Psychiatry Flashcards
Social (Pragmatic) Communication Disorder DSM-5
A. Persistent difficulties in social use of verbal and nonverbal communication - must have difficulties in all of following areas:
- In social communication (greeting people)
- Changing communication to match context (Using overly formal language)
- Following rules of conversation and storytelling
- Understanding what is not explicitly stated (making inferences)
B. The deficits result in functional limitations in effective communication, social participation
C. The onset of sx is in early developmental period but may not become fully manifest until social communication demands exceed limited capacities
Rare among children < 4
Autism spectrum disorder - DSM 5
A. Persistent deficits in social communication as manifested by deficits in:
1- Social-emotional reciprocity
2- Nonverbal communication
3- Developing, maintaining, & understanding relationships
B. Restricted, repetitive, patterns of behavior, interests, or activities as manifested by >2 following: [1] stereotyped or repetitive motor movements, [2] inflexible, [3] Restricted fixated interests [4] Hyper or hypoactive to sensory inputs
C. Sx must be present in early developmental period
D. Sx cause clinically significant impairment in social, occupational, or other areas of functioning
E. Rule out other disorders - social pragmatic communication disorder, ADD/ADHD
Three presentations of ADHD
[1] Inattention
[2] Hyperactivity and impulsivity
[3] Combined inattentive & hyperactive-impulse
Sx must be seen in two or more settings (home, work, school, friends, family)
Social (Pragmatic) Communication disorder - obvious deficits noted
Deficits seen in:
Greeting, sharing info
Tone modulation
Talking differently to adult than child
Speaking differently in a classroom than on playground
Avoiding use of overly formal language
Taking turns, inferences, idioms, humor, metaphors, multiple or abstract meanings
DSM 5 Dx ADHD
[1] INATTENTION -
SIX or more of following symptoms for > SIX months:
Fails to pay close attention to details, distracted, loses focus, difficulty with organization, dislikes tasks that require a lot of thinking, loses things, easily distracted, forgetful in ADLs
[2] HYPERACTIVITY AND IMPULSITIVITY
SIX or more of following symptoms for > SIX months:
Fidgets, difficulty remaining seated, child runs about, adults extremely restless, talks excessively, acts as if driven by motor, blurts out answers, interrupts
Note: 17+ YO only need 5 symptoms
Psychotic disorders - three groups
[1] Schizophrenia - recurring illness & prone to repeated psychotic episodes
[2] Psychotic mood disorders - mania and depression - schizoaffective disorder
[3] Psychosis a/w neurological condition (acute metabolic & toxic states = delirium - Addison’s, Cushing, Dementias (lewy body), folic acid deficiency, pancreatitis, stroke, lupus, temporal lobe epilepsy
Delusions: Definition
Fixed beliefs that are not amenable to change in light of conflicting evidence - content may include:
Persecutory: mafia out to get me
Referential: Gestures, comments, environmental cues are directed at oneself (that rock = sign for me from god)
Grandiose: Individual thinks have exceptional abilities, wealth or fame
Nihilistic: World will end
Somatic: Preocupation regarding health or organ function
Delusional jealousy: Spouse unfaithful
Erotomanic: Person of higher status is in love w/ individual
Hallucinations
Perception-like experiences that occur WITHOUT external stimulus - vivid & clear, NOT under voluntary control
Audio, visual, gustatory, tactile, olfactory
DSM 5 Delusional disorder
- The presence of one or more delusions with a duration of 1 month or longer.
- Criterion A for Schizophrenia not met
- Apart from the impact of the delusions or its ramifications, functioning
is not markedly impaired, and behavior is not obviously bizarre odd. - If manic or major depressive episodes - brief relative to the duration of the delusional periods.
- Many Specifiers – subtypes (grandiose, jealous, somatic) – involve situations that can occur in real life.
The DURATION of impairment is important
DSM 5 Dx Brief Psychotic disorder
Presence of one (or more) of the following symptoms. At least one of these must be from 1-2-3
1- Delusions
2 – Hallucinations
3 – Disorganized Speech
4 – Grossly disorganized or catatonic behavior
Duration of an episode of the disturbance is at least 1 day but less than 1 month with eventual full return to premorbid level of functioning
Disturbance not better explained by MDD or BD
Specify stressors, postpartum onset, with catatonia. Note severity
Positive psychotic symptoms
Changes in thoughts and feelings that are “added on” to a persons experience – Examples – paranoia, voices, hallucinations, disorganized speech.
Negative psychotic symptoms
Things “taken away” or reduced – motivation, intensity of emotions, social withdrawal, poverty of thought.
DSM 5 Schizophreniform Disorder
A. Two (or more) of the following, each present for a significant portion of time during a 1 month period ( or less if successfully treated). At least one of these must be 1-2-3. An episode of the disorder lasts at least 1 month but less than 6 months.
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms (diminished emotional expression, avolition -decrease in the motivation to initiate and perform self-directed purposeful activities. )
Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out
DSM 5 Schizophrenia
A. Two (or more) of the following, present > 1/2 time > 1 mo At least one of these must be 1-2 or 3
- Delusions
- Hallucinations
- Disorganized Speech
- Grossly disorganized or catatonic behavior
- Negative symptoms (diminished emotional expression)
B. Disturbance in the level of functioning in one or more major areas, such as work, interpersonal relationships, or self care, is markedly below the level achieved prior to the onset. If in childhood or adolescence there is a failure to achieve expected level of the above.
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms)
Positive Schizophrenic symptoms
Positive symptoms = symptoms inserted
Delusions and impaired thinking
Hallucinations
Confusion and impaired judgment
Severe anxiety, agitation, and emotional dysregulation
Negative Symptoms Schizophrenia
Negative sx = symptoms taken away….
Flat or blunted affect
Poverty of thought
Emptiness and anhedonia
Psychomotor retardation/inactivity
Blunting of perceptions (dull senses – pain)
DSM 5 Schizoaffective disorder
An uninterrupted period of illness during which there is a major mood episode (Major Depressive or Manic) concurrent with the Criterion A of Schizophrenia:
Two (or more) of the following, each present for a significant portion of time during a 1- month period (or less if successfully treated). At least one of these must be 1-2 or 3
- Delusions
- Hallucinations
- Disorganized Speech
- Grossly disorganized or catatonic behavior
- Negative symptoms (diminished emotional expression)
The delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness
Schizophrenia + Mood Disorder = Schizoaffective Disorder
Comparing Delusional disorder vs brief psychotic disorder, shizophreniform, schizophrenia and szhioaffective
Delusional disorder – 1 month or more – high functioning
Brief Psychotic Disorder – 1 day but less than 1 month. (positive
symptoms)
Schizophreniform – identical to schizophrenia but duration - at least 1 month but not > 6
Schizophrenia – 1 month of active symptoms and then at least 6 months that symptoms are still persistent (negative symptoms).
Schizoaffective Disorder – Schizophrenia with a persistent mood disorder. Simultaneously meeting the diagnostic criteria for schizophrenia and either bipolar disorder or major depressive disorder.
Schizophrenia vs delusional disorder
In a delusional disorder the content of the delusions involves events that may actually occur to some people in real life. Bizarre delusions (thought broadcasting, control) and hallucinations, disorganized speech, catatonic behavior, negative symptoms in Schizophrenia. Delusional disorder is usually circumscribed and schizophrenia is more global.
Schizophrenia vs Schizoaffective Disorder –
Schizophrenia and Schizoaffective Disorder – psychotic symptoms are the same. Schizoaffective Disorder has the mood component.
Schizophrenia vs. Schizophreniform Disorder –
Schizophrenia vs. Schizophreniform Disorder – Primary difference is that schizophrenia lasts for more than six months whereas in schizophreniform disorder the pathology has lasted less than six months.`
Schizophreniform Disorder vs. Brief Psychotic Disorder –
Schizophreniform Disorder vs. Brief Psychotic Disorder – Both refer to psychotic disorder of brief duration. Inclusion criteria are broader for brief psychotic disorder listing any one - delusions, hallucinations and disorganized speech vs two of five features Criterion A of schizophrenia. Schizophreniform disorder lasts a least a month and brief psychotic disorder lasts less than a month.
Symptoms of Mania
Persistent mood of euphoria (elevated or expansive mood)
Grandiosity or elevated self-esteem
Decreased need for sleep
Rapid or pressured speech
Racing thoughts
Distractibility
Increased activity or psychomotor agitation
Behavior that shows expansiveness (lacking restraint in emotional expression), Poor judgment (sexual promiscuity, gambling, buying sprees, giving away money).
Symptoms of Hypomania
Hypomania = milder than mania Increased energy Decreased need for sleep Talkative Elated, mildly grandiose Irritability
Symptoms of depression in BP disorder
Mood of sadness, despair, emptiness
Anhedonia
Low self-esteem
Apathy, low motivation, social withdrawal
Excessive emotional sensitivity
Negative, pessimistic thinking
Irritability and low frustration tolerance
Suicidal thoughts (passive or active)
Excessive guilt
Indecisiveness
Bipolar I vs Bipolar II
Bipolar I – For a diagnosis it is necessary to meet the criteria for a manic episode. Patients often do not see themselves as ill. Ave 18 yrs of age. Can happen throughout life cycle.
Bipolar II – For a diagnosis it is necessary to meet the criteria for a current or past hypomanic episode and the criteria for a current or past major depressive episode. Usually present during a depressed episode. Ave onset mid 20’s. First dx as depression. Depression more enduring and disabling over time.
Cyclothymia
Cyclothymia – hypomania with mild/moderate depression. Can convert to Bipolar I or II. Seen adolescents early adult. Children 6.5 yrs`
DSM 5 Bipoler I Disorder (Mania part)
A. Abnormally and persistently elevated, expansive, or irritable
mood, lasting at least 1 week and present most of the day, nearly everyday.
B. Three (or more) of the following need to be met:
- Inflated self-esteem
- Decreased need for sleep
- More talkative than usual
- Flight of ideas, racing thoughts
- Distractibility
- Inc in goal-directed activity
- Excessive involvement in pleasurable activities that have a high potential for painful consequences
DSM 5 Bipoler I Disorder (Depression part)
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) anhedonia
- Depressed mood
- Anhedonia
- Significant weight loss
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue
- Feelings of worthlessness, excessive guilt
- Can’t concentrate
- Recurrent thoughts of death
MDD DSM 5
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
- Depressed mood
- Anhedonia
- Weight loss or gain
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue
- Feelings of worthlessness, excessive guilt
- Can’t concentrate
- Recurrent thoughts of death
Persistent depressive disorder (Dysthymia)
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:
- Poor appetite or overeating
- Insomnia or hypersomnia.
- Low energy or fatigue.
- Low self esteem.
- Poor concentration or difficulty making decisions.
- Feeling of hopelessness.
C. During a 2-year period (1 year child/adolescents) of the disturbance the individual had never been without symptoms in Criteria A and B for more than 2 months at a time.
Note - Children and adolescents, mood can be irritable and duration must be at least 1 year.
PMDD DSM 5
In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve with a few days after the
onset of menses, and become minimal or absent in the week postmenses.
One or more of the following:
Affective lability – moody, sad, tearful
Irritability or anger – increased interpersonal conflicts
Depressed mood
Anxiety, tension or feelings of being on edge One or more of the following (total of 5):
Decreased interest – anhedonia
Subjective difficulty in concentration
Lethargy, lack of energy
Change in appetite, overeating, food cravings
Hypersomnia or insomnia
Feelings of being overwhelmed or out of control
Breast tenderness, swelling , joint or muscle pain, bloating or weight gain
The above cause distress or interfere with work, school, relationshipsv
Medications PMDD
SSRI -, Paxil, Zoloft
Disruptive Mood Dysregulation Disorder (DMDD)
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level (e.g., the child is older than you would expect to be having a temper tantrum).
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, friends).
Above present > 1 yr. No relief from sx > 3 mo. Present in 2 or more settings.
The diagnosis should not be made for the first time before age 6 years or after age 18. Age of onset of these symptoms must be before 10 years old.
DMDD Treatment
Psychotherapy - CBT
Parent training
CBT Two Tasks
[1] Cognitive restructuring - change thinking patterns
[2] Behavioral activation - patients learn to overcome obstacles to participating in enjoyable activities
CBT focuses on immediate present - what and how a person thinks more than why a person thinks that way. Focuses on specific problems. CBT is goal oriented.
DSM 5 Separation Anxiety Disorder
A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
- Distress when separation
- Persistent excessive worry about possible harm to major attachments
- Persistent excessive worry that event will lead to separation from major attachment
- Persistent refusal to go away from home, school, to work or elsewhere because of fear of separation
- Excessive fear of being alone without major attachment figure
- Persistent refusal to go to sleep without being near major attachment
- Repeat nightmares involving theme of separation
- Complaints of physical symptoms (HA, stomach ache, N/V)
B. The duration of sx is >4wk in children & >6 months in adults
C. Causes impairment in social, academic, occupational functioning
DSM 5 Selective Mutism
A. Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations
B. The disturbance interferes with educational or occupational achievement or with social communication
C. The duration of the disturbance is at least 1 month
D. The failure to speak is not attributable to lack of knowledge or comfort with ,
the spoken language required in the social situation.
Children speak at home but not out socially or school.
Excessive shyness, fear of social embarrassment, social isolation withdrawal, clinging.
DSM 5 Specific Phobia
A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response. In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
C. The phobic object or situation is avoided.
D. The fear or anxiety is out of proportion to the danger posed by the object.
E. The fear, anxiety, or avoidance is persistent lasting for 6 months or more. The fear causes distress or impairment
Treatment Specific Phobia
Exposure therapy - involves the exposure of the patient to the feared object in a safe setting. Small steps - Elevators – airplanes.
DSM 5 Social Anxiety Disorder
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. (being observed eating, giving a speech). With children should be in the peer setting.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (humiliating or embarrassing ; rejected by others).
C. The social situations almost always provoke fear or anxiety. – Children fear expressed by crying, tantrums, freezing, clinging, shrinking or failing to speak in social situations.
**The social situations are avoided or endured with intense fear or anxiety. Fear is out of proportion to actual threat posed. Lasts for 6 months or more. Median age 13 years old.
DSM 5 Panic Disorder
A. Recurrent, unexpected panic attacks.
A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during with time four (or more) of the following symptoms occur:
- Palpitations, pounding heart, or accelerated heart rate
- Sweating.
- Trembling or shaking.
- Sensations of shortness of breath or smothering.
- Feelings of choking.
- Chest pain or discomfort.
- Nausea, ABD pain
- Feeling dizzy, unsteady, light-headed or faint.
- Chills or heat sensations.
- Paresthesia’s (numbness or tingling sensations).
- Derealization (feelings of unreality) or depersonalizations (being detached from one self).
- Fear of losing control or “going crazy”
- Fear of dying.
Note the abrupt surge can occur from a calm state or an anxious state
B. At least one of the attacks have been followed by 1 month (or more) of one or both of the following.
- Persistent concern or worry about additional panic attacks or their consequences.
- A significant maladaptive change in behavior related to the attacks (avoidance).
DSM 5 Agoraphobia
A. Marked fear or anxiety about two (or more) of the following five situations:
- Using public transportation (care, bus, train, ship, planes)
- Being in open spaces (parking lots, supermarkets, bridges)
- Being in enclosed places (shops, theaters)
- Standing in line or being in a crowd
- Being outside of the home alone
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (incontinence).
C. Situations almost always provoke fear or anxiety. Actively avoided or require the presence of a companion. Fear is out of proportion to the actual danger Lasting for 6 months or more.
DSM 5 GAD
A. Excessive anxiety and worry, occurring more days than not for at least 6 months (work and school).
B. The individual finds it difficult to control the worry.
C. 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. (One item for children)
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Irritability.
- Muscle tension.
- Sleep disturbance (difficulty falling, staying asleep or restless, unsatisfying).
D. Causes significant distress or impairment in important area of functioning.
DSM 5 OCD
Obsessions as defined by:
1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
- The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action.
Compulsions as defined by:
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
- The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
ADRs anti-psychotics
EPS:
- Dystonic reactions
- Tardive dyskinesia
- Parkinsonism
NMS
NMS si/sx
Life-threatening disorder 2/2 D2 inhibition in basal ganglia
Mental status change
Muscle rigidity
Tremor
Autonomic instability (tachy, FEVER, diaphoresis)
NMS MC in young adults, occurs w/in 90 d of initiation or dose increase
Tx: stop offending agent, tx hyperthermia w/ cooling, dopamine agonists (bromocriptine, amandatine etc)
Olanzapine ADR
Metabolic syndrome - weight gain, DM
ADR clozapine
Agranulocytosis - monitor CBC
- Weekly from start to 6 months
- Q2 weeks from 6 to 12 months
- Monthly after 12 months
Look at ANC - stop or get consult if < 1000
Lithium - NEC
Ind: Bipolar d/o, acute mania
SE: Endocrine: Hypothyroidism, Dec Na, inc urination & thirst (must drink a ton a day), nephrogenic DI (kidneys insensitive to ADH) Neuro: seizures, HA, sedation Cardiac: Arrhythmias GI: N/V/D, weight gain
NARROW therapeutic index
Serotonin syndrome - causes,CP
Caused by giving two drugs w/ different MOA at raising 5HT levels - SSRI + MAOI = MC
CP: Tachycardia, HTN, AMS, restless, diaphoretic, tremulous, CLONUS, myolonus, hyper-reflexic - ALL JAZZED UP
Severe - seizures, coma, death
What happens if someon on MAOI eats tyramine-containing food?
HTN CRISIS!!!
Ex of MAOI - Phenelzine (Nardil)
Therefore must avoid fermented, cheese, wine, beer, aged foods, smoked meats, etc
First line tx bipolar d/o
Mood stabilizers - lithium is 1st line, also valproid acid, carbamazepine
2nd line - 2nd generation antipsychotics
**SSRIs may precipitate mania
Voyeuristic disorder
Sexual arousal from observing an unsuspecting nude or disrobing individual (often w/ binoculars)
Exhibitionistic disorder
Sexual arousal from exposure of one’s genitals to an unsuspecting person
Sexual masochism disorder
Sexual arousal from the act of being humiliated, beaten , bound, or made to suffer
Sexual sadism dosorder
Sexual arousal from the physical, or psychological suffering of another person
Treatment for paraphilic diosrders (sadism, masochism, exhibitionistic, voyeuristic, pedophilia)
Difficult to treat
Meds if a/w comorbid psych illness
Anti-androgens to decrease sex drive
CBT - used to disrupt learned patterns & modify behavior
Group therapy
12 step programs
Fetishistic disorder
Sexual arousal from either the use of nonliving objects (shoes) or non-genital body parts (feet)
Ex: Man being primarily aroused by women’s shoes causing significant distress and marital problems
Paraphilic disorders DSM-5 qualifications
Must be > 6 months
Sexual fantasies/desires must be acted on unless the desires alone are intense and recurrent and interfere with daily life
Somatic sx disorder
> or equal to 1 somatic sx (PREDOMINATELY PAIN) that are distressing with excessive thoughts, feelings, or behaviors related tot he somatic sx or associated health concerns
Somatic sx d/o vs conversion d/o: Patients express a lot of concern over their condition & chronically perseverate over it, whereas conversion disorder patients often have an abrupt onset of their neurological sx ( ex blindness) but not infrequently appear unconcerned
Sx > 6 months
Tx: Regularly scheduled visits with single primary care physician, who should MINIMIZE unnecessary medical workups and treatments
Conversion disorder - functional neurological symptom disorder
Patients “convert” psychological distress or conflicts to neurological sx
Pts with conversion disorder have at least one neurological sx (sensory or motor)
Cannot be fully explained by neurological condition
PT are often surprisingly calm and unconcerned when describing their sx
Ex = blindness, paralysis, weakness, mutism, seizures)
YOUNG WOMEN = MC
A/w with neurological depressive & anx d/o
Tx = education about the illness and CBT
Illness anxiety disorder
High level of anxiety about health, preoccupation with having or acquiring a serious illness. Present > 6 months. Not better explained by another mental disorder (such as somatic sx disorder)
Tx: Regularly scheduled visits to one primary care physician. CBT is most useful psychotherapy.
Factitious disorder
AKA Munchhausen syndrome
Patients INTENTIONALLY falsify medical or psychological signs or sx in order to assume the role of a sick patient
The ABSENCE of external rewards is a prominent feature of this disorder - akak the deceptive behavior is evident even in the absence of obvious external rewards (such as in malingering - where you falsify sx to get a shelter in ED, to avoid jail etc) - basically you’re just fucked up an want attention & sympathy from others
A/w personality disorders
Tx: - Gather collateral and confront in non-threatening manner - may just leave however & go to another hospital. Repeat and long term hospitalizations are not uncommon
Malingering
Intentional, CONSCIOUS reporting of physical or psychological sx in order to achieve personal gain
Common motivators = to stay out of jail (incarceritis), room and board, obtaining narcotics, receiving monetary compensation
Malingering is not considered to be a mental illness
This sets apart from facticious disorder - where you fake symptoms just to do it & won’t get any obvious external gain/reward from it except empathy & attention
Personality disorder clusters A, B, & C
A = Weird:
Schizoid, schizotypal, paranoid
B = Wild:
Antisocial, histrionic, borderline, narcissistic
C = Worried:
Avoidant, dependent, obsessive-compulsive
Cluster A personality d/o
A = Weird –> perceived as eccentric or odd by others and can have psychotic sx
Schizoid personality disorder
Schizoid = Type A = weird
Prefer to be alone. Lifelong pattern of social withdrawal. Perceived as eccentric and reclusive. Quiet and unsociable. They have no desire for personal relationships
> 4 of following:
- Neither enjoy nor desire close relationships
- Choosing solitary activities
- Little if any interest in sex
- Taking pleasure in few activities
- Few close friends or confidants
- Indifference to prais or criticism
- Emotional coldness, detachment, or flattened affect
Ddx: Schizophrenia - unlike pt with schizophrenia - pt w/ schizoid personality d/o do not have any fixed delusions or hallucinations. Schizotypal personality d/o - pt with schizoid to not have same eccentric behavior or magical thinking seen in pt w/ schizotypal personality d/o. Schizotypal pt are more similar to schizophrenic pt in terms of odd perception, thoughts & behavior
Schizotypal personality disorder
Pervasive pattern of eccentric behavior w/ peculiar thought patterns - perceived as strange and odd
Have > 5 of following:
- Odd beliefs, magical thinking inconsistent w/ cultural norms
- Ideas of reference
- Unusual perceptual experiences (such as bodily illusions)
- Suspiciousness
- Few close friends or confidants
- Odd or eccentric appearance or behavior
- Excessive social anxiety
Magical thinking may include - belief in telepathy or clairvoyance (see future), bizarre fantasies or preoccupations, belief in superstitions - may include involvement in strange cults or strange religious practices
Schizotypal = NOT the normal TYPE
Tx = psychotherapy to help develop social skills training
Short course low does antipsychotics for transient psychosis - may help dec social anxiety and suspicion
Paranoid personality disorder
Dx requires a generalized distrust of others, beginning in early adulthood and present in a variety of contexts -
> 4 of following:
- Suspicion w/o evidence that others are exploiting or deceiving them
- Preoccupation w/ doubts of loyalty or trustworthiness of friends
- Reluctance to confide in others
- Interpretation of benign remarks as threatening or demeaning
- Persistence of grudges
- Perception of attacks on his or her character that is not apparent to others
- Suspicions regarding fidelity of spouse or partners
Tend to blame their problems on others & seem angry and hostile. Often characterized as being pathologically jealous
DO NOT have delusions and are not frankly psychotic - although can have transient psychosis under stressful situations
AVOID group psychotherapy - will mistrust and misinterpret other’s statements
Psychotherapy = TOC
Cluster B personality disorders
A = weird, B = WILD, C = worried
Antisocial, histrionic, borderline narcissistic
Antisocial personality d/o
Class B PD –> WILD!!!
Disorder in which a person violates the rights of others without showing guilt. MEN. Often charming.
Must be > 18 to be dx with this
Must have history of behavior as a child consistent with conduct disorder
Must have > 4 following:
- Failure to conform to social laws
- Impulsive -failure to plan ahead
- Deceitful, repeated lying, manipulating others for personal gain
- Recklessness & disregard for safety of others
- Lack of remorse for actions
Mnemonic for sx of anti-social PD - CONDUCT: Capriciousness Oppressive NUTS Deceitful Unlawful Carefree Temper - bad
Antisocial personality d/o a/w
LSES, genetic predisposition, males,
Higher incidence in pt with parents with: antisocial personality d/o, somatic sx disorder, substance use disorders (alcoholic parents, thing antisocial PD)
No effective tx
Histrionic personality d/o
Attention seeking behavior & excessive emotionality - dramatic, flamboyant, extroverted but unable to form long-lasting meaningful relationships - sexually inappropriate & provocative.
Often use defense mechanism of regression - revert to child-like behaviors
- Uncomfortable when not the center of attention
- Inappropriately seductive or provocative behavior
- Uses physical appearance to draw attention
- Speech that is impressionistic and lacking in detail
- Theatrical and exaggereated epression of emotion
Ddx - borderline - BPD more likely to suffer from depression, brief psychotic episodes & attempt SI. HPD are more functional.
Borderline personality d/o
Unstable moods, behaviors and interpersonal relationships
Fear abandonment and have poorly formed identity.
Relationships begin with intense attachments and end with the slightest conflict. Aggression is common
They are impulsive & may have hx of repeated SI attempts or gestures
Higher rates of childhood physical, emotional, and sexual abuse as children than the general population
Pervasive pattern of impulsivity and unstable relationships, affects, self-image and behaviors present by early adulthood in a variety of contexts
Mnemonic: IMPULSIVE Impulsive Moody Paranoid under stress Unstable self-image Labile, intense relationships Suicidal Inappropriate anger Vulnerable to abandonment Emptiness
Use defense mechanism of splitting - view others and themselves as all good or all bad - “you’re the only dc who has ever helped me.”
Tx: psychotherapy - CBT, mindfulness skills, group therapy. More responsive to pharmacotherapy than all other personality d/o - treat psychotic & depressive sx
Narcissistic personality d/o
Class B PD = WILD
Believes he/she is special or unique and can only a/w other high status individuals
Exaggerate sense of self-importance
Preoccupation with fantasies of unlimited money, success, brilliance,
Requires excessive admiration
Has sense of entitlement
Lacks empathy
Takes advantage of others for self gain
Envious of other or believes others are envious of him or her
Arrogant or haughty
Tx: Psychotherapy
Avoidant personality d/o
Cluster C = Worried
Pervasive pattern of social inhibition and an intense fear of rejection –> overlaps a lot with social anxiety disorder
They desire companionship but are extremely shy and easily injured
Sx of avoidant PD = AFRAID
Avoid occupation with others
Fear of embarrassment & criticism
Reserved unless they are certain they are likes
Always thinking rejection
Distances self unless certain they are likes
DDx - social anxiety d/o - fear of embarrassment in a particular setting - avoidant PD is overall fear of rejection which is an intergral part of a person’s personality & evident as a child - then avoidant PD more likely dx
also on ddx = dependent PD - dependent actively and aggressively seek relationships to cling onto - avoidant are slow to get involved & then can cling
Dependent personality d/o
Class C = WORRIED
Have poor self-confidence - fear of separation. Excessive need to be taken care of & allow others to make decisions for them. Feel helpless when left alone. Submissive and clinging behavior.
MNEMONIC - OBEDIENT OCD about approval Bound by other's decisions Enterprises rarely initiated due to lack of self-confidence Invalid feelings when alone Needs to be in relationship Tentative about decisions
DDx - BPD and HPD - people with DPD usu have ONE long-lasting relationship with one person on whom they are dependent. Pt w/ BPD, HPD are often dependent on other people but they are unable to maintain a long-lasting relationship
Obsessive compulsive PD
Pervasive pattern of perfectionism, inflexibility, orderliness. Become so preoccupied w/ unimportant details that they are often unable to complete simple tasks in a timely fashion
They appear stiff, serious and formal with constricted affect. They are often successful professionally but have poor interpersonal skills
> 4 of following:
- Preoccupation with with details, rules, lists, and organization such that hte moajor point o the activity is lost
- Perfectionism that is detrimental to completion of task
