Psychopathology

Question 1

Seperation Anxiety

Answer 1

• 3 of 8 symptoms
• excessive distress when anticipating or experiencing separation from attachment figures; persistent reluctance to go to school, work, or other place away from home because of fear of separation from attachment figures; repeated complaints of physical symptoms when separation from a major attachment occurs/is anticipated.
• 4 weeks in children; 6 months in adults.

Question 2

Specific Phobia

Answer 2

• 6 month
• specifiers: animal, natural environment, blood-injection-injury, situational, or other.
• 2x common in girls than boys (rates differ for different phobic stimuli).
• onset usually childhood (mean age of onset approx. 10 years).
• Mowrer’s two-factor theory: classical conditioning (stimuli paired with anxiety) and operant conditioning (avoidance reinforced).

Question 3

Tx for Specific Phobia

Answer 3

• flooding
• graduated exposure (list of 10, start at easiest)…less likely to dropout.
• applied tension for blood-injection-injury subtype

Question 4

Social Anxiety

Answer 4

• fear 1+ social sitch.
• must fear will exhibit sx in the situation that will be negatively evaluated AND either avoids the situation or endures it with intense fear or anxiety.
• fear/anxiety must be excessive, and his/her fear, anxiety, or avoidance must be persistent (last for @ 6+mo) and cause significant distress or impaired functioning.

Question 5

Tx for Social Anxiety

Answer 5

CBT w/ERP

-therapy may be combined with an SSRI, SNRI, or beta-blocker.

Question 6

Panic Disorder

Answer 6

• recurrent unexpected panic attacks with at least one attack being followed by one month (or persistent concern about additional attacks /consequences (and/or a significant undesirable change in bx related to the attack).
• reaches peak within minutes; involves 4 of 13 symptoms: heart palpitations, sweating, nausea or abdominal distress, dizziness, fear of losing control or “going crazy,” fear of dying, paresthesia, derealization or depersonalization.
• Must 1st rule out hyperthyroidism, cardiac arrhythmia, and several other medical conditions

Question 7

Tx of Panic Disorder

Answer 7

• cognitive-behavioral intervention.
• Ex: panic control treatment (Barlow et al., 1989), which combines interoceptive exposure with relaxation and other techniques for controlling symptoms. (Interoceptive exposure involves deliberately exposing the person to the physical symptoms associated with panic attacks by, for example, having the person run in place, spin in a circle, or breathe through a straw.)
• Some antidepressants (e.g., imipramine) and benzodiazepines have been found useful for alleviating panic attacks, but they’re associated with a high relapse rate when used alone.

Question 8

Agoraphobia

Answer 8

• fear/anxiety in at least 2/5 situations: using public transportation, being in open spaces, being in enclosed spaces, standing in line or being in a crowd, and being outside the home alone.
• must fear or avoid the situations due to concern that escape will be difficult or that help will be unavailable if he/she develops panic symptoms or other incapacitating or embarrassing symptoms.
• fear or anxiety must be excessive for the actual threat posed by the situations; the situations must almost always elicit fear or anxiety and be actively avoided, require the presence of a companion, or be endured with intense fear or anxiety;
• fear, anxiety, or avoidance must be persistent (typically lasting for at least six months) and cause significant distress or impaired functioning.

Question 9

Tx for Agoraphobia

Answer 9

• in vivo exposure and response prevention (ERP).
• Graded exposure is most commonly used, but there’s evidence that intense (non-graded) exposure is also effective and may have better long-term effects (e.g., Feigenbaum, 1988).
• evidence that combining in vivo exposure with applied relaxation, breathing retraining, or cognitive techniques does not significantly improve outcomes and that the key contributor to the effectiveness of exposure is learning to tolerate high levels of fear and anxiety (Barlow, Conklin, & Bentley, 2015).

Question 10

Generalized Anxiety Disorder

Answer 10

• excessive anxiety and worry about multiple events or activities that occur on most days for @ LEAST 6 MONTHS.
• anxiety/worrying difficult to control, and symptoms cause significant distress or impaired functioning and include @ LEAST THREE of the following (or @LEAST ONE FOR CHILDREN): restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance.
• In contrast to people with nonpathological anxiety, those with GAD feel unable to control their worrying, worry about a larger number of events, and are more likely to have somatic symptoms.

Question 11

Tx for GAD

Answer 11

• CBT
• psychopharm. (e.g., SSRIs and SNRIs, while individuals whose symptoms do not respond to antidepressants may benefit from the anxiolytic buspirone (Buspar) or a benzodiazepine).

Question 12

Obsessive-Compulsive Disorder

Answer 12

• recurrent obsessions and/or compulsions that are time-consuming (more than 1hr/day) and/or cause significant distress or impaired functioning.
• Obsessions are recurrent and persistent thoughts, urges, or images that the person experiences as intrusive and unwanted, that he/she attempts to ignore or suppress, and that usually cause marked anxiety or distress.
• Compulsions are repetitive behaviors or mental acts that the person feels driven to perform either in response to an obsession or according to rigidly applied rules.
• males –> earlier age of onset and have a slightly higher prevalence rate in childhood, while females–> higher prevalence rate in adulthood.
• males more likely to have a comorbid tic disorder.

Question 13

Risk factors: GAD

Answer 13

• fam. hx.
• temperament dimensions of behavioral inhibition, neuroticism, and harm avoidance; and
• exposure to childhood trauma or chronic stress
• associated w/abnormalities in the ventrolateral and dorsolateral prefrontal cortex, anterior cingulate cortex, posterior parietal cortex, amygdala, and hippocampus
• evidence that GAD is associated with reduced connectivity between regions of the prefrontal cortex and anterior cingulate cortex and the amygdala, which suggests there is weak top-down control of amygdala reactivity (Tromp et al., 2012).

Question 14

Risks for OCD

Answer 14

-lower serotonin and elevated activity in caudate nucleus, orbitofrontal cortex, cingulate gyrus, and thalamus

Question 15

Tx for OCD

Answer 15

• ERP
• combining with psychopharm (e.g., SSRI or the tricyclic clomipramine may be best).
• CBT and ACT also good.

Question 16

Body Dysmorphic Disorder

Answer 16

• preoccupation w/perceived defect or flaw in physical appearance
• perform repetitive bx or mental acts due to flaw
• cause sig distress or impaired function

Question 17

Introceptive Exposure

Answer 17

deliberately exposing the person to the physical symptoms associated with panic attacks by, for example, having him/her run in place, spin in a circle, or breathe through a straw.

Question 18

Brief Psychotic Disorder

Answer 18

• @ least 1 of 4 characteristic symptoms for @ least 1 day but < than 1 mo.
• @ least 1 symptom being delusions, hallucinations, or disorganized speech. The four characteristic symptoms are delusions, hallucinations, disorganized speech (e.g., derailment, tangentiality), and grossly disorganized or catatonic behavior.

Question 19

Schizophreniform Disorder

Answer 19

• @least 2 of 5 characteristic symptoms for @least one month but < than 6 mo.
• one symptom = delusions, hallucinations, or disorganized speech.
• five symptoms are: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic bx, and neg symptoms (avolition, alogia, anhedonia)

Question 20

Schizophrenia

Answer 20

• active phase that lasts @least one month and includes @least 2 of 5 symptoms (@least 1 is delusion, hallucination, disorganized speech)
• continuous signs @least 6mo and may include residual phases

Question 21

Schizophrenia: Prodromal/Residual Phases

Answer 21

-for dx of schizophrenia, prodromal and residual phases consist of 2+ symptoms in attenuated form or negative symptoms only (avolition, alogia, anhedonia)

Question 22

Schizophrenia Etiology

Answer 22

• high concordance rate for greater degree of genetic similarity (monozygotic twin = 48%, child of one parent = 13%, Dizyotic twin = 17%, sib = 9%, parent = 6%).
• neotransmitters linked: dopamine, glutamate, serotonin.
• enlarged ventricles and hypofrontality (contributes to cog/neg symptoms)

Question 23

Dopamine Hypothesis

Answer 23

• schizophrenia -> high dopamine or hyperactivity of dopamine receptors.
• amphetamines increase dopamine activity and produce schizophrenia-like symptoms, while drugs that decrease dopamine activity reduce or eliminate these symptoms.
• revised dop. hypothesis (Kuepper, Skinbjerg, & Abi-Dargham, 2012) says pos. symptoms due to dopamine hyperactivity in subcortical regions of the brain (especially in striatal areas), neg. symptoms are due to dopamine hypoactivity in cortical regions (especially in the prefrontal cortex).

Question 24

Schizophrenia Tx Course

Answer 24

• comorbitidies: anxiety, OCD, tobacco use disorder (70-85% are tabacco users while half meet dis. criteria
• onset is early to mid 20s for males, late-20s for females.
• Psyhotic symptoms decrease with age but neg symptoms persist
• Better prog. with female gender, late onset, comorbid mood symptoms, mostly pos symptoms, fam hx of mood disorder, and good premorbid adjustment
• poorer outcomes/relapse with anosognosia and those with fam who are high in expressed emotion/criticism.
• tx is ACT, social skills training, fam psyched, supportive employment, CBT, cog remediation, antipsychotic drugs, and adjunctive meds for comorbidities.

Question 25

Schizoaffective Disorder

Answer 25

Requires concurrent symptoms of schizophrenia and major depressive or manic episode for most of duraction
-Need delusions or hallucinations for 2+ weeks w/o mood symptoms

Question 26

Delusional Disorder

Answer 26

• 1+ delusion for at least one month
• functioning only markedly impaired from delusion direct effects
• subtypes: erotomanic, grandiose, jealous, persecutory, somatic

Question 27

Reactive Attachment Disorder

Answer 27

• Persistent pattern of inhibited and emotionally withdrawn bx toward adult caregivers such as…
• lack of seeking or responding to comfort when distressed
• social and emotional disturbances including 2+: minimal social and emotional responsiveness to others, limited positive affect, unexplained irritability, sadness, or fearfulness when interacting w/caregivers.
• must have hx of extreme insufficient care believed to explain symptoms, onset before five, dev age of @ least 9 months.

Question 28

Disinhibited Social Engagement Disorder

Answer 28

• persistent pattern characterized by inappropriate interactions with unfamiliar adults
• include 2+ of 4: reduced or absent reticence in approaching/interacting w/strangers, overly familiar w/strangers, diminished/absent checking w/adult caregivers after being separated, willingly accompany stranger w/little hesitation.
• requires hx of extreme insufficient care and dev age of @least 9 mo.

Question 29

Posttraumatic Stress Disorder (PTSD)

Answer 29

• symptoms must last for >1mo, cause sig distress or impair functioning, be due to exposure to actual/threatened death, serious injury, or sexual violence.
• 4 types of symptoms: intrusions (intrusive memories/recall), persistent avoidance (of associated stimuli), neg changes in mood or cognition, alterations in arousal and reactivity
• criteria slightly different for children 6 and under and all those over

Question 30

PTSD and the Brain

Answer 30

• linked to: hyperactivity in amygdala, hyperactivity/reduced volume of –> hippocampus, ventromedial prefrontal cortex, and anterior cingulate cortex
• linked to: higher norepinephrine )increased arousal and exaggerated startle response and enhanced encoding of fear memories), higher glutamate –> derealization and dissociation, lower serotonin –> hyper vigilance, impulsivity and memory intrusions…also low GABA increases vulnerability to PTSD

Question 31

PTSD Tx

Answer 31

• Therapy: CBT, cognitive processing therapy (challenge neg cognitions w/writing and reading detailed description of trauma), exposure, EMDR (exposure to memories of events, not rapid eye movements are what work), narrative exposure.
• Single-session psychological debriefing aka critical incident stress debriefing aka group psychological debriefing is not effective and may worsen sx.
• telehealth just as good as in-person, but there may be barriers in dev therapeutic alliance
• APA clinical practice guideline does not address tx for children and teens…but TF-CBT initially designed for children 3 to 18 who experienced sexual abuse. TF-CBT incorporates family therapy, parent skills training, and conjoint parent-child therapy.
• Psycopharm: SSRIs –> fluoxetine, paroxetine, sertraline (Zoloft); SNRI venlafaxine (tx depression and may alleviate core symptoms of re-experiencing, avoidance/numbing, hyperarousal)

Question 32

Acute Stress Disorder

Answer 32

• requires exposure to actual threat (like PTSD).
• @least 9 sx from any 5 categories: intrusion, neg mood, dissociative symptoms, avoidance, arousal.
• sx must have lasted for 3 days to 1 month and cause sig distress or impaired functioning

Question 33

Dissociative Disorders

Answer 33

“a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior”

-include dissociative identity disorder, dissociative amnesia, depersonalization / derealization disorder

Question 34

Dissociative Amnesia

Answer 34

• inability to recall important personal info not attributed for forgetfulness
• causes sig distress or impaired functioning
• can take the following forms: localized (most common- don’t recall all events during a circumscribed period), selective (can’t recall some events during circumscribed period), generalized (complete loss of memory for entire life), systematized (loss of memory for specific category of info), and continuous (can’t remember new events as they happen).
• specifier to indicate dissociative fugue (purposeful travel or purposeless wandering associated w/memory loss)
• often related to trauma

Question 35

Depersonalization/Derealization Disorder

Answer 35

• persistent or recurrent episodes of depersonalization (a sense of unreality, detachment, or being an outside observer of one’s thoughts, actions, etc.) or derealization (a sense of unreality or detachment with regard to one’s surroundings)
• accompanied by intact reality testing and significant distress or impaired functioning.

Question 36

Somatic Symptom and Related Disorders

Answer 36

• involve physical symptoms and/or health-related concerns that cause significant distress or impaired functioning
• previously somatoform disorders in DSM-IV

Question 37

Somatic Symptom Disorder

Answer 37

• involves one+ somatic symptoms that are distressing or cause sig. disruption in daily life
• presence excessive thoughts, emotions, or behaviors related to the symptom(s) or associated health concerns
• @least one of the following: disproportionate or persistent thoughts about seriousness of sx, a persistently high level of anxiety about health or sx, excessive time and energy spent on health concerns or sx.
• Specifiers used to indicate if symptoms are mild, moderate, or severe, involve predominant pain, and are persistent (are severe, have caused marked impairment, and have lasted more than six months).

Question 38

Illness Anxiety Disorder

Answer 38

• preoccupation w/having serious illness w/ no or mild somatic symptoms, excessive anxiety about health, and either excessive health-related behaviors or avoidance of health care.
• Symptoms must be present for at least six months, although the nature of the symptoms may vary over time

Question 39

Conversion Disorder (aka FND/FNSD)

Answer 39

• 1+ sx involving disturbance in voluntary motor or sensory functioning (e.g., paralysis, blindness)
• need r/o of any known neurological or med condition
• causes sig distress/impairment
• specifiers for symptom type, corse of disorder (acute or persistent), and prescient or absence of psychological stressor
• Can involve psychogenic non-epileptic seizures (PNES)…which resemble true seizures w/o brain electrical activity

Question 40

Factitious Disorder

Answer 40

• can be imposed on self (hysteria) or another (munchausen syndrome by proxy)
• falsify or induce physical or psychological symptoms (e.g., deception - take drugs to fake bad)
• present themselves/others as being ill or impaired and engage in deception regardless of external reward

-different from malingering (which is intentional reporting of symptoms for personal gain such as legal reasons)
…also suspect malingering with antisocial personality disorder, lack of cooperation with eval or tx, marked discrepancy between symptoms and objective findings….can sus out with forced-choice test w/ <50% correct (i.e., worse than chance). Also suggested when excessive impairment or unexpected pattern of responding present on NP tests.

Question 41

Feigned Memory Loss w/ Factitious Disorder/Malingering

Answer 41

• for genuine memory loss, beginning and end of amnestic period are gradual and hazy…individuals often remember fragments of some events. Belief that hints or clues may help recall lost memories present.
• for feigned memory loss, onset and termination of amnestic period often sudden w/ no fragments.

-Test of Memory Malingering (TOMM) developed to determine feigned memory loss. Uses forced-choice format. Malingerers perform sig. below chance level, indicating faking bad.

Question 42

Manic Episode

Answer 42

• abnormally and persistently elevated, expansive, or irritable mood and increased activity/energy for at least one week.
• It includes 3+ characteristic symptoms (e.g., inflated self-esteem or grandiosity, decreased need for sleep, flight of ideas) and marked impairment in functioning, a need for hospitalization to avoid harm to self or others, and/or the presence of psychotic features.

Question 43

Hypomanic episode

Answer 43

• abnormally and persistently elevated, expansive, or irritable mood; increased activity or energy
• 3+ symptoms of mania for @ least 4 consecutive days.
• Symptoms are NOT severe enough to cause marked impairment in functioning or a need for hospitalization and DO NOT include psychotic features.

Question 44

Major Depressive Episode

Answer 44

• characterized by 5+ characteristic symptoms with at least one symptom being depressed mood or loss of interest or pleasure in most or all activities.
• Symptoms last for @ least 2 weeks and cause significant distress and/or impaired functioning.

Question 45

Bipolar Disorders

Answer 45

• Bipolar 1: requires 1+ manic episode. Can be preceded or followed by 1+ major depressive episode or hypomanic episode.
• Bipolar 2: requires 1+ hypomanic episode and 1+ major depressive episode
• Cyclothymic Disorder: requires numerous periods of hypomanic symptoms that DO NOT meet criteria for hypomanic episode…and numerous periods of depressive symptoms that DO NOT meet criteria for major depressive episode. Minimum duration is 2 years for adults or one year for children/teens
• specifier “with atypical features” for bipolar disorders that involve mood reactivity and 2+ of the following: significant weight gain or increase in appetite, hypersomnia, leaden paralysis, interpersonal rejection sensitivity

Question 46

Etiology of Bipolar Disorder

Answer 46

• heredity: Concordance rates of .67 to 1.0 for monozygotic twins; .20 for dizygotic twins
• neurotransmitter: norepinephrine, serotonin, dopamine, glutamate
• brain abnormalities: PFC, amygdala, hippocampus, basal ganglia
• circadian rhythms irregularities: sleep-wake cycle, secretion of hormones, appetite, core body temp.

Question 47

Tx of Bipolar Disorder

Answer 47

• psychosocial interventions: family focused therapy, psyched, interpersonal and social rhythm therapy, CBT
• pharmacotherapy: Lithium for “classic bipolar” (onset 15-19, separation of manic/hypomanic and depressive episodes by long periods of recovery, unlikely mixed mood states and rapid cycling). Anticonvulsant and second generation antipsychotic drugs for “atypical bipolar disorder” (onset 10-15, mixed mood states, rapid cycling, lack of full recovery between episodes)

Question 48

Depressive Disorders

Answer 48

• Major depressive disorder: 5+ symptoms of major depressive episode for 2+ weeks AND 1+ symptom being depressed mood OR loss of interest/pleasure in most/all activities.
• Persistent depressive disorder: requires depressed mood with 2+ characteristic symptoms (e.g., poor appetite or overeating, insomnia or hypersomnia, feelings of hopelessness) for 2+ years in adults or 1+ year in children/teens
• Disruptive mood dysregulation disorder: requires 12+ months of (a) severe/recurrent temper outbursts grossly out of proportion and happen 3+/week (b) persistent observable irritable/angry mood most days.
• prevalence by gender similar in childhood. Males stable throughout lifetime but female risk increases (1.5 to 3x higher) in adolescent and persists in adulthood. Could by bio and psychological favors (e.g., hormone levels at puberty sensitizes females but desensitizes males to stressful life events).

Question 49

Major Depressive Disorder Specifiers

Answer 49

• peripartum: aka postpartum depression. Onset during pregnancy or within 4weeks after delivery. 80% experience “baby blues” after birth and 3-6% (or 10-20% per other sources) meet criteria for major depressive episode during pregnancy or weeks/months following.
• seasonal: aka seasonal affective disorder (SAD). Onset usually winter. Temporal. symptoms include hypersomnia, overeating, weight gain, and a craving for carbs. It’s been linked to a lower serotonin and a higher melatonin. SAD is often responsive to phototherapy which suppresses melatonin production.

Question 50

Etiology of Major Depressive Disorder

Answer 50

heredity: concordance rate for unipolar depression = .5 for monozygotic twins and .2 for dizygotic twins
neurotransmitter: low serotonin, dopamine, and norepinephrine
hormone: /brain abnormalities: Abnormal hypothalamic-pituitary-adrenal (HPA) axis (hyperactivity due to chronic stress/cortisol hypersecretion); also issues with PFC, cingulate cortex, hippocampus, caudate nucleus, putamen, amygdala, thalamus, etc.

Re: PFC (high levels of activity in the ventromedial PFC and low activity in dorsolateral PFC…can be reversed in response to tx with antidepressant/psychotherapy)

Psychosocial: Lewinsohn’s social reinforcement theory (1974, result of low rate of response-contingent reinforcement for social bx’s due to environment), Seligman’s learned helplessness model (1974, repeated neg life events = helpless, neg cog style where attribute neg life events to stable, internal, and global factors…new version is neg events/neg cog style –> hopeless –> depression), Beck’s cog theory (neg cog triad).

Question 51

Age & Cultural Factors of MDD

Answer 51

• Age: if younger, like to genetics, stressful events, limits in cog abilities. If older, medical illness decreasing physical functioning –> social isolation
• -If young = report more affective symptoms; old = report more somatic symptoms, cog changes, and loss of interest

-Culture: Latino, Mediterranean, Middle Eastern, Asian, and other non-Western cultures = more somatic symptoms (e.g., appetite and sleep disturbances, headaches, heart palpitations), Western cultures = more psychological symptoms (e.g., depressed mood, loneliness, hopelessness)

Question 52

MDD Comorbidity

Answer 52

-in order starting w/larges: substance use disorder (alcohol most common), anxiety disorder (GAD most common), and personality disorder (borderline personality disorder)

• bidirectional relationship with coronary heart disease (CHD).
• link to sleep abnormalities including: sleep latency (longer time to fall asleep), reduced REM latency (shorter time from sleep onset to REM sleep), reduced slow-wave (stage 3 and 4) sleep, and increase REM density (more rapid eye movements)

Question 53

Major Depressive Disorder Treatment

Answer 53

• children: insufficient evidence for any specific psychosocial or mx tx
• teens: CBT, interpersonal psychotherapy for adolescents (IPT-A), fluoxetine (Prozac). No evidence if therapy or meds work best.
• adults: psychotherapy (CBT, Mindfulness Based CBT, behavior therapy, psychodynamic therapy, supportive therapy) and second-generation antidepressant (SSRI or SNRI). Rec is combined CBT/IPT w/ SSRI or SNRI
• older adults: group-CBT or IPT and 2nd gen antidepressant combo. Conditional rec for St. John’s Wort and other psychotherapies. St. John’s wort not good for sever depression and might cause serotonin syndrome (too much serotonin) and reduce effect of other drugs.

-telehealth = to in-person. some evidence cog bibliotherapy can work for teens and adults with mild to moderate depression.

Question 54

Suicide in the US

Answer 54

• increased substantially since 1999
• 10th leading cause of death in 2017.
• Males > Females
• females ages 45-65 highest (9.7%); white males ages 75+ highest (39.7%)
• re: race/culture –> American Indians/Alaska Natives highest rate for 15-24, and 25-44.
• Whites highest overall for 45-64 and 65-74

Question 55

Delirium

Answer 55

Requires:

(a) disturbance in attn & awareness that dev. over short time (hours to few days) and fluctuates throughout day.
(b) 1 additional disturbance in cognition (e.g., memory, lang.).
* consequence of med conditions, substance intoxication/withdrawal, and/or exposure to toxin.
* Causes: high fever, nutritional deficiency, electrolyte disturbance, head injury, renal or hepatic failure, certain drugs/meds (alcohol, lithium, sedatives, anticolinergic drugs).
* haloperidol or antipsychotic may help reduce agitation/psychotic sx.

Question 56

Major and Mild Neurocognitive Disorder (NCD)

Answer 56

• Major Neurocognitive Disorder AKA dementia.
• Mild Neurocognitive Disorder AKA Cognitive Disorder NOS.

ACQUIRED NOT DEVELOPMENTAL.

• Decline in cog functioning in 1+ domains (e.g., EF, learning/memory, social cognition) and Interferes w/ independence –> Major.
• Modest cog decline that does NOT interfere w/independence (not due to delirium) –> Mild (used to be cognitive disorder not otherwise specified).

Question 57

Sexual Dysfunctions

Answer 57

• a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure
• For all but one diagnosis, specifiers are provided to indicate the disorder’s onset (lifelong or acquired), extent (generalized or situational) and severity (mild, moderate, or severe). The exception is genito-pelvic pain/penetration disorder, which has specifiers only for onset and severity.

Question 58

Erectile Disorder

Premature Ejaculation

Answer 58

• ED: 1/3 sx on 75-100% of sexual activity and cause distress. Difficulty obtaining, maintaining, and w/ rigidity. SIX MONTHS. Organic etiology r/o if spontaneous erections in other contexts. Tx - bx techniques to reduce performance anxiety/increase stimulation (sensate focus…series of couple activities include non-sex touching, sex, touching, then intercourse) also drugs e.g., sildenafil citrate (Viagra), tadalafil (Cialis), vardenafil (Levitra)
• Premature Ej: Pattern of ejaculation within ONE MIN of penetration and before desire. SIX MONTHS+. Occur during 75-100% of all activity and cause distress. Tx: bx tech like sensate focus, start-stop/pause-squeeze technique. Evdicence may be due to low serotonin. SSRI (paroxetine) can help delay.

Question 59

Genito-Pelvic Pain/Penetration Disorder

Answer 59

-Sx duration of SIX MONTHS+ and cause distress. Link to hx of sexual and/or psychical abuse. For some women, onset after hx of vaginal infections. Tx: relaxation training, sensate focus, topical anesthetic, vaginal dilators, Kegel exercises.

Question 60

Gender Dysphoria

Answer 60

• incongruence btwn assigned gender and expressed gender.
• Children need 6/8 dx for SIX MONTHS+ (e.g., desire to be other gender, strong pref for wearing clothes of other gender, strong pref for toys/activities of other gender, strong pref for playmates of opposite gender; a strong desire for primary and/or secondary sex characteristics of one’s experienced gender). Specifier for congenital adrenogenital disorder or other sex dev. disorder.

-Teens/Adults need 2/6 for SIX MONTHS+. (e.g., desire to be rid of one’s primary and/or secondary sex characteristics; a strong desire to be other gender; a strong desire to be treated as the opposite gender; conviction one has feelings/reactions characteristic of opposite gender). Specifiers for disorder of sex development or indicate post-transition.

Question 61

Gender Dysphoria Tx

Answer 61

The Dutch protocol = “gender dysphoria, or a transgender identity, persists into adolescence in only a small minority of people” (Ehrensaft, et al, 2018).

• For children under 12 years of age, recs “watchful waiting” w/child & fam support.
• @ first signs of puberty, social transition and puberty-blocking drugs are started for GD. Gives time to further explore gender and decide if interested in cross-sex hormone therapy (when 16 years) and/or gender-affirming surgeries (after 18; de Vries & Cohen-Kettenis, 2012).

Gender-affirmative model = most widely accepted. Says “child of any age may be cognizant of their authentic identity and will benefit from a social transition at any stage of development”

• Social transition followed, as appropriate, by puberty blockers, cross-sex hormones, and surgeries
• throughout process, gender issues addressed w/ youth and families
• model also assumes (a) gender variations not disorders; (b) gender presentations are diverse and vary across cultures; (c) gender not always binary and may be fluid; and (d) if present, a child’s psychological problems are often secondary to neg interpersonal and cultural reactions to the child (e.g., transphobia, homophobia, sexism).
• Research on the outcomes of gender confirmation surgery (also known as gender-affirming surgery) has generally found that it’s associated with a decrease in gender dysphoria, improved self-satisfaction, and a low incidence of regret.
• evidence that transgender male patients have somewhat more positive outcomes than transgender female patients do (Lawrence, 2017).
• Factors linked to positive outcomes include careful diagnostic screening of individuals seeking surgery, psychological stability, adequate social support, and a lack of surgical complications (Lawrence & Zucker, 2014).

Question 62

Paraphilic Disorders

Answer 62

Frotteuristic Disorder: 6 months. touching or rubbing against non consenting partner. Must have acted or experienced sig distress as result of urge.
Transvestic Disorder: 6 months. cross-dressing for purpose of arousal. Manifested in urges or bx’s that cause distress or impairment.
Pedophilic Disorder: 6 months. urges/bx involving children 13 or younger. Must have acted or experience sig distress/interpersonal impairment. Must be at least 16yo and at least 5 years older than child.
Fetishistic Disorder: 6 months. Arousal for nonliving object or specific non-genital body part with arousal causing sig distress or impairment.
Exhibitionistic Disorder: 6 months. Arousal from exposing oneself to unsuspecting person. Must have acted on urges or have sig distress/impairment from urges. Subtypes: sexually aroused by exposing to prepubertal children, physically mature individuals, or both. Can be applied regardless if person discloses.

Tx: CBT w/ other tx like group therapy, marital therapy, and/or pharmacotherapy. Includes cog restricting and empathy and skills training. Bx strategies based on classical conditioning and include covert sensitization (aversive countercoundtioning i.e., pair with fear) and orgasmic reconditioning. Drugs used: gonadotropin-releasing hormones (e.g., Lupron) and antiandrogens (e.g., Depo-Provera)…but serious side effects and a high risk for relapse when discontinued. SSRIs may be prescribed for less serious disorders to reduce depression or compulsions that trigger paraphilic behavior.

Question 63

Personality Disorders: Cluster A (odd or eccentric bx’s)

Answer 63

Cluster A - onset in adolescence or early adulthood. Stable our time. One year of sx.

Paranoid: Distrust and suspiciousness (interpreting other’s motives as malevolent). 4/7 sx: suspects w/o sufficient reason others exploiting, harming or deceiving; preoccupied w/unjustified doubts re: loyalty/trustworthiness of others; reluctant to confide; reads remaining content in benign remarks/events; has grudges; perceives attacks on character and rep and quick to counter/react; suspicious w/o justification about fidelity of spouse/sexual partner.

Schizoid: Pervasive detachment from social relationships/restricted range of emotional expression. 4/7 sx: no desire/joy for close relationships, tends to choose solitary activities, little or no interest in sex, pleasure in few activities, lacks close friends/confident outside immediate fam., indifferent to praise/critique, emotionally cold/detached or flat affect.

Schizotypal: Pattern of social/interpersonal deficits w/acute discomfort w/and reduced capacity for close relationships, distortions in cognition/perception, eccentric bx. 5/9 sx: exhibits ideas of reference, odd beliefs/magical thinking influence bx, bodily illusions/unusual perceptions, odd thinking and speech, suspicious or paranoid, inappropriate/constricted affect, peculiarities in bx and appearance, lacks close friends or confidents outside immediate fam., excessive social anxiety that doesn’t diminish with familiarity.

Question 64

Personality Disorders: Cluster B (dramatic, emotional, erratic bx)

Answer 64

Cluster B - onset is teen/early adult. Stable over time. Can be dx under 18 EXCEPT for antisocial (needs 18+ AND one year of symptoms)

Antisocial: Disregard&violation of rights of others SINCE 15YO AND hx of conduct disorder before 15. 3/7 sx: fails to conform to social norms/lawful behaviors, is deceitful, is impulsive and fails to plan ahead, is irritable and aggressive, has a reckless disregard for the safety of self and others, is consistently irresponsible, has a lack of remorse. Sx less severe w/age and into 4th decade. Hard to tx bc people don’t believe they have a problem and don’t seek help voluntarily. No strong evidence for tx. However, cog-bx interventions (esp. group) helpful for recidivism rates, contingency management for pos. bx and meds may reduce substance use.

Borderline: Instability in interpersonal relationships, self-image, affects. 5/9 sx: frantic efforts to avoid abandonment, pattern of unstable and intense interpersonal relationships that involve fluctuations between idealization and devaluation, identity disturbance w/ persistent instability in sense of self, is impulsive (self-sabotaging) in at least two areas, has made recurrent suicide threats or engages in self-harm, affective instability, chronic feelings of emptiness, inappropriate intense anger, transient stress-related paranoid ideation or severe dissociative symptoms. Late teen onset. Most severe in early adulthood but decrease in sx w/age. 75% don’t meet full criteria by age 40. Tx - DBT for emotional dysregulation (combo bio/environment).

Histrionic: excessive emotionality and attention seeking. 5/8 sx: uncomfortable when not center of attention, inappropriately sexually seductive/provocative with others, rapidly shifting and shallow emotions, uses physical appearance to gain attention, speech is excessively impressionistic and lacking in detail, exaggerated expression of emotion, easily influenced by others, considers relationships to be more intimate than they are.

*histrionic and antisocial share features – e.g., “a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative” (DSM5). BUT, people with histrionic personality disorder have exaggerated emotions and are manipulative in order to gain nurturance, while those with antisocial personality disorder engage in antisocial behaviors and are manipulative to gain power or material gratification.**

Narcissistic: grandiosity, need for admiration, and a lack of empathy. 5/9 sx: grandiose sense of self-importance; preoccupied w/fantasies of unlimited success/power,/beauty/love; believes unique and can be understood only by special/high-status people; requires excessive admiration; sense of entitlement; interpersonally exploitative; lacks empathy; is often envious of others or believes others are envious of them; exhibits arrogant behaviors and attitudes.

Question 65

Personality Disorders: Cluster C (anxiety/fearfulness)

Answer 65

Cluster C

AVOIDANT: social inhibition, feelings of inadequacy, and hypersensitivity to neg eval. 4/7 sx: avoids occupational activities that involve interpersonal contact due to fear of criticism, disapproval, or rejection; unwilling to get involved with people unless CERTAIN of being liked; shows restraint in intimate relationships due to fear of ridicule; is preoccupied w/concerns about being criticized or rejected in social situations; is inhibited in new relationships because of feelings of inadequacy; views self as socially inept, unappealing, or inferior to others; is usually reluctant to engage in new activities because they may be embarrassing.

DEPENDENT: pervasive and excessive need to be taken care of. Leads to submissive and clinging behavior and a fear of separation. 5/8 symptoms: difficulty making everyday decisions w/o advice and reassurance from others, needs others to assume responsibility for most areas of life, avoids disagreements due to fear of losing support/ approval, difficulty doing things alone, excessive lengths for nurturance/support, feels uncomfortable or helpless when alone, urgently seeks another relationship for care/support when a close relationship ends, unrealistically preoccupied with fears of being left to care for him/herself.

obsessive-compulsive personality: preoccupation w/orderliness, perfectionism, and mental and interpersonal control that severely limits flexibility, openness, and efficiency. 4/8 sx: preoccupied w/details, rules, and schedules so major point of activity is lost; perfectionism that interferes w/task completion; excessively devoted to work and productivity to the exclusion of leisure activities and friendships; overly conscientious, scrupulous, and inflexible about morality, ethics, or values; unable to discard worn-out or worthless objects even when they don’t have sentimental value; reluctant to delegate work to others unless they’ll do it their way; adopts cheap spending style toward self and others; shows rigidity and stubbornness.

As noted in the DSM-5, obsessive-compulsive personality disorder and obsessive-compulsive disorder share some characteristics, but only obsessive-compulsive disorder involves true obsessions and compulsions.

Question 66

Substance-Use Disorder Dx

Answer 66

Sx in 4 categories: Impaired control, social impairment, risky use, and pharmacological criteria (tolerance/withdrawal).
-Need 2+ Sx within 12mo. Any substance except caffeine. Specify severity, stage of remission, etc.

Question 67

Substance-Use Disorder Tx

Answer 67

CBT, MI, contingency management, etc. plus group, family or marital therapy; 12-step program; maybe meds. Combining tx (therapy/meds) most effective.

Meds:
alcohol use disorder: disulfiram, naltrexone.
Opioid use disorder: methadone, naltrexone
Tobacco use disorder: nicotine replacement therapy, bupropion (antidepressant), nicotine nasal spray, nicotine receptor partial agonist varenicline.
Cocaine use disorder: Voucher-based reinforcement (VBRT) and CBT good combo. VBRT - contingency management, good for initial abstinence. CBT to maintain. No FDA approved med, NDRI bupropion, psychostimulant modanfinil, long-acting amphetamine, anticonvulsant topiramate may help.

Relapse Prevention = Marlatt and Gordon’s Relapse Prevention Therapy (RPT; cog/bx approach). Addiction is learned habit pattern, lapses causes by high-risk sitch. Lapses become FULL relapses if have bad coping skills, low self-efficacy, high expectations of positive effects of substance.

Abstinence Violation Effect (response to lapse): negative emotions, guilt, sense of failure.

Project MATCH: client outcomes improved by matching clients w/certain characteristics to tx most appropriate. Still good outcomes at 1 & 3 year f/u. If have drinking friends do best with 12 step, if high anger do best from Motivational Enhancement Therapy.

Question 68

Substance Intoxication (Substance-Induced Disorders)

Answer 68

Alcohol: Prob bx and psych changes (e.g., inappropriate sexual/aggressive bx, mood lability, impaired judgement). 1/6 sx required: slurred speech, incoordination, unsteady gait, nystagmus/rapid eyes, impaired attention/memory, stupor/coma.

Opioid: Prob bx and psych changes (e.g., euphoria followed by apathy/dysphoria, impaired judgement), pupillary constriction. 1/3 sx required: drowsiness/coma, slurred speech, impaired attention/memory. (Opioids=opium, heroin, morphine, codeine; synthetic/partly=methadone, oxycodone, hydrocodone, fentanyl).

Sedative, Hypnotic, Anxiolytic: prob bx and psych changes (e.g., inappropriate sex/aggro bx’s, mood lability, impaired judgment). 1/6 sx required: slurred speech, incoordination, unsteady gait, nystagmus, impaired cognition, stupor/coma.

Stimulant: prob bx and psych changes (e.g., euphoria/affective blunting, hyper vigilance, interpersonal sensitivity, anxiety/anger, impaired judgement). 2/9 sx required: tachycardia or bradycardia, pupillary dilation, elevated/lowered blood pressure, perspiration/chills, nausea/vomiting, weight loss, psychomotor agitation/retardation, respiratory depression/cardiac arrhythmia, seizures/coma. (stims= amphetamines, methamphetamines, cocaine).

Question 69

Substance Withdrawal (Substance-Induced Disorders)

Answer 69

Alcohol: 2+/8. Following cessation/reduction. Automatic hyperactivity, hand tremor, insomnia, nausea/vomiting, transient hallucinations/illusions, anxiety, psychomotor agitation, generalized tonic-clonic seizures.

Opioid: 3+/9 sx following cessation or opioid antagonist. Dysphoric mood, nausea/vomiting, muscle aches, diarrhea, yawning, fever, insomnia.

Sedative, Hypnotic, or Anxiolytic: 2+/8 sx following cessation or reduction. Autonomic hyperactivity, hand tremor, insomnia, nausea or vomiting, transient hallucinations or illusions, psychomotor agitation, anxiety, grand mal seizures.

Stimulant: Requires dysphoric mood and +2/5 physio-changes following cessation. Fatigue, vivid/unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor agitation or retardation.

Tabacco: 4+/7 sx in 24 hours of abrupt cessation/reduction. Irritability, anger or anxiety, impaired concentration, increased appetite, restlessness, depressed mood, insomnia. Sx peak 48-72 hours then wane overall several weeks. Cravings last longer than sx.

Question 70

Alcohol-Induced Major Neurocognitive Disorder

Answer 70

Sig decline in 1+ cog domain that interferes with autonomy. Specifier if nonamnestic- confabulatory type or amnestic-confabulatory type.

Amnestic-confabulatory type = Korsakoff Syndrome. Link to thiamine deficiency. Involves antero-grade and retrograde amnesia and confabulation.

Question 71

Alzheimer’s

Answer 71

60-80% of NCD.
Dx: Meet criteria for mild/major NCD. Gradual onset and progression in 1+ cog domains but doesn’t interfere with daily activities for mild NCD (2+cog issues for major NCD).
-major NCD w/Alzheimer’s: genetic mutation/fam hx and/or decline in memory and learning AND 1+ other cog domain, steady decline. (if not met, use POSSIBLE Alzheimer’s dx).
-mild NCD w/Alzheimer’s: NO genetic mutation/fam hx BUT decline in memory and learning, steady decline.
*Can be confirmed w/brain biopsy/autopsy.
*Early onset= more likely to survive full course.
*More likely to deny cog probs, have severe memory impairment, apathy and avolition, respond w/wrong answers.

Question 72

Pseudodementia

Answer 72

Depression w/ prominent cognitive sx.
ABRUPT onset, exaggerate cog probs, moderate memory loss, melancholia and anxiety, often say “I don’t know” in response to questions.
Respond well to treatment.

Question 73

Etiology of Alzheimer’s

Answer 73

Chromosomal: ApoE4 variant on chromosome 19.

Neurotransmitter: Reduced acetylcholine (ACh), excessive glutamate. (both involved in learning/memory).

Brain: amyloid plaques (clumps of beta-amyloid protein broken from amyloid precursor protein), neurofibrillary tangles (abnormal amt of tau protein) due to protein buildup (more excessive than normal w/age). These disrupt cell-to-cell communication.

• Protein buildup first in medial temporal lobe (entorhinal cortex, amygdala, hippocampus), then frontal and parietal lobes.
• LOCUS COERULEUS (in brain stem) first affected before sx onset. (also implicated in NCD w/Lewy bodies and NCD w/Parkinson’s)

Question 74

Stages of Alzheimer’s

Answer 74

Duration approx 8-10 years.

Early Stage: 2-4 years. Short-term memory loss, anomia (trouble recall ppl&objects), personality changes (indifference/lack of spontaneity), anxiety/depression, impaired attn&focus, poor judgement, disorientation to time/space.

Middle Stage: 2-10 years. Increased short-term memory loss, long-term memory loss, labile mood, irritability, increased disorientation, delusions/hallucinations, wandering/pacing, perseveration (rep. speech/actions), loss of impulse control, impaired speech, disrupted sleep, probs w/daily activities, sundowning (increased confusion/agitation later in day).

Late Stage: 1-3 years. Severely deteriorated cog functioning, severe disorientation, apathy, severely impaired communication, agitation/aggression, decreased appetite, urinary/fecal incontinence, loss of basic motor skills and self-care skills, abnormal reflexes, seizures, frequent infections.

Question 75

Tx of Alzheimer’s

Answer 75

No cure but CHOLINESTERASE inhibitors and MEMANTINE to reduce/stabilize memory loss, confusion, other cog sx.

Cholinesterase inhibitors (done-evil, rivastigmine) -> delay breakdown of ACh.

Memantine -> NMDA receptor antagonist/regulates glutamate.

Therapy: cog/bx intervention to improve cog functioning/reduce prob bx. Also antidepressants for depression/irritability, anxiolytics for anxiety and restlessness, and antipsychotics for mania or psychosis.
-remaining at home = better outcomes (then nursing home).

Question 76

NCD w/Lewy Bodies

Answer 76

Buildup of Lewy bodies (abnormal protein).

-Gradual onset/progression.
-CORE FEATURES: Fluctuating cognition w/variations in attn/alterness, recurrent VISUAL HALLUCINATIONS, and sx of Parkinsonism that develop AFTER cog sx.
-SUGGESTIVE FEATURES: REM sleep bx disorder and severe neuroleptic sensitivity.
For Probable, need 2+ core or 1core and 1suggestive.
For Possible, need 1core and 1sugg. or 2+sugg.

Lewy bodies = Eary cog sx impact attn and visuospatial and EF. Cog sx BEFORE/SAME TIME as motor sx.
Alzheimer’s = Early cog sx impact learning/memory.
Parkinsons= Motor sx before cog. sx.

Question 77

Vascular Neurocognitive Disorder

Answer 77

Meet criteria for major/mild NCD AND sx consistent w/ vascular event (e.g., stroke) OR prominent decline in complex attn/EF; evidence of cerebrovascular disease.

• Prognosis: depends on cause. May be acute onset w/partial recovery, stepwise decline, pr progressive course w/fluctuations in sx severity and duration plateaus.
• Risks: hypertension, heart disease, diabetes mellitus, obesity, high cholesterol, cigs.

Question 78

NCD due to HIV Infection

Answer 78

Meet major/mild NCD PLUS have HIV.
Sx similar to damage to subcortical areas. Include: forgetfulness, impaired attn/concentration, cog slowing, psychomotor retardation, clumsiness, tremors, apathy, social withdrawal.

Question 79

NCD due to Prion Disease

Answer 79

Meet major/mild NCD.
Slow onset followed by RAPID PROGRESSION. Include motor features or biomarker lesions on MRI.

Types: Creutzfeldt-Jakob (CJD) disease -> rapid progression and meet major NCD in 6mo.
-Can be Sporadic (most common, unknown cause), Familial (inherited), Acquired/Variant (infected meat), Iatrogenic (via blood transfusion).

Sx: confusion/disorientation, impaired memory/judgement etc., ataxia, myoclonus chorea (jerky involuntary movements), etc., apathy, anxiety, mood swings.

Question 80

Frontotemporal Neurocognitive Disorder

Answer 80

MOST COMMENT FOR EARLY-ONSET NCD (before 65). Gradual onset/progression, NO sig impact on learning/memory/perceptual-motor functioning, AND meet criteria for behavioral or language variant.

Behavioral (most common): impacts social cognition, EF (planning), plus 3+ of following: disinhibition, apathy, inertia, loss of sympathy/empathy, RRB’s, hyperorality (examine objects by mouth), dietary issues.

Language (AKA Primary Progressive Aphasia or PPA): Prominent decline in language. Impacts speech production, word finding, object naming, grammar, word comprehension.
-Semantic (impaired written and spoken comprehension), agrammatic/nonfluent (impaired grammar and effortful speech), logopenic (word finding issues, repetition of phrases/sentences)

Question 81

Pica

Answer 81

• 1 month and inappropriate to developmental level.
• not culturally/socially acceptable.
• more common for children but elevated rate for pregnant women.

*leads to intestinal obstruction, lead poisoning, other complications.

Question 82

Anorexia Nervosa

Answer 82

Dx: MUST have intense fear of gaining weight, body dysmorphia, or lack of awareness of seriousness of low weight. Specifiers to indicate type (restricting, binge-eating/purging), course (partial remission, full remission), and severity (per BMI).

• Co-occurs w/depression or anxiety disorder (e.g., OCD).
• Anxiety PRECEDES onset.
• Tx: frequent relapses, ppl often deny problem/resistant to tx.
• Prognosis poorer at first than bulimia BUT long-term outcomes may be similar. 31.4% recover at 9year f/u but 62% recover at 22year f/u. (compared to 68% at 9 and 22 f/u for bulimia).

Tx: First restore healthy weight/address physical complications. THEN increase tx motivation, psychoed, ID/change beliefs/attitudes/emotions, improve impulse control/low self-esteem, enlist social support (e.g., family therapy), help ID strategies to prevent relapse.
Strategies:
-Enhanced CBT for eating disorders (CBT-E)…focus nonclinical perfectionism, core low self-esteem, intense mood states, interpersonal difficulties.
-Family-based tx (FBT). Outpatient. For teens. Phases are FULL PARENTAL CONTROL, GRADUAL RETURN OF CONTROL, ESTABLISH APP AUTONOMY AND HEALTHY FAM RLTP.

Meds: inconsistent. Antipsychotic olanxapine to initially gain weight and SSRI fluoxetine to improve weight maintenance MAY help. But meds rec meds only tx comorbid sx (depression/anxiety).

Question 83

Bulimia Nervosa

Answer 83

Recurrent episodes of binge-eating w/ sense of lack of control, inappropriate compensatory bx to prevent weight gain (e.g., purging, excessive exercise), and neg self-eval. EPISODES MUST OCCUR AT LEAST ONCE A WEEK FOR 3+ MO.

• Specifiers for course and severity (#of episodes).
• Co-occurs w/depression and anxiety. Anxiety SOMETIMES precedes eating disorder. Medical complications bc of compensatory bx (dental issues, electrolyte imbalance -> heart arrhythmias, gastroesophageal reflux).

Tx: nutritional rehab+CBT/IPT. (CBT preferred bc IPT takes longer). Meds-SSRI’s/tricyclic for depression AND reducing binge/purge for those w/o depression. Inconsistent if CBT needs meds - combo may be best for full remission; CBT alone may have lowest rate of dropout. *med alone=worst outcome.

CBT-E most effective. 4 stages.

1. engage in tx, ID what’s maintaining, establish self monitoring, psychoed, establish regular patterned eating.
2. Brief transition stage. Review progress, ID new probs/barriers, revise if needed.
3. Address over-evaluation of self, explore origins, ID triggers, address clinical perfectionism, low self-esteem, interpersonal probs.
4. ID ways to maintain progress/reduce relapse.

*telepsych comparable to face2face BUT slight (but not sig) higher rate of abstinence from binge/purge for face2face CBT and less eating-disordered cognitions.

Compared to anorexia…more distress by sx and more motivated to change. Higher autonomous/intrinsic motivation (but not controlled/extrinsic) predict lower dropout and great sx reduction.

Question 84

Elimination Disorders

Answer 84

Enuresis. Needs to occur 2+ times/week for 3+mo OR cause sig distress/impaired functioning. Must be @least 5yo. Can be nocturnal, diurnal, or both.

Tx: Moisture alarm (bell-and-pad) or antidiuretic hormone (DESMOPRESSIN) for bedwetting (higher relapse though when used alone and discontinued).

Question 85

Insomnia Disorder

Answer 85

3+ dx: difficulty w/ sleep onset, maintenance, early waking w/inability to return to sleep. Sleep disturbance -> 3x/week, 3+mo.

3 types: sleep-onset (initial), sleep maintenance (middle), and late (early morning awakening).
-Combo most common overall but of single types, maintenance insomnia most common (followed by onset).

Tx: cognitive-behavioral intervention that incorporates stimulus control or sleep restriction with sleep-hygiene education, relaxation training, and/or cognitive therapy.

• stimulus control = strengthen bedroom cues for sleep (only go to bed when tired)
• sleep restriction = limit time allotted for sleep to match sleep requirements

Question 86

Narcolepsy

Answer 86

3x/week for 3+mo.

• requires episodes of cataplexy (loss of muscle tone; triggered by strong emotion), hypocretin deficiency, or a rapid eye movement latency of 15 minutes or less (per nocturnal sleep polysomnography).
• may have hypnagogic (just before sleep) or hypnopompic (just after waking) hallucinations, and/or sleep paralysis.

Tx: combo therapy/meds.

• bx: good sleep hygiene, naps, active.
• meds: improve alertness (modafinil/armodafinil for +dopamine, stimulants for +dopamine, +serotonin, +norepinephrine) and reduce cataplexy (anti depressant like venlafaxine, fluoxetine, clomipramine). Sodium oxybate for nonresponders (natural chemical taken @bedtime to improve deep sleep and reduce cataplexy/daytime sleepiness).

Question 87

Non-Rapid Eye Movement Sleep Arousal Disorders (sleepwalking and sleep terrors)

Answer 87

Both: recurrent episodes of incomplete awakening @ Stage 4/5 Sleep in first 3rd of major sleep period. Occur mostly in childhood and decrease w/age. Person unresponsive to awakening or comfort w/little memory of episode.

Sleepwalking: get out of bed, include sleep-related eating or sexual bx.

Sleep terror: abrupt arousal w/panicky scream, intense fear, autonomic arousal (tachycardia, rapid breathing).

Question 88

Nightmare Disorder

Answer 88

Nightmares: occur during REM sleep in second half of major sleep period. If awaken, person oriented/alert but experiences dysphoric mood.

Question 89

Oppositional Defiant Disorder

Answer 89

Requires recurrent angry/irritable mood, argumentative/defiant bx, and/or vindictiveness via 4+ more characteristic sx (and not w/sibling).

-Sx 6+mo. Cause distress for individual and others OR neg impact on functioning.

• Age: ODD more common in young boys, but then equal in older children/teens.
• 30% eventually get Conduct disorder dx (especially if early age of sx onset).

Tx: multimodal and tailored. Psychosocial interventions are first line.

Question 90

Conduct Disorder

Answer 90

Patterned bx that violates basic rights of others and/or age-appropriate social norms/rules.

Sx in FOUR categories: aggression to people and animals, destruction of property, deceitfulness or theft and serious violation of rules.

• Need 3+ sx in 12mo AND 1+ in past 6mo.
• Can’t be over 18 and meet criteria for antisocial personality disorder.
• more common in males. sx usually emerge btwn middle childhood and middle adolescence.
• SUBTYPES: childhood-onset (1+ sx before 10yo), adolescent-onset (no sx before 10yo), and unspecified onset.

*childhood-onset = greater risk for Antisocial Personality Dis.; more aggression; substance-related dis.

Question 91

Etiology of Conduct Disorder

Answer 91

ETIOLOGY (bio, environment, prenatal exposure to opiates/alcohol)

neuro: reduced serotonin/dopamine = +aggression, reduced sensitivity to punishment, +risk-taking.
- more cortisol for teens w/CD in evening. Atypical cortisol/cardiovascular response to stressful events despite reporting similar +neg. affect to teens w/o CD.

Moffitt (1993)
LIFE-COURSE-PERSISTANT TYPE (+anitsocial bx that are consistent; due to neuro deficit/adverse child-rearing environment).
ADOLESCENCE-LIMITED TYPE (temp and due to maturity gap btwn bio/sexual maturity and social maturity…use antisocial bx to gain mature status)

*Per DSM-5, remits by adulthood (typical for adolescent onset) but not for childhood onset.

Question 92

Tx of Conduct Disorder

Answer 92

CHILD-FOCUSED INTERVENTION
-Problem-solving skills training (PSST): Help perceive others feelings, understand consequences, and ID prosocial ways to resolve interpersonal probs/conflicts.

PARENT-FOCUSED INTERVENTION

• Parent management training - Oregon model (PMTO): (for 2-18yo) Child prob bx’s due to escalating cycle of coercive parent-child interactions. Teach positive parenting practices (pos reinforcement, set limits, etc.)
• Kazdin’s parent management training (PMT): (for 2-17yo) Based on operant conditioning ->replace antecedents and consequences that maintain prob bx. COMBO w/PSST is most effective.
• Parent-child interaction therapy (PCIT): (for 2-7yo) Alter neg parent-child interactions and consists of child-directed interaction phase (to enhance relationship) and parent-direction interaction phase (to teach effective discipline)

FAMILY-FOCUSED INTERVENTION

• Functional family therapy (FFT): (for 11-18yo). Prob bx’s in family regulate relational connections(interdependence or independence) and regular relational hierarchies (w/power structures). Goal to replace prob bx that serve same function.
• Multidiminsional family therapy (MDFT): (11-21yo more for substance use). Includes family systems/ecological theory, and dev psych. Goal to reduce/eliminate substance use, aggression, etc. Facilitate change in 4 domains: adolescent, parents, family interactions, and extra -familial influence

MULTIMODAL INTERVENTION
Multisystemic therapy (MST): (12-18yo; more if getting kicked out). Based on Bronfenbrenner - prob bx due to multiple risk factors. MST-CAN for 6-17yo and abused/neglected.
Multidimensional treatment foster care (MTFC): Alt to residential care. Includes Bx management plan. Tx team includes home, school, community. Reside w/highly trained and supervised foster parents (while bios get help).

**Scared Straight and other confrontational or educational approaches have neg effects/don’t work

Question 93

Intermittent Explosive Disorder

Answer 93

Failure to control aggressive/bx outbursts. Verbal/Physical Aggression occurs 2x/week for 3+mo (no damage to property/others), 3+ outbursts in 12mo (that do damage).
-outburst not premeditated, tied to tangible outcome, or provoked.
MUST BE AT LEAST 6. Onset in childhood/adolescence.