Specialty Disciplines - Psychiatry

Cluster B Personality Disorders

"Dramatic, wild, erratic, impulsive and emotional"

What are the Cluster C personality disorders?

"anxious, fearful" and "worried" i. Dependent ii. Obsessive-compulsive iii. Avoidant

What are the Cluster A personality disorders?

"weird, wacky, odd and eccentric" i. Paranoid ii. Schizoid iii. Schizotypal

Intermittent Explosive Disorder

**Don't need to know this in depth. Just know it exists**

Characteristics of Coercive Parent-Child Interactions

**More often then not, kids with ODD have parents who treated them like this

Cluster C Personality Disorders

Anxious, worried and fearful

Peak Symptoms: • Heroin • Buprenorphine • Methadone

Heroin: 3-4 days Buprenorphine: 4 days Methadone: 8 days

Psychiatric Conditions in Children and Adolescence

Neurodevelopmental Disorders - Intellectual Disability - Autism Spectrum Disorder - Attention-Deficit/Hyperactivity Disorder Disruptive and Impulse-Control Disorders - Oppositional Defiant Disorder - Conduct Disorder Gender Dysphoria Mood Disorders - Anxiety Disorders - Depressive Disorders - Suicidal Behavior

Panic Disorder - Treatment

SSRI's 1st line (Paroxetine, Sertraline, Fluoxetine); SNRI's also used (ex. Venlafaxine)

Unconsciously-Produced Somatoform Disorders

Somatic symptom, illness anxiety, and conversion disorders In somatic symptom, illness anxiety, and conversion disorders the symptoms and illness motivation are NOT intentionally produced (unconscious).These are more common in women.

Narcolepsy - Treatment

Stimulant drugs such as Sodium oxybate and Modafinil

Schizophrenia - Treatment

Antipsychotic medication as well as close psychiatric follow-up PPP: 1. Antipsychotics: dopamine receptor antagonists - 2nd generation: 1st line treatment for schizophrenia* ex. Risperidone, Olanzapine, Quetiapine - 1st generation: ex. Haloperidol and Chlorpromazine are better at treating the positive symptoms but are associated with increased extrapyramidal symptoms SEE HANDOUT "DRUGS FOR PSYCHOSIS" -- TESTABLE MATERIAL

Anorexia Nervosa - Level of Severity

Based on WHO categories of thinness in adults Mild: BMI >/= 17 kg/m^2 Moderate: BMI 16-16.99 kg/m^2 Severe: BMI 15-15.99 kg/m^2 Extreme: BMI <15 kg/m^2 Also reflected by symptoms and degree of functional disability

Gender Dysphoria - DSM-5 Diagnostic Criteria

Children A. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least six of the following (one of which must be Criterion A1): 1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one's assigned gender). 2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing. 3. A strong preference for cross-gender roles in make-believe play or fantasy play. 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. 7. A strong dislike of one's sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender. B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning. Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivity syndrome). Coding note: Code the disorder of sex development as well as gender dysphoria. Adolescents A. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least two of the following: 1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics). 2. A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). 3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender). B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivity syndrome). Coding note: Code the disorder of sex development as well as gender dysphoria. Specify if: Posttransition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen—namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female).

Gender Dysphoria - Clinical Presentation

Clinical Presentation - Males: preoccupation with activities that are traditionally considered feminine (dressing in female clothes and having feminine appearance, female role-playing, drawing pictures of females, playing with feminine toys and predominantly female peers, interest in female fantasy figures), express wish to become a female, pretend to not have male genitalia - Females: preoccupation with activities that are traditionally considered masculine (dressing in male clothes and having masculine appearance, male role-playing, drawing pictures of males, playing with masculine toys and predominantly male peers, interest in male fantasy figures), express wish to become a male, pretend to have male genitalia or will eventually grow them - Wish to proceed with medical (hormones) or surgical treatment to become other sex Important things to consider: - Is this significant enough to proceed with medical/surgical therapy and does patient WANT that - What do parents perceive and what are their wishes/concerns/expectations - Ask which pronoun they prefer

Which of the following is/are true regarding Binge eating disorder? A. Binge eating disorder is the most common eating disorder B. Folks with binge eating disorder do not purge C. Many folks on "weight loss programs" are suffering from binge eating disorder D. All of the above are true

D. All of the above are true

Which of the following is/are true regarding Bulimia? A. Folks suffering a from bulimia can be hard to detect B. Folks with bulimia binge and purge C. Those with bulimia are usually average weight D. All of the above are true

D. All of the above are true

Which of the following is/are true regarding anorexia nervosa (AN)? A. Folks suffering from AN might restrict caloric consumption B. Folks with AN might binge and purge C. Those with AN are usually underweight D. All of the above are true

D. All of the above are true

Manic and Hypomanic Episodes

DIGFAST https://unelib.kanopy.com/video/mental-disorder-illness-symptoms?pos=4 (Mania) Watch together https://unelib.kanopy.com/video/mental-disorder-illness-symptoms?pos=4 (Pressured speech)

Suicidal Behavior - Determining Level of Care in ED and Outpatient Treatment

Determining Level of Care in ED • Need for hospitalization: increased risk of repetition and completion - Persistent suicidal ideation - Serious intent or high lethality of an attempt - History of multiple attempts - Severe depression or psychosis - Persistent, current, serious life stresses - Active substance use - Minimization by patient and punitiveness by parents - Family turmoil (physical/sexual abuse, active parental substance use, parental psychosis, high expressed emotion) • Outpatient treatment - Unwavering parental support, high level of direct supervision, complete commitment to treatment - Guarantee that firearms, dangerous meds, and poisons will be secured in household Measures to Ensure Safety • Means restriction - No firearms in home - No lethal quantities of medication or poisons • Safety plans and "no harm" contracts - Review precipitant of current suicidal episode - Plan for reasonable steps to be taken by patient and family if stresses recur - Devise coping measures - Identify responsible adults who patient can turn to for help - How emergency mental health providers (or treating provider) can be contacted - End with explicit agreement by patient to refrain from self-harm, employ alternatives agreed upon, and to contact provider if suicidal thoughts return Optimize Treatment Compliance and Follow-Up: - About half of adolescent suicide attempters receive little to no follow-up outpatient treatment - Arrange appointment BEFORE child leaves ED - Provider should personally contact accepting agency instead of leaving it to patient or family Psychotherapeutic Interventions - Target hopelessness, emotional dysregulation, and impaired emotional and social problem solving - Address family, social, school and other stressors that precipitate, exacerbate or perpetuate suicidal impulses Psychopharmacologic Interventions: - Treat underlying mental disorders

Adjustment Disorder - Diagnostics

Diagnostic clues: presenting complaints include a "nervous breakdown", inability to manage life problems, and overwhelming anxiety or depression associated with life stressors. The person often exhibits normal functioning before the onset of the stressor, and mental status exam shows anxiety, depression or disturbed conduct Diagnostic Criteria: 1) Occurs within 3 months of the onset of a stressor 2) Marked by distress that is in excess of what would be expected, given the nature of the stressor, or by significant impairment in social or occupational functioning 3) Should not be diagnosed if the disturbance meets the criteria for another Axis I disorder or if it is an exacerbation of a preexisting Axis I or II condition 4) Should not be diagnosed when the symptoms represent bereavement (grief) 5) The symptoms must resolve within 6 months of the termination of the stressor but may persist for a prolonged period (longer than 6 months) if they occur in response to long-term exposure to a stressor or to a stressor that has enduring consequences **Subtypes include: adjustment disorder with depressed mood, or with anxiety, or with disturbance of conduct, or with mixed disturbances of emotions and conduct ex. 28-yr-old female becomes bitter and angry when her husband of 5 years leaves her for a younger man. One week later, the woman quits her job without giving notice, and begins drinking heavily. She telephones friends over the next several weeks and tells them how she has passive suicidal ideation. She also makes several threatening calls to the new boyfriend. Husband came back and her stressor went away

Hoarding Disorder

Diagnostic criteria include persistent difficulty in discarding or parting with possessions regardless of actual value, an accumulation of possessions that congests living areas, and it causes clinically significant distress or impairment. - Insight can be good or poor into this condition and there can be delusional content - As it is a new diagnosis, not much is known about it Treatment: same as above; serotonergic agents; CBT primarily Example: 50-year-old female with a past history of sexual abuse presents with recurrent abrasions on her legs and arms, and a mild concussion last week. Visiting nurse reports that her house is in disarray, and she has trash bags and boxes filled with material stacked to the ceiling in her home. Her bathroom plumbing is not functional, and the toilet and bathtub are filled to the brim with feces and dried urine; there is a strong ammonia smell in the house

Separation Anxiety Disorder - Diagnostic Criteria

Diagnostic criteria loosely include excessive or persistent anxiety surrounding leaving the caregivers, fantastic worries, school refusal, academic difficulties, co-morbid depression, and familial conflict over separation i. Kids may also worry about harm befalling parents, and as a result the child is reluctant to leave the home, fearing never seeing them again ii. They often feign illness to avoid leaving the home 2. Symptoms exacerbate due to acute stress, death of a relative, abuse, etc. Always look for a trigger and try to treat that trigger. Symptoms can wax and wane.

Trichotillomania

Diagnostic features: this is "hair pulling disorder," which is recurrent hair pulling that results in hair loss; there are attempts to decrease or stop the hair pulling; there is clinically significant distress or impairment. Treatment: same as above for other anxiety disorders (SSRI's, etc.) Example: 49-yr-old female presents with major depressive disorder, and in the examination you notice that she has patches of hair missing; during the encounter, she is twirling her hair in her fingers, and you notice that she pulls a strand out at a time and rolls it into a ball in her fingers.

A 7-year-old girl is brought to her pediatrician on the suggestion of her second-grade teacher. The patient has been back in school for 3 weeks following a summer break. According to the teacher, the patient has found it very difficult to complete her classroom tasks since returning to school. The child is seldom disruptive but cannot finish assignments in the allotted time although her classmates do so without difficulty. She also makes careless mistakes in her work. Although she is still passing her classes, her grades have dropped, and she seems to daydream a great deal in class. The teacher reports that it takes several repetitions of the instructions for the patient to complete a task (e.g. in an art class). The patient enjoys physical education and does well in that class. The child indicates that when it appears to others that she is not paying attention she is thinking about other things. Teachers report that her attention wanders constantly and they have to call her name or wave to get her immediate attention. There have been no episodes where she stares blankly or is briefly nonresponsive. Although her parents have noticed some of the same behaviors at home, they have not been particularly concerned because they have found ways to work around them. If they monitor the child and her work directly, she can complete her homework, but they must continually check her work for careless mistakes. She does seem to know the right answer when it is pointed out. The parents also report that the patient does not get ready for school in the mornings without moment-by-moment monitoring. Her bedroom is in shambles, and she loses things all the time. The parents describe their daughter as a happy child who enjoys playing with her siblings and friends. They note that she does not like school, except for the physical education classes. She does not have any symptoms of depression, psychosis, or developmental problems.

Dx: ADHD, inattentive type (girls usually have inattentive whereas boys have hyperactivity) Tx: - Environmental restructuring - Behavioral therapy - Parent education on effective parenting - Classroom modification programs - Stimulant medication --> Atomoxetine if stimulant contraindicated or tx failure

A 2½-year-old boy is brought to a pediatrician by his parents for his regular yearly examination. He is the couple's only child. The parents relate a normal medical history with a single episode of otitis media. They recently placed their son in day care for 2 half-days a week. However, he has not adjusted well, crying and having tantrums during the first hour of school. Then he usually quiets down, but he does not interact with the rest of the children. The teacher cannot seem to make him follow directions and notes that he does not look at her when she is near him and attempting to interact with him. On further discussion with the parents, the pediatrician finds that the patient has only a limited vocabulary of perhaps 10 words. He does not use these words in any greater length than two words in a row and often uses them inappropriately. He did not speak his first clear word until 6 to 9 months. The patient does not interact well with other children but does not seem upset by them. His favorite toys are often used inappropriately-he performs single, repetitive movements with them for what seems like hours on end. The pediatrician picks the child up to help him onto the examination table and notices that he seems quite stiff, pushing himself away from the examiner with his hands. Although his hearing and eyesight appear to be intact, the child does not respond to requests by the pediatrician and does not make eye contact. All other gross neurologic and physical features are within normal limits.

Dx: Autism Spectrum Disorder Tx: - Environmental restructuring - Behavioral therapy - Parent education on effective parenting - Classroom modification programs Speech therapy/OT

A 15-year-old girl is brought to a psychiatrist by her parents because they are concerned that she might be depressed. The parents had no complaints until 2 or 3 years ago. The patient's grades have fallen because she cuts classes. She gets into fights, and her parents claim that she hangs out with the "wrong crowd"; some nights she does not come home until well past her curfew. The patient says that there is "nothing wrong" with her and that she wants her parents to "butt out of her life." She claims that she is sleeping and eating well. She says she skips school to hang out with her friends and admits that they frequently steal food from a convenience store and spend time watching movies at one of their homes. She claims that she fights only to prove that she is as tough as her friends but admits that she often picks on younger students. She shows limited guilt or remorse about this. She seems cold and uncaring about how her behavior might affect others. She is not concerned about her grades and just wants her parents to "lay off" and let her enjoy her youth. She denies the use of drugs or alcohol other than occasionally at parties. She denies having any depressive symptoms such as sleep or appetite disturbances and says she feels pretty good about herself. She does not report any suicidal or homicidal thoughts. Her blood alcohol level is zero, and the results of a urinalysis are negative for drugs of abuse.

Dx: Conduct Disorder Tx: - Intensive parent education on effective parenting - Individual and family therapy - Maybe medications to reduce aggression, anxiety, or comorbid ADHD

A 10-year-old girl from a close, supportive family presents to her pediatrician for abdominal pain and behavior problems. She complains several times of severe abdominal pain that is worst in the morning and never present at night. She has missed about 20 days of school during the previous year because of the pain. She also avoids school excursions, fearing the bus would crash. She has difficulty falling asleep and frequently asks her parents for their reassurance. She used to be a shy, reserved young girl at pre-school, but she had integrated well in grade 1 and began making friends and succeeding academically. She worries that she and members of her family might die. She is unable to sleep at all before a test. She cannot tolerate having her parents on a different floor of the house from herself, and she insists on securing the house to an unnecessary extent in the evenings, fearing intruders. Her insecurity, need for constant reassurance, and school absenteeism are frustrating and upsetting for her parents. Hannah has no personal history of traumatic events.

Dx: Generalized Anxiety Disorder Tx: Behavioral therapy SSRI medication like fluoxetine considered

A 4-year-old girl was brought to the infant/preschool mental health clinic by her parents because of concerns about extreme irritability, periods of social withdrawal, negativity, and periods of decreased appetite during which she lacks interest in even her favorite foods. These behaviors were first noted by her parents at age 3 and have been increasing in intensity and frequency until becoming the source of family problems. She attends preschool 3 half days a week, and no problems have been reported in that setting. There is a family history of affective disorders. Both parents are employed, there are no reported significant psychosocial stressors, and two older siblings are developmentally on track without behavioral or emotional problems. On further interview, her parents described her as reacting to minor frustrations with intense sadness and/or anger often lasting hours. Along with these symptoms, a lack of interest in activities and play was also noted. Play observations with the child interacting in turn with each parent revealed a young child who displayed elaborate and age-appropriate representational play as well as intact motor and language skills. However, also notable was a preoccupation with negative play themes and pessimistic thoughts. Despite being engaged, she was unusually quiet and withdrawn during play, and this mood state was sustained throughout both play observations. Despite an interest in play, she lacked the expected age-appropriate exuberance during play.

Dx: Major Depressive Disorder, moderate Tx: Behavioral therapy SSRI medication like fluoxetine considered

A 12-year-old boy presents to his pediatrician because his parents are concerned about his behavior. He does not have any friends or associates. He also has a history (five years) of becoming agitated and angry with his family members when he is asked to do any household chores or his homework. He challenges everything he is asked to do, including getting up in the morning and preparing for school. He is isolated and often grounded at home because he refuses to do what is expected of him. He is not doing well in school, because his interactions with peers and teachers are mostly negative and contrary. He often starts arguments with his peers. He does not complete his schoolwork during class and often tears up assignments or throws them in the trash rather than handing them to the teacher. Because of his lack of progress in school, he was placed in a behavior adjustment class and labeled as emotionally disturbed. In the class, he often blames others for his misbehaviors and refuses to take responsibility for any of his actions. He becomes angry quickly when he is asked to comply with rules.

Dx: Oppositional Defiant Disorder Tx: - Intensive parent education on effective parenting - Individual and family therapy - Maybe medications to reduce aggression, anxiety, or comorbid ADHD

A 10-year-old boy with chronic asthma is brought to a pediatrician for his 6-month checkup. In addition, he has complained of chronic headaches for the past 3 months, as well as increasing gastric upsets, which his family believes are caused by multiple food allergies. The patient has a severe allergy to peanuts, which limits the number of places he can go in public. Thus, he has been homeschooled for a year and is doing well. A review of his history shows that he is a highly articulate, thoughtful child who appears to be at or above the educational level of his peers. The child does not agree to be interviewed separately from his mother, stating, "I don't go anywhere without my mother." The two of them are almost never apart. Two years ago, the mother was hospitalized after a serious bout with lupus. She continues to struggle with her disease, and despite having a thriving career before her illness, she can do very little now. She is home all the time, dealing with her own recovery and the management of her illness. During her hospitalization, the patient was quite worried about her illness and even now believes that if he is not around to monitor her condition, she might get sick and require hospitalization again-or even worse. The mother has difficulty sleeping and is most comfortable on the living room couch. The patient no longer uses his own room but sleeps in a chair next to his mother to continue to keep an eye on her. He has very few friends and can be separated from his mother only briefly, and only if he is in the company of his brother or father. After a short period, he becomes anxious and upset and must be reunited with his mother.

Dx: Separation Anxiety Disorder Tx: Behavioral therapy SSRI medication like fluoxetine considered

Histrionic Personality Disorder

Emotionality and attention seeking behavior is expressed, and are not happy unless they are the center of attention. In order to gain attention, they often are swayed by fads, become overly trusting, and even may interact in inappropriately sexual manners. Displays of emotion are often theatrical and overly dramatic, yet are superficial and can change immediately i. Sea glass pt story https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-7 Notes: - If they have some sort of a personality insult by others, they fall apart (ex. cry at drop of hat if somebody judges them negatively) - Way they speak lacks detail and make big deal out of nothing and often talk in theatrical manner

Define Dependent Personality Disorder

Excessively clingy and have a pervasive need to be cared for. They are prone to experience separation anxiety, and jump from relationship to relationship when one ends. They have trouble making everyday decisions on their own, and they go out of their way to make sure others have responsibility to make major decisions. https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-6 Notes: - When somebody abuses them, they will cling to that person rather than act out - End up being taken advantage of often - Have no self esteem (dependent on their partner) - Have difficulty finishing projects because of low self esteem PPP: - Dependent, submissive behavior (very needy and clingy) Clinical Manifestations: - Constantly needs to be reassured, relies on others for decision-making and emotional support, will not initiate things, intense discomfort when alone. May volunteer for unpleasant tasks

Eating Disorders - Treatment

Family medicine practitioners can fill the central role in monitoring and treatment - Referral to psychotherapist or psychiatrist (ideally eating disorder specialist) --> Cognitive Behavior Therapy is cornerstone of treatment --> Family based treatment and support --> Group therapy, equine therapy (care of others), yoga/meditation (mindfulness) Goals: Reduce body image distortion, resume healthy eating, social engagement and physical activities - Referral to a dietician --> Nutritional intervention and healthy weight restoration --> Underweight: reasonable initial goal is 90% of healthy BMI, but may need to approach gradually --> Consider pre-eating disorder weight - School involvement for accommodations --> Snack breaks --> School absences

Eating Disorders - Etiologies

Genetic, Social and Psychological causes

Hallucinogens Addiction

Hallucinogens include LSD, Mescaline, PCP, Psilocybin, Dextromethorphan - Modulate serotonin, dopamine and glutamate activity - Cause euphoria, sensory distortion - Can precipitate serotonin syndrome - Benzos are possibly agents such as haldol for excessive agitation

Eating Disorders - Diagnostic Tests

If highly suspicious, consider the following: - Urine (ketones, pH, hydration, specific gravity) - Height, weight, BMI in gown (remove baggy clothes) - Temperature - Orthostatic blood pressure - EKG - CBC, CMP, Amylase and Lipase, Phosphorus, Magnesium, Thyroid Screening

Define Obsessive-Compulsive Personality Disorder

Inflexible and rigid strive for perfection ("Type A Personality; "Anal-Retentive"); rigidity is to the point that projects and tasks cannot be completed on time because they are not perfect enough. The preoccupation with details, rules, lists, and organization can be very invasive to the point that it affects interpersonal functioning. i. Contrast this to obsessive-compulsive disorder (OCD). How are they similar? Different? - OCPD is essentially a Type A inflexible person who strives for perfection - OCD is anxiety disorder marked by thoughts and recurring behaviors that interfere with functioning ii. https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-7 (OCPD) Notes: - Often do not finish projects because too concerned about it being perfect - Think of patient that gets to bottom of a type writer, messes one thing up and then tears paper up rather than covering with white out

Borderline Personality Disorder

Instability in self-image and interpersonal relationships. Impulsivity may lead to self-harm, such as drug abuse and promiscuous sex, and relationships are often polarized (black-white, love-hate) such that a pattern of extreme valuation-devaluation is expressed. This can lead to efforts to avoid real or imagined abandonment and feelings of emptiness i. Condiment patient story; contrast with bipolar disorder (often confused!) ii. "Borderline" of depression and psychosis https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-6 Notes: - If a person's personality changes rapidly (seconds, minutes, hours), we are talking about Borderline whereas if changes over days, weeks or months then talking about Bipolar disorder - Borderline = Borderline of Depression and Psychosis - Often will rebound quickly after relationships - Very impulsive - Suicidal gestures --> cutting behavior, burning or headbanging (self harm); Often say they will often feel physical pain vs. emotional pain they are feeling from their disorder - Will see a lot of patients with this disorder PPP: - Unstable, unpredictable mood and affect. Unstable self image and relationships. MC seen in women Clinical Manifestations: 1. Extreme pattern of instability in relationships but cannot tolerate "being alone". Often have "mood swings", Marked sensitivity to criticism and rejection (fear of abandonment) 2. Black and white thinking: thinks in extremes "all good" or "all bad" with no middle ground 3. Impulsivity in self-damaging behaviors: suicide threats, self-mutilation, substance abuse, reckless driving, binge eating, spending

What are the Typical drugs used for treating psychosis?

Listen to lecture at 1 hr 56 minutes

Consciously-Produced Somatoform Disorders

Malingering and factious disorder involve the intentional production or feigning of medical symptoms - Difference between 2 is type of gain they are after - Person with Factitious disorder is looking for primary gain (attaining the sick role) whereas person with malingering is looking to attain secondary gain (money, time off from work, drugs/opioids etc.) - Both of these conditions often produce anger and exasperation in doctors and medical staff which may lead to suboptimal healthcare and failure to diagnose medical conditions (Boy Who Cried Wolf) ex. they pretend to have an illness for so long and then when they really have a heart attack you don't believe them and they die i. Some patients will harm themselves during attempts

Munchausen Syndrome and Munchausen Syndrome by Proxy

Munchausen syndrome: is a chronic factitious disorder with predominantly physical signs and symptoms, characterized by a history of multiple hospital stays and willingness to receive invasive procedures Munchausen syndrome by proxy: when illness in a child or elderly patient is caused by the caregiver. Motivation is to assume the sick role by proxy a. This is a form of child/elder abuse - should be reported to authorities

Define Narcissistic Personality Disorder

Narcissistic: prone to grandiose fantasies, with the need for admiration. Generally lacking empathy, narcissists are arrogant and feel a sense of entitlement. They expect others to acknowledge their supposed superiority and feel overly jealous when others receive praise. https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-7 Notes: - Thinks they are better than everyone else - Tend to be less impulsive - Downfall is when they are confronted by someone who proves they are not as grand as they think, they fall apart - Have strong inner will but personality collapses when they are challenged PPP: - Grandiose often excessive sense of self-importance but needs praise and admiration. MC in males Clinical Manifestations: 1. Inflated self image: considers themselves special, entitled, requires extra special attention BUT they have fragile self-esteem (occupied with fantasies, jealousy of others, believes others are envious of them and has difficulty with aging process). Reacts to rejection/criticism with rage. Often becomes depressed. Lacks empathy for others.

Autism Spectrum Disorder - DSM-5 Diagnostic Criteria

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history: 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. 3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. - Severity is based on social communication impairments and restricted, repetitive patterns of behavior Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history: 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). - Severity is based on social communication impairments and restricted, repetitive patterns of behavior - Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). - Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. - These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level. Specify if: - With or without accompanying intellectual impairment - With or without accompanying language impairment - Associated with a known medical or genetic condition or environmental factor - Associated with another neurodevelopmental, mental, or behavioral disorder - With catatonia

Antisocial Personality Disorder

Pervasive pattern of disregard for and violation of the rights of others. Very impulsive and show disregard for the safety and welfare of others and of themselves. They fail to conform to social norms, participate in unlawful activities, and lack remorse for those they have wronged. https://unelib.kanopy.com/video/icd-9-guided-collection-vol-7 Notes: - Conduct Disorder --> hurting animals, being unlawful, etc. - Most personality disorders you need to be 18 to be diagnosed with it because until then your personality is still developing - Lack a Superego; Superego = what governs how somebody functions; part of personality that instills morality in what you do and don't do - Obligations not honored --> ex. might get girlfriend pregnant and refuse to father them - Safety of self and others ignored --> don't see this as a disorder and act impulsively - Aggressive --> think about Aaron Hernandez how he killed somebody because they spilt his drink PPP: - Behaviors deviating sharply from the norms, values and laws of society (harmful or hostile to society). May commit criminal acts with disregard to violation of laws. - May begin in childhood as conduct disorders but must be >18y to diagnose - 3x more common in males Clinical Manifestations: 1. Inability to conform to social norms with disregard and violation of the rights of others, lack of empathy, pattern of criminal behavior, shows little anxiety. Extremely manipulative, deceitful, impulsive, promiscuous, spouse/child abuse, lacks remorse, lies frequently, endangers others (ex. drunk driving common)

Illness Anxiety Disorder

Preoccupation with and fear of having a serious medical illness despite medical evidence and reassurance to the contrary https://unelib.kanopy.com/video/icd-9-guided-collection-volumn- PPP: - Preoccupation with the fear or belief one has or will contract a serious, undiagnosed disease (despite reassurance and medical workups showing no disease) - Symptoms last >6 months - Somatic symptoms often not present (if they are, they are mild) - Age 20-30y Management: Regularly scheduled appointments with their medical provider for continued reassurance

Differentiate Primary Psychiatric Disorder and Secondary Psychiatric Disorder

Primary Psychiatric Disorder --> Major Depressive Disorder Tx: Psychotherapy, antidepressants Secondary Psychiatric Disorder --> Depressive disorder due to hypothyroidism Tx: often medical or drug abuse cause so treat that medical or drug problem

What are clinical features of Psychosis/How is it defined?

Psychosis is defined if one or more of the following: A. Hallucinations - sensory impressions that occur without external stimulation of the relevant sensory organ (auditory, visual, tactile, gustatory, olfactory) ex. look over and see lamp that isn't there B. Delusions - fixed, false beliefs even in the presence of evidence to the contrary. The beliefs are firmly held and do not waver (Patient: "My face is made out of air.") ex. see lamp and think it's a monster C. Disorganized speech - incoherence or rambling, such as intermittently muttering and shouting unintelligible statements and monologues. (Neologisms, derailments) ex. make up words D. Disorganized behavior - aimless, bizarre, agitated, or grossly inappropriate behavior (wandering alone dressed inappropriately) ex. behavior that looks strange and out of ordinary E. Disorganized motor behavior - aka catatonia, marked motor abnormalities, including immobility, excessive motor activity, extreme negativism, mutism (don't speak), posturing (ex. waxy flexibility), stereotyped movements, echolalia, and echopraxia F. Negative symptoms - such as diminished emotional expression and avolution (lacking symptoms of normal individual)

Bulimia Nervosa - Diagnostic Criteria (DSM-5)

Recurrent episodes of binge eating characterized by both of the following: 1) Eating in a discreet period of time (ex. within any 2 hr period) an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances 2) A sense of lack of control over eating during the episode - Includes recurrent inappropriate compensatory behaviors in order to prevent weight gain such as purging (self-induced vomiting), laxative abuse, diuretics, fasting, excessive exercise - The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months - Self-image is unduly influenced by body shape and weight - Not associated with anorexia nervosa

Obsessive-Compulsive Disorder - Diagnostics

Recurrent obsessions and/or compulsions that are disruptive to the patient's life, and greatly interferes with daily functioning (must be at least 1 hour a day per DSM) - Obsession: recurent thought that individual has difficulty getting out of mind (ex. did I lock my car?; Counting) - Compulsions: Recurrent act (ex. going to check if they locked their car over and over again) - Do not need both obsession and compulsion to have OCD - There is an association with this diagnosis and ADHD and Tourette Syndrome so important to check for these as well ("Terrible Triad") **OCPD is perfectionist Type A personality whereas OCD is obsessive-compulsive disorder

Excoriation (skin-picking) disorder

Recurrent skin picking and there are attempts to decrease the skin picking which are often met with failure; this causes clinically significant distress or impairment - Constantly picking at scabs

Timeline Schizophrenia ______ months Schizophreniform disorder: _____-_____ Brief psychotic disorder: ______ to ______

Schizophrenia --> >6 months Schizophreniform --> same diagnostic criteria as Schizophrenia but 1 month to 6 months Brief Psychotic Disorder --> 1 day to 1 month Symptoms are virtually identical to schizophrenia, but the timeline differs for the two other conditions above

Anxiety Disorders in Children and Adolescents - Clinical Presentation

Separation Anxiety -Severe distress when separated or threatened with separation from their parent (usually mother) -Wish to sleep in parental bed, nightmares about separation - Refusal to be alone, school refusal - May run away from school and hide near home - Comorbid conduct disorders or ADHD - Somatic symptoms when forced to separate (more in adolescents) ---Abdominal pain, nausea, vomiting, diarrhea, urinary frequency, palpitations, PANIC ATTACKS Generalized Anxiety - Worry about clothes, schoolwork, social relationships, sporting performance - Worry about past/present/future - Exceedingly self-conscious, low self-esteem, perfectionism, need reassurance - Impaired concentration/focus - Withdrawal from activities - Comorbid depression - Somatic symptoms ---Headaches, nausea/vomiting, diarrhea, abdominal pain, SOB, palpitations, globus sensation, diaphoresis, urinary frequency, dry mouth, muscle tension/aches/twitching/tremors

Anxiety Disorders in Children and Adolescents - Prognosis

Separation Anxiety - Variable (complete recovery vs. chronic anxiety) - More likely to develop panic disorder/agoraphobia/depressive disorders in adolescence/adulthood Generalized Anxiety - Acute vs. Chronic - More likely to develop other anxiety disorders and/or depression - At risk for substance use in adolescence - Higher risk for cardiovascular and GI disorders in adulthoo

Binge Eating Disorder - Severities

Severity based on frequency of binge eating episodes Mild: 1-2 binge eating episodes per week Moderate: 4-7 episodes per week Severe: 8-13 episodes per week Extreme: 14 or more episodes per week

Bulimia Nervosa - Level of Severity

Severity based on frequency of inappropriate compensatory behaviors Mild: 1-3 episodes/week Moderate: 4-7 episodes/week Severe: 8-13 episodes/week Extreme: 14 or more episodes per week

What are the stages of opiate withdrawal syndrome?

Stage I: Up to 8 hours Fear of withdrawal, anxiety and drug craving Stage II: 8-24 hours Insomnia, restlessness, anxiety, yawning, stomach cramps, lacrimation, rhinorrhea, diaphoresis, mydriasis (dilation of pupils) Stage III: Up to 3 days Vomiting, diarrhea, fever, chills, muscle spasms, tremor, tachycardia, piloerection, hypertension, seizures* (seizures only seen in neonates) Symptoms attributable to rebound sympathetic nervous system activity. Long-term opiate use promotes neurological adaptations that bring neurons in the locus ceruleus, the major noradrenergic center in the brain, closer to their normal firing rates.

Define Psychosis

Syndrome characterized by gross impairment in the ability to assess reality and behave coherently - Attitudes toward psychotic individuals vary greatly, from fascination to distain to disgust; psychotic individuals in the past have thought to be deities, or monsters, and have been both honored and neglected and mistreated - Psychosis is observed in all cultures, and is never a normal phenomenon - The presence of psychosis is of critical importance as its presence is accounted for by few psychiatric disorders

General Principles of Addiction

The DSM-5 has replaced "Abuse" and "Dependence" with: • Substance Use Disorder - Mild - Moderate - Severe • Modifiers: - Early remission - Sustained remission - "on maintenance therapy" Addiction is a primary, chronic, and relapsing disease of neurochemical and psychiatric reward, motivation, tolerance, disinhibition, and behavioral conditioning with significant health and social consequences.

Malingering

The intentional/conscious production of false or grossly exaggerated physical or psychological symptoms and is motivated by external incentives. a. Involves "faking" or profoundly exaggerating a condition in order to obtain specific secondary gain (for instance: malingering due to financial compensation, to get time off of work, or to avoid undesired activities b. Poor compliance with treatment or follow-up or diagnostic tests. c. The complaints cease after the gain (vs. factitious disorder) https://unelib.kanopy.com/video/icd-10-guided-collection-vol-5 (Z76.5 Malingering) ex. Middle schooler fakes sick to avoid going to school; Patient comes in complaining of severe pain to obtain a narcotic

What is the treatment for Personality Disorders?

There is no FDA-Approved medication to treat any personality disorder 1. Borderline personality disorder: EBM is lacking regarding use of pharmacotherapy in this condition. However, polypharmacy is common i. > 50% are on 2 psychotropics ii. > 11% are on 5+ psychotropics 2. The major use of drugs in borderline PD is to treat symptoms, such as depression, paranoia, irritability i. Quetiapine has been useful showing significant improvement in the Zanarini Rating Scale for BPD (82% response vs 48% placebo) ii. APA recommends medication as adjunctive treatment of symptoms of affective instability, impulsivity, psychosis, and self-destructive behavior 3. Other personality disorders can be treated with medications, but largely psychotherapy is the mainstay of treatment, and often continues when medications are started; meds often are useful for symptoms alone, not for treating the condition itself. B. Drugs are not cost-effective substitutes for behavioral psychotherapies, particularly dialectical behavioral therapy for BPD and cognitive behavioral therapy for the others PDs -- Dialectical Behavioral Therapy (DBT) is 1st line treatment for Borderline Personality Disorder and is ONLY used to treat patients with Borderline Personality Disorders

Depressive Disorders - Epidemiology

These are very common disorders; - Lifetime prevalence rate=up to 15% (up to 25% in women) - Annual prevalence is 10% - Female to male ratio is 2:1 - Prevalence is higher in rural vs urban area - No racial differences PPP: - Highest incidence is 20's-40's

Paranoid Personality Disorder

This disorder is marked by intense distrust due to assuming that motives of others are malicious. Because of the preoccupation with unjustified doubts, a person with this disorder may perceive even an innocuous interaction as a character assassination. The result of this is extreme suspicion and strained interpersonal relationships and the ability to interact becomes stilted **This disorder if often confused with aspects of a true psychotic disorder PPP: - Pervasive pattern of distrust and suspiciousness of others - Begins in early adulthood and is MC in males Clinical Manifestations: - Distrust and suspiciousness: misinterprets the actions of others as malevolent, sees hidden messages, easily insulted, appears cold and serious, lack of interest in social relationships, bears grudges, doesn't forgive, blames their problems on others. Preoccupation with doubt regarding the loyalty of others

Diagnostic Clues to Consciously-Produced Somatoform Disorders

i. Presenting complaints are often dramatic, peculiar, and changing medical complaints associated with potential environmental incentives for illness ii. History may include vague and complex medical problems, guardedness about revealing past complaints or medical assessments, multiple past medical workups with inconclusive findings, past or current treatment by many physicians, history of signing out of hospitals AMA, and noncompliance with treatment or diagnostics iii. Mental status exam may show anxiety, peculiar indifference to significant medical complaints, and extreme familiarity with medical terminology or procedures iv. Physical exam and lab work are often inconsistent with medical complaints or known physiological mechanisms, and there may be sings of multiple surgical procedures.

What are some diagnostic clues to somatoform disorders (don't need to memorize)

i. Presenting complaints may include dramatic, multiple, and peculiar complaints, extreme anxiety or profound lack of anxiety about minor medical problems, and medical complaints in the presence of psychological issues. ii. History is often vague and complex medical problems abound, multiple past medical workups with inconclusive findings, past or current treatment by many physicians. iii. Mental status exam may show anxiety or peculiar indifference to significant medical complaints iv. Physical examination with lab studies are often inconsistent with medical complaints or physiological mechanism

Generalized Anxiety Disorder - Treatment

medication-based, with antidepressant therapy as well as anxiolytics being very important, as well as some forms of behavioral therapy such as relaxation training and biofeedback PPP: 1. Antidepressants: SSRI's; SNRI's (Venlafaxine) 2. Buspirone: stimulates serotonin receptors and blocks dopamine receptors. May take several weeks before clinical improvement. Buspirone does not cause sedation. S/E: nausea, restless leg syndrome, extrapyramidal symptoms, dizziness 3. Benzodiadepines; Beta Blockers; TCA's 4. Psychotherapy

Somatic Symptom Disorder

variety of complaints in one or more organ systems lasting for months to years. Associated with excessive, persistent thoughts about symptoms; may co-occur with medical conditions PPP: - Chronic condition in which the patient has physical symptoms involving >1 part of the body but no physical cause can be found - MC in women. Onset is usually before 30 years of age - Many patients previously diagnosed with hypochondriasis are now classified as having somatic symptom disorder Criteria: - One or more vague somatic symptoms that are distressing or result in significant disruption of daily life. These symptoms cannot be explained by a physical or medical cause - Excessive thoughts, feelings, or behaviors related to the somatic symptoms: --> disproportionate and persistent thoughts about the seriousness of the symptoms --> persistently high level of anxiety about symptoms or health --> excessive time and energy devoted to the symptoms and health concerns - Although any one of the somatic symptoms may not be continuously present, the state of being symptomatic is persistent (usually >6 months) - May or may not be associated with other medical conditions - Specifiers: with predominant pain Treatment: Regularly scheduled visits to a healthcare provider

Medication options for Anorexia Nervosa and Bulimia Nervosa

• Anorexia Nervosa: some studies show limited benefit of SSRI's, atypical antipsychotics but these SHOULD NOT BE SOLE THERAPY • Bulimia Nervosa: SSRI's may decrease frequency of binging, added benefit to CBT • Binge Eating: SSRI's, TCA's and Appetite suppressants can be an added benefit to CBT In ALL these cases, CBT is 1st line treatment

Suicidal Behavior - Management

• Assessment of Suicide Risk - Interview child and parents, separately and together - Presence of suicidal ideation - Explicit plans for self-injury - Detailed history of past incidents of self-harm Precipitants, context, outcome • If patient has plans to commit suicide: GO TO ED! • If patient has no plans but has suicidal ideation, may do outpatient treatment • If you're not sure, GO TO ED! • Assessment of Intent, Motivation, and Lethality - Did patient truly wish to die? - Did patient believe the means (overdose, hanging, etc.) was lethal? - How intense and persistent was patient's suicidal ideation preceding the attempt? - Did patient plan and take premeditated steps and over how long (hoarding pills, leaving a note)? - Did patient take measures to avoid or ensure discovery and rescue (isolated location, seeking help, telling immediately or not telling)? - Did suicidal ideation persist after the attempt?

What are important questions to ask regarding substance use?

• Drug of choice • Route of administration - Shared needles or straws - Potential infection, complication • First use • When did it become a problem - Duration and level of use influence health risks • Most recent pattern of use • Last use - Risk for potentially fatal consequences can be higher during acute withdrawal • Other substances • Negative consequences of use (or perceived benefits) - It makes me feel better because . . . - Can target underlying issues to help treat some of the causes • Prior treatment - Inpatient - Outpatient - AA/NA or other peer support - Sponsorship - Anti-craving medications or opiate replacement - Longest period of abstinence and how was it achieved • Social and sober support • Home environment • Use in significant other • Mental health issues • Prior suicide attempts • Psyc admits • Psyc care

Opiate Withdrawal - Treatment

• Food or electrolyte replacement • Symptomatic Control - Muscle aches: Tizanidine, clonidine, Methocarbamol, Anti-Parkinsonians (ex. ropinirole) for leg cramps, "restless legs" - Stomach cramps: Dicyclomine, reglan - Nausea: Compazine, onsansetron - Diarrhea: Loperamide - Constipation: Senna - Anxiety: Clonidine, hydroxyzine - Insomnia: Trazadone, Remeron, Doxepin • Long-Term Management of Dependence or Detoxification --> Opiate Replacement - Suboxone [Buprenorphine/Naloxone] - Buprenorphine if pregnant - Methadone *Opiate receptor pathways require time to reset *The most comfortable cessation would be slowly stepping down the opiate dose over the course of weeks to months

Eating Disorder - Genetic/Neurochemical Causes

• Genetic/Neurochemical - There may be a genetic component or inherited predisposition - Greater co-occurrence among identical twins vs. fraternal twins - Increased incidence if parents/siblings have disorder (esp. in dysfunctional families) - Serotonin has been found to contribute to Eating Disorders --> Increased re-uptake in anorexics and bulimics (increased re-uptake, decreased blood levels and decreased appetite) --> Increased release of serotonin during binging - Peptide Tyrosine Tyrosine (PYY) is a Satiety peptide; there is an increased level in the gut of anorexics and bulimics which results in decreased appetite - Baseline and post-prandial cholecystokinin (CKK) - another satiety peptide that when elevated results in a decrease in appetite - Ghrelin (hunger hormone) is dysfunctional in binge eaters

Bipolar Disorder - Treatment

• If patient is having a manic episode --> Antipsychotic medication (long acting injectables ex. Haloperidol) or Benzo, +/- mood stabilizer - Lithium is often gold standard; Valproate, Carbamazepine, Lamotrigine

What are some treatment options for Substance Use Disorder?

• Inpatient care - Dual diagnosis - Detox • Residual Programs - Sober living with peer support groups - Residential substance abuse treatment with integrated counseling • Partial hospitalization programs - ex. Recovery centers - 9am-3pm M-Sat group therapy, counseling, peer volunteer groups medical monitoring • Intensive outpatient programs (IOP) - Recover Center IOP - 9am-12pm or 5:30pm-8:30pm: group therapy, counseling, peer volunteer groups • Outpatient visits: one-on-one substance abuse counselor or combined mental health/SA • Peer Support Groups - AA/NA - Moderation Management • Medications (Anti-craving) - Naltrexone (opiates and alcohol) - Acamprosate (alcohol) - Baclofen (alcohol) - Antidepressants - Opiate replacement - Phase III US Nalmefene - Metadoxine (prospective) - For patients receiving outpatient treatment, the 1st few weeks are critical - Patients who are able to stop using alcohol and drugs during these early weeks are likely to do well with less intensive continuing care - Relapse prevention, which is a form of CBT, helps identify cognitive, behavioral and environmental risk factors for relapse, as well as rehearsing coping responses for those risk factors - A meta-analysis of 26 studies found that relapse prevention was generally efficacious in reducing substance use and improving psychosocial outcomes when compared to other active treatments, no treatment, or other control conditions. - Maintaining regular attendance and participating more actively at peer support meetings have been associated with better outcomes.

Anxiety Disorders in Children and Adolescents - Etiology/Epidemiology

• Separation Anxiety - Up to 4% of children/adolescents, 50% of referrals for pediatric anxiety disorder evaluation --> Lower socioeconomic status, single-parent households --> Slightly more females --> Average onset is 8-9 years old • Generalized Anxiety - Up to 5% in children and adolescents - Higher socioeconomic status - Average onset is 10 years

What are the Cluster B personality disorders?

"dramatic, emotional, erratic" and "wild" i. Antisocial ii. Borderline iii. Histrionic iv. Narcissistic

Cyclothymic Disorder

*If meets criteria for major depression then it is considered Bipolar

Schema for Remembering Side Effect Profile of Atypicals

- "dones" are more likely to cause EPS - "pine" drugs are very sedating and are linked to causing metabolic syndrome, Diabetes, elevated A1c, elevated cholesterol, obesity - Aripripazole is categorized with the dones

Body Dysmorphic Disorder - Epidemiology and Clinical Manifestations

- 1:1 M:F ratio, more common in cultures that place an emphasis on physical appearance; also more common in male homosexual patients - This was originally classified as a somatoform disorder in DSM-IV-TR, but is now considered an OCD-related disorder in DSM-5 - A normal appearing individual has excessive preoccupation with an imagined physical defect (commonly ears and nose) - There may be a minor physical defect that is perceived as a massive issue; there may be a co-morbid delusional disorder present i. Patients often keep this a secret and only divulge when they are distressed to the point of not functioning ii. They can become overly-concerned with grooming and trying to hide the physical defect, and social avoidance may result and cause interpersonal and occupational difficulties Example: 45-yr-old man refuses to cut his shoulder-length hair for a new job and his employer threatens to dismiss him. The man admits to the employer that he wears his hair so long because he wants to cover his excessively large and pointy ears. Physical examination reveals mildly prominent ears that would not attract attention. The man fears being made fun of if the public was able to see his ears.

Obsessive-Compulsive Disorder - Epidemiology and Pathophysiology

- 1:1 M:F ratio; prevalence is ~2% of the population; 4th most common psychiatric diagnosis. There is a strong genetic component to this disorder. - Pathophysiology is largely thought to be serotonin-mediated in the orbitofrontal cortex, anterior cingulate cortex, and striatum - If new and sudden onset, look for acute medical or drug-related infections and treat

Childhood Depressive Disorders - Etiology/Epidemiology

- 2% of children and 4-8% of adolescents - Up to 20% by age 18 - After puberty: females > males - Low socioeconomic status

Suicidal Behavior - Etiology

- 3rd leading cause of death in adolescents (10-14 years of age) - 2nd leading cause of death in young adults (15-34 years of age) - Rare in prepubertal children (<10 years old) - 1/3 of pediatric patients have nonfatal self harm events 3 months prior to completing suicide - Females > males attempt suicide in 15-19 age group ---Males > females complete suicide - 50% of adolescent suicides have 1+ psychiatric disorder present for at least 3 years - Alternative groups Goths, Emos, Punks

Separation Anxiety Disorder - Epidemiology

- 4% of school-aged children - Females > Males - Familial pattern - These kids often come from close-knit families; undue parental anxiety about a child leaving for school may be copied by the child - Exposure to traumatic separation may predispose Examples 1. Example 1: 6-yr-old boy worries constantly that "bad men" are going to come in to his house and abduct his mom when he is away at school. Recently, he has been refusing to get on the school bus in the AM 2. Example 2: 10-yr-old boy with previous interpersonal issues refuses to attend a 2-week summer camp away from home with his peers, but he is forced by his parents to go; it is the first time he has been away from home. After the first day, a staff member calls and tells the parents that the child stayed in his bunk all day complaining of stomach cramps and dizziness. The boy demands to be sent home.

Suicidal Behavior - Epidemiology

- 50% have wish to die to obtain relief from unbearable state of mind - 25-50% endorse interpersonal motives --> "To make people understand how desperate I was" --> "To show how much I loved someone" --> "To find out whether someone really love me" - 1/3 of adolescents are unable to describe any precipitant or motivation --> "I don't know why I did it, I was upset" --> Difficulty articulating feelings, poor emotional regulation, impaired social problem solving skills - Lethality of event does not correspond to intensity of conscious intent to die --> Overestimate lethality of medication --> Underestimate what is needed to complete suicide

Binge Eating - Prevalence

- 60-75% female - Up to 30-40% of obese people may meet the criteria - Those seeking help with weight - 10-20% - Bariatric Surgery - 30-50% - Overeaters anonymous - 70% - Overall prevalence: 2.8%

Substance Use Disorder - Prevalence

- 8% of the US population carry a diagnosis of substance use disorder within a given year - Limited data from toxicology samples on patients admitted to a hospital indicate alcohol or drug use may be involved in 14% of medical admissions and 26% of psychiatric admissions

Schizoaffective Disorder

- A disorder characterized by a baseline of psychosis with inter-episode mood symptoms, with at least a 2 week period with the absence of mood symptoms and just psychotic symptoms - Mood symptoms can be depression, mania, hypomania, mixed states, etc. - 2 week period in which person ONLY has pyschotic symptoms but NO mood disorders - Bipolar and depressed subtypes Treatment: Antipsychotics, mood stabilizers, and antidepressants depending on course of illness

Reactive Attachment Disorder

- A disorder of childhood, a consistent pattern of inhibited and emotionally withdrawn behavior toward adult caregivers where the child seeks minimal comfort when distressed, and/or does not respond to comforting measures when distressed. The social and emotional disturbance is characterized by limited positive affect, minimal social responsiveness to others, and unexplained irritability and sadness. The child has experienced extremes of insufficient care such as social neglect, repeated changes of primary caregivers, and rearing in unusual settings. - Disturbance occurs before age 5 and the child has a developmental age of at least 9 months - Just know that this exists!

Selective Mutism

- A fairly common condition involving the patient, usually a child, failing to speak in certain venues where there is an expectation of speaking (eg., school) despite talking in other situations (eg., at home) which interferes with functioning, and also lasts at least 1 month - Example: 2 months after a 9-yr-old girl begins attending a new school, her teaching informs her parents that she never raises her hand to answer questions in class and refuses to speak to anyone, even if she is called on. The girl interacts normally with others at home, but she often wakes in the middle of the night crying. (Note: there may be also an underlying social phobia here also) - Need to differentiate from social phobia, which is fear of being judged. In selective mutism alone, child will just not speak

Major Depressive Disorder - Diagnostic Criteria

- A major depressive episode (MDE) is a PART of the Dx of MDD, but is not, in and of itself, a diagnosis. a. One can have a MDE as part of bipolar disorder as a for instance. - Patient Health Questionnaire (PHQ-2) form for initial screen. If positive, use PHQ-9 form. Higher number, more severe condition is Diagnostic Criteria for Major Depressive Disorder (DSM-5) A. Five or more out of nine symptoms (including symptoms 1 and 2) in the same 2-week period: 1) A depressed mood or anhedonia (subjective or observed); can be irritable mood in adolescents and children 2) Loss of interest of pleasure in most daily activities 3) Change in weight or appetite 4) Insomnia of hypersomnia 5) Psychomotor agitation or retardation (observed) 6) Loss of energy or fatigue 7) Inappropriate guilt or sense of worthlessness 8) Impaired concentration or indecisiveness 9) Thoughts of death, suicidal ideation or suicidal attempt B. Symptoms cause significant distress or impairment C. Episode is not attributable to substance or medical condition D. Episode is not better explained by a psychotic disorder E. Patient has not had a previous manic or hypomanic episode **If they have had a manic episode then diagnosis is BIPOLAR

Gender Dysphoria - Treatment

- ACCEPTANCE and SUPPORT with multidisciplinary team - Goal is not to FIX the patient and revert to natal gender like before - Changes in gender expression and role by living part time or full time in desired gender role - Counseling for comorbid mental disorders and to aid in transitioning ---School, work, relationships in future ---Counseling is extensive, especially before sexual reassignment to determine if patient truly wants it and will do well afterwards - Family counseling to provide supportive environment - Suppress/prevent puberty and relieve distress with gonadotropin-releasing hormone analogs (GnRHa) like leuprolide - World Professional Association for Transgender Health (WPATH) has summary of standards of care for transgender, transsexual, and gender non-conforming people Prognosis: - Higher risk for other mental disorders - Higher risk for suicide - Higher risk for hate crimes - Increased risk for VTE in those receiving estrogen

Sedative/Hypnotics Addiction

- Ambien, etc. - Increased risk of death when combined with other sedatives or alcohol - Long-term use may have ill-defined consequences

Cocaine/Crack Addiction - Clinical Manifestations

- An estimated 25% of the 1.6 million US adults who use cocaine in a year meet criteria for moderate to severe use disorder - Drug most associated with ED visits - Heavy users who stop abruptly can exhibit withdrawal syndrome but it's features are usually not life-threatening Treatment/Management: - Can treat with benzos to manage aggressive behavior and control hyperthermia - Disulfram - inhibits the enzyme dopamine b-hydroxylase, which converts dopamine to norepinephrine and may reduce cocaine use because it inhibits the associated noradrenergic-mediated "high"

Benzodiazepines Addiction

- Are addictive. - Stopping high doses carries a risk of seizure. - Benzodiazepine withdrawal is characterized by: --> Increased anxiety --> Palpitations --> Tachycardia --> Restlessness --> Peripheral sensory disturbances - Benzodiazepines enhance GABA-mediated inhibitory tone - Long-acting benzos, e.g. Diazepam [Valium], can be used for detox in gradually decreasing dose. - Alternatively, Phenobarbital "loading" has been used for benzodiazepine detox --> Phenobarbital also enhances GABA effects --> Has a long half-life (2-7 days) --> Aim for target cumulative dose between 750-1200mg --> Dose to control symptoms 30mg to 120mg --> Start low and increase to control, then achieve target total dose --> Stop abruptly and allow the drug to taper itself - Additional adjunct agents might be used to control symptoms --> Gabapentin, Lyrica, Tegretol, Depakote, etc.; especially for anxiety

Oppositional Defiant Disorder (ODD) - Clinical Presentation

- Argumentative, defiant, deliberately annoying, irritable/moody, resentful, vindictive behavior, low self-esteem - Tendency to blame others for own transgressions or omissions - Can be only at home or to all authorities (teachers and other adults) - Verbal aggression, NOT physical (if physical, that is more conduct disorder) - Reactive aggression, NOT proactive (bullying) - Overt aggression (shouting), NOT covert (spreading rumors) - Loners or gravitate towards group of similar "outlaws" - Substance use, especially tobacco

Opiates Abuse/Substance Use Disorder - Epidemiology

- As of 2012, an estimated 4.6 million Americans (1.8% of people age 12 and older) used heroin at some point in their lives; 335,000 (0.1%) reported use in the last month - It is estimated that 23% of individuals who use heroin develop opioid addiction - Drug overdose is the leading cause of accidental death in the US - An estimated 4.5% of US adults reported non-medical use of prescription opioids in 2002-2004

Intellectual Disability - What is it?

- Behavioral syndrome characterized by intellectual and adaptive functioning below level expected for the person's age, education and sociocultural context - IQ score of 2 SD or more below the mean of age-matched controls

Bulimia Nervosa - Prognosis

- Better prognosis than that of anorexia - Up to 50-80% short term remission with psychosocial/medication treatment - Better prognosis after one year of remission - Long term remission approx. 60% (definition varies from study to study) - 20-85% relapse rate

Eating Disorders - Symptoms

- Body image distortion - Extreme fear or being fat - The desire to reduce body fat to levels below those considered healthy - Restrictive and fad eating (obsession with a "healthy diet") - Amphetamine and cocaine abuse for anorexic effect - Purging by means of vomiting, laxative abuse, diuretic abuse - Compulsive exercise - Poor self-esteem

What labs should you order when evaluating a patient who likely has Major Depressive Disorder?

- CBC - CMP - TSH - Urine drug screen - Alcohol level maybe or GTT level - usually psychologist will order labs based on clinical suspicion

Childhood Depressive Disorders - Labs/Imaging

- CBC, CMP - TSH - UDS - B12, folate, vitamin D levels

Anxiety Disorders in Children and Adolescents - Labs/Imaging

- CBC, TSH - UA, UDS - Abdominal Imaging, EKG/echo

Intellectual Disability - Prognosis

- Can be life-long, progressive, or improve - Other mental disorders - Self-injurious behavior - Feeding/eating disorders - "Challenging behaviors" - Chronic pulmonary problems due to aspiration - Sleep disorders - Hearing/vision loss

Conduct Disorder - Prognosis

- Can be transitory or turn into antisocial personality disorder (up to 40%) - Often victims of childhood abuse (physical, sexual, emotional) - Comorbid ADHD - worse outcomes - At risk for substance use, depression, and anxiety - At risk for suicide, homicide, and other criminality - At risk for risky sexual behavior

Oppositional Defiant Disorder (ODD) - Prognosis

- Can be transitory or turn into conduct disorder (25%) - Often victims of childhood abuse (physical, sexual, emotional) - Comorbid ADHD - worse outcomes - At risk for substance use, depression, and anxiety

Childhood Depressive Disorders - Prognosis

- Can remit spontaneously without treatment - Often are recurrent and continue into adulthood - 20% have resistant depression lasting >2 years - Educational and occupational underachievement - Relationship difficulties - At higher risk for personality disorders, bipolar, substance use - At higher risk for suicidal behavior --> Remove lethal means from household --> Ask about suicidal ideation

Alcohol - Withdrawal Pathophysiology

- Causes neuronal dysfunction GABA - Major inhibitory neurotransmitter - ETOH binds to GABA receptors - ETOH supplants ordinary inhibitory signals - Tolerance develops - Alcoholics can function at an alcohol level that would ordinarily induce sedation or coma - Sudden ETOH cessation leads to decreased inhibitory tone Glutamate - An excitatory neurotransmitter - ETOH interferes with glutamate-triggered NMDA receptor activation - With sustained and increasing ETOH use, accommodation occurs and more glutamate receptors are produced - Sudden ETOH cessation leads to increased excitatory activity - (unopposed by concurrent lack of inhibitory tone)

Alcohol Withdrawal - Diagnostics

- Clinical diagnosis but need to rule out alternate pathology such as traumatic injury, CNS lesion, GI bleed, meningitis, thyrotoxicosis, drug overdose, hypoglycemia, hypothermia, primary seizure disorder - History/Physical Exam - Frequent Vitals

Premenstrual Dysphoric Disorder (PMDD) - Pathophysiology

- Cluster of physical and psychological symptoms that occur during the luteal phase (final week) of the menstrual cycle and resolve with menstruation - Need 5 physical and psychological symptoms in majority of cycles to be PMDD - Poorly understood mechanism: possibly dysregulation of serotonergic activity and/or GABAergic receptor functioning during luteal phase of cycle with heightened sensitivity to circulating progesterone metabolites

What are some factors associated with relapse?

- Co-morbid psychatric issues (ex. depression and anxiety) - Sleep difficulties - Poor social support for recovery - Low motivation for recovery - High levels of personal stress or low stress tolerance - History of multiple relapses - Continued use of alcohol or drugs early in treatment

Anxiety Disorders in Children and Adolescents - Treatment

- Cognitive Behavioral Therapy (CBT) -- Family therapy, individual therapy, and liaison with school - Anxiolytics --> SSRI's (fluoxetine, fluvoxamine, sertraline) and SNRI;s (duloxetine) - Benzodiazepines (for acute anxiety, but try not to use often) - Buspirone, hydroxyzine - Clonidine, guanfacine, propranolol - Exercise - Avoid caffeine or stimulants

Social Anxiety Disorder - Treatment

- Cognitive Behavioral Therapy: Particularly assertiveness training (a type of psychotherapy in which negative patterns of thought about the self and the world are challenged in order to alter unwanted behavior patterns) - Pharmacotherapy: --> SSRI's, buspirone, benzodiazepines PRN --> Beta-Blockers for circumscribed social phobias

Adjustment Disorder - What is it?

- Common so KNOW! - Environmental stressors such as interpersonal issues (divorce), occupational issues (job loss), and medical issues (cancer) can be very trying and cause anxiety, depression, or behavioral symptoms (erratic actions) that interfere with functioning - As the stressor resolves, or new coping skills develop, the symptoms remit - These disorders are diagnosed when there is a clinically significant impact on the patients live as a direct result of the stressor --> The risk of developing an adjustment disorder depends on the person's coping skills and emotional strength PPP: An emotional or behavioral reaction to an identifiable stressor (ex. job loss, physical illness, leaving home, divorce, etc.) or event that causes a disproportionate response that would normally be expected within 3 months of the stressor and resolves usually within 6 months of the stressor

Childhood Depressive Disorders - Clinical Presentation

- Consistent sad or depressed mood, anhedonia, change in appetite (increase or decrease), sleep disturbances, anergia, amotivation, irritability or agitation, psychomotor retardation, worthlessness or guilt, poor concentration, morbid ideation or thoughts of suicide - Children: somatic symptoms, irritability, social withdrawal - Adolescents: psychomotor retardation, hypersomnia, delusions - In response to stressor(s) or not - Often comorbid anxiety that predates depression - Comorbid ADHD, PTSD, conduct disorder, substance use - Can have psychosis: auditory/visual hallucinations or delusions

Conduct Disorder - Clinical Presentation

- Delinquency, drug use, running away, stealing, vandalism, aggression (verbal or physical), spitefulness, anger, lying, argumentativeness, stubbornness, defiance, truancy, poor educational achievement, fire setting, animal abuse, risky sexual behaviors - Refuse to take responsibility for actions - Usually after parent/teacher/community members cannot tolerate disruptive or dangerous behavior anymore - Sometimes after juvenile justice authorities have been involved - Physical AND verbal aggression - Proactive AND reactive aggression (aggressive when provoked and not provoked) - Covert AND overt aggression - 50% of these patients also have ADHD

Specific Phobia - Diagnostics

- Diagnostic features include the presence of phobias involving objects or situations that invoke anxiety - The individual may have restricted lifestyle as a result of this disorder. Animal phobia often originates in childhood, blood-injection-injury type in adolescence, and others in the 20's DSM-5: - The phobic object or situation is actively avoided or endured with intense fear or anxiety - The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context - The fear, anxiety or avoidance is persistent, typically lasting 6 months or more and causes significant distress or impairment in social, occupational, or other important areas of functioning - Disturbance is not better explained by symptoms of another mental disorder

Schizophrenia - Clinical Manifestations and Diagnostics

- Disorder characterized by psychosis, and disintegration of abilities to think logically and maintain normal social behavior. - Patients exhibit both positive and negative symptoms, as well as various other symptoms Diagnostics: To diagnose Schizophrenia, need to meet the following criteria 2 or more symptoms: - Delusions - Hallucinations - Disorganized Speech - Grossly Disorganized or Catatonic Behavior - Negative Symptoms (Diminished emotional expression or Avolition) PLUS - Postmorbid Decline (Individual in prime of their lives then suddenly declines) --> Occupational --> Social --> Self-Care - Duration 6+ Months

Childhood Depressive Disorders - Treatment

- Early diagnosis and treatment is key - Mild Depression: psychotherapy - Moderate-Severe Depression: Pharmacotherapy AND psychotherapy --> Medication for 6-12 months after remission --> May need hospitalization for severe depression - SSRI's (fluoxetine, fluvoxamine, sertaline, citalopram, paroxetine) --> Can cause behavioral activation in children, less so in adolescents --> Increased risk of SI in pediatric population (magnitude is small though) --> close monitoring - CBT and family therapy - Light therapy for seasonal components - ECT for treatment-resistant, severe psychotic or life-threatening depression

Autism Spectrum Disorder - Treatment

- Early intervention is KEY! --> Focus on social, language, and adaptive (self-help) skills --> Improve cognitive abilities - Maximize normative developmental processes - Minimize effects of ASD on development - Structured, comprehensive program with multiple professions - Anti-epileptics, SSRIs, mood stabilizers (2nd gen antipsychotics), stimulants Referrals: - Speech therapy - Psychotherapy and psychiatry - Social work Prognosis: - Life-long disability - 20% gain functional independence and self-sufficiency - Best outcomes: Asbergers and high-functioning - Higher risk of injury or accidental death

Conduct Disorder - Treatment

- Early intervention is key - Intensive parent education on effective parenting - Individual and family therapy - May need foster family placement - "Juvie" does not work - Medications to reduce aggression, anxiety or comorbid ADHD (Stimulants, buspirone, SSRI's, propranolol, buproprion, guanfacine, carbamazepine, divalproex, lithium) Referrals: - ALL patients with CD should see psych for therapy and med management

Intellectual Disability - Treatment

- Early intervention or special education (mandated by Individuals with Disabilities Act until age 21) - Prevocational and vocational training - Supported employment and living - Other comorbid disorders must be treated - Behavioral management (psychotherapy and/or medications)

Gender Dysphoria - Referrals

- Endocrinology (hormonal replacement) - Speech therapy (hormones do not change voice after puberty) - Plastic surgery (sexual reassignment surgery) after 18 years old AND after at least 1 year of consistent and compliant hormone treatment - Fertility specialists for preservation of eggs/sperm

Panic Disorder - Epidemiology and Clinical Manifestations

- Epi: 1:2 M:F ratio; prevalence is 2% of the population - Recurrent, unexpected panic attacks of abrupt surges of intense fear and discomfort that peaks in 1 minute or so, and during which the patient experiences 4 of the 13 symptoms listed in the DSM (e.g. sweating, palpitations, chest pain, nausea) - The person also has to exhibit either persistent concern or worry of the recurrence of these attacks, or a significant maladaptive change in behavior as a result of the disorder Example: 52-year-old female is brought to the ER with complaints of severe SOB, dizziness, tremulousness, and diaphoresis while shopping. Medical records indicate several previous ER visits for similar sxs in the past week. General medical assessment, including physical exam, lab studies, EKG, cardiac enzymes, are unremarkable. The patient states that she is becoming increasingly concerned over these episodes, and that she is hesitant to travel alone PPP: Criteria: - Recurrent, unexpected panic attacks (at least 2 attacks) may or may not be related to a trigger. Usually sudden in onset, peaks within 10 minutes and usually lasts <60 minutes - At least one of the following must occur for at least 1 month: 1) Panic attacks often followed by concern about future attacks 2) worry about implication of the attacks 3) significant change in behavior related to the attacks - Must exhibit at least 4/13 typical symptoms of panic - +/- Agoraphobia (anxiety about being in places or situations from which escape may be difficult)

Generalized Anxiety Disorder - Epidemiology and Clinical Manifestations

- Epi: 2:3 M:F ratio, 5% prevalence in the general population - "feels keyed up and tense all the time" PPP: - Excessive anxiety or worry a majority of days, >6 months period about various aspects of life. It is not episodic (as seen in panic disorders), situational (phobias) or focal. - Associated with >3 of the following symptoms: fatigue, restlessness, difficulty concentrating, muscle tension, sleep disturbance, irritability, shakiness and headaches. Not due to medical illness Example 21-year-old male worries excessively about his performance in school; he states that he knows that he is a good student and does well, but is not able to "shut down my mind" when it comes to worrying about schoolwork. He also seems to worry a great deal about money and the condition of his house. He has no issues with money and his house is in a good state of repair. He also experiences trouble concentrating and muscle tension and being easily fatigued.

Social Anxiety Disorder - Epidemiology and Clinical Manifestations

- Epi: F > M, 2% prevalence in population; 10% lifetime prevalence - This disorder can result from avoidant personality traits and there sometimes is a co-morbid Dx of avoidant personality disorder - These folks often have fears of speaking or performing in public ("stage fright"), public speaking, speaking in classrooms, eating or writing in public, urinating in public restrooms, and attending social events - They may socially isolate themselves as a result and have low self-esteem; symptoms often wax and wane Examples A. Example: 28-yo-woman complains of being lonely. She says that she longs to have a close circle of friends, but is terrified in social situations and avoids all invitations from co-workers to attend social events. She worries that others will notice her social withdrawal and talk about her. B. Example 2: 31-yo-male politician has a sudden onset of extreme anxiety, tremulousness, and diaphoresis immediately before his first scheduled TV appearance. He is unable to go on the air, fearing ridicule. For the next week, he is paralyzed with fear each time he faces an audience, and he cancels all his scheduled TV and public appearances.

Alcohol Substance Use Disorder - Epidemiology

- Excessive alcohol consumption is the 3rd leading preventable cause of death in the US - About 88,000 deaths per year in the US are directly attributed to alcohol use - More than half of alcohol-related deaths are due to binge drinking - About 38 million US adults report binge drinking of 8 or more drinks at a time more than 4 times per month, though most binge drinkers may not evidence alcohol dependence - Excessive drinking, defined as binge drinking, heavy weekly alcohol consumption and drinking while underage or pregnant has been found to result in 1/10 deaths among working age adults - Nearly 17,000 traffic fatalities in the US in 2000 were related to alcohol use, 40% of all traffic fatalities - Data suggests the lifetime rate of suicide attempts among frequent alcohol users is well above that of the general population - Data from the third National Epidemiologic Survey on Alcohol and Related Conditions suggest about 14 percent of adults meet criteria for a current alcohol use disorder and 29 percent had met criteria for an alcohol use disorder in their lifetime.5 - These data also revealed more than 8% of men and more than 4% of women age 18+ met criteria for an alcohol use disorder - Groups with higher prevalence include young (e. 18-29), men and native americans

Bulimia Nervosa - Clinical Manifestations

- Feeling lack of control while eating - Regularly engages in inappropriate compensatory behavior to prevent weight gain (vomiting, laxatives, enemas, increased exercise) - Typically normal weight - Diagnosed later in life: "sneaky" and good at "hiding behavior"

Generalized Anxiety Disorder - Diagnostics

- GAD7 Scale - Diagnostic features include excessive, poorly controlled anxiety about routine life circumstances that continues for more than 6 months, where the person finds it difficult to control the worry and the worry impairs daily functioning. - The anxiety is associated with three or more symptoms of restlessness, easily fatigued, poor concentration, irritability, muscle tension, and sleep disturbance. Restlessness Easily fatigued Poor concentration Irritability Muscle tension Sleep disturbance

Gender Dysphoria - Pathophysiology

- Gender at birth is not one which child identifies with --> Transgender: person who's gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth - Establish gender identity at 2 years old --> May be homosexual, heterosexual, bisexual, or asexual - Multifactorial, but unsure of triggers or risk factors yet - Differences in child-rearing patterns in retrospective studies of transgender adults --> Male to female: fathers were less emotionally available, less warm, more rejecting, controlling --> Female to male: both parents more rejecting and less emotionally warm, overly protective mothers

Conduct Disorder - Pathophysiology/What is it?

- Genetic risk for behavior problems triggered by initially adverse environment (maternal rejection, birth complications, below risk factors) propagated by defective/abusive parenting - Smaller size and abnormalities of amygdala and insula, decreased dopamine response to reward, increased risk-taking behaviors due to disrupted frontal lobe activity - Evolves from prior ODD (90%)

What are some clinical issues with use of alcohol?

- HTN - GI Symptoms - esophagitis, gastritis, gastric ulcer, esophageal varices - Arrhythmia - Neuropathy - Sleep disturbance - Alcoholic liver disease (Cirrhosis, Ascites) - Pancreatitis - Bone marrow suppression - Electrolyte disturbance - Immunosuppression - Increased cancer risk - Injury - Exacerbation of depression, anxiety

Childhood Depressive Disorders - Pathophysiology

- High heritability - Genetic variants of serotonin receptor - Reduced volume of prefrontal cortex and increased ventricle size - Decreased Amygdola activation - Non-inherited forms, parental substance use disorder, parental criminality, family discord, low family cohesion, history of abuse

Suicidal Behavior - Prognosis

- Higher rates of subsequent suicide attempts - Higher rates of motor vehicle accidents, accidental injuries, and homicidal death - Male attempters (especially those hospitalized) have worse prognosis than females

Alcohol Withdrawal - Treatment

- IV fluids - Vitamins, electrolytes --> Thiamine (B1), Folate, Magnesium, Potassium, Multivitamins - PRN Medications for Nausea, GI upset, Pain, Insomnia, Anxiety, Nicotine replacement - Seizure/DT Prophylaxis --> Benzodiazepines 1st line --> Scheduled or symptom-based Valium, Ativan **Withdrawal seizures are generalized, tonic-clonic convulsions, usually singular or occur in small bursts. Status epilepticus is not consistent with withdrawal pathology and warrants aggressive investigation Do NOT give Bupropion (lowers seizure threshold) or Beta Blockers (masks symptoms)

Attention-Deficit/Hyperactivity Disorder - Pathophysiology

- Imbalances in dopaminergic and noradrenergic (norepi) systems - Smaller volumes in frontal cortex, cerebellum, and subcortical structures - Motor control, executive functions, inhibition of behavior, modulation of reward pathways affected

Major Depressive Episode - Diagnostic Criteria

- In short, you must have a continuous TWO WEEK period of either depression AND/OR anhedonia, and a total of at least 5 of the 9 symptoms in the above list - if you do, this constitutes a MDE - For the presence of an MDE to signify an overall Dx of MDD, one must also have the following criteria in place: - As you can see, an MDE is "Criterion A" in the overall MDD Dx. b. The addition of the B-E criterion completes the Dx of MDD

Attention-Deficit/Hyperactivity Disorder - Clinical Presentation

- Inattentiveness, distractibility, impulsivity, and/or hyperactivity that is inappropriate for developmental stage of child - Low frustration tolerance, shifting activities frequently, difficulty organizing, daydreaming - Fidgeting, "running around the room", "energizer bunny", loud - Euthymic usually (usually don't present with depression), sometimes dysthymic or irritable - No euphoria, pressured speech, racing thoughts, hallucinations, delusions, psychosis, SI/HI, long-term memory deficits, problems with orientation or abstract thinking (how to differentiate from mania) - Symptoms are pervasive (school AND home)

Intellectual Disability - Clinical Presentation

- Language delay (after 1 year), motor delay (during first year), delays in play/social/adaptive skills, fine and oral motor skills may be affected, developmental milestone delays/regression/plateaus (Denver Developmental Screening Test) - Do thorough neuro exam...try to find organic cause - Check for neurocutaneous lesions (NF), coarse facies, hepatomegaly, splenomegaly, muscle distribution and bulk, asymmetries, head circumference, hearing/vision impairments

Tobacco Addiction

- Leading preventable cause of mortality - Best not to ask addict to quit smoking at the same time - Nicotine is addictive and physiologic dependence occurs - Quitting can cause withdrawal symptoms including weight gain, irritability, depression, insomnia, etc. Treatment: - Buproprion - Varenicline [Chantix] - Nicotine replacement

Anorexia Nervosa - Prognosis

- Lifetime prevalence of Major Depressive Disorder 50%; OCD 25% - Full recovery within a few years is 30-50% - 30% remission - 25% never achieve normal weight - Death from starvation, arrhythmias, suicide: --> 5-10% within 10 years --> up to 20% in 20 years

Suicidal Behavior - Family Factors and Problem Behaviors

- Loss of parent (death or divorce) - Residential instability - Change in caretaking parent - Living apart from parent - Family conflict - Low parental care - Low social support (especially if gender noncomformity) - Sexual or physical abuse Problem behaviors - Substance use - Fighting - Antisocial behavior - Early sexual intercourse - Weapon carrying

Opiates (Substance Use Disorder) - Clinical Issues/Things to consider when working these patients up

- Make sure symptoms aren't due to something else - Important to test for pregnancy before prescribing medication - Assess injection sites for infection - STD testing - Hepatitis C is VERY prevalent --> HCV Ab positive does not mean patient has active infection as 1/5 or more patients may clear HCV on their own and may then test positive for HCV Ab though negative by HCV RNA PCR testing

Gender Dysphoria - Etiology/Epidemiology

- Males: up to 0.014%, females: up to 0.003% - Males > females

Acamprosate

- Mechanism of action poorly understood. May affect GABA and glutamate signaling to restore a balance between neuronal excitation and inhibition - Less evidence of effectiveness vs. Naltrexone - Generally well-tolerated - Useful 2nd line agent for those with advanced liver disease; no adjustment for Child-Pugh Class A or B disease - Contraindicated in significant renal disease when CrCl < 30 - Downside: Need to take 3x a day

Methamphetamines Addiction - Clinical Manifestations

- Methamphetamines increases ones risk of death, cardiovascular disease, risky sexual behavior, psychosis and tooth decay - Symptoms include teeth grinding, irritability, sleeplessness, weight loss and GI symptoms

Attention-Deficit/Hyperactivity Disorder - Etiology/Epidemiology

- Most common mental disorder treated in youth (up to 9%) - Combined type > inattentive > hyperactive/impulsive - Males > females - Females: inattentive - Risk factors: maternal smoking or alcohol exposure during pregnancy, pregnancy and delivery complications (toxemia, eclampsia, poor maternal health, maternal age, fetal postmaturity, duration of labor, fetal distress, antepartum hemorrhage), low birth weight, psychosocial adversity - Highly inheritable (77%)

Cannabis Addiction

- Most used illegal psychoactive substance worldwide - Use patterns can meet criteria for a substance use disorder - Large-scale epidemiologic data and some prospective, longitudinal study results suggest cannabis use is not overtly associated with severe medical conditions or adverse health outcomes with the exception of a small correlation with increased risk of fatal motor vehicle accidents - Evidence for long-term neurocognitive sequelae from heavy cannabis use is mixed - Use acutely increases sympathetic and decreases parasympathetic activity leading to some transient tachycardia, orthostasis, catecholamine release and increased cardiac output and associated myocardial oxygen demand without increased blood pressure (There may be a small association with increased risk of MI, stroke or paroxysmal atrial fibrillation during acute use) - Chronic cannabis use is not associated with impaired pulmonary function or increased risk of lung cancer - Rates of severe functional disability relating to addiction are much lower than those for other substances such as alcohol - Cannabinoid Hyperemesis syndrome (clinical nausea and vomiting) can occur in heavy users but resolves shortly after cessation of use - Synthetic cannabinoids e.g. dronabinol and nabilone are FDA-approved schedule III medications indicated for the treatment of AIDS-related anorexia or nausea and vomiting associated with chemotherapy refractory to other treatments.

Medical complications associated with Anorexia and Bulimia Nervosa

- Muscular: cachexia, loss of Body fat & muscle mass, decreased Metabolism - Reproductive: infertility, amenorrhea - Neuropsych: abnormal taste Sensation, apathetic Depression, mild cognitive Impairment, seizures - Skeletal: osteopenia/ Osteoporosis - Metabolic: electrolyte Abnormalities - Purging: dehydration, hypoglycemic seizures - Vomiting: Electrolyte abnormalities (hypokalemia), enamel erosions, Russell's sign - Vomiting and diuretics: hypochloremic metabolic alkalosis - Laxatives: Hyperchloremic metabolic acidosis, hemorrhoids - Ipecac abuse: life threatening cardiomyopathy - Stimulant abuse: hypertension and cerebral hemorrhage - Excessive exercise: overuse injuries, stress fractures, decreased performance

Intellectual Disabilities - Labs/Imaging

- Neuropsychiatric testing to find deficits - IQ testing - Assess for metabolic, neurodegenerative, neurophysiologic disorders - CT/MRI brain if abnormal neuro exam

Autism Spectrum Disorder - Labs

- No specific lab tests - EEG if seizure development (25%) - Polysomnography

Obsessive-Compulsive and Related Disorders

- Obsessive Compulsive Disorder - Body Dysmorphic Disorder - Hoarding - Trichotillomania - Excoriation (skin-picking) disorder

Separation Anxiety Disorder - Treatment

- Often involves identifying the trigger and, through therapy, helping the child understand the trigger and coping with the trigger in other ways - May also involve additional medication treatment, such as anxiolytics or antidepressants, but only in combination with behavioral psychotherapy and family therapy

Intellectual Disability - DSM-5 Diagnostic Criteria

- Onset during developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social and practical domains - Following 3 criteria must be met: 1) Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgement, academic learning and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing 2) Deficits in adaptive functioning that results in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communications, social participation, and independent living, across multiple environments, such as home, school, work and community. 3) Onset of intellectual and adaptive deficits during the developmental period - Severity based on adaptive functioning, NOT IQ scores (mild, moderate, severe, profound) - Severity determines levels of supports required

Intellectual Disability - Referrals

- Ophthomology or audiology - Neuropsychiatry - PT/OT for comorbid cerebral palsy - Speech therapy - Social work

Naltrexone

- Opioid Antagonist - Demonstrated efficacy for boosting abstinence - 40-50% chance from refraining from drinking - If drinking resumes, quantity tends to be moderated when still using naltrexone - Generally well-tolerated; 10% of patients experience headache or nausea which tends to resolve within the first week of treatment; symptoms can be avoided by taking the medication before bed - Will severely blunt opiate medication efficacy and should be discontinued prior to planned surgeries - Typical dose 50mg PO QD - Also available in monthly depot injection formulation

Disruptive and Impulse-Control Disorders

- Oppositional Defiant Disorder - Conduct Disorder

Eating Disorders - Psychological Causes

- Overwhelming feelings or emotions - Negative remarks - Major life change: death, job loss, major move, divorce - Only sense of life control and autonomy over otherwise uncontrollable life - Expression of something they have found no other way of expressing - Comorbidities: Depression, Anxiety, Bipolar, Borderline Personality Disorder, Impulse Disorder, Obsessive-Compulsive - Comorbid Behaviors: Kleptomania (urge to steal), suicide, drug and ETOH abuse, sexual promiscuity ^Improving these increases efficacy of treatment

When should you screen for substance use disorders?

- Patients reporting new or increasing difficulty with work, relationships or legal issues - Areas of high prevalence - When about to prescribe potentially addictive medications - During routine physical exams - Prior to experiences hospitalization or major surgical procedures

Anorexia Nervosa - Diagnostic Criteria (DSM-5)

- Persistent restriction of energy intake leading to significantly low body weight - Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low weight). - Disturbance in the way one's body weight or shape is experienced (undue influence of body shape and weight on self-evaluation...)

Premenstrual Dysphoric Disorder (PMDD) - Clinical Presentation

- Physical symptoms: fatigue, bloating, breast tenderness, headache, myalgia, increased appetite, and food craving - Psychological symptoms: mood lability, anxiety, depression, irritability, hostility, sleep dysfunction, impaired social function

Eating Disorders - Epidemiology

- Prevalence highest in adolescents and young adult women (median age is 18-21 years) - Women 90-95% of cases - Prevalence is increasing in males, older women, ethnic minorities and female athletes

Oppositional Defiant Disorder (ODD) - Treatment

- Primarily provided through parents with children <12 years of age - Replace coercive discipline with more effective techniques (assertive discipline) --> Provide positive attention with praise and reinforcement of desirable behavior --> Ignore inappropriate behavior unless it is serious --> Give clear, brief demands, reduce task complexity, eliminate competing influences (TV) --> Establish a token economy at home with tokens/points awarded for compliance to be "cashed in" --> Do not remove points for noncompliance for first 8 weeks --> Use response cost (removal of tokens) or time out soon after noncompliance (1-2 minutes of time out per year of age) --> Do not release child from time out until quiet and agrees to obey --> Extend time out to noncompliance in public places Indications for Referral: - Severe ODD needs individual AND family therapy --> Working on problem solving and fixing dysfunctional beliefs child has about parents and parents have about child - Family members: therapy to help provide more emotionally stable environment

Substance-Induced Psychosis

- Psychosis due to a substance or general medical condition - Presence of one or both of the following --> Delusions or Hallucinations (Don't need to memorize table) - If a patient presents to you with psychosis, always need to rule out other causes (medical and drug)

Trauma and Stressor-Related Disorders

- Reactive Attachment Disorder - Acute Stress Disorder - Adjustment Disorder - Posttraumatic Stress Disorder

Anorexia Nervosa - Restricting Type

- Reduced calorie, intake, dieting, fasting, exercise and diet pills - Can limit intake to as little as 300-600cal/day - Limited food selection - Obsessive and compulsive symptoms regarding food, eating habits and exercise

Insomnia - Treatment

- Refer to pharm

Post-Traumatic Stress Disorder - Treatment

- Relieve the patient of intrusive recollections and decrease symptoms of anxiety and improve social relations and capacity for enjoyment 1. Group psychotherapy is particularly helpful with other survivors of trauma of similar origin Pharmacology: with serotonergic drugs and anxiolytics - caution needs to be exercised as these folks have an increased propensity to abuse drugs 2. Antidepressants: SSRI's 1st line medical treatment - Not debriefing (ex. flooding - actually worsens), but immediate therapy/counselling may help stave off PTSD from developing

Body Dysmorphic Disorder - Treatment

- SSRI's at maximal doses - CBT may help patient develop a more accurate body image - Antipsychotic medications may be used when there are delusions of psychotic proportions that are affecting the patient

Persistent Depressive Disorder (Dysthemia) - Diagnostics

- Same criteria as Major Depression but need just 3/9 of the criteria and need for 2 years vs. 2 weeks, or 1 year in those <18 years old - Milder, higher functioning Criteria: - Sleep problems - Low self-esteem - Energy problems - Disinterest - Poor concentration - Appetite change - Agitated or slow - Suicidal ideation Take home point: think of "Negative Nancy," never really happy, but also never majorly depressed. It is the limbo between MDD and euthymia. Time duration is 2 years here, not 2 weeks like for MDD, and is 1 year in < age 18. Treatment is same as MDD

Alcohol Withdrawal - Clinical Manifestations

- Seizures - Alcohol hallucinosis - Delirium Tremens (confusion/altered mental status, tachycardia, hypertension) - Unstable Vitals (elevated BP, tachycardia, tachyarrhythmia, efever) - Arrhythmia - Encephalopathy --> Wernicke Encephalopathy: Acute injury precipitated by alcoholic thiamine deficiency --> Korsakoff Syndrome: Chronic condition caused by brain tissue degradation marked by amnestic features, apathy and confabulation (more on these in powerpoint) - Electrolyte disturbance (Hypokalemia, hypomagnesemia, hypophosphatemia, hyponatremia) - Alcoholic Ketoacidosis - Liver failure (ascites, spontaneous bacterial peritonitis) - GI bleed - Pancreatitis - Pancytopenia - Death

Anxiety Disorders in Children and Adolescents - Pathophysiology/Types

- Separation Anxiety, Generalized Anxiety, Social Anxiety, Panic Disorders, Selective Mutism Pathophysiology: - High inheritability: genetic (up to 65%) AND behavior modeling - Parents are anxious and hypercritical with high expectations for children's performance - Shy children, behavioral inhibition, withdrawal from unfamiliar situations - Potential triggers: parental emotional problems, disrupted attachment (especially during neonatal period), stressful life events (divorce, death), traumatic experiences - Maternal endocrine activation during pregnancy and/or early separation/loss --> lower cortisol levels - Alterations in amygdala functional connectivity cause internalization and dysregulation of fear and stress response system - Separation Anxiety --> Insecure attachment precipitated by loss, separation, or threat of either --> Normal behavior in toddlers until 3-4 years old: mild distress/clinging --> Parental anxiety/depression and enmeshed mother-child relationship - Generalized Anxiety --> Excessive anxiety and worry about many events/activities causing significant impairment or distress --> Somatic symptoms, self-consciousness, social inhibition

Obsessive-Compulsive Disorder - Treatment

- Serotonergic antidepressants at maximal doses - Clomipramine (a TCA that is very serotinergic and if often 1st line) - Fluvoxamine (only SSRI approved for OCD) - behavioral therapies such as relaxation training, guided imagery, response prevention, thought stopping and modeling are used - Disorder rarely remits without treatment

Alcohol Withdrawal - Labs and Imaging

- Serum ETOH - CBC, CMP, Mg, UA, UDS - Lipase, PT/INR, Ammonia level if encephalopathic, TSH - EKG - Imaging - as needed for injuries, concerning complaints, or suspected infection (abdominal US, non-contrast CT brain, CT abdomen/pelvis possible with IV contrast only, x-ray)

Suicidal Behavior - Risk Factors

- Severe mood disorders (depression, bipolar, anxiety) - Psychotic disorders - especially with command auditory hallucinations - Conduct disorders - Substance use disorders (depressogenic and disinhibiting effects) - Eating disorders (females) - Gender noncomformity - Recent life stressor(s) ---Physical assault, sexual abuse, teasing/bullying, arguments with parent or romantic partner, perceived failure, shame, humiliation - Family psychiatric disorders and history of suicide - Past suicidal ideation or behavior - Legal or disciplinary problems in prior year - Firearms in the home - Suicide "contagion" - sensationalized media coverage of local/celebrity/fictional suicides - Evidence of specific plans and attempt to avoid discovery - Impulsivity, aggression, hopelessness, impaired social and problem solving skills

Eating Disorders - Sociological Causes

- Society reinforces idea that to be happy and successful we must be thin - Influence of peers during adolescence: teasing and pressure to conform - Dysfunctional families/relationships --> Sexual abuse, physical abuse, controlling coaches and parents, controlling relationships --> Eating may be the only thing they can control in their life - Some cultures more accepting of higher body weights

Somatoform Disorders, Factitious Disorder and Malingering

- Somatoform Disorder: Physical manifestation of an underlying psychiatric issue; ex. having stomach ache when anxious - Different ways to group these disorders based on etiology

Anxiety Disorders

- Specific Phobia - Social Anxiety Disorder - Generalized Anxiety Disorders - Panic Disorder - Separation Anxiety Disorder - Selective Mutism

Autism Spectrum Disorder - Pathophysiology

- Spectrum of developmental disorders probably linked to a combination of prenatal viral exposure, immune system abnormalities and/or genetic factors - Neuro and brain architecture changes --> Enlarged amygdola and hippocampus --> Increased neurons in prefrontal cortex --> Reduced and atypical frontal connectivity --> Thin corpus callosum --> Abnormal neuron patches in frontal/temporal lobes (social, emotional, communication and language functions) - Elevated serotonin, abnormal neurotransmitter functions, impaired phenolic amine metabolism - No biologic markers exist

Attention-Deficity/Hyperactivity Disorder - Treatment

- Stimulants: increase inhibitory influences of frontal cortical activity on subcortical structures (usually rich in catecholamines but not in ADHD) --> Methylphenidate (Ritalin, Concerta, Focalin, Metadate) --> Dextroamphetamine (Dexedrine, Adderall) --> Side effects: reduced appetite/weight loss, insomnia, GI upset, edginess, worsening of tics --> Long acting better, do weekend holidays if possible - Non-stimulants --> Treatment failure with stimulants (anxiety, tics, oppositionality) vSpecific-norepi reuptake inhibitors: atomoxetine (Strattera) --> Antidepressants: bupropion (Wellbutrin) --> Antihypertensives: clonidine (Catapress), guanfacine (Tenex) --> Antinarcoleptics: modafinil (Provigil) careful of SJS! - Environmental restructuring, behavioral therapy, behavioral classroom management and parent training - Exercise! - Free fatty acid supplementation? Indications for Referral: - Multiple treatment failures - Severe ADHD Prognosis: - Need tutoring, special placement, education plan - At risk for other mental disorders (anxiety, substance abuse, mood disorders, conduct disorders, tics, SI and self-harm) - At risk for school failure, poor peer relationships, and trouble with the law - Persists into adulthood (majority) --> Lower socioeconomic status, work difficulties, frequent job changes, less higher education, lower rate of professional employment, high rates of divorce/separation, immaturity

Binge Eating Disorder - Prognosis

- Studies are lacking - Long term prognosis remains unclear

Conversion Disorder

- Sudden loss of sensory or motor function (paralysis, blindness, mutism, etc.) often following an acute stressor; patient is aware of it but sometimes indifferent to the symptom (la belle indifference - dont seek medical attention cause they're fine with it); more common in females, young adults, adolescents https://unelib.kanopy.com/video/icd-9-guided-collection-volumn-2 PPP: - Neurological dysfunction suggestive of a physical disorder that cannot be explained clinically (or by neurological pathophysiology). The symptoms cause significant distress or impairment. - Symptoms are not intentionally produced or feigned - Patients often have depression, anxiety, schizophrenia or personality disorders Clinical Manifestations: - Symptoms tend to be episodic and may recur during times of stress - MC in females and onset is usually in adolescence or young adulthood 1. Motor dysfunction: paralysis, aphonia, mutism, seizures, gait abnormalities, involuntary movements, tics, weakness, swallowing 2. Sensory dysfunction: blindness, anesthesia, paresthesias, visual changes, deafness 3. Patients often have depression, anxiety, schizophrenia or personality disorders

Specific Phobia - Treatment

- Systematic desensitization (feared stimuli are paired with relaxation training) - Flooding (massive exposure to a feared stimulus until anxiety subsides)

What are some labs often ordered when evaluating a patient with probable Bipolar Disorder

- TSH (looking for hyperthyroidism) - MRI or brain scan, especially if new onset mania in 50's or 60's - Electrolytes (BMP) - can cause manic like picture

Disinhibited Social Engagement Disorder

- This is another new Dx in DSM-5 - Diagnostic criteria: pattern of behavior in which a child approaches and interacts with unfamiliar adults and exhibits at least two of these sxs: reduced or absent reticence in approaching adults; overly familiar verbal or physical behavior; diminished checking back with primary caregiver; and willingness to go off with unfamiliar adult with no hesitation - Insufficient care can be documented; social neglect, repeated changes of primary caregivers, and rearing in unusual settings. - Child has a developmental age of at least 9 months 5. Just know that it exists!

Suicidal Behavior - Prevention

- Treat mental illness - Screen everyone at risk for suicide or suicidal thoughts --> Asking does not cause suicide - Hotlines and crisis centers - Means restriction --> Ask everyone about firearms in homes and if kept safe --> Restrict amount of potentially lethal medications - Minimize contagion --> Avoid romanticizing or sensationalizing suicides --> Focus on causal connection to mental disorder instead

Anorexia Nervosa - Clinical Manifestations

- Typically weight loss is the most obvious clue - Usually detected earlier than other disorders, but you must have suspicion - Emaciated (thin and weak) person believes they are overweight and tries to lose more weight - Exhibits behaviors targeted at maintaining a low weight or certain body image - Two Types: Restricting and Binge/Purge

Anorexia Nervosa - Binge/Purge Type

- Unable to refrain from binge eating and purging - Often self-destructive tendencies - Often impulsive, dramatic, emotional personalities - Frequently abuse alcohol and drugs, stimulants or laxatives - Evident by continued weight loss - Viscous cycle in which they purge, feel guilty and then restrict and repeat

Oppositional Defiant Disorder (ODD) - Pathophysiology/What is it?

- Unclear of cause, low heritability - Hyperreactive, irritable, difficult to soothe, slow to adapt to new circumstances as infants - Highly stressed parents (marital discard, single parenthood, parental psychopathology (maternal depression), socioeconomic disadvantage) fail to provide adequate praise and attention --> Set limits harshly and inconsistently --> Children react defiantly to test limits --> Escalating coercivess with shouting and mutual accusations, terminated by harsh physical punishment or capitulation (giving up an argument) --> Similar aggressiveness as parents when they were young

Oppositional Defiant Disorder (ODD) - Etiology/Epidemiology

- Up to 10% prevalence - Average age of onset is 6-8 years - Males > females until adolescence

Premenstrual Dysphoric Disorder (PMDD) - Etiology/Epidemiology

- Up to 5.8% of women of reproductive age - Highly associated with unipolar depressive disorders and anxiety disorders (OCD, GAD, panic disorder)

Conduct Disorder - Etiology/Epidemiology

- Up to 9% prevalence - Males > females - More African American males diagnosed - Risk factors: poor parental supervision, lack of parental involvement/ absence, poor/abusive discipline, poor parental health, maternal depression, family adversity, multiple family transitions, low socioeconomic status, association with deviant peers, second hand smoke

Autism Spectrum Disorder - Etiology/Epidemiology

- Usually diagnosed in 1st year of life - Increasing prevalence (over-diagnosis vs. actually increasing incidence) now possible 2.5% of children - Boys > girls 4:1 - Genetic and environmental influences - Family history of autism, mental disorders, learning disabilities - Risk Factors: seizure disorders, fragile X, Rett syndrome, tuberous sclerosis, congenital rubella, maternal valproate use, advanced maternal age, ? environmental toxins, ? obstetric complications, ? oxidative stress

Why are personality disorders often viewed as some of the most difficult-to-treat diagnoses in psychiatry?

- Varying combinations of dysfunction in affectivity, cognition, interpersonal function and impulse control are observed - We have NO medications FDA approved to treat these conditions, nor are there psychotherapies, other than dialectial behavior therapy for borderline personality disorder --> There are several medications used "off-label", often which target symptoms of the personality disorder and how the disorder affects the patient in their daily life

Autism Spectrum Disorder - Clinical Manifestations

- Wide range of symptoms - Mute to nromal verbal ability (Asberger's) - Delays in language development --> Echolalia, pronoun reversal, abnormal rhythm and ability to infer from language - Difficulties with social interaction and unable to read social cues --> Decreased eye contact, defective imitation, lack of interest in joint attention, lack of protodeclarative pointing (child doesn't point and go "look mommy!"), absence of smiling with recognizing familiar faces - Failure to develop symbolic-imaginative play - Verbal concept formation, abstract thinking, social reasoning weaknesses - Occasional "savant skills" --> music, arts, hyperlexia (numbers and letters) - More interest in nonsocial/inanimate environment Other Clinical Features: - Difficulties in changes in routine - Repetitive behaviors - Unusual attachments (to inanimate objects usually) - Hypersensitivity or hyposensitivity - Sleeping problems - Eating problems - Difficulties in mood regulation - Self-injurious behaviors - Increased susceptibility to infections - Aberrant palmar creases - Small head circumference at birth, but have an increased head circumference from 6 months - 2 years of age, normal in adolescence

Diabulemia

- eating disorder behavior associated with Type 1 diabetes - Intentional manipulation of insulin for the purpose of weight control, esp. in adolescent girls - Not recognized in DSM-5 as a diagnosis. - Patients deliberately skip or reduce insulin dose for the purpose of losing weight or preventing weight gain. - Results in hyperglycemia, glucosuria, diabetic ketoacidosis, ketonuria, and rapid weight loss. •The diagnostic manual, DSM-5, classifies insulin omission as a purging behavior, -considered as bulimia nervosa if the person is binging then restricting insulin. -Considered a purging disorder if the person is eating normally and restricting insulin -considered anorexia nervosa if the person is severely restricting both food and insulin. Dire Consequences: - Vulnerable adolescent population --> 40% females, 11% of males --> Risks associated with traditional eating disorders --> Additional risk of not taking care of a potentially life-threatening medical condition Screening tool: DEPS-R, SEEDS

Post-Traumatic Stress Disorder

- very common disorder --> KNOW abbreviated DSM-5 criteria - The disorder is more common in times and places of increased disaster, and traumatic events precipitate symptomatology of this diagnosis. Symptoms often begin immediately after the stressor has occurred. - Clinical course can be variable; most cases resolve within 3 months; other cases can last a lifetime - The disorder is often complicated by phobic avoidance, impaired interpersonal relations, emotional lability, feeling of guilt, self-destructive behavior, and substance abuse.. Example: 34-yo-female is unable to sleep at night and is troubled by intrusive thoughts of her automobile accident 6 weeks ago in which her girlfriend was killed. She avoids driving and has become socially withdrawn. She has nightmares about the incident almost nightly, and then awakens screaming. She feels guilty about surviving and feels chronically depressed.

Anorexia Nervosa - Prevalence and Two Types

0.6% Two Types: Restricting and Binge Eating/Purging

Post-Traumatic Stress Disorder - Diagnostics

1 month or more of symptoms required to diagnose; if less than 1 month but >3 days then this is acute stress disorder DSM-5 Criteria: • Exposure to trauma (abuse, veteran, combat, etc.) • 1+ Intrusion Symptoms / re-experiencing --> Recurrent memories --> Recurrent dreams --> Feeling of recurrence --> Distress at re-exposure --> Phsyiological reactivity • 1+ Avoidance Symptoms --> memories, thoughts, feelings --> external reminders • 2+ Negative Cognitions --> poor memory --> self-concept --> cause/consequences --> emotional state --> interest/participation --> detachment --> loss of positive emotions • 2+ Arousal Symptoms --> irritability --> recklessness --> hypervigilance --> exaggerated startle --> poor concentration --> sleep disturbance (dont memorize details, just know exposure to trauma, 1+ intrusion symptoms, 1+ avoidance symptoms, 2+ negative symptoms, 2+ Arousal symptoms)

What are the components of a substance use disorder?

1) Physical Dependence: Withdrawal symptoms in the absence of the drug 2) Addiction: A neurobiologic disease with genetic and psychosocial contributions leading to a compulsive use and cravings despite harmful consequences Addiction and dependence are not character flaws - They result from a host of factors that cannot be fought without help - Genetics creates unique phenotypes responding to chemical use in different ways --> increased/decreased tolerance, increased susceptibility to craving or dependence, modified physiologic consequences - There is a hereditary component to mental illness which is prevalent in substance users; they try to self medicate - Improperly and insufficiently treated chronic pain conditions predispose toward self-medication - Unhealthy behavioral patterns are learned from childhood experiences that could not be avoided - Social forces such as peer use serve as triggers for recurrent setbacks - Stigma is a barrier to gainful employment and rewarding social contacts which are barriers to a fulfilling and enjoyable life which are predisposing factors for continued or augmented substance use

Binge Eating Disorder - Diagnostic Criteria (DSM-5)

1) Recurrent episodes of binge eating characterized by both of the following: - Eating in a discreet period of time an amount of food larger than what most would eat - A sense of a lack of control over eating during the episodes Differs from Bulimia as there is NO compensatory behavior so they DO gain weight 2) The binge eating episodes are associated with 3 or more of the following: - Eating very rapidly - Eating until uncomfortably full - Eating large amounts when not hungry - Eating alone due to embarassment over the amount - Feeling disgusted with oneself, depressed or very guilty afterward 3) Marked distress regarding the binge eating 4) At least one a week for three months 5) Not associated with bulimia or anorexia nervosa 6) No compensatory behavior

What is the difference between Bipolar I and II?

1. Bipolar I is more severe, has manic episodes > 7 days, and can have psychotic symptoms or necessitate hospitalization; functioning in impaired 2. Bipolar II is less severe, has hypomanic episodes > 4 days, and can NOT have psychotic symptoms or necessitate hospitalization (if it does = bipolar I); functioning may or may not be in impaired

Premenstrual Dysphoric Disorder (PMDD) - Treatment

1. Medications to reduce rise/fall of ovarian steroids: combo OCPs 2. Serotonin augmentation: SSRIs (continuously or during luteal phase) - Lifestyle changes: increasing exercise, smoking cessation, calcium supplementation - CBT and stress reduction - Education on pathophysiology

Major Depressive Disorder - Treatment

1. Psychotherapy: principle therapy in mild-moderate depression. Cognitive behavioral therapy: exposure/response prevention, psychoeducation, support groups. Particularly beneficial when combined with medical therapy 2. Medications: SSRI's are first line in mild to moderate; Bupropion and Mirtazapine are 2nd line. TCA's and MAO inhibitors are usually 3rd line (very easy to overdose). 3. Electroconvulsive therapy (ECT): patients who fail to respond to medical therapy, positive previous response to ECT or for rapid response in patients with severe symptoms. ECT is safe in pregnancy and in elderly

Schizoid Personality Disorder

1. Schizoid: Blunted affect associated with feelings of detachment and desire relationships to be distant and often choose to be solitary. As they do not show much emotion, they often are perceived as having an emotionally cold disposition. i. Think of the night watchman (contrast with avoidant PD) https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-7 (Schizoid PD) **Very happy being alone **Often will have just one or two friends PPP: - Long pattern of voluntary withdrawal and anhedonic (Inability to feel pleasure) introversion - usually early childhood onset - Loner, hermit-like behavior; MC in males Clinical Manifestations: 1. Inability to form relationships. Lifelong pattern of social withdrawal 2. Anhedonic: appears indifferent to others, lacks response to praise or criticism or feelings expressed by others. Prefers to be alone (little enjoyment in close relationships, sex) 3. Appears eccentric, isolated and lonely. Cold flattened affect, quiet and usually not sociable

Schizotypal Personality Disorder

1. Schizotypal: Inability to interact with others due to discomfort which arises from the actual act of having to interact, NOT due to negative self-image. They may also demonstrate cognitive distortions, odd speaking patterns, and experience strange perceptual occurrences influencing their behavior. i. Contrast with schizophrenia/primary psychotic disorders https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-7 **Often feel they can see into the future **Have "devine powers" **He had a patient who had this that would speak in old english and though that was normal **This disorder has the strongest correlation to Schizophrenia Notes: - Highlight Odd beliefs, thinking and speech - Ideas of Reference - ex. listening to TV and think TV is talking to them - Get very anxious when dealing with other people - Remember "magical thinking" PPP: - Odd, eccentric behavior and peculiar thought patterns. Suggestive of Schizophrenia but without psychosis (delusions). Usually early adulthood onset. Clinical Manifestations: 1. Odd in behavior or appearance, inappropriate affect or speech, "Magical Thinking" (believes in clairvoyance, telepathy, superstition, bizarre fantasies, etc.). May talk to self in public 2. Pervasive discomfort with close relationships +/- restricted affect

Oppositional Defiant Disorder (ODD) - DSM-5 Diagnostic Criteria for ODD

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling. Angry/Irritable Mood 1. Often loses temper. 2. Is often touchy or easily annoyed. 3. Is often angry and resentful. Argumentative/Defiant Behavior 4. Often argues with authority figures or, for children and adolescents, with adults. 5. Often actively defies or refuses to comply with requests from authority figures or with rules. 6. Often deliberately annoys others. 7. Often blames others for his or her mistakes or misbehavior. Vindictiveness 8. Has been spiteful or vindictive at least twice within the past 6 months. Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual's developmental level, gender, and culture. B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning. C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder. Specify current severity: Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers). Moderate: Some symptoms are present in at least two settings. Severe: Some symptoms are present in three or more settings.

What is the DSM-5 Criteria of a General Personality Disorder?

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition (ex. ways of perceiving and interpreting self, other people and events) 2. Affectivity (ex. the range, intensity, lability and appropriateness of emotional response) 3. Interpersonal functioning 4. Impulse Control B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Doesn't happen in just one area, happens in a wide range of areas) C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The pattern is stable and a long duration, and its onset can be traced back at least to adolescence and early childhood E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder F. The enduring pattern is not attributable to the physiologic effects of a substance (ex. drug of abuse, medication) or another medical condition (ex. head trauma)

Separation Anxiety Disorder - DSM-5 Criteria

A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. 2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. 3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. 5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. 6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. 7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

Delusional Disorder

A. Disorder involving delusions about plausible events, such as being persecuted, having a serious illness, or having a secret, often sexual, relationship with another person; these people are often not overly bizarre and thought process is generally organized, and their functioning is not markedly impaired B. They present to clinical attention when: i. Anxiety overtakes them about their delusion ii. Discovery by a relative or friend or during the medical examination that a delusion is present iii. Threats or illegal activities related to the delusion C. Case: 54 year old lady from NH - Face made out of air D. Subtypes of delusions include: erotomanic, grandiose, jealous, persecutory, somatic, mixed https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-3 (Several videos are available; watch Erotomanic together; watch the other videos on your own including jealous, mixed, persecutory and somatic types) PPP: >1 delusion lasting >/= month WITHOUT other psychotic symptoms. +/- Nonbizarre = possible but highly unlikely (ex. being poisoned). Apart from the delusion, behavior is not obviously odd or bizarre and there is no significant impairment of function. Not explained by another disorder.

Narcolepsy - Diagnostic Criteria

A. Excessive Daytime Sleepiness (EDS) at least 3 times per week over the past 3 months B. Presence of at least 1 of the following: 1. Episodes of cataplexy, defines as either a) or b) a) In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking b) In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers 2. Low CSF hypocretin-1 (</= 110 pg/ml or < 1/3 of normal) a) Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation or infection 3. Nocturnal PSG showing rapid eye movement (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and 2 or more sleep-onset REM periods *Don't need to memorize, just be familiar

Generalized Anxiety Disorder - DSM-5 Diagnostic Criteria

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). 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): Note: Only one item is required in children. REPIMS 1. Restless 2. Easily Fatigued 3. Poor concentration 4. Irritability 5. Muscle tension 6. Sleep disturbance D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Diagnostic Clues of Psychosis

A. Presenting complaints of auditory (Most common!!) and/or visual hallucinations, bizarre beliefs, unusual suspiciousness, change in social behavior, marked decrease in motivation or self-care, and peculiar behaviors or mannerisms B. History may include past episodes of psychosis, past psychiatric hospitalization or treatment with antipsychotics, marked decline of level of function, use of substances that cause psychosis, and family history of psychiatric disorders C. Mental status examination shows hallucinations, delusions, disorganized speech or behavior, peculiar psychomotor activity D. Physical examination often unremarkable (smooth pursuit eye saccades- difficulty with eye tracking) E. Lab studies may show + toxicology for substances inducing psychosis, and metabolic disturbances, and imaging findings consistent with a general medical condition

Bipolar Disorders

- Bipolar I - Bipolar II - Cyclothymic disorder

Intellectual Disability - Etiology/Epidemiology

- ~1% of population, usually mild (2/3 of cases) - Onset before age 18 but not necessarily lifelong - Variable etiology - Genetic causes: metabolic disorders, chromosomal abnormalities/mutations, CNS malformations - Perinatal insults: birth asphyxia, hypoxia/ischemia, infections, toxin exposure, deprivation of nutrients - Postnatal causes: environmental deprivation (nutritional or social support), infections, toxin exposures, anoxia (lack of oxygen), trauma, cerebral vascular events, malignancy

Specific Phobia - Epidemiology

9% of the population (VERY common disorder)

Attention-Deficity/Hyperactivity Disorder - Diagnostic Criteria

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. A. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). B. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). C. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). D. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). E. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). F. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). G. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). H. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). I. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. A. Often fidgets with or taps hands or feet or squirms in seat. B. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). C. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) D. Often unable to play or engage in leisure activities quietly. E. Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). F. Often talks excessively. G. Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation). H. Often has difficulty waiting his or her turn (e.g., while waiting in line). I. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing). Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). - There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal). Specify whether: Combined presentation: If both inattention and hyperactivity-impulsivity are met for the past 6 months. Predominantly inattentive presentation: If inattention is met but hyperactivity-impulsivity is not met for the past 6 months. Predominantly hyperactive/impulsive presentation: If hyperactivity-impulsivity is met and inattention is not met for the past 6 months. Specify whether: Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. Moderate: Symptoms or functional impairment between "mild" and "severe" are present. Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

Define personality disorder

A pervasive, inflexible, maladaptive manner by which the world is viewed, which originates in adolescence or earlier (some even cite from the first 2 years or life), and alters how the patient views the world PPP: 10-15% of the population; Pervasive inflexible personality trait causing impaired function or distress 1. They are dysfunctional characteristics of a person's personality that are incongruent with social norms 2. Most psychiatric diagnoses we will discuss in this course are ego-dystonic: there is conflict between the person and the world; a depressed patient knows they are depressed and wants to change it (They are aware of their condition) 3. Personality disorders are ego-systonic: there is no conflict between the person and the way they view the world; thus, they rarely see difficulty with how they act and thus rarely seek help and tend to have maladaptive lives riddles with legal and other psychosocial dysfunction (They are unaware of their condition) 4. They have large environmental and genetic components that drive their development and expression

Substance Use Disorder DSM-5 Criteria

A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of the following occurring within a 12-month period: - The substance is often taken in larger amounts or over a longer period than was intended. - There is a persistent desire or unsuccessful efforts to cut down or control use of the substance. - A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. - Craving, or a strong desire or urge to use the substance. - Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home. - Continued use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by its effects - Important social, occupational, or recreational activities are given up or reduced because of use. - Recurrent use in situations in which it is physically hazardous. - Use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. - Tolerance. - Withdrawal. - Current severity can be specified in the diagnosis based on the number of symptoms present: Mild: Two to three symptoms Moderate: Four to five symptoms Severe: Six or more symptoms

Conduct Disorder - DSM-5 Diagnostic Criteria

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to People and Animals 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). 7. Has forced someone into sexual activity. Destruction of Property 8. Has deliberately engaged in fire setting with the intention of causing serious damage. 9. Has deliberately destroyed others' property (other than by fire setting). Deceitfulness or Theft 10. Has broken into someone else's house, building, or car. 11. Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others). 12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). Serious Violations of Rules 13. Often stays out at night despite parental prohibitions, beginning before age 13 years. 14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. 15. Is often truant from school, beginning before age 13 years. B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. Specify whether: Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years. Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years. Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years. Specify if: With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual's typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual's self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (e.g., parents, teachers, co-workers, extended family members, peers). Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules. Callous—lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others. Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance. Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions "on" or "off" quickly) or when emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate others). Specify current severity: Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule breaking). Moderate: The number of conduct problems and the effect on others are intermediate between those specified in "mild" and those in "severe" (e.g., stealing without confronting a victim, vandalism). Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).

What are psychiatric disorders incorporating psychosis?

A. Cognitive disorders, such as delirium and dementia B. Mood disorders i. Major depressive disorder ii. Bipolar disorder --> Occurs only during depression and mania, not during euthymia iii. Is either mood congruent or mood incongruent C. Autistic disorder (disorganized speech and behavior) D. Psychotic disorders (see below)

Childhood Depressive Disorders - DSM-5 Diagnostic Criteria

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. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. Note: Criteria A-C represent a major depressive episode. Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss. In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in an MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of an MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of an MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in an MDE. In grief, self-esteem is generally preserved, whereas in an MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about "joining" the deceased, whereas in an MDE such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition. The diagnostic code for major depressive disorder is based on whether this is a single or recurrent episode, current severity, presence of psychotic features, and remission status. Current severity and psychotic features are only indicated if full criteria are currently met for a major depressive episode. Remission specifiers are only indicated if the full criteria are not currently met for a major depressive episode. In recording the name of a diagnosis, terms should be listed in the following order: major depressive disorder, single or recurrent episode, severity/psychotic/remission specifiers, followed by as many of the following specifiers without codes that apply to the current episode.

Several diagnostic groups in DSM-5 are characterized by psychological problems that cause physical symptoms

A. Psychological factors affecting other medical conditions - psychological factors are temporally associated with the initiation or exacerbation of a medical condition: "GERD" B. Somatoform disorders are mental disorders characterized by physical symptoms but without a physical cause of the symptoms. --> The symptoms suggest, but are not fully explained by, a general medical condition. --> They can be unconsciously-produced (somatic symptom, illness anxiety, and conversion disorders) or they can be consciously-produced (factitious and malingering). That is the major differentiating factor to start with. **HAVE to rule out medical and drug-induced causes before you call it psychiatric (ex. brain tumor or drinking problem) C. Have to differentiate disorders that are unconsciously produced and consciously produced

Premenstrual Dysphoric Disorder (PMDD) - Diagnostic Criteria

A. ≥5 symptoms below: occur in most cycles during the week before menses onset, improve within a few days after menses onset, and diminish in the week postmenses B. One (or more) of the following symptoms must be present: Marked affective lability Marked irritability or anger or increased interpersonal conflicts Marked depressed moods, feelings of hopelessness, or self-deprecating thoughts Marked anxiety, tension C. One (or more) of the following symptoms must be also present: Decreased interest Difficulty concentrating Easy fatigability, low energy Increase or decrease in sleep Feelings of being overwhelmed Physical symptoms such as breast tenderness, muscle or joint aches, "bloating" or weight gain Note: Criteria A-C must be present for most menstrual cycles in the preceding year D. Symptoms are associated with significant distress or interferences with work, school, relationships E. The disturbance is not merely an exacerbation of another disorder such as major depression, panic disorder, persistent depressive disorder, or a personality disorder F. Criterion A should be confirmed by prospective daily ratings in at least two symptomatic cycles G. The symptoms are not due to physiological effects of a substance or another medical condition

Acute Stress Disorder

All I want you to know about this is that it is the anxiety-related equivalent of brief psychotic disorder; this is a disorder that is essentially early or acute PTSD: has to last from 3 days to 1 month. Once it has lasted more than 1 month, it reverts to PTSD

Define personality trait

An enduring, repetitive pattern of perceiving, relating to and thinking about the environment and oneself

Define Avoidant Personality Disorder

Avoidant: they want friends but do not know how to obtain them; dysfunction in ability to act interpersonally due to discomfort. They have self-inadequacy (compare to schizoid). Because of their fear of shame, ridicule, or rejection, they choose to interact with others as little as they possibly can. New activities are rarely attempted and new relationships are seldom formed. i. Know schizoid vs avoidant difference ii. https://unelib.kanopy.com/video/dsm-5-guided-collection-vol-6 Notes: - Schizoid individuals do not want friends and are often asexual whereas Avoidant will want friends but doesn't know how to make them and will often have sexual relationships - Long for attachment of others and fear embarrassment if they were to engage with somebody and feel rejected PPP: Desires relationships but avoids relationships due to "inferiority complex" (intense feeling of inadequacy, sensitive to criticism, fears rejection and humiliation). Timid, shy and lacks confidence

What is the only SSRI indicated for OCD?

Fluvoxamine

Factitious Disorder

Involves the intentional/conscious production or feigning of physical or psychological illness based primarily upon a desire to assume the sick role and get medical attention, not as a response to external incentives i. This involves primary gain PPP: Intentional falsification or exaggeration of signs and symptoms of medical or psychiatric illness for "primary gain" (motivation of their actions is assuming the sick role to get sympathy) - Patients with factitious disorder have an inner need to be seen as ill or injured, but NOT for concrete personal gain (as seen in malingering). The main difference between factitious and somatic symptom disorder is that patients with factitious deliberately fake their symptoms. Types: 1. Factitious disorder imposed on self 2. Factitious disorder imposed on another (by proxy)

Adjustment Disorder - Treatment

Psychotherapy 1st line Treatment involves removing the etiologic stressor (if possible) and engagement in CBT or psychodynamic psychotherapy; supportive psychotherapy also can be helpful in these cases. The focus is on improving coping skills, strengthening defense mechanisms, or changing the way the person interacts with the stressful situation. i. Medication targeting symptoms can also be helpful adjunctively, such as for anxiety, improving secondary insomnia, and to alleviate depressive symptoms

Intellectual Disability - Risk Factors

multiple births, low maternal education, teen pregnancy, male gender, low birth weight, older maternal age

Recurrence rates for Major Depression

very important to educate patients on staying compliant with medication regimine