" = cluster C
All Cluster A personality disorders are linked to higher rates of Schizophrenia
People with relatives of Schizophrenia are at higher risk for developing a Cluster A personality disorder (suggests a genetic link)
SCHIZOID PERSONALITY DISORDER (cluster A)
“ALOOF” = avoid social interaction because they simply aren’t interested in getting to know others
- Long pattern of VOLUNTARY SOCIAL WITHDRAWAL
- ANHEDONIC INTROVERSION (constricted affect)
Usually early childhood onset
- Loner
- “hermit like behavior” (reclusive)
- MC in Males
The diagnostic criteria for schizoid personality disorders include four of more of the following:
1) Does not desire or enjoys close relationships
2) Always chooses solitary activities
3) Little interest in sexual experiences
4) Takes pleasure in few, if any, activities
5) Lacks close friends
6) Appears indifferent to praise or criticism
7) Shows flattened affect, detachment, or emotional coldness
CLINICAL MANIFESTATIONS
⦁ Inability to form relationships
⦁ Lifelong pattern of social withdrawal
⦁ Anhedonic = appears indifferent to others; lack response to praise or criticism or feelings expressed by others
⦁ Prefers to be alone
⦁ Little enjoyment in close relationships or sex
⦁ Appears eccentric, isolated, or lonely
⦁ “cold” flattened affect, quiet, usually not sociable
MANAGEMENT
⦁ Psychotherapy = 1st line (individual or group)
⦁ Pharmacologic = antipsychotics** antidepressants or psychostimulants
Group therapy is a type of psychotherapy that is the first line treatment for schizoid personality disorder.
Schizoid - “aloof” - avoid social interaction because they aren’t interested in getting to know others. Results in isolation, like Paranoid, but because they want to be isolated, and not because other people isolate them due to their behavior. Schizoid = find less pleasure in physical contact - like sex or holding hands.
= far less likely to seek out relationships than the average person
- may also have a flat affect or emotional blunting- don’t show positive or negative emotions
Schizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency towards a solitary lifestyle, secretiveness, emotional coldness, and apathy. Affected individuals may simultaneously demonstrate a rich, elaborate and exclusively internal fantasy world.
- hardly ever diagnosed
- least commonly diagnosed personality disorder*
Schizoid personality disorder is the mildest form of the “schizo” disorders, in terms of how it affects their daily life.
Schizoid
PARANOID PERSONALITY DISORDER (cluster A)
- “ACCUSATORY”
- MC in males
- begins in early adulthood
- PERVASIVE PATTERN OF DISTRUST + SUSPICIOUSNESS OF OTHERS***
CLINICAL MANIFESTATIONS
⦁ Distrust + suspiciousness
⦁ Misinterprets the actions of others as Malevolent
⦁ Sees hidden messages
⦁ easily insulted
⦁ appears cold + serious
⦁ lack of interest in social relationships
⦁ bears grudges
⦁ doesn’t forgive
⦁ blames their problems on others
⦁ preoccupation with doubt regarding the loyalty of others*****
PROJECTION = Projection is the major defense mechanism seen in this PARANOID personality disorder, in which patients take an unacceptable internal impulse, wish, or desire and attributes it to an external source. For example, a man may think about cheating on his wife so he blames his wife for having an affair. Another example would be a boy who talks about his stuffed animal as having certain feelings, which are really what the boy feels. Projection is an immature defense mechanism and paranoia tends to result from the use of projection
- generally distrustful + suspicious of people
- Assumes others will disappoint them, manipulate them, and talk about them behind their back…
- Think excessively about whether or not they have the loyalty of their friends + family; these beliefs are so strong that they end up having a huge impact on the person’s behaviors
- They then react severely if they feel they have been lied to or slighted in any way
- Can result in them holding grudges for a long time - Can almost lead to a self-fulfilling prophecy. The strong reactions may lead to others actually talking about them behind their back
- Tend to have superficial relationships and be in a state of isolation since they’re so suspicious of others
Paranoid personality disorder is a mental disorder characterized by paranoia and a pervasive, long-standing suspiciousness and generalized mistrust of others. Individuals with this personality disorder may be hypersensitive, easily feel slighted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. Paranoid individuals are eager observers. They think they are in danger and look for signs and threats of that danger, potentially not appreciating other evidence.
There is a genetic association between paranoid personality disorder and schizophrenia.
People with paranoid personality disorder are typically difficult to treat because of the lack of trust that defines the disorder.
TREATMENT FOR PPD =
⦁ Psychotherapy - CBT, individual or group therapy = therapy of choice*****
⦁ Pharmacological treatment = low dose of antipsychotics if severe (Haldol) or Benzos (for anxiety / agitation) if necessary, SSRIs
Paranoid Personality Disorder vs Schizophrenia
- Schizophrenia = more paranoia than PPD, and delusions***
- NO PSYCHOSIS in paranoid personality disorder
- Also have the positive symptoms of hallucinations and racing thoughts
SCHIZOTYPAL PERSONALITY DISORDER (cluster A)
“AWKWARD”
“awkward” - engage in excessive magical thinking - think that 2 random events are linked - like waking up on left side of the bed means its going to rain, because that happened last time.
- Ideas of Reference - belief that everything, including innocuous events or coincidences in the world, directly relate to ones own destiny
Speak in overconfidence and self-centered way of speaking that leads to socially inappropriate actions that turn people off
- Poor at gauging other people’s perception of them;
- Also have few social relationships, like Schizoid, but unlike schizoid (don’t want to be social), schizotypals want to be social - have a strong desire for relationships, but have a hard time maintaining them
schizotypal want social interaction, but are too “weird”
Patients with schizotypal personality disorder usually want to have interpersonal relationships.
Unlike the other cluster A disorders, patients with schizotypal personality disorder experience perceptual and cognitive dysfunction
Patients with schizotypal personality disorder that have behaviors similar to schizophrenia are often treated with haloperidol, an antipsychotic medication
Patients with schizotypal personality disorder that have behaviors similar to obsessive-compulsive disorder are often treated with SSRIs
TREATMENT
1) Psychotherapy: CBT, individual or group therapy = treatment of choice**
2) Pharm therapy: low dose antipsychotics, antidepressants or benzos
SchizoiD = Distant SchizoTypal = magical Thinking
These patients often have BIZARRE ATTIRE, SPEECH AND BEHAVIOR. They may wear MISMATCHING CLOTHING and say UNUSUAL / MADE-UP WORDS. They often have IDEAS OF REFERENCE in which they interpret events that are completely unrelated as having specific meaning toward themselves. The treatment of choice, as with all personality disorders, is psychotherapy.
CLUSTER B PERSONALITY DISORDERS
“WILD”
⦁ ANTISOCIAL
⦁ BORDERLINE
⦁ HISTRIONIC
⦁ NARCISSISTIC
= Dramatic, WILD, Erratic, Impulsive, Emotional
Genetic relationship to mood disorders such as depression and bipolar disorder
These are the substance abuse disorders
ANTISOCIAL PERSONALITY DISORDER (cluster B)
Behaviors **Deviating sharply from the norms, values and laws of society
- Harmful or hostile to society
- May commit criminal acts with disregard to violation of laws
- May begin in childhood as conduct disorders, but MUST BE >/= 18 to diagnose
- 3x MC in Males
- have a total disregard for moral values and societal norms
- lack empathy and impulse control
- will hurt others to get ahead, show aggressive behaviors, or will break the law
- at times, earn the label sociopath or psychopath
- are often in prison and are drug users
- do not show remorse or guilt
- do not accept responsibility for the harm they have caused others
- can be superficially charming - often use this to manipulate others for their personal gain
FOR DIAGNOSIS
must be > 18 y/o
must have hx of conduct disorder
CLINICAL MANIFESTATIONS
⦁ Inability to conform to social norms - with disregard and violation of the rights of others
⦁ lack of empathy
⦁ pattern of criminal behavior
⦁ shows little anxiety
⦁ extremely manipulative, deceitful, impulsive, promiscuous, spouse/child abuse, lacks remorse, lies frequently, endangers others (ex: drunk-driving common)
Can be really CHARMING, and often use that to MANIPULATE others for their personal gain
Have a DISREGARD FOR MORAL VALUES + SOCIETAL NORMS
LITTLE EMPATHY and POOR IMPULSE CONTROL, making them more willing to hurt others if it helps them, making them prone to aggressive or unlawful behavior, making them a “sociopath” or “psychopath”
Over-represented in prison populations and have higher rates of substance abuse
Are charming - manipulate others for their personal gain, have no remorse or guilt
Antisocial personality disorder is characterized by disregard for and violation of the rights of others, criminality, and impulsivity.
AGGRESSIVE + UNLAWFUL BEHAVIOR
Don’t accept responsibility for any harm that they cause
Individuals MUST BE OVER 18 and may have a history of conduct disorder in order to meet diagnosis
Antisocial personality disorder is characterized by a pervasive pattern of disregard for, or violation of, the rights of others. An impoverished moral sense or conscience is often apparent, as well as a history of crime, legal problems, and/or impulsive and aggressive behavior
***After age 18, many of conduct disorder patients will meet criteria for diagnosis of antisocial personality disorder.
Patients have to be at least 18 years old to be diagnosed with antisocial personality disorder.
TREATMENT
⦁ Psychotherapy - establishing limits
- Pharmacologic treatment = NOT helpful
A history of preceding conduct disorder before the age of 18 is necessary to diagnose a patient with antisocial personality disorder.
BORDERLINE PERSONALITY DISORDER (cluster B)
Unstable, Unpredictable Mood + Affect
Unstable self image
Unstable relationships - will have intense + passionate relationships that quickly turn dramatic and sour over time
MC in Women
CLINICAL MANIFESTATIONS
⦁ Extreme pattern of instability in relationships, but cannot tolerate being alone
⦁ “Mood Swings”
⦁ Marked sensitivity to criticism + rejection (fear of abandonment)
⦁ “Black + White” thinking - think in extremes - all good or all bad, no middle ground
⦁ Impulsivity in self-damaging behaviors = suicide threats, self-mutilation, substance abuse, reckless driving, binge-eating, spending
Unstable moods - intense joy one minute to rage the next minute
Leads to intense relationships that become dramatic
“Stable Instability” because the only consistent thing is instability
TERRIFIED OF ABANDONMENT - will sometimes threaten suicide to prevent someone from leaving
SPLITTING is an ego defense mechanism seen commonly in patients with borderline personality disorder.
Borderline personality disorder is a personality disorder. The essential features include a pattern of impulsivity and unstable behaviors, unstable sense of self, and unstable emotions.. There may be uncontrollable anger and depression. There is often an extreme fear of abandonment, frequent dangerous behavior, a feeling of emptiness, and self-harm. Substance abuse, depression, and eating disorders are commonly associated with Borderline PD.
Patients with borderline personality disorder often have unstable moods and relationships, impulsivity, a sense of emptiness, self-mutilation, and suicidality.
TREATMENT
⦁ Psychotherapy: Dialectical, CBT, group therapy = treatment of choice***
⦁ Pharmacologic tx: short term low doses of antipsychotics, antidepressants or benzos
Dialectical behavior therapy = FIRST LINE** psychotherapy used in the management of patients with borderline personality disorder.
DIALECTICAL BEHAVIORAL THERAPY = targets specific thoughts / behaviors
HISTRIONIC PERSONALITY DISORDER (cluster B)
attention seeking + excessive emotions
- starts by early adulthood
MC seen in women
Someone with histrionic personality disorder is often described as very emotional, attention seeking, and sexually provocative.
- OVERLY EMOTIONAL, DRAMATIC, SEDUCTIVE
- ” Attention-seeking”
- Manipulate others to draw attention - like being overly flirtations and telling over-dramatic stories
CLINICAL MANIFESTATIONS
⦁ Self-absorbed
⦁ “temper tantrums”
⦁ efforts to draw attention to themselves with the need to be the center of attention
⦁ often inappropriate, sexually provocative, seductive with shallow or exaggerated emotions
⦁ seek reassurance + praise often
⦁ **may believe their relationships are more intimate than they actually are**
⦁ can be suggestible = easily influenced by others or circumstances
May act inappropriately flirtatious or tell overly dramatic stories to remain center of attention. Result in superficial relationships with lots of people, but few solid friends, because people tend to view them as shallow and egocentric
- Superficial relationships: lots of acquaintances and few deep relationships
- viewed as shallow, flighty, and egocentric
Patients with histrionic personality disorder often show a tendency towards instant gratification, and are highly suggestible.
Histrionic personality disorder is characterized by excessive attention-seeking behavior.
TREATMENT
⦁ Psychotherapy - CBT, individual or group therapy = treatment of choice***
NARCISSISTIC PERSONALITY DISORDER (cluster B)
Grandiose, often excessive sense of self-importance - but needs praise and admiration
MC in Males
CLINICAL MANIFESTATIONS
⦁ Inflated self-image - considers themselves special, entitled, requires extra special attention, BUT they have a fragile self-esteem
⦁ Occupied with fantasies, jealousy of others, believes others are envious of them, has difficulty with the aging process
⦁ Reacts to rejection / criticism with rage
⦁ Often becomes depressed
⦁ Lacks empathy for others
grandiose self image - think they’re more attractive/intelligent/talented than they are
Believe they are so special, so believe they deserve the best of everything
Think their ideas are the best, and other people should always believe so
Fragile self-esteem, however, that is vulnerable to the slightest criticism but lash out if they feel slighted
Pretentious, self-centered, entitled
Often lack empathy and are oblivious to other’s feelings.
A person who has narcissistic personality disorder can be described as being very competitive, and reacts poorly to criticism.
A patient with narcissistic personality disorder is characterized by grandiose ideation, a sense of entitlement, lack of empathy for others, and requirement for excessive admiration.
Narcissistic personality disorder is a personality disorder in which a person is excessively preoccupied with personal adequacy, power, prestige and vanity, mentally unable to see the destructive damage they are causing to themselves and often others
Narcissistic personality disorder is included in cluster B, and is characterized by lack of empathy for others but excessive requirement for admiration.
TREATMENT
⦁ Psychotherapy - individual or group therapy = treatment of choice***
A patient with a personality change after head trauma or substance abuse cannot be said to have narcissistic personality disorder.
CLUSTER C PERSONALITY DISORDERS
“WORRIED”
⦁ AVOIDANT - “cowardly”
⦁ DEPENDENT - “clingy”
⦁ OBSESSIVE-COMPULSIVE PERSONALITY DISORDER - “compulsive”
anxious or fearful
“worried”
- all have a genetic association with anxiety disorders
Anxiety disorders have a genetic relationship with avoidant, obsessive-compulsive, and dependent personality disorders (cluster C).
The non-medical treatments often used in patients with cluster C personality disorders are social skill training, anxiety management, and group therapy.
AVOIDANT PERSONALITY DISORDER (cluster C)
- Desires relationships but avoids them due to “inferiority complex”
- Intense feelings of inadequacy, sensitive to criticism, fears rejection / humiliation
- Timid, shy, lacks confidence
“cowardly” - shy / timid / socially inhibited
- extremely low self esteem. See themselves as inadequate, incapable, undesirable
- Want close relationships, but avoid social situations - rarely take social risks => makes it hard for them to meet new people
- Hypersensitive to negative feedback and rejection –> become even more withdrawn when that happens
don’t date, don’t get out much - afraid of being seen as inadequate, fear of social situations, social phobia** - stay in house and don’t leave
Unlike schizoid personality disorder, patients with avoidant personality disorder (do/do not) do desire relationships with others.
Avoidant personality disorder is characterized by social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Some overlap with avoidant personality and social phobias, however, social phobias = anxiety in specific situations such as public speaking or dancing in public
While avoidant personality = anxiety in more general situations
A person who avoids social interaction due to fear of being humiliated or rejected likely has avoidant personality disorder.
A child who has grown up with anxiety disorders can develop avoidant personality disorder, withdrawing from social situations in their future.
Avoidant personality disorder is a cluster C personality disorder recognized in the DSM handbook as afflicting persons when they display a pervasive pattern of social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation, and avoidance of social interaction despite a strong desire to be close to others. Individuals afflicted with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others
MANAGEMENT
⦁ Psychotherapy = social training, CBT or group therapy
⦁ Pharmacotherapy = may try beta blockers for anxiety or SSRIs for depression
DEPENDENT PERSONALITY DISORDER (cluster C)
- Dependent, Submissive behavior
- “needy + clingy”
- Constantly needs to be reassured
- Relies on others to make decisions / emotional support
- Will not initiate things
- Intense discomfort when alone
- May volunteer for unpleasant tasks
“clingy” - intense fear of separation and rejection.
Overly depend or “cling” to relationship.
Lack self-confidence, and can’t adequately care for themselves. Difficult to make simple decisions, and become desperate and hold on to people who can completely take care of them.
Often get trapped in abusive relationships
difficulty making everyday decisions with an excessive amount of advice and reassurance from others, have a hard time being assertive, will do things they don’t want to do to avoid criticism, always in relationships
Dependent personality disorder is a personality disorder that is characterized by a pervasive psychological dependence on other people. This personality disorder is a long-term (chronic) condition in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence.
Patients with dependent personality disorder are characterized as submissive and clingy with low self-confidence, and often get stuck in abusive relationships.
MANAGEMENT
⦁ Psychotherapy - behavioral + group therapy
⦁ Pharmacotherapy - may try anxiolytics or antidepressants may be used in some cases for symptomatic control
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (cluster C)
PERFECTIONISTS who require a great deal of Order + Control
- rigid adherence to routine = rules, lists, details
- inflexible, stubborn, lacks spontaneity
- any change in their routine may lead to extreme anxiety
- often makes moral judgment on others
This condition is more common in first born males (i.e., oldest brother), who had a harsh discipline upbringing (i.e., his father working in the army).
- Preoccupied with minute details - may find it difficult to finish projects, hesitates to delegate work to others, devotes themselves to their work
- May avoid intimacy
“compulsive” - obsessed with orderliness, perfectionism, having complete control: rules / details / schedules
- Often inflexible and are easily stressed
- Often inefficient because they spend so much time planning and worrying that they don’t get the task itself done.
- Very rigid moral beliefs and values.
- Stubborn
Overlap in symptoms with OCD (actions & thoughts).
OCD = anxiety disorder that revolves around repetition of ritualistic actions (checking door over and over again to make sure that it is locked)
Defense mechanism of UNDOING = This mechanism consists of performing the reverse of unacceptable behavior in an attempt to counteract it, such as repeated hand washing after shaking people’s hands or opening doors
Key difference = with OCD = person is Ego-Dystonic - meaning they wish they could stop, don’t like this about themselves. are aware that they have a problem.
With OCPD = Ego-Syntonic - happy with how they are and don’t want to change their behavior. Don’t think they have a problem.
Unlike in obsessive-compulsive disorder, the behavior of a person with obsessive-compulsive personality disorder IS consistent with their beliefs and attitudes.
Behaviors of people with obsessive-compulsive personality disorder are ego-SYNTONIC, in that the behaviors to deal with their obsessions are known and wanted by the person.
Obsessive-compulsive personality disorder (OCPD), also called anankastic personality disorder, is a personality disorder characterized by a general pattern of concern with orderliness, perfectionism, excessive attention to details, mental and interpersonal control, and a need for control over one’s environment, at the expense of flexibility, openness, and efficiency. Workaholism and miserliness are also seen often in those with this personality disorder. In contrast to OCD, the symptoms seen in OCPD, though they are repetitive, are not linked with repulsive thoughts, images, or urges. OCPD characteristics and behaviors are known as ego-syntonic, as persons with the disorder view them as suitable and correct.
MANAGEMENT
⦁ Psychotherapy
⦁ Pharmacotherapy = may try beta blockers for anxiety or SSRIs for depression
OBSESSIVE COMPULSIVE DISORDER (OCD)
Obsessive–compulsive disorder (OCD) is a mental disorder where people feel the need to check things repeatedly, perform certain routines repeatedly (called “rituals”), or have certain thoughts repeatedly.
- average onset = 19 y/o
- equally common in men + women
- Perfectionists who require a great deal of ORDER + CONTROL - rigid adherence to routine (rules, lists, details, inflexible, stubborn, lacks spontaneity
- Any change in their routine may lead to extreme anxiety; often makes moral judgement on others
- Preoccupied with minute details - may find it difficult to finish projects, hesitates to delegate work to others, devotes themselves to work
- May avoid intimacy
People are unable to control either the thoughts or the activities. Common activities include hand washing, counting of things, and checking to see if a door is locked. Some may have difficulty throwing things out. These activities occur to such a degree that the person’s daily life is negatively affected. Often they take up more than an hour a day.
To diagnose obsessive-compulsive disorder, both obsessions and compulsions DO NOT have to be present.
Most adults realize that the behaviors do not make sense. The condition is associated with tics, anxiety disorder, and an increased risk of suicide.
In order to diagnose an individual with obsessive-compulsive disorder, the repetitive activities done in response to obsessions must be time-consuming.
Tourette syndrome is the most common comorbid psychiatric condition associated with OCD
Ego-dystonic behavior is seen in patients with obsessive-compulsive disorder.
Obsessive-compulsive disorder is characterized by recurring and intrusive thoughts, feelings, or sensations that cause distress and are partly relieved by performing certain repetitive actions.
Exposure and response prevention is a type of cognitive behavioral therapy that is first-line psychotherapy for patients with obsessive-compulsive disorder
- Characterized by intrusive thoughts that produce uneasiness, apprehension, fear or worry (obsessions), repetitive behaviors aimed at reducing the associated anxiety (compulsions), or a combination of such obsessions and compulsions
o OBSESSIONS
- recurrent + persistent thoughts, impulses, or images that cause distressing emotions, such as anxiety or disgust
o COMPULSIONS - repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession ⦁ cleaning ⦁ repeating ⦁ checking ⦁ ordering + arranging
TREATMENT
o Psychotherapy
⦁ 1st line = CBT - exposure + response prevention
o Medication
⦁ 1st line = SSRI (FLUVOXAMINE - LUVOX, fluoxetine, sertraline, paroxetine)
⦁ TCA = 2nd line (clomipramine - anafranil)
⦁ SNRI = 3rd line (venlafaxine)
First line treatment of choice is an SSRI such as fluvoxamine or fluoxetine.
SSRIs are used in conjunction with cognitive behavioral therapy as first-line treatment for the management of obsessive-compulsive disorder.
CLOMIPRAMINE (Anafranil) is the first-line TCA used for the management of obsessive-compulsive disorder.
- can use beta blockers for anxiety or SSRIs for depression
CYCLOTHYMIC DISORDER
Cyclothymia = milder form of bipolar II = have milder episodes of hypomania, and also have milder forms of depression - frequently switch between the two
a milder form of bipolar disorder where for AT LEAST 2 YEARS there are fluctuating periods of mild hypomanic and depressive symptoms.
Duration = AT LEAST 2 YEARS
- Does not meet DSM criteria for major depression, but still have hypomania (mild)
- Is considered to be one of the bipolar disorders, and is treated with same kinds of meds
- Defined by the presence of numerous periods of hypomania and depression, **Persisting for AT LEAST 2 YEARS
⦁ this is different from bipolar I and bipolar II - where there is a predominance of depressive symptoms
so in Cyclothymia = normal to hypomanic to normal to depressed (not high enough to be classified as manic, not low enough to be classified as major depression)
Similar to bipolar disorder II, but LESS SEVERE
Prolonged period of MILDER ELEVATIONS AND DEPRESSIONS IN MOOD
about 15% may eventually develop bipolar disorder
CLINICAL MANIFESTATIONS
- recurrent episodes of HYPOMANIC symptoms that don’t meet criteria for “hypomania” that cycles with RELATIVELY MILD DEPRESSIVE EPISODES for AT LEAST A 2 YEAR PERIOD in adults, and 1 YEAR in children
- these patients may have symptom free periods, however, those symptom-free periods don’t last longer than 2 months at any time
***manic or mixed episodes DO NOT OCCUR
TREATMENT
- similar to bipolar I = mood stabilizers and neuroleptics
MOOD STABILIZERS
⦁ Lithium
⦁ Anti-convulsants - Valproic Acid, Carbamazepine
NEUROLEPTICS = anti-psychotics
TRICHOTILLOMANIA
Trichotillomania, also known as trichotillosis or hair pulling disorder, is an obsessive compulsive disorder characterized by the compulsive urge to pull out one’s hair, leading to hair loss and balding, distress, and social or functional impairment.
Trichotillomania patients often eat their own hair, and may thus present with trichobezoars (hairballs) in their intestines.
The body area most affected by trichotillomania is the scalp, but hair loss is significant over all other areas of the body as well.
Habit reversal therapy is a type of psychotherapy that trains people to identify and react to the impulses that lead to their repetitive behaviors.
Women suffer more from trichotillomania, an impulse control disorder that may be difficult to treat.
OTHER REPETITIVE BEHAVIORS
Dermatophagia, which involve picking or biting the inside of the mouth, the cheeks, and the lips, often appears alongside onychophagia, and onychotillomania.
People with excoriation disorder feels an irresistible urge to pick at their skin which can lead to skin lesions, infection, and scarring
OPPOSITIONAL DEFIANT DISORDER
WILLFUL DEFIANCE
- present > 6 months
- Persistent pattern of negative, hostile, + DEFIANT BEHAVIOR TOWARDS ADULTS
ODD = defiant behavior that is both persistent and willful
At least 6 months of the following 3 components
1) angry / irritable mood (often blames others for their misbehaviors, has negative attitudes, has anger / resentment) = emotional
2) argumentative / defiant behavior = behavioral
3) vindictiveness = cognitive
No association with psychosis
***May progress to conduct disorder (which can then progress to antisocial personality disorder)
ODD –> conduct disorder –> antisocial personality
Emotional / Behavioral / Cognitive disruption must persist >/= 6 months, and must disrupt social interactions (family / school / etc)
⦁ emotional dysregulation –> irritable and resentful towards others
⦁ behavioral dysregulation –> frequent arguments, angry outbursts, and dislikes authority (teachers)
⦁ cognitive dysregulation –> vindictive and spiteful - believe that others are to blame for their own behavior
- may deliberatively annoy their family or friends
- purposely defy anyone that tries to control their behavior
Oppositional defiant disorder is characterized by a pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness lasting at least 6 months. Cannot be due to substance abuse or a psychotic disorder
Presentation includes recurrent loss of temper, arguing, refusing to comply with rules, deliberately annoying others, blaming others for behavior, and resentfulness
ODD is often co-morbid with ADHD, and can sometimes lead to the development of conduct disorder. ADHD must first be ruled out in children with ODD, and treatment consists of therapy for the patient and parent management training
MANAGEMENT
⦁ Psychotherapy - behavioral therapy
CONDUCT DISORDER
WILLFUL AGGRESSION
- present > 12 months
Behaviors used to classify conduct disorder would fall into the 4 main categories of
(1) aggression toward people and animals
(2) destruction of property without aggression toward people or animals
(3) deceitfulness, lying, and theft
(4) serious violations of rules
Conduct disorder has a lot of overlap with ODD, but also has one key feature = aggressive behavior towards people and animals
- Such people may
⦁ violently destroy property
⦁ steal things
⦁ hurt pets - considered antisocial behaviors because they completely break the boundaries of social norms
- 2 types
⦁ childhood onset: < 10 y/o
⦁ adolescent onset = 10-18 - the earlier the onset of symptoms = the more severe the behavioral problems
NOT all patients with ODD will go on to develop conduct disorder, and not all patients with conduct disorder will go on to develop antisocial personality disorder
Individuals with a conduct disorder have numerous antisocial activities such as lying, stealing, running away, physical violence, sexually coercive behaviors, and destruction of property. Children and adolescence with conduct disorder will have defiant behavior toward everyone. In oppositional defiant disorder the poor behavior is directed toward authority figures.
Conduct disorder is characterized by physical aggression and kleptomania in a child. These behaviors are often referred to as “antisocial behaviors.” It is often seen as the precursor to antisocial personality disorder, which is not diagnosed until the individual is 18 years old
A 16 year old boy who started behaving very aggressively towards his parents after suffering head trauma CANNOT be said to have conduct disorder.
Patients have to be YOUNGER than the age of 18 for a diagnosis of conduct disorder to be made.
Conduct disorder < 18 > antisocial personality disorder
Patients under the age of 18 years with conduct disorder exhibit repetitive and pervasive behavior violating the basic rights of others or societal norms.
Conduct disorder is a psychological disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated. These behaviors are often referred to as “antisocial behaviors.” It is often seen as the precursor to antisocial personality disorder, which is not diagnosed until the individual is 18 years old
Physical aggression and Kleptomania are characteristic of conduct disorder. Have little regard for others’ bodies or property. Any other diagnosis would require additional symptoms and would be in addition to a diagnosis of conduct disorder.
MANAGEMENT
⦁ Cognitive behavioral therapy is the first line psychotherapy used in managing conduct disorder.
TOURETTE’S SYNDROME
ONSET
- usually in childhood (2-5 y/o)
- MC in boys
*** Associated with OCD + ADHD
CLINICAL MANIFESTATIONS = TICS
TIC = quick, non-rhythmic movements or vocalizations that happen over and over again. Are not caused by another disorder such as Huntington’s or substance abuse
1) MOTOR TICS*** of the face, head and neck
⦁ blinking
⦁ shrugging
⦁ head thrusting
⦁ sniffling
⦁ obscene gestures (copropraxia)
⦁ repeating motions of others (echopraxia)
2) VERBAL or PHONETIC TICS*** ⦁ grunts ⦁ throat clearing ⦁ obscene words (coprolalia) ⦁ repetitive phrases ⦁ repeating the words/phrases of others (echolalia)
3) SELF-MUTILATING TICS
⦁ hair pulling
⦁ nail biting
⦁ lip biting
- Abnormal because they occur in inappropriate situations
- May engage in repetitive behaviors such as clapping, grimacing or grunting, or even hidden behaviors such as moving the tongue
⦁ Simple Tics = usually shorter (milliseconds) such as blinking / clearing throat
⦁ Complex Tics = a bit longer (seconds / minute) and are a combination of tics such as shaking head + shrugging shoulders
DIAGNOSIS - Need a Tic + additional criteria ⦁ A) number of tics ⦁ B) duration of tics ⦁ C) age on onset
- For diagnosis of Tourette’s
⦁ A) need 2+ motor tics AND 1+ vocal tic (don’t have to happen at same time)
⦁ B) tics must persist for 1+ year
⦁ C) onset must be before 18
If < 1 year = diagnosed with Provisional Tic Disorder
TREATMENT
⦁ Habit reversal therapy / CBT = 1st line tx
- 50% have symptom resolution by 18 y/o
- Medications = usually only if severe
⦁ dopamine blocking agents (antipsychotics) = haloperidol, risperidone, fluphenazine, pimozide
Pimozide = only FDA approved drug for Tourette’s
⦁ alpha-adrenergics = clonidine, guanfacine (usually if in addition to ADHD) or strattera
In a patient with Tourette syndrome, it is important to avoid CNS stimulants that can further increase dopaminergic signaling
⦁ benzos = clonazepam (klonopin)
⦁ can also use botox
Tics tend to lessen when person is calm, so treating anxiety / depression can also help
PYROMANIA
- people who purposefully and repeatedly start fires
- unlike arsonists = are not motivated by destruction of property or political power
- simply driven by compulsion - feel a strong impulse to set fires
- often gives them relief and happiness when they set fires
- fixated by anything with fire = hang around fire stations, watch videos of fires, want to be firefighter
KLEPTOMANIA
- strong impulse to steal things
- don’t steal out of need, but theft is for pleasure and for relief of tension they get once they steal something
- often steal items that are of little value to them, or items that they could easily afford
- often associated with conduct disorder
GENERALIZED ANXIETY DISORDER
GAD = EXCESSIVE ANXIETY OR WORRY FOR
6+ MONTHS ABOUT VARIOUS ASPECTS OF LIFE
Excessive, persistent, and unreasonable anxiety about everyday things
Can range from mild (able to function socially and hold down a job) to severe (completely debilitated)
- feelings of anxiety may worsen or improve over time
GAD is not episodic (like panic disorder)
GAD is not situational (like phobias)
GAD is not focal
Associated with >/= 3 of the following symptoms ⦁ fatigue ⦁ restlessness ⦁ difficulty concentrating ⦁ muscle tension ⦁ sleep disturbance** (common - can have significant impact on physical well-being) ⦁ irritability ⦁ shakiness ⦁ headaches
= NOT due to medical illness
GAD = more common in FEMALES
onset of symptoms = usually in early 20’s
SIGNS/SYMPTOMS ⦁ can't relax ⦁ startle easily ⦁ have difficulty concentrating ⦁ trembling ⦁ irritability ⦁ sweating
- may have stomach pain from eating too much or not eating enough (due to anxiety)
Generalized anxiety disorder (GAD) involves persistent and excessive worry pertaining to multiple events or domains that continues for > 6 months
Anxiety is not related to a specific focus, but rather is generalized to most issues
GAD is the most common psychiatric illness seen by primary care providers.**
DSM-5 DIAGNOSTIC CRITERIA FOR GAD
o Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
o The individual finds it difficult to control the worry.
o The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children.
- present for 90+ days out of 180 days
- adults = 3+ symptoms
- children = 1+ symptom
⦁ Restlessness or feeling keyed up or on edge.
⦁ Being easily fatigued.
⦁ Difficulty concentrating or mind going blank.
⦁ Irritability.
⦁ Muscle tension
⦁ Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
EVERYDAY ANXIETY VS ANXIETY DISORDER
- Everyday Anxiety
⦁ worry about paying bills, landing a job, a romantic breakup, other important life events
⦁ embarrassment or self-consciousness in an uncomfortable or awkward social situation
⦁ nerves/sweating before a big test, business presentation, stage performance, etc.
⦁ realistic fear of a dangerous object, place or situation
⦁ anxiety, sadness or difficulty sleeping immediately after a traumatic event
- Anxiety Disorder
⦁ constant worry that causes significant distress + interferes with daily life
⦁ avoiding social situations for fear of being judged / embarrassed / humiliated
⦁ out of the blue panic attacks, preoccupation with the fear of having another panic attack
⦁ irrational fear or avoidance of an object / place / situation that poses little or not threat of danger
⦁ recurring nightmares / flashbacks / emotional numbing related to a traumatic event that occurred several months or years before
Anxiety is not related to a specific person, situation, or event in generalized anxiety disorder.
At least 80% of patients with GAD have had at least one other anxiety disorder in their lifetime.
Patients with GAD are at increased risk of developing other conditions such as depression and bipolar disorder.
CAUSE = uncertain, but thought to be a combination of genetic + environmental factors
GABA and serotonin levels are DECREASED in patients with generalized anxiety disorder.
⦁ MOST IMPORTANT = decreased GABA levels*****
do have decreased serotonin as well
Norepinephrine levels are INCREASED in patients with generalized anxiety disorder
GAD-7 scale = out of 21 points = 0 / 1 / 2 / 3 on 7 questions regarding feelings of anxiety in past 2 weeks
TREATMENT FOR GAD
- 1st line = Combo or Monotherapy of
⦁ Psychotherapy (CBT) - alone or with SSRI
⦁ SSRI: Paroxetine (Paxil), Sertraline (Zoloft), Escitalopram (Lexapro)
*****SSRI of choice = Paxil; sertraline is more activating - has more stimulation, which is not good for GAD…unless patient also has significant depression
⦁ SNRI = alternative to 1st line - Effexor (venlafaxine) or Duloxetine (Cymbalta)
SNRI of choice = Effexor
- 2nd line =
⦁ Buspirone (Buspar) - can be used solo or with SSRI
= stimulates serotonin receptors, and blocks dopamine receptors. May take several weeks to see clinical improvement - ** Buspirone does NOT cause sedation**
- SE = nausea, RLS, EPS, dizziness
⦁ Benzo’s (low dose)
- short half life = alprazolam (Xanax) (11.2 hrs) or lorazepam (Ativan) (12 hrs) - longer half life = diazepam (valium) (45-100 hrs) or flurazepam (dalmane) (74-90hrs)
Benzos = short term use only) - used in interim until SSRI takes effect or for acute exacerbations / anxiety attacks / panic attacks (not used long-term due to abuse potential)
⦁ TCAs
⦁ Beta-Blockers
⦁ Pregabalin (Lyrica)
SELECTIVE MUTISM
Selective mutism (SM), formerly called elective mutism, is best understood as a childhood anxiety disorder characterized by a child or adolescent’s inability to speak in one or more social settings (e.g., at school, in public places, with adults) despite being able to speak comfortably in other settings (e.g., at home with family).
Affected individuals understand language use and, although they have the physical and cognitive ability to speak, they demonstrate a persistent inability to speak in particular settings over a particular period of time due to anxiety
Selective mutism is a disorder in which an individual is not able to speak aloud in specific situations when there is an expectation of conversational speech.
Communicative language is generally intact in such individuals, although selective mutism can coexist with language and communication disorders.
Selective mutism can be accompanied by other anxiety disorders such as separation anxiety disorder, social anxiety disorder (formerly called social phobia), agoraphobia, and panic disorder, as well as by shyness and anxiety; however, it can also exist without other anxiety-related disorders.
Selective mutism is an anxiety disorder in which a person who is normally capable of speech does not speak in specific situations or to specific people.
Selective mutism usually co-exists with shyness or social anxiety.
People with selective mutism stay silent even when the consequences of their silence include shame, social ostracism or even punishment.
Most patients with selective mutism suffer from social anxiety and do not speak even when significant social or occupational dysfunction occurs as a result.
Selective mutism is an anxiety disorder in which a person who is normally capable of speech does not speak in specific situations or to specific people
TREATMENT
⦁ Fluoxetine / Prozac (SSRI) is the pharmacologic treatment that has shown efficacy to treat this type of anxiety disorder.
MALINGERING
INTENTIONAL FALSIFICATION OR EXAGGERATION OF SIGNS / SYMPTOMS OF MEDICAL OR PSYCHIATRIC ILLNESS
NOT a mental illness
The primary motivation of their actions is SECONDARY GAIN (financial gain - insurance money / lawsuits), food, shelter, avoidance of prison / school / work / military services / to obtain drugs (narcotics)
Both factitious disorder (munchausen’s) and malingering are associated with intentionally faking signs and symptoms. Difference = in malingering, they feign illness for secondary gain, whereas in factitious disorder, the primary motive is to “assume the sick role” and get sympathy
Malingering is fabricating or exaggerating the symptoms of mental or physical disorders for a variety of “secondary gain” motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy.
Failure to detect actual cases of malingering imposes a substantial economic burden on the health care system
False attribution of malingering imposes a substantial burden of suffering on a significant proportion of the patient population.
DYSTHYMIA
PERSISTENT DEPRESSIVE DISORDER
Dysthymia is a more chronic and milder form of depression that lasts at least two years.
Dysthymia, also called persistent depressive disorder, is a mood disorder consisting of the same cognitive and physical problems as in depression, but persisting for at least two years. Dysthymia is less acute and severe than major depressive disorder.
CHRONIC DEPRESSED MOOD > 2 YEARS IN ADULTS (> 1 year in children / adolescents)
*usually milder than major depression, but can include symptoms of chronic major depression
- no symptoms of hypomania, mania or psychotic features
- patients are usually able to function**
- may experience mild decreased productivity
MC IN WOMEN
- onset = begins MC in late teens / early adulthood
May progress over time to develop into MDD or bipolar disorder
CLINICAL MANIFESTATIONS
⦁ Generalized loss of interest, social withdrawal, PESSIMISM, decreased productivity
⦁ Chronic depressed mood > 2 years in adults (> 1 year in children / adolescents) for most of the day, more days than not. In that 2 year period, the patient is not symptom free for > 2 months at a time
- may say things like “I’ve always been this way”
At least 2 of the following conditions must be present:
1) Insomnia / hypersomnia
2) fatigue
3) low self-esteem
4) decreased appetite / overeating
5) hopelessness
6) poor concentration
7) indecisiveness
TREATMENT
⦁ SSRIs = 1st line tx
- similar to depression - psychotherapy = principal tx
⦁ SNRIs, Bupropion, TCAs, and in some cases, MAOIs = 2nd line tx
BODY DYSMORPHIC DISORDER
Type of Obsessive-Compulsive Disorder
- Excessive PREOCCUPATION THAT >/= 1 BODY PART IS DEFORMED, OR AN OVEREXAGGERATION OF A MINOR FLAW
Body dysmorphic disorder is a type of obsessive-compulsive disorder characterized by preoccupation with a minor or imagined defect in appearance, leading to significant emotional distress.
Someone experiencing body dysmorphic disorder ruminates over the perceived bodily defect for multiple hours everyday.
- this often causes a person to be ashamed or to feel self-conscious - causes functional impairment
Body dysmorphic disorder presents as a compulsion to normalize appearance of an otherwise unnoticeable flaw.
The perceived bodily defect in body dysmorphic disorder is typically on the nose, thighs, stomach, or skin.
o used to be a somatoform disorder in DSM III, but now categorized within Obsessive Compulsive spectrum
- Excessive concern with real or imagined defects in appearance, especially facial marks or features
- Person may commit repetitive acts in response to this preoccupation of physical flaw / defect
⦁ mirror checking / mirror fixation or mirror avoidance
⦁ skin picking
⦁ seeking reassurance - or mental acts
⦁ comparison to others
Suicidal ideation and suicidal behavior are common
- frequent visits to plastic surgeons
- culturally influenced, but not culture bound
- may be a symptom of a more pervasive disorder (Obsessive-compulsive or delusional disorder)
CHARACTERISTICS OF BODY DYSMORPHIC DISORDER
⦁ Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
⦁ The preoccupation causes clinically significant distress or impairment in functioning
⦁ The preoccupation is not better accounted for by another mental disorder
ASSOCIATIONS ⦁ Excessive checking/grooming ⦁ removal of mirrors ⦁ social isolation ⦁ surgical procedures ⦁ suicide
- likely greatly underdiagnosed
MC IN FEMALES
- often begins in teenage years
- patients may also have anxiety disorder or depression
Body dysmorphic disorder is often associated with social anxiety disorder in an individual who avoids the public in an attempt to hide flaws.
Body dysmorphic disorder can be mistaken for major depressive disorder or social phobia.
Body dysmorphic disorder is a mental disorder characterized by an obsessive preoccupation that some aspect of one’s own appearance is severely flawed and warrants exceptional measures to hide or fix it.
⦁ In BDD’s delusional variant, the flaw is imagined
⦁ If the flaw is actual, its importance is severely exaggerated
- Either way, one’s thoughts about it are pervasive and intrusive, occupying up to several hours a day. The DSM-5 categorizes BDD in the obsessive–compulsive spectrum, and distinguishes it from anorexia nervosa.
TREATMENT
⦁ Antidepressants = SSRIs (Prozac), TCAs (Clomipramine) - like 2nd line OCD tx
⦁ Psychotherapy
CBT = 1st line psychotherapy used for patients with body dysmorphic disorder.
EXCORIATION DISORDER
Excoriation disorder is repetitive picking, scratching, rubbing, digging, or squeezing of skin, resulting in visible damage and impairment in social functioning.
Excoriation disorder (skin picking disorder) is defined in the DSM-V as repetitive picking, scratching, rubbing, digging, or squeezing of skin, resulting in visible damage and impairment in social functioning. It is grouped with trichotillomania and body dysmorphic disorder.
Patients with excoriation disorder have polymorphic lesions of varying size and severity due to their own scratching by fingers, teeth, or sharp instruments.
Acute lesions may have a serosanguinous crust, and older, scarred and pigmented lesions are also present.
The excoriations can be made until they are deep below the skin and are at risk of infections and ulcerations. They are scattered symmetrically within reach of the hands, especially on the face. Patients may scratch normal skin or already existing minor skin lesions, such as this patient with her IV site, or insect bites, acne, or a mole. Psychiatric referral is strongly encouraged due to the high rate of comorbidities.
Excoriation disorder (also known as dermatillomania, skin-picking disorder, neurotic excoriation, acne excoriee, pathologic skin picking (PSP), compulsive skin picking (CSP) or psychogenic excoriation) is a mental disorder characterized by the repeated urge to pick at one’s own skin, often to the extent that damage is caused.
OBSESSIVE COMPULSIVE RELATED DISORDERS
⦁ OCD ⦁ Body Dysmorphic Disorder ⦁ Trichotillomania ⦁ Hoarding Disorder ⦁ Excoriation Disorder
SOMATOFORM DISORDERS
⦁ SOMATIC SYMPTOM DISORDER
⦁ Illness Anxiety Disorder (Hypochondriasis)
⦁ Conversion Disorder (Functional Neurological Symptom Disorder)
⦁ Factitious Disorder
⦁ Malingering
