cmn 552 Unit 3

What is the DSM 5 Diagnostic Criteria for disinhibited social engagement disorder? (DSM, 268)

A Pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: Reduced or absent reticence in approaching and interacting with unfamiliar adults. Overly familiar verbal or physical behavior (not considered culturally sanctions & with age-appropriate social boundaries) Willingness to go off with an unfamiliar adult with minimal or no hesitation The behaviors in Criterion A are not limited to impulsivity (as in no ADHD) but include socially disinhibited behavior The child has experienced a pattern of extremes of insufficient care AEB at least one of the following: Social neglect or deprivation in the form of persistent lack of having basing emotional needs for comfort, stimulation, & affection met by caregiving adults Repeated changes of primary caregivers that limit opportunities to forms table attachments (frequent changes in foster care) Rearing in unusual settings that severely limit opportunities to form selective attachments (institutions with high child-to-caregiver) ratios The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A The child has developmental age of at least 9 months Specify if: Persistent: >12mos Specify current severity: It's specified as severe when the child exhibits ALL symptoms of the disorder at high levels

What are the diagnostic and associated features of disinhibited social engagement disorder? (pg. 1218, Sadock)

A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: 1 . Reduced or absent reticence i n approaching and interacting with unfamiliar adults. 2 . Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). 3 . Diminished or absent checking back with adult caregiver after venturing away, even i n unfamiliar settings. 4 . Willingness to go off with an unfamiliar adult with minimal or no hesitation.

What are the common comorbid disorders in patients with PTSD? (Sadock, pg. 437)

Comorbidity rates are high among patients with PTSD, with about ⅔ having at least two other disorders. Common conditions: depressive, substance-related, anxiety and bipolar disorders. Comorbid disorders make persons more vulnerable to develop PTSD. (DSM, pg. 280) Those w/PTSD are 80% more likely than those w/out PTSD to have symptoms that meet diagnostic criteria for at least one other mental disorder (see above mentioned disorders). Comorbid substance substance use and conduct disorder = more common in males than females. US military personnel and combat veterans deployed to recent wars in Afghanistan and Iraq, co-occurrence of PTSD and mild TBI = 48%. Although most young children w/PTSD also have at least one other diagnosis, the patterns of comorbidity are different than in adults, w/oppositional defiant disorder and separation anxiety disorder predominating. Finally, there is considerable comorbidity between PTSD and major neurocognitive disorder and some overlapping symptoms between these disorders.

How does OCD in children and adolescents differ from OCD in adults? Sadock, pg. 1263

Compared to adults, children and adolescents with OCD more often do not consider their obsessional thoughts or repetitive behaviors to be unreasonable.

What is dissociative trance disorder? (DSM 5 p.307)

Condition characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotyped behaviors (e.g., finger movements) of which the individual is aware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice.

Review the specifier for DSM 5 Diagnostic Criteria for dissociative amnesia. (DSM V pg 298)

A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/ traumatic brain injury, other neurological condition). D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder. Coding note: The code for dissociative amnesia without dissociative fugue is 300.12 (F44.0). The code for dissociative amnesia with dissociative fugue is 300.13 (F44.1). Specify if ; 300.13 (F44.1) With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information.

What is the DSM 5 Diagnostic Criteria for PTSD for children 6 and younger? (DSM-5, p. 272-273)

A. Exposure to actual or threatened death or serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing a traumatic event(s) 2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures. B. Presence of one (or more) of the following intrusions symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment. 2. Recurrent distressing dreams in which the content and/or affect the dream are related to the traumatic event(s). Note: It may not be possible to ascertain that the frightening content is related to the traumatic event. 3. Dissociative reactions (e.g., flashbacks) in which the child feels or act as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma specific reenactment may occur in play. 4. Intense or prolonged psychological distress that exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to reminders of the traumatic event(s). C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s): Persistent Avoidance of Stimuli 1. Avoidance of or efforts to avoid activities, places, or will physical reminders that arouse recollections of the traumatic event(s). 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s). Negative alterations in cognitions 3. Substantially increased frequency of negative emotional states (e.g. fear, guilt, sadness, shame, confusion). 4. Markedly diminished interest or participation in significant activities, including constriction of play. 5. Socially withdrawn behavior. 6. Persistent reduction in expression of positive emotions. D. Alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums). 2. Hypervigilance 3. Exaggerated startle response 4. Problems with concentration 5. Sleep disturbance (ie. Difficulty falling or staying asleep or restless sleep). E. The duration of the disturbance is more than one month. F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior. G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition. (Sadock, p. 1223) According to the DSM-5 the symptoms must be present for at least one month, and cause distress and impairment in important functional areas of life. When all the diagnostic symptoms of PTSD are met following the traumatic event, persists for at least 3 days, but resolved within one month, acute PTSD is diagnosed. When the full syndrome of PTSD persists beyond 3 months, it is designated as chronic PTSD.

What is the DSM 5 Diagnostic Criteria for depersonalization/derealization disorder? (DSM 302)

A. The presence of persistent of recurrent experiences of depersonalization, derealization, or both: Depersonalization: Experiences of unreality, detachment, or being an outside observer with the respect to one's thoughts, feelings, sensations, body, or actions( e.g, perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). B. During the depersonalization or derealization experiences, reality testing remains intact. C. The symptoms cause clinically significant distress or impairment in social occupational, or other important areas of functioning. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures). E. The disturbance is not better explained by another mental disorder,such as schizophrenia, panic disorder, acute stress disorder, major depression disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

12. What is the DSM 5 diagnostic criteria for diagnosing a patient with OCD? Sadock 422

A: The presence of obsessions, compulsions, or both. Obsessions are defined by (1) and (2) as follows: 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and cause marked anxiety and distress 2. The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action (i.e. performing a compulsion Compulsions are defined by (1) and (2): 1. Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a way that could realistically neutralize or prevent whatever they are meant to address, or they are clearly excessive NOTE: young children may not be able to articulate the aims of these behaviors or mental acts. B: The obsessions or compulsions are time consuming (e.g. take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C: The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance(e.g., a drug of abuse, a medication) or another medical condition. D: the disturbance is not better explained by the symptoms of another mental disorder Specify if: -with good or fair insight: the individual recognizes that OCD beliefs are definitely or probably not true or that they may not be true -with poor insight: the individual thinks OCD beliefs are probably true -with absent insight/delusional beliefs: the individual is completely convinced that OCD beliefs are true Specify if: Tic-related: the individual has a current or past history of a tic disorder

What differential diagnosis should be considered for children and adolescents with PTSD? DSM-V pg. 279

Adjustment disorders and anxiety disorders maybe had to distinguish between those and PTSD in patients. Looking at the patient's stressors related to the symptoms present or absent. Other differential diagnoses to be aware of are major depressive disorder, obsessive-compulsive disorder, and borderline personality disorder. These or PTSD should be ruled out based on the symptoms the patient is experiencing, but PTSD can also be in combination with these diagnoses.

What are the common comorbid conditions in patient with adjustment disorder? (DSM 5,- 289)

Adjustment disorders can accompany most mental disorders and any medical disorder. Adjustment disorders can be diagnosed in addition to another mental disorder only if the latter does not explain the particular symptoms that occur in reaction to the stressor. For example, an individual may develop and adjustment disorder, with depressed mood, after losing a job and at the same time have a diagnosis of OCD. Or, a person may have a depressive or bipolar disorder and an adjustment disorder as long as the criteria for both are met. Adjustment disorders may be the major psychological response to a medical disorder.

In evaluating patients for PTSD, the psychiatric nurse practitioner should consider which differential diagnosis? (DSM, pg. 279)

Adjustment disorders, other PTSD and conditions, acute stress disorder, personality disorder, anxiety and OCD disorder, MDD, dissociative disorder, conversion disorder, psychotic disorder, TBI. (Sadock, pg. 444) The NP must be careful to exclude other syndromes when evaluating patients presenting in the wake of trauma. Particularly important to recognize potentially treatable medical contributors to posttraumatic symptomatology, esp. head injury during trauma. Medical contributors can usually be detected through a careful H&P.

What are the differential diagnosis for Acute Stress Disorder? (DSM 5 p.285)

Adjustment disorders, panic disorder, dissociative disorders, posttraumatic stress disorder, obsessive-compulsive disorder, psychotic disorders, traumatic brain injury.

What psychiatric disorders do juveniles in justice residential facilities commonly have? Pg.1308

Adolescents in juvenile justice residential facilities not only have higher rates of psychiatric disorders, including depression, substance use, and suicidal behavior, but they are also significantly more likely to have been victims of physical and sexual abuse, educational failure, and family conflict.

What are the clinical features of sexually abused children? Sadock p 1316

Anxiety symptoms, dissociative reactions and hysterical symptoms, depression, disturbances in sexual behavior, somatic complaints

What are the diagnostic and clinical features of dissociative fugue? (DSM V, pg 298)

Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information. dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis. Behavior during a dissociative fugue is usually purposeful, complex, and goal directed and may last for days, weeks, or longer

What are the conditions/comorbid associated with reactive attachment disorder? (DSM,268)

Associated with neglect are cognitive delays, language delays & stereotypies. Medical conditions such as severe malnutrition may accompany. Depressive symptoms may also occur.

What are the differential diagnosis to consider for OCD in children and adolescents? Sadock, pg. 1265

Autism Spectrum D/O, Tourette's syndrome, delusional symptoms, generalized anxiety d/o, separation anxiety d/o, and social phobia.

What are the differential diagnosis to consider for reactive attachment disorder? (DSM, 267)

Autism spectrum disorder: Differentiated based on neglect (typical in reactive attachment d/0, rare in autism) and on the presence of restricted interests or ritualized behaviors, specific deficit in social communication, and selective attachment behaviors (typical in autism) Intellectual disability (intellectual developmental disorder): Children with intellectual disabilities who have reached cognitive age of 7-9 mos should demonstrate selective attachment regardless of chronological age. They also lack the affect and emotion dysregulation that's commonly seen in reactive attachment. Depressive disorders: Children with depression should still seek out and respond to comforting efforts of caregivers unlike in reactive attachment disorders

What is the general course of an adjustment disorder? (DSM-5, p. 287)

By definition, the disturbance in adjustment disorders begins within 3 months of onset of a stressor and last no longer than 6 mo. After the stressor or its consequences have ceased. If the stressor is an acute event (e.g., being fired from a job), the onset of the disturbance is usually immediate (i.e., within a few days) and the duration is relatively brief (no more than a few months). If the stressor or its consequences persist, the adjustment disorder may also continue to be present and become the persistent form. (sadock, p. 449) Overall prognosis of an adjustment disorder is generally favorable. Most patients return to their previous level of functioning within 3 months. Some persons particularly adolescents who receive a diagnosis of an adjustment disorder later have mood disorders or substance related disorders. Adolescents usually require a longer time to recover than adults. Research over the past 5 years has disclosed a risk for suicide, especially in adolescent patients with adjustment disorder, no previously fully appreciated. A recent study indicated that 60 % had documented suicide attempts in the hospital. 50% had attempted suicide immediately prior to their hospital admission. Comorbid diagnosis of substance abuse and personality disorder contributed to the suicide risk profile in adolescents.

What is kinship care? Sadock, p 1310

Care of children by relatives which more states are recognizing as an alternative placement option and are authorizing licensing and reimbursement to kinship caregivers who are generally female (mostly maternal grandmothers), of low income, of low education, and of minority status.

How does DID presentation in children and adolescents differ from that of an adult? (Sadock, pg 460)

Children & adolescents manifest the same core dissociative symptoms & secondary clinical phenomena as adults. Age-related differences in autonomy and lifestyle, however, may significantly influence the clinical expression of dissociative symptoms in youth. Younger children, in particular, have a less linear and less continuous sense of time and often are not able to self-identify dissociative discontinuities in their behavior. A number of normal childhood phenomena, such as imaginary companionship and elaborated daydreams, must be carefully differentiated from pathological dissociation in younger children.

Review confidentiality in relation to child/adolescent relationship with the psychiatric provider. Sadock PG 1306

Confidentiality, or intensive trust, refers to the relationship between two persons with respect to the "entrustment of secrets." Until the 1970s, little attention was paid to issues of confidentiality pertaining to minors. In 1980, among the items in the AACAP Code of Ethics, six principles were related to confidentiality. Breaches and limits of confidentiality can be obtained in cases of child abuse or maltreatment or for purposes of appropriate education. Although unnecessary with a child or adolescent, consent for disclosure should be obtained when possible. In 1979, the American Psychiatric Association (APA) stated that a child 12 years of age could give consent for disclosure of confidential information and, with the exception of safety issues, a minor's consent is required for disclosure of information to others, including the child's parents. According to the AACAP Code of Ethics, the consent of a minor is not required for disclosure of confidential information. Specific ages for consent are not addressed in the code. Child and adolescent psychiatrists often face the dilemma of weighing the potential benefits and possible harm in sharing information obtained confidentially from a child with the child's parents. Although the smoothest transition occurs when the child and the physician agree that certain information can be shared, in many situations that border on "dangerousness to the child or others," the child or adolescent does not agree to share the information with a parent or another responsible adult. Among adolescents, these secrets that are sometimes shared with a psychiatrist may involve drug or alcohol use, unsafe sex practices, or a thrill-seeking act that places the adolescent in danger. A psychiatrist may choose to work with the child or adolescent toward agreeing to share confidential information when it is determined by the treating psychiatrist that the probable outcome would be beneficial. The initial treatment contract, however, limits confidentiality to situations of "danger" to the child or others.

What is ritual abuse? (Sadock 1315)

Cult-based ritual abuse which includes satanic rituals, is physical, sexual or psychological abuse that involves bizarre or ceremonial activity that is religiously or spiritually motivated. Typically, multiple perpetrators abuse multiple victims over extended periods of time.

Review the classic and nonclassic presentation of individuals with dissociative amnesia (Sadock, Sadock & Ruiz pg 451-452

Classic presentation: The classic disorder is an overt florid, dramatic clinical disturbance that frequently results in the pt being brought quickly to medical attention specifically for symptoms related to the dissociative disorder. It is frequently found in those who have experienced extreme acute trauma. It also commonly develops in the context of profound intrapsychic conflict or emotional stress. Pt may present with intercurrent somatoform or conversion symptoms, alterations in consciousness depersonalization, derealization, trance states, spontaneous age regression and even ongoing anterograde dissociative amnesia. Depression and suicidal ideations are reported in many cases. (Sadock, Sadock & Ruiz pg 452) Nonclassic presentation: These pts frequently come to treatment for a variety of symptoms, such as, depression, or mood swings, substance abuse, sleep disturbances, somatic form symptoms, anxiety and panic, suicidal or self-mutilating impulses and acts, violent outbursts, eating problems, and interpersonal problems. Note that Self-mutilating and violent behaviours may be accompanied by amnesia. Amnesia may also occur in for flashbacks interpersonal problems. Note that Self-mutilating and violent behaviours may be accompanied by amnesia. Amnesia may also occur in for flashbacks or behavioral re-experiencing episodes related to trauma

What is psychosocial dwarfism? (pg. 1219 Sadock)

Classic psychosocial dwarfism or psychosocially determined short stature is a syndrome that usually is first manifest in children 2 to 3 years of age. The children are typically unusually short and have frequent growth hormone abnormalities and severe behavioral disturbances. All of these symptoms result from an inimical caregiver-child relationship. The affectionless character may appear when there is a failure, or lack of opportunity, to form attachments before the age of 2 to 3 years. Children cannot form lasting relationships, and their inability is sometimes accompanied by an inability to obey rules, a lack of guilt, and a need for attention and affection. Children with disinhibited social engagement disorder appear to be overly friendly and familiar with little fear.

What are the psychotherapeutic options in the treatment of DID? (Sadock, p. 461)

Clinician should be comfortable with a range of psychotherapeutic interventions and willing to actively work on structuring the treatment. These modalities include: psychoanalytical psychotherapy, cognitive / behavioral therapy, hypnotherapy, and familiarity with psychotherapy and pharmacological management of the traumatized patient. Family treatment and systems theory is helpful for Pts who subjectively experiences themselves as a complex system of selves with alliances, family-like relationships, and intragroup conflict. A grounding work with pts with somatoform disorders is helpful in sorting through somatic disorders with which they commonly present.

What are the etiological factors for the development of DID? (Sadock, P. 458)

DID is strongly linked to severe experiences of early childhood trauma, usually maltreatment. The rates of reported severe childhood trauma for child and adult patients with DID range from 85 to 97 percent of cases. Physical and sexual abuse are the most frequently reported sources of childhood trauma

What are risk factors for developing disinhibited social engagement disorder? (pg 1217, Sadock)

"Given that pathogenic care, including maltreatment, occurs more frequently in the presence of general psychosocial risk factors, such as poverty, disrupted families, and mental illness among caregivers, these circumstances are likely to increase the risk of reactive attachment disorder and disinhibited social engagement disorder."

What are the epidemiological characteristics for depersonalization/derealization disorder? (Sadock pg 454) (DSM pg 303)

- Transient in general population lasting hours to days - 3rd most commonly reported psychiatric symptom after depression/anxiety -1 year prevalence: 19% general population - Women 2 to 4 times more likely -½ of all adults experienced at least one episode - Lifetime prevalence in US and non-US is approximately 2% (range 0.8% to 2.8%) -Gender ratio: 1:1 - Common in: seizure patients, migraine sufferers, mild to moderate head injury, life threatening experiences with/without serious bodily injury -Substances: psychedelic drugs, marijuana, LSD, mescaline, anticholinergic medications, tetrahydrocannabinol, hallucinogens, ketamine, MDMA (ecstasy), salvia - Other causes: meditation, deep hypnosis, extended mirror/crystal gazing, sensory deprivation experiences

What are the treatment options for dissociative fugue? (Sadock pg 458)

- usually treated with an eclectic, psychodynamically oriented psychotherapy that focuses on helping the patient recover memory for identity and recent experience. - Hypnotherapy and pharmacologically facilitated interviews are frequently necessary adjunctive techniques to assist with memory recovery. - medical treatment for injuries sustained during the fugue as well as food and sleep. - Psychiatric hospitalization may be indicated if the patient is an outpatient. be prepared for the emergence of suicidal ideation or self-destructive ideas and impulses as the traumatic or stressful prefugue circumstances are revealed. - family treatment and social service interventions may be necessary to help resolve such complex difficulties. - the most desirable therapeutic outcome is fusion of the identities, with the person working through and integrating the memories of the experiences that precipitated the fugue. The clinician should appreciate the importance of the psychodynamic information contained within the alter personality state and the intensity of the psychological forces that necessitated its creation.

What are the epidemiological characteristics for adoption? Sadock. 1313

-2.5-3.5% of children in US are adopted -More than 2% adopted by non relatives -1.5% by relatives - this includes stepparents -Foster care children -account for about 15% 125, 000 children are adopted each year - variety of scenarios -50,000 "open" adoptions - infants relinquished at birth and adopted through private agencies; some contingency for contact with bio parents -50,000 through child welfare system; these children often exposed to multiple foster home placements before finally being adopted >½ older than 6 -majority experienced significant early abuse or neglect

What are the 4 major symptom patterns in OCD? Sadock p421-422

-Contamination -Pathological Doubt -Intrusive Thoughts -Symmetry -Other: religious obsessions and compulsions, hair pulling, nail biting, masturbation

Review Gulf War Syndrome, 9/11, Iraq and Afghanistan, Natural Disasters, and Torture. (Sadock pg 442-444)

-Gulf War SyndromeIn the Persian Gulf War against Iraq, which began in 1990 and ended in 1991, approximately 700,000 American soldiers served in the coalition forces. Upon their return, more than 100,000 US veterans reported a vast array of health problems, including irritability, chronic fatigue, shortness of breath, muscle and joint pain, migraine headaches, digestive disturbances, rash, hair loss, forgetfulness, and difficulty concentrating. Collectively, these symptoms were called the Gulf War syndrome. The US Department of Defense acknowledges that up to 20,000 troops serving in the combat area may have been exposed to chemical weapons, and the best evidence indicates that the condition is a disorder that in some cases may have been precipitated by exposure to an unidentified toxin (Table 11.1-5). One study of loss of memory found structural change in the right parietal lobe and damage to the basal ganglia with associated neurotransmitter dysfunction. A significant number of veterans have developed amyotrophic lateral sclerosis (ALS), thought to be the result of genetic mutations.In addition, thousands of Gulf War veterans developed PTSD and the differentiationbetween the two disorders has proved dicult. PTSD is caused by psychological stress,and Gulf War syndrome is presumed to be caused by environmental biological stressors.Signs and symptoms often overlap and both conditions may exist at the same time.-9/11/01On September 11, 2001, terrorist activity destroyed the World Trade Center in New York City and damaged the Pentagon in Washington (Fig. 11.1-1). It resulted in more than 3,500 deaths and injuries and left many citizens in need of therapeutic intervention. One survey found a prevalence rate of 11.4 percent for PTSD and 9.7 percent for depression in US citizens 1 month after 9/11. It is estimated that more than 25,000 people suffer symptoms of PTSD related to the 9/11 attacks beyond the 1-year mark.-Iraq and AfghanistanIn October 2001, the United States, along with Australia, Canada, and the UnitedKingdom, began the invasion of Afghanistan in the wake of the September 11, 2001,attacks. US forces are scheduled to withdraw by the end of 2014. On March 20, 2003, USforces, along with their allies, invaded Iraq, marking the beginning of the Iraq War,which officially ended on December 15, 2011. Both wars caused an estimated 17 percent of returning soldiers to develop PTSD. The rate of PTSD is higher in women soldiers. Women account for 11 percent of those who served in Iraq and Afghanistan and for 14 percent of patients at Veterans Administration (VA) hospitals and clinics. Women soldiers are more likely to seek help than men soldiers. The rate of suicide for active duty personnel in both of these warshave assumed epidemic proportions, with the likelihood of suicide being double that ofthe general population. Traumatic brain injury (TBI), the result of direct or indirect trauma to the brain, causes changes in either the gross or microscopic structure of the brain with associatedsigns and symptoms depending on the location of the lesion. In most cases of TBI therewill be signs and symptoms of PTSD as well, complicating the picture. According to the Department of Veterans Affairs, 19 percent of veterans may have TBI. -Natural DisastersTsunami. On December 26, 2004, a massive tsunami struck the shores of Indonesia, Sri Lanka, South India, and Thailand and caused serious damage and deaths as far west as the coast of Africa and South Africa. The tsunami caused nearly 300,000 deaths and left more than 1 million people without homes. Many survivors continue to live in fear and show signs of PTSD; fishermen fear venturing out to sea, children fear playing at beaches they once enjoyed, and many families have trouble sleeping for fear of another tsunami.Hurricane. In August 2005, a category 5 hurricane, Hurricane Katrina, ravaged the Gulf of Mexico, the Bahamas, South Florida, Louisiana, Mississippi, and Alabama. Its high winds and torrential rainfall breached the levee system that protected New Orleans, Louisiana, causing major flooding. More than 1,300 people were killed and tens of thousands were left stranded. In October 2012, Hurricane Sandy landed on the eastern coast of the United States and in the New York-New Jersey metropolitan area caused almost 150 deaths with an estimated 650,000 homes damaged or destroyed. Over 50,000 persons were believed to have developed full blown PTSD as a result.Earthquake. On January 12, 2010, a 7.0 magnitude earthquake hit Port-au-Prince, the capital of the Republic of Haiti, which had a population of approximately 3 million people. Approximately 316,000 people died, 300,000 were injured, and 1 million were made homeless. The government of Haiti also estimated that 250,000 residences and 30,000 commercial buildings had collapsed or were severely damaged, leaving 10 million cubic meters of rubble. On March 11, 2011, a 9.0 magnitude earthquake hit northeastern Japan, causing a 10-meter tsunami that reached as far as the western coast of the United States, making it the fifth largest earthquake since 1900. Approximately 15,700 people were killed, 4,700 were missing, and 5,700 were injured. It also brought Japan into its second recession in 3 years and triggered the world's biggest nuclear disaster since Chernobyl in 1986. PTSD developed among those who experienced these disasters, the full extent of which remains to be determined. Some estimates range from 50 to 75 percent of survivorsexperienced some or all of the signs and symptoms of PTSD.Torture: The intentional physical and psychological torture of one human by another can have emotionally damaging effects comparable to, and possibly worse than, those seen with combat and other types of trauma. As defined by the United Nations, torture is any deliberate infliction of severe mental pain or suffering, usually through cruel, inhuman, or degrading treatment or punishment. This broad definition includes various forms of interpersonal violence, from chronic domestic abuse to broad-scale genocide. According to Amnesty International, torture is common and widespread in most of the 150 countries worldwide where human rights violations have been documented. Recent figures estimate that between 5 and 35 percent of the world's 14 million refugees have had at least one torture experience, and these numbers do not even account for the consequences of the current political, regional, and religious disputes in various parts of the world where torture is still practiced.

What are the epidemiological characteristics of PTSD? (Sadock, P. 437)

-Lifetime incidence estimated to be 9-15 percent. -Lifetime prevalence is estimated to be 8 percent in gen population, an additional 5-15 percent may experience subclinical forms of the disorder. -Lifetime prevalence rate is 10 percent in women and 4 percent in men. -30 percent of men develop full blown PTSD after serving in war & additional 22.5 percent develop partial PTSD. -Most prevalent in young adults. -Men & women differ in types (men's trauma = combat, women's trauma = assault or rape) Most likely to occur in single, divorced, widowed, socially withdrawn, or low socioeconomic level. -Most important risk factor are severity, duration, and proximity of exposure to actual trauma. -Familial pattern. First degree bio relative of persons with a history depression have increased risk for developing PTSD after a traumatic event.

What are the differential diagnosis for dissociative amnesia? (Sadock, P 453-454, Table 453)

-Ordinary Forgetfulness and Nonpathological Amnesia -Dementia, Delirium, and Amnestic Disorders due to Medical Conditions -Posttraumatic Amnesia -Seizure Disorders -Substance-Related Amnesia -Transient Global Amnesia -Dissociative Identity Disorders -Acute Stress Disorder, Posttraumatic Stress Disorder, & Somatic Symptom Disorder -Malingering and Factitious Amnesia

What is the usual course and progression of PTSD? (DSM, pg. 276)

-PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before criteria for the diagnosis are met. -Duration of the symptoms varies, with complete recovery within 3 months occurring in approximately one-half of adults, while some individuals remain symptomatic for longer than 12 months and sometimes for more than 50 years. -Symptom recurrence and intensification may occur in response to reminders of the original trauma, ongoing life stressors, or newly experienced traumatic events. -For older individuals, declining health, worsening cognitive functioning, and social isolation may exacerbate symptoms.

What are the etiological factors in the development of an adjustment disorder? (Sadock, P. 446).

-Precipitated by one or more stressors. Severity of stressor(s) does not always predict severity of disorder. -Stressor severity is complex function of degree, quantity, duration, reversibility, environment, and personal context. -Personality organization and cultural norms and values also contribute to disproportionate response to stressor(s). -Stressors can be single (divorce or loss of job) or multiple (death of important person which coincides with other stressors), be seasonal (business difficulties), or continuous (chronic illness or poverty). -Discordant intrafamilial relationship can produce the disorder that affects the entire family. -Sometimes occur in group or community setting and stressors affect several people (natural disaster or in racial, social, or religious persecution). -Specific developmental stages (beginning school, leaving home, getting married, becoming a parent, failing to achieve occupational goals, having the last child to leave home, and retiring) are often associated with the disorder.

What is the DSM 5 Diagnostic Criteria for dissociative amnesia?

-Unable to recall important autobiographical information, usually of a stressful or traumatic event. Inconsistent with normal forgetting. . -The inability to recall traumatic events creates distress, or impairment in social, occupational or other important areas of functioning.. -The memory dysfunction does not have a physiological cause. -The memory dysfunction is not better explained by dissociative identity disorder. -The memory loss is not a result of substance abuse or other substance.

What are the different types of dissociative amnesia?

1) Localized amnesia: Inability to recall events related to a circumscribed period of time. 2)Selective Amnesia: Ability to remember some, but not all of the events occurring during a circumscribed period of time. 3)Generalized amnesia: Failure to recall one's entire life. 4) Continuous amnesia: Failure to recall successive events as they occur. 5) Systematized amnesia: Failure to remember a category of of information such as all memories relating to one's family of to a particular person.

What are the risk factors for developing PTSD in children and adolescents? (Sadock, p. 1222)

1. Biological Factors a. Preexisting anxiety d/o & depressive d/o b. IQ > 115 at age 6 - lower risk of developing PTSD c. Among children exposed to trauma that developed PTSD - greater risk of comorbid d/o (ie, depression); suggests predisposition for anxiety d/o (+ family HX w/risk of depressive d/o = trauma exposed child to develop PTSD) d. Children w/PTSD - increased excretion of adrenergic & dopaminergic metabolites, smaller intracranial volume & corpus callosum, memory deficits, & lower IQ 2. Psychological Factors a. Classic Conditioning - Extreme physiological responses may accompany fear of given traumatic event (i.e., beat up at school & now extreme negative physiological reaction when near school) b. Operant Conditioning - Child learns to avoid traumatic reminders to prevent distressing feelings (i.e., child in MVA now refuses to ride in cars altogether to prevent negative physiological reactions & fear from occurring) c. Modeling - Child emulates parental responses & "learn" to respond to own memories of event in same manner 3. Social Factors a. Adverse parental emotional reactions to child's abuse may increase child's risk of developing PTSD b. Lack of parental support & psychopathology among parents are risk factors for PTSD after exposure to traumatic event

What are the 5 phases of sexual abuse? sadock p 1317

1. engagement phase- adult induces child into a special relationship. 2. sexual interaction phase- progress from less to more intrusive. 3. secrecy phase- threatens victim not to tell, perpetrator becomes possessive 4. disclosure phase- accidental or when clinician asks the right questions 5. suppression phase- child often retracts statements due to pressure from family or own mental processes. Sometimes affection from perpetrator outweighs the facts of abuse and victims recant statements

What are 3 distinct features of terrorism? (Sadock, P. 1321)

1. they produce a societal atmosphere of extreme danger and fear.2. They inflict personal harm and destruction3. They undermine the expectation of citizens that the state is able to protect them

What are the epidemiological characteristics for adjustment disorders? (Sadock, P. 446).

2-8% in general population. Women diagnosed 2 times more than men. Single women overly represented as most at risk. In children & adolescents boys and girls are equally diagnosed. Can occur at any age but most frequently in adolescents. One of the most common psych diagnosis of pt's hospitalized for med or surg problem.

What are the treatment options for depersonalization/derealization disorder? (Sadock, pg. 454)

Clinicians working with patients with depersonalization/derealization disorder often find them to be a singularly clinically refractory group. Some systematic evidence indicates that SSRI antidepressants, such as fluoxetine (Prozac), may be helpful to patients with depersonalization disorder. Two recent, double-blind, placebo-controlled studies, however, found no efficacy for fluvoxamine (Luvox) and lamotrigine (Lamictal), respectively, for depersonalization disorder. Some patients with depersonalization disorder respond at best sporadically and partially to the usual groups of psychiatric medications, singly or in combination: antidepressants, mood stabilizers, typical and atypical neuroleptics, anticonvulsants, and so forth. Many different types of psychotherapy have been used to treat depersonalization disorder: psychodynamic, cognitive, cognitive-behavioral, hypnotherapeutic, and supportive. Many such patients do not have a robust response to these specific types of standard psychotherapy. Stress management strategies, distraction techniques, reduction of sensory stimulation, relaxation training, and physical exercise may be somewhat helpful in some patients.

What are the treatment options for dissociative amnesia? Sadock p. 454

Cognitive Therapy - helps to correct cognitive distortions, particularly about the meaning of prior trauma. Hypnotic interventions can be used to contain, modulate, and titrate the intensity of symptoms; to facilitate controlled recall of dissociated memories; to provide support and ego strengthening for the patient; and, finally, to promote working through and integration of dissociated material. Self-hypnosis can be used to apply containment and calmness in everyday life. No known pharmacotherapy exists for dissociative amnesia other than pharmacologically facilitated interviews. Somatic therapies utilizes pharmacologically facilitated interviews with sodium amobarbital, thiopental (Pentothal), oral benzodiazepines, and amphetamines. Intravenous amobarbital or diazepam (Valium) are used primarily in working with acute amnesias and conversion reactions or refractory cases of chronic dissociative amnesias. Time-limited and longer-term group psychotherapies have been reported to be helpful for combat veterans with PTSD and for survivors of childhood abuse.

What are the epidemiological characteristics for Body Dysmorphic Disorder? (Sadock, pg 427)

Common age of onset is 15-30 yrs. Women are affected somewhat more than men, affected patients are also likely to be unmarried.

In evaluating a child/adolescent for physical or sexual abuse, what factors should the clinician consider? (Sadock, p. 1318)

Depends on its circumstances and context. Practitioners must consider whether they are conducting a forensic evaluation, which has legal implications and may ultimately be used in court, or a clinical evaluation, which is done for a therapeutic purpose. A forensic evaluation emphasizes collecting accurate and complete data to determine—as objectively as possible—what happened to the child. Was the injury an accident, was it self-inflicted, or was it a result of parental abuse? Was the child actually sexually abused, or was he or she indoctrinated to believe that he or she was abused? The data collected in a forensic evaluation must be preserved in a reliable manner through audiotape, videotape, or detailed notes. The results of the forensic evaluation are organized into a report that is read by attorneys, a judge, and others. The emphasis in a therapeutic evaluation is to assess psychological strengths and weaknesses, to make a clinical diagnosis, to develop a treatment plan, and to lay the foundation for continuing psychotherapy. The clinician is also interested in determining what happened to the child, but it is not as essential to distinguish facts from fantasies. Compared with the forensic evaluation, the psychotherapist does not need to keep such detailed records and ordinarily does not prepare a report for court.In addition to distinguishing a forensic examination from a therapeutic consultation, a number of factors can affect the evaluation of a child who was abused or may have been abused: whether one is a pediatrician in an emergency department or a child psychiatrist in an office, whether a parent or another person is suspected of the abuse, the severity of the abuse and the victim's relationship to the perpetrator, whether physical signs of abuse are obvious or absent, the age and gender of the child, and the degree of anxiety, defensiveness, anger, or mental disorganization that the child exhibits. Often, the examiner must be creative and persistent.From the psychiatric perspective, the interview is usually the primary source of information, and the physical examination is secondary. When the child is brought to the emergency room, a detailed and spontaneous account of the injury should be obtained promptly from parents or other caregivers before secondary details and rationalizations cloud the information provided.

What are the functional consequences of depersonalization/derealization disorder? Sadock Pg 456

Depersonalization after traumatic experience or intoxication commonly remits spontaneously after removal from the traumatic circumstance or ending of the episode of intoxication. Depersonalizations accompany mood, psychotic, or other anxiety disorders commonly remits with definitive treatment of these conditions. Depersonalization disorder itself may have an episodic relapsing and remitting, or chronic course. Many patients with chronic depersonalization may have a coarse characterization by severe impairment in occupational, social, and personal functioning. Mean age of onset is thought to be in the late adolescence or early adulthood in most case

. What are the diagnostic, clinical, and associated features of depersonalization/derealization disorder? Sadock pg 454-456

Depersonalization is defined as the persistent or recurrent feeling of detachment or estrangement from one's self. The individual may report feeling like an automation or watching himself or herself in a movie. Derealization is somewhat related to and refers to feelings of unreality or of being detached from one's environment. The patient may describe his or her perception of the outside world as lacking lucidity and emotional coloring, as though dreaming or dead. DSM-5 Diagnostic Criteria for Depersonalization/Derealization Disorder Table 12-5 on pg 455 sadock A. The presence of persistent or recurrent experiences of depersonalization, derealization or both: 1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one's thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). 2. Derealization: "Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted." B During the depersonalization or derealization experiences, reality testing remains intact. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or other medical condition (e.g., seizures). E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder." Association of depersonalization with migraines and marijuana, its generally favorable response to SSRIs and the increase in depersonalization symptoms seen with the depletion of L-tryptophan, a serotonin precursor, point to serotoninergic involvement. Depersonalization is the primary dissociative symptoms elicited by the drug-challenge studies described in the section on neurobiological theories of dissociation

In what ways are PTSD and Acute Distress Disorder similar?

Diagnostic criteria and symptoms are the same except ADD must occur within 1 month of the traumatic event and resolve within that 1 month.

What are the diagnostic, clinical, and associated features of PTSD?(Sadock, pg. 439)

Diagnostic features-the symptoms of intrusion, avoidance, alterations of mood and cognition, and hyperarousal must have lasted more than 1 month. Diagnostic features: (DSM, pg. 274) the essential feature is the development of characteristic symptoms following exposure to one or more traumatic events In some individuals, fear-based re-experiencing, emotional, and behavioral symptoms may predominate. In others, anhedonia or dysphoric mood states and negative symptoms may be most distressing. Arousal and reactive-externalizing symptoms may be prominent in some. Dissociative symptoms may be prominent in others. *Some individuals experience combinations of the above-mentioned symptoms patterns. Clinical features-individuals with PTSD show symptoms in 3 domains: (Sadock, pg.439) Intrusion symptoms following the trauma Intrusive symptoms: -Flashbacks, in which the individual may act and feel as if the trauma were reoccurring, represents a classic intrusion symptoms. -Distressing recollections or dreams and either physiological or psychological stress reactions to exposure to stimuli that are linked to the trauma. Avoiding stimuli associated with the trauma Avoidance symptoms: -Efforts to avoid thoughts or activities related to the trauma, -anhedonia -reduced capacity to remember events related to the trauma -blunted affect -feelings of detachment or derealization -a sense of a foreshortened future Experiencing symptoms of increased automatic arousal, such as an enhanced startle. Increased arousal symptoms: Insomnia Irritability Hypervigilance Exaggerated Startle Associated features-(DSM, pg. 276) Developmental regression-such as loss of language in young children, may occur Auditory pseudo-hallucinations-such as having the sensory experience of hearing one's thoughts spoken in one or more different voices, as well as paranoid ideation, can be present. Following prolonged, repeated, and severe traumatic events (childhood abuse, torture), the individual may additionally experience difficulties in regulating emotions or maintaining stable interpersonal relationships, or dissociative symptoms. When the traumatic event produces violent death, symptoms of both problematic bereavement and PTSD may be present.

What are the differential diagnosis to consider in determining depersonalization/derealization disorder? Page 456 sadock

Differential Diagnosis The variety of conditions associated with depersonalization complicate the differential diagnosis of depersonalization disorder. Depersonalization can result from a medical condition or neurological condition, intoxication or withdrawal from illicit drugs, as a side effect of medications, or can be associated with panic attacks, phobias, PTSD, or acute stress disorder, schizophrenia, or another dissociative disorder. A thorough medical and neurological evaluation is essential, including standard laboratory studies, an EEG, and any indicated drug screens. Drug-related depersonalization is typically transient, but persistent depersonalization can follow an episode of intoxication with a variety of substances, including marijuana, cocaine, and other psychostimulants. A range of neurological conditions, including seizure disorders, brain tumors, postconcussive syndrome, metabolic abnormalities, migraine, vertigo, and Ménière's disease, have been reported as causes. Depersonalization caused by organic conditions tends to be primarily sensory without the elaborated descriptions and personalized meanings common to psychiatric etiologies.

What are the differential diagnosis for adjustment disorders? (DSM-5, 288-289)

Differential Diagnosis : Major depressive disorder, posttraumatic stress disorder and acute stress disorder. Personality Disorders, Psychological factors affecting other medical conditions(e.g., psychological symptoms, behaviors, other factors) exacerbate a medical condition. Normative stress reactions: When bad things happen, most people get upset. THIS IS NOT AN ADJUSTMENT DISORDER. (Sadock, p. 448) Other disorders from which adjustment disorder must be differentiated include MDD, brief psychotic disorder, GAD, somatic symptom disorder, substance-related disorder, conduct disorder, and PTSD. These diagnoses should be given precedence in all cases that meet their criteria, even in the presence of a stressor or group of stressors that served as a precipitant. Patients with adjustment disorder are impaired in social or occupational functioning and show symptoms beyond the normal and expectable reaction to the stressor. Because no absolute criteria help to distinguish and adjustment disorder from another condition, clinical judgement is necessary.

What is the DSM 5 Diagnostic Criteria for DID? (DSM 5, pg. 292)

Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: in children, the symptoms are not better explained by imaginary playmates or fantasy play. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

How is dissociation defined? (Sadock 451)

Dissociation is defined as an unconscious defense mechanism involving the segregation of any group of mental or behavioral processes from the reset of the person's psychic activity

What are the epidemiological characteristics for dissociative amnesia? Sadock, p451

Dissociative amnesia has been reported in a range of approximately 2 to 6 percent of the general population. No known difference is seen in incidence.between men and women. Cases generally begin to be reported in late adolescence and adulthood. Dissociative amnesia can be especially difficult to assess in preadolescent children because of their more limity ability to describe subjective experience.

In what ways do unconscious defense mechanisms disrupt mental functions? (Sadock 451)

Dissociative disorder involves mechanism so that there is disruption in one or more mental functions such as memory, identity, perception, consciousness, or motor behavior.

What is a dissociative fugue? Sadock p. 456-457

Dissociative fugue is described as sudden, unexpected travel away from home or one's customary place of daily activities, with inability to recall some or all of one's past. This is accompanied by confusion about personal identity or even the assumption of a new identity. The disturbance is not due to the direct physiological effects of a substance or a general medical condition. The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Dissociative fugue was deleted as a major diagnostic category in DSM-5 and is now diagnosed on a subtype (specifier) of dissociative amnesia. Dissociative fugue can be seen in patients with both dissociative amnesia and dissociative identity disorder.

What are the differential diagnosis for dissociative fugue? (DSM V pg 403)

Dissociative fugue may be extremely difficult to distinguish from sleepwalking. Unlike all other parasomnias, nocturnal dissociative fugue arises from a period of wakefulness during sleep, rather than precipitously from sleep without intervening wakefulness. A history of recurrent childhood physical or sexual abuse is usually present (but may be difficult to obtain) a. Dissociative amnesia: The individual may engage in confused wandering during an amnesia episode. However, in dissociative fugue there is purposeful travel away from the individual's home or customary place of daily activities, usually with the individual preoccupied by a single idea that is accompanied by a wish to run away. b. Dissociative identity disorder: May have symptoms of dissociative fugue, usually recurrently throughout their lives. Patients with dissociative identity disorder have multiple forms of complex amnesias and, usually, multiple alter identities that develop, starting in childhood c. Complex partial seizures: patients have been noted to exhibit wandering or semi-purposeful behavior, or both, during seizures or in postictal states, for which subsequent amnesia occurs. Seizure patients in an epileptic fugue often exhibit abnormal behavior, however, including confusion, perseveration, and abnormal or repetitive movements. Other features of seizures are typically reported in the clinical history, such as an aura, motor abnormalities, stereotyped behavior, perceptual alterations, incontinence, and a postictal state. Serial or telemetric EEGs, or both, usually show abnormalities associated with behavioral pathology. d. General medical conditions, toxic and substance-related disorders, delirium, dementia, and organic amnestic syndrome: could theoretically be confused with dissociative fugue. In most cases, however, the somatic, toxic, neurological, or substance-related disorder can be ruled in by the history, physical examination, laboratory tests, or toxicological and drug screening. Use of alcohol or substances may be involved in precipitating an episode of dissociative fugue. e. Bipolar or schizoaffective disorder: Wandering and purposeful travel can occur during the manic phase. Patients who are manic may not recall behavior that occurred in the euthymic or depressed state and vice versa. In purposeful travel owing to mania, however, the patient is usually preoccupied with grandiose ideas and often calls attention to himself or herself because of inappropriate behavior. Assumption of an alternate identity does not occur. f. Schizophrenia: Memory for events during wandering episodes in such patients may be difficult to ascertain owing to the patient's thought disorder. Patients with dissociative fugue, however, do not demonstrate a psychotic thought disorder or other symptoms of psychosis. g. individuals who are attempting to flee a situation involving legal, financial, or personal difficulties, as well as in soldiers who are attempting to avoid combat or unpleasant military duties: No test, battery of tests, or set of procedures exist that invariably distinguish true dissociative symptoms from those that are malingered. Malingering of dissociative symptoms, such as reports of amnesia for purposeful travel during an episode of antisocial behavior, can be maintained even during hypnotic or pharmacologically facilitated interviews. Many malingerers confess spontaneously or when confronted. In the forensic context, the examiner should always carefully consider the diagnosis of malingering when fugue is claimed.

What are the treatment options for extreme cases of OCD that are treatment resistant? Sadock, p. 426

Eelectroconvulsive therapy (ECT) and psychosurgery are considerations. ECT should be tried before surgery. Cingulotomy: Surgical procedure which may be successful in treating otherwise severe/treatment-unresponsive patients. Other surgical procedures (e.g., subcaudate tractotomy, also known as capsulotomy) have also been used for this purpose. Deep brain stimulation (DBS): Indwelling electrodes in various basal ganglia nuclei are under investigation to treat both OCD and Tourette's disorder. DBS is performed by using MRI-guided electrode implantation. Complications of DBS include infection, bleeding, or the development of seizures, which are almost always controlled by treatment with Dilantin. Some patients who do not respond to psychotherapy alone and who do not respond to pharmacotherapy or behavior therapy before the operation do respond to pharmacotherapy or behavior therapy after psychosurgery.

What is the DSM 5 Diagnostic Criteria for Acute Stress Disorder?( Sadock p. 442)

Exposure to actual or threatened death, serious injury, or sexual violation in one or more of the following ways: directly experiencing the traumatic events, witnessing the event, learning the event happened to a close family member or friend, experiencing extreme or repeated exposure to aversive details of the traumatic events (not through electronic media unless part of work responsibility). Presence of nine or more symptoms from the categories of intrusion, negative mood, dissociation, avoidance, and arousal: Intrusion: recurrent, involuntary, and intrusive distressing memories of the traumatic event, recurrent distressing dreams, dissociative reactions(flashbacks) in which the individual feels or acts if the events were recurring, intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues. negative mood: persistent inability to experience positive emotions. dissociative symptoms: an altered sense of the reality of one's surroundings or oneself, inability to remember an important aspect of the traumatic events. avoidance symptoms: efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events, efforts to avoid external reminders that arouse distressing memories, thoughts or feelings about the event. arousal symptoms: sleep disturbance, irritable behavior and angry outbursts, hypervigilance, problems with concentration, exaggerated startle response. 3) Duration of the disturbance is 3 days to 1 month after trauma exposure. 4) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 5) The disturbance is not attributable to the physiological effects of a substance or another medical condition.

What is factitious dermatitis? (Sadock, pg 435)

Factitious dermatitis or dermatitis artefacta is a disorder in which skin-picking is the target of self-inflicted injury and the patient uses more elaborate methods than simple excoriation to self-induce skin lesions.

What are the prevalence rates for DID? (Sadock, P. 458)

Few epidemiological data exist fo DID however, studies report female to male ratios between 5 to 1 and 9 to 1 for diagnosed cases. (Found on google-NIH- approximately 0.5-1% of population

How is ECT helpful in treating DID?

For some patients, ECT is helpful in ameliorating refractory mood disorders and does not worsen dissociative memory problems. Clinical experience in tertiary care settings for severely ill patients with dissociative identify disorder suggest that a clinical picture of major depression with persistent, refractory melancholic features across all alter states may predict a positive response to ECT

What are the different types of bullying? Pg.1308

Four different realms: physical, relational, verbal, and cyberbullying.

What are the differential diagnosis to consider when evaluating for Ganser Syndrome? (Sadock P.464)

Given the reported frequent history of organic brain syndromes, seizures, head trauma, and psychosis is Ganser syndrome, a thorough neurological and medical evaluation is warranted. Differential diagnoses include organic dementia, depressive pseudodementia, the confabulation of Korsakoff's syndrome, organic dysphasias, and reactive psychoses. Patients with dissociative identity disorder occasionally may also exhibit Ganser-like symptoms.

What are the adjunct treatments available in the treatment of DID? (Sadock, p. 462)

Group Therapy - Therapy groups composed only of patients with dissociative identity disorder are reported more successful, although the groups must be carefully structured, must provide firm limits, and should generally focus only on her-and-now issues of coping and adaptation. Family Therapy - Family or couples therapy is often important for long-term stabilization and to address pathological family and marital processes that are common in patients with dissociative identity disorder and their family members. Self-Help Groups - Patients with dissociative identity disorder usually have a negative outcome to self-help groups or 12-step groups for incest survivors. Expressive and Occupational Therapies - Expressive and Occupational therapies, such as art and movement therapy, have proved particularly helpful in treatment of patients with dissociative identity disorder. Eye Movement Desensitization and Reprocessing (EMDR) - The International Society for the Study of Trauma and Dissociation dissociative identity treatment guidelines suggest that EMDR only be used in patient population by clinicians who have taken advanced EMDR training, are knowledgeable and skill in phasic trauma treatment for dissociative disorder, and have received supervision in the use of EMDR in dissociative identity disorder.

What are some common health problems seen in foster care children? Sadock, p. 1310

Growth abnormalities (including failure to thrive), neurological abnormalities, neuromuscular disorders, language disorders, cognitive delays, and asthma are prevalent.

What are the etiological factors of physical abuse?

Highly associated with poverty and psychosocial stress, parental substance abuse and mental illness. Child maltreatment is strongly correlated with less parental education, underemployment, poor housing, welfare reliance, and single parenting. Child abuse tends to occur more often in families characterized by domestic violence, social isolation, parental mental illness and drug and alcohol abuse. The probability of maltreatment may be increased by risk factors in the child such as prematurity, intellectual disability, and physical handicap. In addition, the risk of child abuse increases in families with many children.

What are the driving forces for hoarding? (Sadock, pg 429)

Hoarding disorder is commonly driven by an obsessive fear of losing important items that the person believes may be of use at some point in the future, by distorted beliefs about the importance of possessions, and by extreme emotional attachment to possessions. Most hoarders do not perceive their behavior to be a problem.

How is hypnosis helpful in treating DID?

Hypnosis can often alleviate self-destructive impulses or reduce symptoms, such as flashbacks, dissociative hallucinations, and passive influence experiences. Teaching the patient self-hypnosis may help with crisis outside of sessions. Hypnosis can be useful for accessing specific alter personality states and their sequestered affects and memories. Hypnosis is also used to create relaxed mental states in which negative life events can be examined without overwhelming anxiety (Sadock, p. 461).

What are some questions that the psychiatric nurse practitioner can use when performing a mental status exam on a patient presenting with dissociative amnesia? Table 12-3 Sadock p 452

If answers are positive, ask the patient to describe the event. Make sure to specify that the symptoms does not occur during an episode of intoxication. 1. Do you ever have black outs? Memory lapses? 2. Do you lose time? HAve gaps in your experience of time? 3. Have you travelled a considerable distance without recollection of how you did this or where you went exactly? 4. Do people tell you of things that you have said or done that you do not recall? Do you find objects in your possession that you do not remember acquiring? 5. Have you ever been told or found evidence that you have talents and abilities that you did not know you had? 6. Do you have gaps in your memory of your life? Are you missing parts of your memory for your life history or important events in your life? 7. Do you lose track of or tune out conversations or therapy sessions as they are occurring? DO you find that while you are listening to someone talk you did not hear all or part of what was just said? 8. What is the longest period of time that you have lost? minutes? hours? days? weeks? months? years? Describe.

What are the functional consequences of DID? (DSM-5, p. 295)

Impairment varies widely, from apparently minimal to profound. Regardless of level of disability, individuals with DID commonly minimize the impact of their dissociative and posttraumatic symptoms. The symptoms of higher-functioning individuals may impair their relational, marital, family, and parenting functions more than their occupational and professional (although the latter may be affected). With appropriate treatment, many impaired individuals show marked improvement in occupational and personal functioning. However, some remain highly impaired in most activities of living. These individuals may only respond to treatment very slowly, with gradual reductions in or improved tolerance of their dissociative and posttraumatic symptoms. Long-term supportive treatment may slowly increase these individuals' ability to manage their symptoms and decrease use of more restrictive levels of care. (Sadock, p. 460) Most patients with DID meet criteria for a mood disorder, usually one of the depression spectrum disorders. Frequent, rapid mood swings are common, but these are usually caused by posttraumatic and dissociative phenomena, not a true cyclic mood disorder. Considerable overlap may exist between PTSD symptoms of anxiety, disturbed sleep, and dysphoria and mood disorder symptoms. Obsessive-compulsive personality traits are common in DID, and intercurrent obsessive-compulsive disorder symptoms are regularly found in patients with DID.

What are the diagnostic and clinical features in children and adolescents with PTSD? Sadock pg. 440

In addition to what was previously mentioned in the diagnostic criteria for PTSD for adults, children and adolescents (children older than 6 years) the following may apply to the patient: a. repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. b. there may be frightening dreams without recognizable content. c. trauma-specific reenactment may occur in play.

What are the components for recovery from exposure to terrorism? (Sadock, p. 1323)

In order to begin the process of recovery from exposure to mass trauma, an assessment of a child's current coping must be done. Numerous instruments to measure coping exist. These include COPE, a self-report questionnaire which has 52 items that can be used with children, adolescents, and adults; Children's Coping Strategies Checklist (CCSC), a self-report questionnaire with 45 general coping items used with children 9 to 13 years of age; and How I Coped Under Pressure (HICUPS), which has 45 event specific questions for children in the 4th and 6th grade. Once this assessment has been determined, the next steps can be taken to being the road to recovery.

What are the cognitive features in hoarding disorder patients? (DSM 5 pg 249)

Indecisiveness Perfectionism Avoidance Procrastination Difficulty planning and organizing tasks Distractibility.

What are the etiological factors of sexual abuse?

Insestious behavior is associated with etoh abuse, overcrowding, rural isolation, some cultures more tolerant of insest. Major mental disorders and intellectual deficiency has been described in some perpertrators of insest and sexual abuse.

What are the arousal and reactivity symptoms in PTSD? (DSM-5, p. 272)

Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. o Reckless or self-destructive behavior o Hypervigilance o Exaggerated startle response o Problems with concentration o Sleep disturbance (ie. Difficulty falling or staying asleep or restless sleep). What are these for children 6 and younger? (DSM-5, p. 273) o Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums). o Hypervigilance o Exaggerated startle response o Problems with concentration o Sleep disturbance (ie. Difficulty falling or staying asleep or restless sleep).

How is Dissociative Identity Disorder (DID) characterized in relation to distinct identities or personality states? (Sadock, pg. 458)

It is characterized by the presence of two or more distinct identities or personality states. The identities or personality states, sometimes called alters, self-states, alter identities, or parts, among other terms, differ from one another in that each presents as having its own pattern of perceiving, relating to, and thinking about the environment and self, in short, its own personality. Dissociative Identity Disorder is a disruption of identity characterized by two or more distinct personality states, which may be described in some cultures an experience of possession.

What is brainwashing? (DSM-5 p. 306) Identity disturbance due to prolonged and intense coercive persuasion.

Largely occurs in settings of political reform (Cultural Revolution in communist China, war imprisonment, torture of political dissidents, terrorist hostages, & totalitarian cult indoctrination. Implies individuals under conditions of adequate stress and duress, individuals can be made to comply with demands of those in power, thereby undergoing major changes in personality, beliefs, and behaviors. Persons subjected to conditions can undergo considerable harm including loss of health and life and typically manifest a variety of post-traumatic and dissociative symptoms Likened to the artificial creation of an identity crisis, with the emergency of a new pseudo-identity that manifests characteristics of a dissociative state. Under circumstances of extreme and malignant dependency, overwhelming vulnerability, and danger to one's existence, individuals develop a state characterized by extreme idealization of their captors, with ensuing identification with the aggressor and externalization of their superego, regressive adaptation known as traumatic infantilism, paralysis of will, and a state of frozen fright. The coercive techniques are typically used to induce such a state in the victim have been amply described and include isolation of the subject, degradation, control over all communications and basic daily functions, induction of fear and confusion, peer pressure, assignment of repetitive and monotonous routines, unpredictability of environmental supplies, renunciation of past relationships and values, and various deprivations. Physical or sexual abuse, torture, and extreme sensory deprivation and physical neglect can be a part of the process but are not required to define coercive process. As a result, victims manifest extensive post-traumatic and dissociative symptomatology including drastic alteration of their identity, values & beliefs; reduction of cognitive flexibility with regression to simplistic perceptions of good versus evil and dominance versus submission; numbing of experience and blunting of affect; trance-like states and diminished environmental responsiveness; and in some cases, more severe dissociative symptoms such as amnesia, depersonalization, and shifts in identity. Treatment varies but includes validation of traumatic experience and coercive techniques used,, cognitive reframing of events that transpired, exploration of preexisting psychopathology; Family therapy may be required in cases of cult indoctrination. (Sadock p. 819) First practiced by Chinese Communists on American prisoners during Korean War, it is the deliberate creation of culture shock. Individuals are isolated, intimidated, and made to feel different and out of place to break their spirits and destroy their coping skills. When a person appears mentally weak and helpless, the aggressors impose new ideas on them that they would never have accepted in their normal state. As with those in cults, on release and return to their homes, brainwashed individuals with PTSD require deprogramming treatment, including re-education and ongoing supportive psychotherapy, both on an individual and group basis. Treatment is usually long term to rebuild health self-esteem and coping skills.

What are the common comorbid conditions in individuals with depersonalization/derealization disorder? Page 306 DSM-5

Lifetime commodities were high for unipolar depressive disorder and for any anxiety disorders, with a significant proportion of the sample having both disorders. Comorbidity with post-traumatic stress disorder was low. The three most commonly co-occurring personality disorders were avoidant borderline and obsessive compulsive.

3. What is the prevalence of OCD?

Lifetime prevalence in the general population estimated at 2 to 3 percent. Fourth most common psychiatric diagnosis. Among adults, men and women are equally likely to be affected. Among adolescents, boys are more commonly affected than girls. Mean age of onset is about 20 years. The onset of the disorder can occur in adolescence or childhood, in some cases as early as 2 years of age. Single persons are more frequently affected with OCD than are married persons, although this finding probably reflects the difficulty that persons with the disorder have maintaining a relationship. Occurs less often among blacks than among whites, although access to health care rather than differences in prevalence may explain the variation.

What is the general course and prognosis for DID? (Sadock, p. 461)

Little is known about the course of untreated DID. Some individuals may continue involvement in abusive relationships or violent subcultures that may traumatize their children, with the potential for family transmission of the disorder. Some patients with undiagnosed or untreated DID die by suicide or d/t risk-taking behaviors. Prognosis is worse in patients with comorbid organic mental disorders, psychotic disorders (other than pseudopsychosis), severe medical illnesses, refractory substance abuse, eating disorders, significant antisocial features, current criminal activity, ongoing abuse, current victimization, with refusal to leave abusive relationship. Repeated adult traumas with recurrent acute stress disorder may severely complicate clinical course (DSM-5, p.295) Ongoing abuse, later-life retraumatization, comorbidity with mental disorders, severe medical illness, and delay in appropriate treatment also associated with poorer prognosis

What are the common comorbid conditions in individuals with DID?

Most develop PTSD. Other disorders that are highly comorbid with DID include depressive disorders, trauma and stressor related disorders, personality disorders (especially avoidant and borderline personality disorder), conversion disorder (functional neurological symptom disorder), somatic symptom disorder, eating disorders, substance-related disorders, OCD, and sleep disorders. Dissociative alterations in identity, memory, and consciousness may affect the symptom presentation of comorbid disorders.

What are the alterations in cognition and mood associated with PTSD? (DSM-5 Pg 271-272)

Negative alterations in cognitions and mood associated with the traumatic events, beginning or worsening after the traumatic events occurred, as evidenced by two or more of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," 'The world is completely dangerous," "My whole nervous system is permanently ruined"). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feeling

What are the risk factors for the development of dissociative amnesia?

No single personality profile or antecedent is consistently reported in these patients, although a prior personal or family history of somatoform or dissociative symptoms has been shown to to predispose the individual to develop acute amnesia during traumatic circumstances. Many of these patients have histories of prior adults or childhood abuse or trauma. In wartime cases, as in other forms of combat related posttraumatic disorders, the most variable in the development of dissociative symptoms, however, appears to be the intensity of combat. Sadock, p 452

What are the etiological factors for dissociative amnesia?

No single personality profile or antecedent is consistently reported in these patients, although a prior personal or family history of somatoform or dissociative symptoms has been shown to to predispose the individual to develop acute amnesia during traumatic circumstances.Many of these patients have histories of prior adults or childhood abuse or trauma. In wartime cases, as in other forms of combat related posttraumatic disorders, the most variable in the development of dissociative symptoms, however, appears to be the intensity of combat. Sadock, p 451

What are the treatment options for Ganser Syndrome? (Sadock P.464)

No systematic treatment studies have been conducted, given given the rarity of this condition. In most case reports, the patient has been hospitalized and has been provided with a protective and supportive environment. In some instances, low doses of antipsychotic medications have been reported to be beneficial. Confrontation or interpretations of the patient's approximate answers are not productive, but exploration of possible stressors may be helpful. Hypnosis and amobarbital narcosynthesis have also been used successfully to help patients reveal the underlying stressors that preceded the development of the syndrome, with concomitant cessation of the Ganser symptoms. Usually, a relatively rapid return to normal function occurs within days, although some cases may take a month or more to resolve. the individual is typically amnesic for the period of the syndrome.

7. Review the psychosocial factors for the development of OCD. (Sadock, p. 420)

OCD differs from obsessive-compulsive personality disorder, which is associated with an obsessive concern for details, perfectionism, and other similar personality traits. Most persons with OCD do not have premorbid compulsive symptoms, and such personality traits are neither necessary nor sufficient for the development of OCD. Only about 15 to 35 percent of patients with OCD have had premorbid obsessional traits. Many patients with OCD may refuse to cooperate with effective treatments such as selective serotonin reuptake inhibitors (SSRis) and behavior therapy. Patients may become invested in maintaining the symptomatology because of secondary gains. For example, a male patient, whose mother stays home to take care of him, may unconsciously wish to hang on to his OCD symptoms because they keep the attention of his mother. Research suggests that OCD may be precipitated by a number of environmental stressors, especially those involving pregnancy, childbirth, or parental care of children. An understanding of the stressors may assist the clinician in an overall treatment plan that reduces the stressful events themselves or their meaning to the patient.

What are the epidemiological characteristics for OCD among children and adolescents? Sadock, pg. 1263

OCD is common among children and adolescents, with a lifetime prevalence of 2-4%. The rate of OCD among youth rises exponentially with increasing age, with rates of 0.3% in children between the ages of 5 and 7 years, rising to rates between 0.6 percent and 1 percent among teens. Rates of OCD among adolescents are greater than schizophrenia or bipolar disorder. Among young children with OCD there appears to be a slight male predominance, which diminishes with age.

2. Differentiate between an obsession and a compulsion. (Sadock, p. 418)

Obsession: A recurrent and intrusive thought, feeling, idea, or sensation. Compulsion: A conscious, standardized, recurrent behavior, such as counting, checking, or avoiding

What is the best way to distinguish between OCD and major depressive disorder? Sadock pg 418

Obsessive compulsive disorder ( OCD) is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations,and compulsions. These recurrent obsessions or compulsion cause severe distress to the person. The obsessions or compulsions are time consuming and interfere significantly with the person's normal routine, occupational functioning , usual social activities, or relationships. A patient with OCD may have an obsessive, a compulsion, or both. Sadock pg 347. A major depressive disorder occurs without a history of a manic,mixed ,or hypomanic episode. A major depressive episode must last at least 2 weeks , and typically a person with a diagnosis of a major depressive episode also experiences at least four symptoms from a list that includes changes in appetite and weight , changes in sleep and activity ,lack of energy , feelings of guilt , problems thinking and making decisions, and recurring thoughts of suicide.

What is emotional abuse? (Sadock p.1315)

Occurs when a person conveys to children they are worthless, flawed, unloved, unwanted or endangered. exmp. belittling, screaming, threats, blaming or sarcasm. Severity depends on 1. if perpetrator actually intends to inflict harm 2. Whether abuse is likely to cause harm to the child.

What are alterations in cognition and mood associated with PTSD for children 6 and younger? (DSM-5 Pg 273)

One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s): Persistent Avoidance of Stimuli 1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s). Negative Alterations in Cognitions 3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion). 4. Markedly diminished interest or participation in significant activities, including constriction of play. 5. Socially withdrawn behavior. 6. Persistent reduction in expression of positive emotion

What symptoms do children exhibit in response to terrorism? (Sadock, p. 1319)

One predominant and near universal symptom in children in response to these stimuli is anxiety. Young children may cling excessively to their parents, whereas older children may become preoccupied with fear about unrelated issues. Some youth express overt anger, and others experience a sense of hopelessness, lack of control, and/or depression. Severe traumas, such as experiencing a terrorist event, may be more likely to result in posttraumatic stress syndromes among exposed youth, compared to less severe forms of trauma. The number of traumas experienced by a child, degree of family support provided after the exposure, and the reactions of parents are all important factors in a child's reaction.

What are some common coexisting conditions in BodyDysmorphic Disorder? (Sadock, pg 427)

One study found that 90 % of pts with BDD had experienced a Major Depressive episode in their lifetime. 70% had anxiety disorder, 30 % had experienced a psychotic disorder.

How often do patients seeking plastic surgery meet the diagnostic criteria for BDD? (Sadock, pg. 429)

One study found that only 2 percent of the patients in a plastic surgery clinic had the diagnosis, but DSM-5 reports the figure to be 7 to 8 percent. The overall percentage may be much higher. Surgical requests are varied: removal of facial sags, jowls, wrinkles, or puffiness; rhinoplasty; breast reduction or enhancement; and penile enlargement. Commonly associated with the belief about appearance is an unrealistic expectation of how much surgery will correct the defect. As reality sets in, the person realizes that life's problems are not solved by altering the perceived cosmetic defect. Ideally, such patients will seek out psychotherapy. Absent that, patients may take out their unfulfilled expectations and anger by suing their plastic surgeons—who have one of highest malpractice-suit rates of any specialty—or by developing a clinical depression.

What are the differential diagnosis to consider when evaluation for DID? (DSM-5, P. 292)

Other specified dissociative disorders, Major depressive disorders, Bipolar disorders, PTSD, Psychotic disorders, Substance/medication-induced disorders, Personality disorders, Conversion disorders, Seizure disorders, Factitious disorder and malingering.

What is the risk of suicide in DID? (DSM-5, p. 295)

Over 70% of outpatients with DID have attempted suicide; multiple attempts are common, and other self-injurious behavior is frequent. Assessment of suicide risk may be complicated when there is amnesia for past suicidal behavior or when the presenting identity does not feel suicidal and is unaware that other dissociated identities do,

What are the etiological factors in the developing depersonalization/derealization disorder?(Sadock pg 455) (DSM pg 304)

PSYCHODYNAMIC: disintegration of ego; defense of ego; painful/conflictual experiences as triggering events; harm-avoidant temperament; Immature defenses: idealization/devaluation; projection and acting out result in denial of reality and poor adaptation Cognitive disconnection schemata: defectiveness and emotional inhibition, and themes of abuse, neglect and deprivation Over Connection schemata: impaired autonomy w/themes of dependency, vulnerability, and incompetence TRAUMATIC STRESS: ⅓ to ½ report significant trauma ; evoked by stress/fatigue; emotional abuse/neglect; physical abuse, domestic violence witness, growing up with mentally ill/impaired parent; unexpected death/suicide of family member/friend NEUROBIOLOGICAL THEORIES: - marijuana and migraines- favorable response to SSRI - Depletion of L-tryptophan (serotonin precursor) - NMDA- subtype of glutamate receptor (excitatory)

What are the commonly found DID associated symptoms in DID (PTSD symptoms, somatic symptoms, affective symptoms, and obsessive-compulsive symptoms)? (Sadock, P. 459 Table 12-6)

PTSD symptoms: Intrusive symptoms, hyperarousal, avoidance and numbing symptoms Somatic symptoms: Conversion and pseudoneurological symptoms Seizure-like episodes Pain symptoms Headache, abdominal, musculoskeletal, pelvic pain psychophysiological symptoms of disorders Asthma and breathing problems Perimenstrual disorder IBS GERD Somatic memory Affective symptoms: Depressed mood, dysphoria, or anhedonia Brief mood swings or mod lability Suicidal thoughts and attempts of self-mutilation Helpless and hopeless feeling Obsessive-compulsive symptoms: Rumination about trauma Arranging Washing Checking

How can the psychiatric nurse practitioner differentiate between hoarding from OCD? (Sadock, pg 431)

Patients do not display some of the classic symptoms of OCD such as recurring intrusive thoughts or compulsive rituals. Unlike symptoms of OCD, symptoms of hoarding worsen with time, rituals are not fixed, and obsessions about dirt or contamination are absent. OCD patients have better insight into their condition. Symptoms are usually ego-dystonic, whereas hoarding disorder they are ego-systonic. Hoarding behavior is seldom repetitive and is not viewed as intrusive or distressing to the hoarder. Distress mainly comes at the prospect of having to discard items and it manifests more as guilt and anger than anxiety. Hoarding disorder also tends to be less responsive to classic treatments for OCD such as exposure therapy and cognitive behavioral therapy, and SSRI's

What are the diagnostic/clinical features of OCD? Sadock p.421

Patients with OCD often take their complaints to physicians other than psychiatrist. Most patients with OCD have both obsessions & compulsions - up to 75%. Obsessions and compulsions are the essential feature of OCD. Sometimes, patients overvalue obsessions and compulsions, for example they may insist that compulsive cleanliness is morally correct, even though they have lost their jobs because of time spent cleaning.

What are the reasons other clinical specialists are likely to be seeing a patient with OCD?

Patients with OCD often take their complaints to physicians rather than psychiatrists (Table 10.1-2). Most patients with OCD have both obsessions and compulsions—up to 75 percent in some surveys. Some researchers and clinicians believe that the number may be much closer to 100 percent if patients are carefully assessed for the presence of mental compulsions in addition to behavioral compulsions. For example, an obsession about hurting a child may be followed by a mental compulsion to repeat a specific prayer a specific number of times. Other researchers and clinicians, however, believe that some patients do have only obsessive thoughts without compulsions. Such patients are likely to have repetitious thoughts of a sexual or aggressive act that is reprehensible to them. Sadock pg 421. See Table 10.1-1

In what ways can the psychiatric nurse practitioner characterize (specify) insight in the OCD patient? (Sadock, p. 421)

Patients with good or fair insight recognize that their OCD beliefs are definitely or probably not true or may or may not be true. Patients with poor insight believe their OCD beliefs are probably true. Patients with absent insight are convinced that their beliefs are true.

What are the epidemiological characteristics for children and adolescents for PTSD? (Sadock, p. 1222)

Peak age - 16-20 yrs · Females > Males - due to increased risk of exposure (near equal rates in natural disasters) · Lifetime risk in U.S. - 6.8%-12.2% · In 9-17 y/o - 3 month prevalence rates - 0.5% -4% · In 4-5 y/o - 1.3% · Among samples of those NOT referred for treatment - 25%-90% reported to exhibit full diagnosis of PTSD ·Children w/chronic exposure - greatest risk of developing PTSD w/symptoms severe enough to disrupt functioning even without full diagnosis

What are some influential factors in how a child responds to terrorist exposure? (Sadock, P. 1321)

Personal appraisal of persisting danger, the likelihood of recurrent attack, and the perception of the relative safety of one's family and close friends. Children's responses are influenced by how their parents cope with trauma and the resulting turmoil and how well they understand the situation. Reactions to exposure from terrorism are mediated by numerous factors including: personal appraisal for persisting danger, the likelihood of a recurrent attack, and the perception of one's safety of one's family and close friends. Children's response to terrorist exposure are influenced by how their parents cope with the trauma and resulting turmoil and how well they understand the situation.

8. In OCD patients, what is "magical thinking"? (Sadock, p. 421)

Persons believe that merely by thinking about an event in the external world they can cause the event to occur without intermediate physical actions.

What are the pharmacotherapeutic options for the treatment of PTSD? (Sadock pg 445)

Pharmacotherapy Selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft) and paroxetine (Paxil), are considered first-line treatments for PTSD, owing to their efficacy, tolerability, and safety ratings. SSRIs reduce symptoms from all PTSD symptom clusters and are effective in improving symptoms unique to PTSD, not just symptoms similar to those of depression or other anxiety disorders. Buspirone (BuSpar) is serotonergic and may also be of use. The efficacy of imipramine (Tofranil) and amitriptyline (Elavil), two tricyclic drugs, in the treatment of PTSD is supported by a number of well-controlled clinical trials. Although some trials of the two drugs have had negative findings, most of these trials had serious design flaws, including too short a duration. Dosages of imipramine and amitriptyline should be the same as those used to treat depressive disorders, and an adequate trial should last at least 8 weeks. Patients who respond well should probably continue the pharmacotherapy for at least 1 year before an attempt is made to withdraw the drug. Some studies indicate that pharmacotherapy is more effective in treating the depression, anxiety, and hyperarousal than in treating the avoidance, denial, and emotional numbing. Other drugs that may be useful in the treatment of PTSD include the monoamine oxidase inhibitors (MAOIs) (e.g., phenelzine [Nardil]), trazodone (Desyrel), and the anticonvulsants (e.g., carbamazepine [Tegretol], valproate [Depakene]). Some studies have also revealed improvement in PTSD in patients treated with reversible monoamine oxidase inhibitors (RIMAs). Use of clonidine (Catapres) and propranolol (Inderal), which are antiadrenergic agents, is suggested by the theories about noradrenergic hyperactivity in the disorder. There are almost no positive data concerning the use of antipsychotic drugs in the disorder, so the use of drugs such as haloperidol (Haldol) should be reserved for the short-term control of severe aggression and agitation. Research is ongoing about the use of opioid receptor agonists during traumatic events as a preventative against developing PTSD.

What are the treatment options for children and adolescents with PTSD? Sadock pg. 445-446

Pharmacotherapy- SSRIs like Zoloft or Paxil are first line for PTSD, Buspirone may also be of use. Other medications such as imipramine (Tofranil) and amitriptyline (Elavil) have seen to be somewhat effective in treating the depression, anxiety, and hyperarousal than in treating the avoidance, denial, and emotional numbing. Clonidine and propranolol may also help with the hyperactivity in the disorder. Psychotherapy- behavior therapy, cognitive therapy, and hypnosis, all with a focus of trauma-based therapy. Individual, family, and group therapy has shown to be beneficial to patients with PTSD because of the supportive aspect.

What is Ganser Syndrome?

Poorly understood condition characterized by the giving of approximate answers (paralogia) together with a clouding of consciousness and is frequently accompanied by hallucinations and other dissociative, somatoform, or conversion symptoms.

What are the etiological factors in the development of Ganser Syndrome?

Precipitating stressors are personal conflicts, financial reverses, organic brain syndromes, head injuries, seizures, medical/psychiatric illness. Organic etiology is stressed over psychodynamic explanations. Childhood maltreatment and adversity are also present in some patients.

What are the intrusion symptoms in PTSD? (DSM-5 Pg 271)

Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings. Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events. 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). What are these for children 6 and younger? DSM-5 Pg 272-273 A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures. 3. Learning that the traumatic event(s) occurred to a parent or caregiving figure.

What are the pretraumatic, peritraumatic, and posttraumatic risk factors for the development of PTSD? (DSM-5 Pg 277-278)

Pretraumatic Temperamental: Childhood emotional problems by age 6 (e.g., prior traumatic exposure, externalizing or anxiety problems) and prior mental disorders (e.g., panic disorder, depressive disorder, PTSD, or OCD). Environmental: Lower socioeconomic status; lower education, exposure to prior trauma (especially during childhood); childhood adversity(e.g., economic deprivation, family dysfunction, parental separation or death); cultural cx's (e.g., fatalistic, or self blaming coping strategies);lower intelligence,; minority racial/ethnic issues; and a family psychiatric history. Social support prior to exposure is protective. Genetic & physiological: Female gender and younger age at time of trauma exposure (for adults). Certain genotypes may be protective or increase risk of PTSD after exposure to traumatic events. Peritraumatic Environmental: Severity (dose) of the trauma (the greater the magnitude of trauma, the greater the likelihood of PTSD), perceived life threat, personal injury, interpersonal violence (particular trauma from caregiver or witnessed threat of caregiver to children), and, for family military personnel, being a perpetrator, witnessing atrocities, or killing the enemy. Dissociation that occurs during the trauma and persists afterwards is a risk factor. Posttraumatic Temperamental: Negative appraisals, inappropriate coping strategies, and development of acute stress disorder. Environmental Subsequent exposure to repeated upsetting reminders, subsequent adverse life events, and financial or other trauma-related losses. Social support (including family stability, for children) is a protective factor that moderates outcome after trauma.

What psychiatric conditions are commonly seen in foster care children? Sadock, p. 1310

Psychiatric disorders found with increased frequency in foster youth are ADHD, PTSD, conduct disorders, attachment disorders, substance abuse, depression, and eating disorders.

What differential diagnosis should be considered in disinhibited social engagement disorder? (pg 1220, Sadock)

Psychiatric disorders to consider in the differential diagnosis include language disorders, autism spectrum disorder, intellectual disability, and metabolic syndromes.

Review the psychosocial treatment options for OCD. Sadock, pp. 424-426

Psychodynamic exploration of a patient's resistance to treatment may improve compliance. Well-controlled studies have found that pharmacotherapy, behavior therapy, or a combination of both is effective in significantly reducing the symptoms of patients with OCD. The decision about which therapy to use is based on the clinician's judgment and experience and the patient's acceptance of the various modalities. Behavior therapy - Behavior therapy is as effective as pharmacotherapies in OCD, and some data indicate that the beneficial effects are longer lasting with behavior therapy. Many clinicians, therefore, consider behavior therapy the treatment of choice for OCD. Behavior therapy can be conducted in both outpatient and inpatient settings. The principal behavioral approaches in OCD are exposure and response prevention. Desensitization, thought stopping, flooding, implosion therapy, and aversive conditioning have also been used. Psychotherapy: Individual analysts have seen striking and lasting changes for the better in patients with obsessive-compulsive personality disorder, especially when they are able to come to terms with the aggressive impulses underlying their character traits. Some clinicians have observed marked symptomatic improvement in patients with OCD in the course of analysis or prolonged insight psychotherapy. Supportive psychotherapy undoubtedly has its place, especially for those patients with OCD who, despite symptoms varying degrees of severity, are able to work and make social adjustments. With continuous and regular contact with an interested, sympathetic, and encouraging professional person, patients may be able to function by virtue of this help, without which their symptoms would incapacitate them. Occasionally, when obsessional rituals and anxiety reach an intolerable intensity, it is necessary to hospitalize patients until the shelter of an institution and the removal from external environmental stresses diminish symptoms to a tolerable level. A patient's family members are often driven to the verge of despair by the patient's behavior. Any psychotherapeutic endeavors must include attention to the family members through provision of emotional support, reassurance, explanation, and advice on how to manage and respond to the patient. Other therapies - Family therapy is often useful in supporting the family, helping reduce marital discord resulting from the disorder, and building a treatment alliance with the family members for the good of the patient. Group therapy is useful as a support system for some patients.

What are the psychotherapeutic options for the treatment of PTSD? (Sadock, p. 445 - 446)

Psychotherapeutic Interventions · Behavior Therapy · Cognitive Therapy · Hypnosis Should be time-limited (usually takes a cognitive approach & also provides support & security) - minimizes the risk of dependence & chronicity. Should follow a model of crisis intervention w/support, education, & the development of coping mechanisms & acceptance of the event. Two major psychotherapeutic approaches 1. Exposure Therapy - pt re-experiences the traumatic event through imaging techniques or in vivo exposure. (results last longer than other techniques) 2. Stress Management - relaxation techniques & cognitive approaches to coping w/stress. Other Approaches · Eye Movement Desensitization & Reprocessing (EMDR) - symptoms relieved as pts work through traumatic event while in a state of deep relaxation · Group Therapy - sharing experiences & receiving support · Family Therapy - helps sustain marriage through periods of exacerbated symptoms · Hospitalization - severe symptoms, risk of suicide or if other violence exists

What are the treatment options (psychotherapeutic, pharmacotherapeutic, and crisis) for adjustment disorders? (Sadock, 449)

Psychotherapy remains treatment of choice for adjustment disorders. Group therapy is useful to patients with similar stresses. Psychotherapy can help persons adapt to stressors that are not reversible or time limited and can serve as a preventive intervention if the stressor does remit. Crisis intervention and case management are short-term treatments aimed at helping persons with adjustment disorders resolve their situations quickly by supportive techniques, suggestion, reassurance, environmental modification & hospitalization. Psychopharmacology: It is reasonable to use medication to treat specific symptoms for a brief time. Antianxiety agent & antidepressants Psychostimulants-for those withdrawn or inhibited Valium or other anxiolytics for those with severe anxiety and panic SSRI for traumatic grief Antipsychotic with signs of decompensation or impending psychosis

How does reactive attachment disorder and disinhibited social engagement disorder develop? Sadock 1217

Reactive attachment and disinhibited social engagement disorder are clinical disorders characterized by aberrant social behaviors in a young child that grossly negligent parenting and maltreatment that disrupted the development of normal attachment behavior.

What are the risk factors for developing reactive attachment disorder? Sadock 1217 -1218

Reactive attachment disorder and disinhibited social engagement disorder are presumed to be linked to maltreatment of the child, including emotional neglect, physical abuse or both.

What defense mechanism(s) does the Body Dysmorphic Disorder patient employ? (Sadock, pg 428)

Repression, dissociation, distortion, symbolization, and projection.

What are the pharmacological options in the treatment of DID? (Sadock, p. 461)

SSRIs, tricyclics, MAOIs, B-blockers, clonidine (Catapres), anticonvulsants, and benzodiazepines are reported by clinicians to reduce intrusive symptoms, hyperarousal, and anxiety in DID patients. The a-adrenergic antagonist prazosin (Minipress) may be helpful for PTSD nightmares. Aggression may respond to Tegretol (carbamazepine) in some individuals if EEG abnormalities are present. Patients with OCD symptoms may respond to antidepressants with anti-obsessive efficacy. Naltrexone (Revia)may help for amelioration of recurrent self-injurious behaviors in a subset of traumatized patients. Atypical neuroleptics (risperidone [Risperdal], quetiapine [Seroquel], ziprasidone [Geodon], and olanzapine [Zyprexa]) may be more effective and better tolerated than typical neuroleptics for overwhelming anxiety and intrusive PTSD symptoms in DID patients. Occasionally, an extremely disorganized, overwhelmed, chronically ill patient with DID that has not responded to other neuroleptics respond favorably to clozapine (Clozaril). [Sadock, p.461]

In performing a custody evaluation, what should the evaluator consider?

Sadock pg 1306 In undertaking a custody evaluation, an evaluator is expected to determine the best interests of the child while keeping in mind the standard elements that the court considers. These considerations include the wishes of the parents and the child's; relationships with significant others in the child's life; the child's adjustment to the current home, school, and community; the psychiatric and physical health of all parties; and the level of conflict and potential danger to the child under the care of either parent.

What is sexual abuse?

Sexual behavior between an adult and child or 2 children when one is older or uses coercion. Same sex or opposite sex, touching, exploitation and penetration with sexual organs or objects.

What are the symptoms associated with increased epinephrine in patients with PTSD? (Sadock pg 439)

Soldiers with PTSD-like symptoms exhibit nervousness, increased blood pressure and heart rate, palpitations, sweating, flushing, and tremors-symptoms associated with adrenergic drugs. Studies found increased 24-hour epinephrine concentrations in veterans with PTSD

What are the common comorbid conditions seen in patients with dissociative amnesia

Somatic symptom disorder and conversion disorder

What kinds of complications can occur and be seen by the psychiatric evaluator when there is a dispute between divorcing or divorced parents? (Sadock p. 1307)

Some complications include both true and false allegations of psychiatric illness, drug or alcohol abuse, or sexual or physical abuse are not uncommon during custody battles. The evaluator must be prepared to verify any allegations and to carefully discuss their effects on custody and visitation. Evidence suggests that markedly elevated numbers of unfounded allegations of child sexual abuse occurred during the course of custody disputes.

What is RADI and PIP? Pg.1309

Some researchers argue that evidence supports a trauma-related psychopathology in youth that evolves into aggressive behavior, and often into delinquency. It appears that brain circuits that monitor "threat response," that is, circuits that run from the medial nucleus of the amygdala to the medial hypothalamus and to the periaqueductal gray matter, are overly reactive in reactive/affective/ defensive/impulsive aggression (RAD I, also referred to as "hot" aggression), as well as in planned or predatory aggression (PIP, also referred to as "cold" aggression). Particularly in RADI, structures may have become dysregulated by traumatic emotional activation, resulting in a lack of subtle differentiation between emotions such as sadness, anger, and fear. The result is that any stress is perceived as a threat, and activates the "defense" system, leading to the flight or fight decisions.

What specifiers should the psychiatric nurse practitioner use when diagnosing PTSD? In Adults: (DSM-5, p.272)

Specify whether: With dissociative symptoms: The individual's symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or trying moving slowly). 2. Derealization: persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). Specify if: With delayed if the full diagnostic criteria are not met until at least six months after the event (although the onset and expression of some symptoms may be immediate). In Children: (DSM-5, p. 274) (Sadock, 1223) Specify whether: With dissociative symptoms: The individual symptoms meet the criteria for posttraumatic stress disorder, and individual experiences persistent or recurrent symptoms of either of the following: 1. Depersonalization: persistent or recurrent experiences of feeling detached from and as if one were an outside observer of one's mental processes are body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 2. Derealization: persistent or recurrent experiences of unreality surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To is this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures). Specify if: With delayed expression: If the full diagnostic criteria are not met until at least six months after the event (although the expression of some symptoms may be immediate).

What are the risk factors for the development of DID?

Strongly linked to severe experiences of early childhood trauma, usually maltreatment. The rates of reported severe childhood trauma for child and adult patients with dissociative identity disorder range from 85 to 97 percent of cases. Physical and sexual abuse are the most frequently reported sources of childhood trauma Preliminary studies have found no significant genetic contribution. Environmental: interpersonal physical and sexual abuse is associated with an increased risk of DID. Prevalence of childhood abuse and neglect in the US, Canada and Europe are about 90%. Other forms of traumatization include childhood medical and surgical procedures, war, childhood prostitution, and terrorism.

Review the DSM 5 Diagnostic Criteria for unspecified trauma- and stressor- related disorder. (DSM 5-290)

Symptoms characteristic of trauma- and stressor-related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the trauma- and stressor-related disorders diagnostic class -Used in situations in which the clinician chooses NOT to specify the reason that the criteria are not met for a specific trauma- and stressor-related disorder -Insufficient information to make a more specific diagnosis

What are the etiological factors in the development of these two disorders? Sadock 1218-1219

The core features of reactive attachment disorder and disinhibited social engagement disorder are disturbances of normal attachment behaviors. The inability of a young child to develop normative social interactions that culminate in aberrant attachment behaviors in reactive attachment disorder is inherent in the disorder dyad and their interactions.

What are the diagnostic, clinical, and associated features of dissociative amnesia?

The defining characteristic of dissociative amnesia is an inability to recall important autobiographical information that A) should be stored in memory and B would be readily remembered. It differs from the permanent amnesias that occurs due to neurobiological damage or toxicity in that it is always potentially reversible. Individuals with dissociative amnesia are frequently unaware or only partially aware of their memory problems, may minimize the importance of the memory loss. Many individuals with dissociative amnesia are chronically impaired in their ability to form and sustain satisfactory relationships. HIstories of trauma, child abuse and victimization are common. Some individuals report flashbacks. Many have a history of self mutilation or suicide attempts. sexual dysfunctions are common. DSM-V p 298-299

What is the DSM 5 Diagnostic Criteria for Adjustment Disorder? (DSM-5, pgs. 286-287)

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). These symptoms of behaviors are clinically significant, as evidenced by one or both of the following: Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. Significant impairment in social, occupational, or other important areas of functioning. C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. D. The symptoms do not represent normal bereavement. E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. Specify whether: 309.0 (F43.21) With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant. 309.24(F43.22) With anxiety: nervousness, worry, jitteriness, or separation anxiety is predominant. 309.28(F43.23) With mixed anxiety and depressed mood: a combination of depression and anxiety is predominant 309.3(F43.24) With disturbance of conduct: Disturbance of conduct is predominant 309.4(F43.25) With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g. depression, anxiety) and a disturbance of conduct are predominant 309.9(F43.20) Unspecified: for maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder.

What are the differential diagnosis for hoarding disorder?(Sadock pg 431)

The diagnosis of hoarding disorder should not be made if the excessive acquisition and inability to discard possessions is better accounted for by another medical or psychiatric condition. Until recently, hoarding was considered to be a symptom of OCD and obsessive-compulsive personality disorder. However, there are some major differences. Hoarding disorder patients do not display some of the classic symptoms of OCD such as recurring intrusive thoughts or compulsive rituals. Unlike symptoms of OCD, symptoms of hoarding worsen with time, rituals are not fixed, and obsessions about dirt or contamination are absent. OCD patients have better insight into their condition. Symptoms are usually ego-dystonic, whereas in hoarding disorder they are ego-syntonic. Hoarding behavior is seldom repetitive and is not viewed as intrusive or distressing to the hoarder. Distress mainly comes at the prospect of discarding items, and it manifests more as guilt and anger than anxiety. Hoarding disorder also tends to be less responsive to classic treatments for OCD such as exposure therapy, cognitive-behavioral therapy (CBT), and selective serotonin reuptake inhibitors (SSRIs). Some case reports show the onset of this behavior in patients after suffering brain lesions. Hoarding associated with brain lesions is more purposeless than hoarding that is motivated by emotional attachment or high intrinsic value of possessions. It is a common symptom in moderate to severe dementia. In cases of dementia, hoarding is often associated with a higher prevalence of hiding, rummaging, repetitive behavior, pilfering, and hyperphagia. Onset of the behavior usually coincides with onset of the dementia, starting in an organized manner, and becomes more disorganized as the disease progresses. The onset of dementia in a patient who has hoarded throughout his or her lifetime can aggravate the hoarding behavior. Hoarding behavior can be associated with schizophrenia. It is mostly associated with severe cases and is seen as a repetitive behavior associated with delusions, self-neglect, and squalor. Bipolar disorder is ruled out by the absence of severe mood swings.

How does the psychiatric nurse practitioner differentiate between excoriation disorder and OCD? (Sadock, pg 435)

The disorders differ in a few ways. Skin-picking disorder is prevalent in females while OCD is equal between genders. The compulsions associated with OCD are usually driven by intrusive thoughts, while the compulsion to pick the skin is usually not. Although skin-picking generally decreases anxiety, it can also entice pleasure in the patient, which is rarely the case in OCD. Skin-picking in OCD patients is usually the result of obsessions about contamination or skin abnormalities.

What is the DSM 5 Diagnostic Criteria for PTSD? (DSM-5 Pg 274)

The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. The directly experienced traumatic events in Criterion A include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault (e.g., physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual violence (e.g., forced sexual penetration, alcohol/drug-facilitated sexual penetration, abusive sexual contact, non contact sexual abuse, sexual trafficking), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents. For children, sexually violent events may include developmentally inappropriate sexual experiences without physical violence or injury. A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event.

What is neglect?

The failure to provide adequate care and protection for children. Children can be harmed by malicious or ignorant withholding of physical, emotional or educational necessities. neglect includes failure to feed children adequately and to protect them from danger. Physical neglect includes abandonment, expulsion from home, disruptive custodial care, inadequate supervision, and reckless disregard for a child's safety and welfare. Medical neglect includes refusal , delay, or failure to provide medical care. Educational neglect includes failure to enroll a child in school and allow chronic truancy.

What are the treatment options for reactive attachment disorder and disinhibited social engagement disorder? (Sadock 1220)

The first consideration is the child's safety. Thus the management of these disorders must begin with a comprehensive assessment of the current level of safety and adequate caregiving. When there is suspicious of maltreatment, first decision is often whether to hospitalize child or attempt treatment while the child remains in the home. Hospitalization is necessary for malnourishment.

What are the treatment options for maltreatment? (Sadock, p. 1319)

The immediate strategic intervention is to ensure the child's safety, which may require the child's removal from an abusive or neglectful home environment. Multisystemic Therapy for Child Abuse and Neglect (MST-CAN) uses a home-based model in which therapists come to the home to involve families in a highly monitored positive interactional approach toward their physically abused children. Parent-Child Interaction Therapy (PCIT), adapted for children who have been physically abused, consists of combined treatment for parents and children in which parenting is coached directly by the therapist and practiced in sessions with parents and children together. Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT) is designed to help parents to develop more positive strategies with their children and to help children to cope more effectively with their past abuse and to learn more positive interactions with parents.

What factors are considered when evaluating the competency of a juvenile? (Sadock p. 1308)

The juvenile must possess "sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding and they rational as well as factual understanding of the proceedings against him". Thus, there is no legal requirement for juveniles be competent to participate in delinquency proceedings. Other factors include 1. Age, with special consideration in any child of 12 years or younger; 2. Developmental stage with respect to judgment, reasoning, responsibility, risk perception, suggestibility, temperance (seeking advice rather than acting without the facts), and future orientation; 3. Assessment of mental disorder and intellectual level.

What are the diagnostic, clinical, and associated features for DID?

The key feature in diagnosing this disorder is the presence of two or more distinct personality states. There are many other signs and symptoms, however, that define the disorder, and because of great diversity, this make the diagnosis difficult. These are listed in Table 12-6, which describes the many other associated symptoms commonly found in patients with dissociative personality disorder As part of the general mental status examination, clinicians should routinely inquire about experiences of losing time, blackout spells, and major gaps in the continuity of recall for personal information Patients with dissociative disorder often report significant gaps in autobiographical memory, especially for childhood events Clinically, dissociative alterations in identity may first be manifested by odd first-person plural or third-person singular or plural self-references. In addition, patients may refer to themselves using their own first names or make depersonalized self-references, such as "the body," when describing themselves and others. Patients often describe a profound sense of concretized internal division or personified internal conflicts between parts of themselves. In some instances, these parts may have proper names or may be designated by their predominant affect or function, for example, "the angry one" or "the wife." Patients may suddenly change the way in which they refer to others, for example, "the son" instead of "my son (DSM-5 P 293-294) Associated Features: depression, anxiety, substance abuse, self-injury, non-epileptic seizures, dissociative flashbacks.

4. What are the common comorbid psychiatric conditions in patients with OCD? Sadock p. 418

The lifetime prevalence for major depressive disorder with OCD is 67 percent and social phobia 25 percent. Also, alcohol use disorder, generalized anxiety disorder, specific phobia, panic disorder, eating disorders, and personality disorders. Tourette's disorder 5-7 percent. Tics 20-30 percent.

What are the clinical features of Body Dysmorphic Disorder? (Sadock, pg. 428)

The most common concerns involve facial flaws, particularly those involving specific parts (e.g., the nose). Sometimes the concern is vague and difficult to understand, such as extreme concern over a "scrunchy" chin. One study found that patients had concerns about four body regions during the course of the disorder. Other body parts of concern are hair, breasts, and genitalia. A proposed variant of dysmorphic disorder among men is the desire to "bulk up" and develop large muscle mass, which can interfere with ordinary living, holding a job, or staying healthy. The specific body part may change during the time a patient is affected with the disorder. Common associated symptoms include ideas or frank delusions of reference (usually about persons' noticing the alleged body flaw), either excessive mirror checking or avoidance of reflective surfaces, and attempts to hide the presumed deformity (with makeup or clothing). Almost all affected patients avoid social and occupational exposure. As many as one-third of patients may be housebound because of worry about being ridiculed for the alleged deformities; and approximately one-fifth of patients attempt suicide. Comorbid diagnoses of depressive disorders and anxiety disorders are common, and patients may also have traits of OCD, schizoid, and narcissistic personality disorders.

What are some comorbid conditions commonly seen in patients with hoarding disorder? (Sadock, pg 430)

The most significant comorbidity is found between hoarding disorder and OCD. Studies have found an association between hoarding and compulsive buying. Hoarding is associated with high rates of personality disorder. In one study, 20% of patients met the criteria for ADHD. Hoarding behaviors are relatively common among schizophrenic patients, and have been noted in patients with dementia and other neurocognitive disorders. Other disorders include eating disorders, depression, anxiety, substance abuse disorders, kleptomania, and compulsive gambling. Among anxiety disorders, hoarding is most associated with generalized anxiety disorder (27 %) and social anxiety disorder (14 %)

What are the epidemiological characteristics of children entering foster care?

The number of children entering foster care due to maltreatment has risen in the last decade by 19 percent. Of those children who entered foster care, there was an increase of 60 percent in the number who were identified as emotionally disturbed. In the United States, one of the most common scenarios of children being placed in foster care involves parental substance abuse, which leads to inability of the parent to care for their children. The National Center on Addiction and Substance Abuse of Columbia University reported that seven of ten abused or neglected children had parents with substance abuse. Furthermore, children in foster care were more often being raised by a single mother prior to placement compared to children in the community. Minority children are overrepresented in the foster care population. In a study utilizing birth records and child protective service (CPS), black children were more than twice as likely to be referred due to maltreatment, be substantiated as victims of maltreatment, and enter the foster care system before age 5 years, compared to white children. However, low socioeconomic black children had a lower rate of referral, substantiation, and placement in foster care than socioeconomically similar white children. Among Latinos, children of U.S.-born mothers were significantly more likely to have involvement with CPS, compared to Latino children of foreign-born mothers. However, after adjusting for socioeconomic factors, the relative risk of referral, substantiation, and entry into the foster care system was significantly higher for all Latino children than for white children. Approximately 38 percent of children in the foster care system are African American, more than three times their representation in the general population. Whites make up approximately 48 percent, and Hispanics make up almost 15 percent of foster children; 55 to 69 percent are girls, and 83.4 percent enter foster care at a mean age of 3 years. Children placed in care as infants are more likely to stay in care. Those younger than 5 years of age currently comprise the fastest growing segment of the foster care population. Studies reveal that up to 62 percent of foster children had prenatal drug exposure.

What is the role of the psychiatric evaluator when undertaking a custody evaluation? (Sadock p. 1306-1307)

The role of the psychiatric evaluator is an advocate for the best interest of the child and does not consider the fairest outcome for the parents. The psychiatric evaluator is asked to assist in successful negotiations of custody for the parents without going to a trial when there are allegations of parental incompetence, or issues of alleged physical or sexual abuse. The psychiatric evaluator may be asked to give an opinion about child custody at various points during the separation and divorce process, or during a mediation process. Many times the opinion is regarding visitation. They were asked to determine the best interest of the child while keeping in mind the standard elements that the court considers. The psychiatric evaluator conducts a series of interviews, often including at least one separate interview with each parent and the child alone and one interview with the child and both parents. The evaluator uses direct questioning as well as observations of the relationship between the child and each parent. Finally, the evaluator determines the need for psychiatric treatment of any of the parties involved.

How do the roles of a child/adolescent psychiatric forensic evaluator differ for a psychiatric nurse practitioner doing a clinical evaluation and providing treatment intervention?' Sadock pg 1305

The specific tasks and role of a child and adolescent psychiatric forensic evaluator are distinctly different from a child and adolescent psychiatrist doing a clinical evaluation and clinical treatment intervention. In clinical settings, child mental health professionals provide psychotherapy, medication evaluations, and advocacy for youth with psychiatric diagnoses. As a forensic child psychiatric evaluator, however, the main task is to be an expert, to report objective psychiatric findings related to the questions asked. Two essential characteristics of a forensic evaluator, in contrast to a clinician are (1) the relationship between the evaluator and the patient is not therapeutic, rather, it is information seeking, and (2) there are clear limits of confidentiality in this situation, that is, the information disclosed during a forensic evaluation may be brought to court, or to an attorney, or to whomever initiated the evaluation.

Review the pharmacotherapy treatment options for OCD. Sadock, pp. 424-425.

The standard approach is to start treatment with an SSRI or clomipramine and then to move to other pharmacological strategies if the serotonin-specific drugs are not effective. The serotonergic drugs have increased the percentage of patients with OCD who are likely to respond to treatment to the range of 50 to 70 percent. Each of the SSRIs available in the United States has been approved by the FDA for the treatment of OCD. Higher dosages have often been necessary for a beneficial effect, such as 80 mg a day of fluoxetine. SSRI side effects are generally less troubling than the adverse effects associated with tricyclic drugs such as clomipramine. Clomipramine: The most selective for serotonin reuptake versus norepinephrine reuptake and is exceeded in this respect only by the SSRIs. The potency of serotonin reuptake of clomipramine is exceeded only by sertraline and paroxetine. Its dosing must be titrated upward over 2 to 3 weeks to avoid gastrointestinal adverse effects and orthostatic hypotension, and as with other tricyclic drugs, it causes significant sedation and anticholinergic effects, including dry mouth and constipation. As with SSRIs, the best outcomes result from a combination of drug and behavioral therapy. Other drugs: Augment the first drug by the addition of valproate, lithium, or carbamazepine. Other drugs that can be tried in the treatment of OCD are venlafaxine, pindolol, and the monoamine oxidase inhibitors, especially phenelzine (Nardil). Other pharmacological agents for the treatment of unresponsive patients include Buspar, 5-hydroxytryptamine (5-HT), L-tryptophan, and clonazepam. Adding an atypical antipsychotic such as risperidone has helped in some cases.

What are the sub-types of adjustment disorders? (Sadock, p. 446)

The subtypes are Adjustment disorder with depressed mood, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, features of acute stress disorder or posttraumatic stress disorder (PTSD), bereavement, and unspecified type.

What are the diagnostic and clinical features of Ganser Syndrome? (Sadock, P. 464)

The symptom of passing over (vorbeigehen) the correct answer for a related, but incorrect one, is the hallmark feature. The approximate answers often just miss the mark but bear an obvious relation to the question, indicating that it has been understood. Clouding of consciousness (disorientation, amnesias, loss of personal info, and some impairment in reality testing. Visual and auditory hallucinations occur in roughly half of cases. Neuro exam may reveal hysterical stigmata (for example a non-neurological analgesia or shifting hyperalgesia). It must be accompanied by other dissociative symptoms such as amnesia, conversion symptoms, or trance-like behaviors.

6. What etiological factors have been attributed to the development of OCD? Sadock p. 419-420

There is a positive link between streptococcal infections and OCD. Altered function in neurocircuitry between orbitofrontal cortex, caudate, and thalamus. Increased activity in the frontal lobes, basal ganglia and cingulum. Bilaterally smaller caudates.

What are the risk factors for the development of OCD? Sadock p. 419

There is a significant genetic component.

What is the DSM 5 Diagnostic Criteria for other specified dissociative disorder? (DSM-5 p. 306)

This category applies to presentations in which symptoms characteristic of a dissociative d/o that cause clinically significant distress or impairment in social, occupational, or other impt. areas of functioning predominate but do not meet full criteria for any of the disorders in the dissociative disorders diagnostic class. The other specified dissociative disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific dissociative disorder. This is done by recording "other specified dissociative disorder" followed by the specific reason (e.g., "dissociative trance"). Examples of presentations that can be specified using the "other specified: designation include the following: 1. Chronic & recurrent syndromes of mixed dissociative symptoms: This category includes identity disturbance associated with less than marked discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia 2. Identity disturbance d/t prolonged and intense coercive persuasion: Individuals who have been subjected to intense coercive persuasion (e.g. brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, recruitment by sects/cults or by terror organizations) may present with prolonged changes in, or conscious questioning of, their identity. 3. Acute dissociative reactions to stressful events: This category is for acute, transient conditions that typically last less than 1 month, and sometimes only a few hours or days. These conditions are characterized by constriction of consciousness; depersonalization; derealization; perceptual disturbances (e.g., time slowing, macropsia); micro-amnesias; transient stupor; and/or alterations in sensory-motor functioning (e.g., analgesia, paralysis). 4. Dissociative trance: This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifest as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may may be accompanied by minor stereotyped behaviors (e.g. finger mvmts) of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not normal of a broadly accepted collective cultural or religious practice.

What are the epidemiological characteristics of dissociative fugue? Sadock p. 457

This disorder is thought to be more common during natural disasters, wartime, or times of major social dislocation and violence, although no systematic data exist on this point.

What would the psychiatric nurse practitioner consider as differential diagnosis when evaluating a patient for OCD?

Tourette's Disorder

What are the risk factors for the development of depersonalization/derealization disorder? (Sadock 454-455)

Transient experiences of depersonalization and derealization are extremely common in normal and clinical populations. They are the third most commonly reported psychiatric symptoms , after depression and anxiety. One survey found a 1-year prevalence of 19 percent in the general population. It is common in seizure patients and migraine suffers; they can occur with use of psychedelic drugs, especially marijuana, lysergic acid diethylamide (LSD), mescaline, and less frequently as a side effect of some medications, such as anticholinergic agents. they have been described after certain types of meditation, deep hypnosis, extended mirror or crystal gazing, and sensory deprivation experiences . They are also common after mild to moderate head injury, wherein little or no loss of consciousness occurs, but they are significantly less likely if unconsciousness lasts for more than 30 minutes. They are also common after life-threatening experiences, with or without serious bodily injury. depersonalization is found two to four times in women than in men.

What are the etiological factors in the development of dissociative fugue? Sadock, p. 457

Traumatic circumstances (i.e., combat, rape, recurrent childhood sexual abuse, massive social dislocations, natural disasters), leading to an altered state of consciousness dominated by a wish to flee, are the underlying cause of most fugue episodes. In some cases a similar antecedent history is seen, although a psychological trauma is not present at the onset of the fugue episode. In these cases, instead of, or in addition to, external dangers of traumas, the patients are usually struggling with extreme emotions or impulses (i.e., overwhelming fear, guilt, shame, or intense incestuous, sexual, suicidal, or violent urges) that are in conflict with the patient's conscience or ego ideals.

What is the risk for suicide in PTSD patients? (DSM. pg. 278)

Traumatic events, such as childhood abuse increase a person's suicide risk. PTSD is associated w/suicidal ideation and suicide attempts, and presence of the disorder may indicate which individuals with ideation eventually make a suicide plan or eventually attempt suicide.

What is recovered memory syndrome? (Sadock p. 463)

Under hypnosis, or during psychotherapy, a pt. may recover a memory of a painful experience or conflict-particularly of sexual or physical abuse-that is etiologically significant. When the repressed material is brought back to consciousness, the person not only may recall the experience but may relive it, accompanied by the appropriate affective response (process called abreaction). If the event recalled never really happened, but the person believes it to be true and reacts accordingly, it is called false memory syndrome.

What are the epidemiological characteristics for Ganser Syndrome?

Variety of cultures affected with overall frequency declining with time. Men outnumber women 2 to 1. Considered a disorder of penal populations and an indicator of potential malingering.

What are some of the adverse psychological reactions of children associated with terrorism? (Sadock, p. 1320)

What are some of the adverse psychological reactions of children associated with terrorism? (Sadock, p. 1320)One predominant and near universal symptom in children in response to these stimuli is anxiety. Young children may cling excessively to their parents, whereas older children may become preoccupied with fear about unrelated issues. Some youth express overt anger, and others experience a sense of hopelessness, lack of control, and/or depression. Severe traumas, such as experiencing a terrorist event, may be more likely to result in posttraumatic stress syndromes among exposed youth, compared to less severe form of trauma. The number of traumas experienced by a child, degree of family support provided after the exposure, and the reactions of parents are all important factors in a child's reaction.Sadock, Page 1323Table 31.1 Psychological Disorders Associated with Terrorism Acute Stress DisorderPTSDDepressionAnxietySeparation Anxiety DisorderAgoraphobiaPhobic DisordersBereavementSomatization IrritabilityDissociative reactionsSleep disturbancesDiminished self-esteemDeterioration school performance Distress when exposed to traumatic remindersSubstance Abuse

Review the DSM 5 Diagnostic Criteria for other specified trauma- and stressor- related disorder. (DSM 5-289)

a) symptoms characteristic of a trauma- and stressor-related disorder that cause clinically significant disters or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the trauma- and stressor-related disorders diagnostic class b) situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific trauma- and stressor-related disorder followed by the specific reason (e.g. "persistent complex bereavement disorder")

What are the functional consequences for individuals with PTSD? (DSM, pg. 278)

a. High levels of social, occupational, and physical disability, as well as considerable economic costs and high levels of medical utilization. b. Impaired functioning is exhibited across social, interpersonal, developmental, educational, physical health, and occupational domains. c. Poor social and family relationships, absenteeism from work, lower income, and lower educational and occupational success.

What are the diagnostic and associated features of Acute Stress Disorder? (DSM 5, p.283)

an individual may feel excessively guilty about not having reinvented the traumatic event or about not adapting to the experience more successfully. Panic attacks may occur the month following the trauma. May display chaotic or impulsive behavior. Children may show separation anxiety. Bereavement following a traumatic death can involve acute grief reactions. Postconcussive symptoms such as headaches, dizziness, sensitivity to light or sound, irritability concentration deficits may occur.

What symptoms complex is associated with adjustment disorders? (Sadock, p. 446)

anxious or depressive affect or may present with a disturbance of conduct

What are the clinical features of physically abused children? Sadock p1315-1316

behaviors- unusually fearful, docile, distrustful, guarded, or disruptive, aggressive. May be wary of physical contact and show no expectation of being comforted by adults, may be on alert for danger and continually size up environment, and may be afraid to go home. Psychological consequence: affect dysregulation, insecure and atypical attachment patterns, impaired peer relations involving aggression or social withdrawal, and academic underachievement. Psychopathology- depression, conduct disorder, ADHD, oppositional defiant disorder, dissociation, and PTSD

What is considered physical abuse? --(Sadock, p.1314)

defined as any act that results in a nonaccidental physical injury, such as beating, punching, kicking, biting, burning and poisoning. Some physical abuse is the result of unreasonably severe corporal punishment or unjustifiable punishment. Physical abuse can be organized by damage to the side of injury: skin and surface tissue, the head, internal organs, and skeletal.

What health risks are associated with maltreatment? -- (Sadock, p. 1314)

depression, regular alcohol use, binge drinking, marijuana use, overweight status, generally poor health, inhalant use, and aggressive behaviors, including fighting and hurting others.

What is derealization? (Sadock, pg. 295)

experiencing the environment as unreal or distorted.

What are the typical stressors that lead to the development of adjustment disorders?

financial issues, a medical illness, or relationship problem

What is depersonalization? (Sadock, pg. 295)

in an altered sense of one's physical being, including the feeling that one is outside of one's body, physically cut off or distanced from people, floating, observing oneself from a distance as though in a dream

1. What are the common symptoms represented in OCD? (Sadock, p. 418)

intrusive thoughts, rituals, preoccupations, and compulsions

What are the rates of incidence of child maltreatment? Sadock, p1314

one in every five children in the United States has been a victim of child maltreatment. Among the CDC's estimates of maltreated children, 9 percent were victims of physical abuse, 1 percent were victims of sexual abuse, 4 percent were victims of neglect, and 12 percent experienced emotional abuse. Estimates of children maltreated in the United States each year are close to 1 million, and the annual number of deaths caused by abuse or neglect is reported to be about 1,500

What are the diagnostic, clinical, and associated features in reactive attachment disorder? Pg. 1219,1220 Sadock

the DSM 5 diagnostic criteria in the table above; clinical/associated features include: Children with reactive attachment disorder and disinhibited social engagement disorder may initially be identified by a preschool teacher or by a pediatrician based on direct observation of the child's inappropriate social responses. The diagnoses of reactive attachment disorder and disinhibited social engagement disorder are based partially on documented evidence of pervasive disturbance of attachment leading to inappropriate social behaviors present before the age of 5 years. The clinical picture varies greatly, depending on a child's chronological and mental ages, but expected social interaction and liveliness are not present. Often, the child is not progressing developmentally or is frankly malnourished. Perhaps the most common clinical picture of an infant with reactive attachment disorder is the nonorganic failure to thrive. Such infants usually exhibit hypokinesis, dullness, listlessness, and apathy, with a poverty of spontaneous activity. Infants look sad, joyless, and miserable. Some infants also appear frightened and watchful, with a radar-like gaze. Nevertheless, they may exhibit delayed responsiveness to a stimulus that would elicit fright or withdrawal from a normal infant. Infants with failure to thrive and reactive attachment disorder appear significantly malnourished, and many have protruding abdomens. Occasionally, foul-smelling, celiac-like stools are reported. In unusually severe cases, a clinical picture of marasmus appears. The infant's weight is often below the third percentile and markedly below the appropriate weight for his or her height. If serial weights are available, the weight percentiles may have decreased progressively because of an actual weight loss or a failure to gain weight as height increases. Head circumference is usually normal for the infant's age. Muscle tone may be poor. The skin may be colder and paler or more mottled than skin of a normal child. Laboratory findings may indicate coincident malnutrition, dehydration, or concurrent illness. Bone age is usually retarded. Growth hormone levels are usually normal or elevated, a finding suggesting that growth failure in these children is secondary to caloric deprivation and malnutrition. Cortisol secretion in children with reactive attachment disorder or disinhibited social engagement disorder is lower than in typical developing children. For children with failure to thrive, improvement physically and weight gain generally occur rapidly after they are hospitalized. Socially, the infants with reactive attachment disorder usually show little spontaneous activity and a marked diminution of both initiative toward others and reciprocity in response to the caregiving adult or examiner. Both mother and infant may be indifferent to separation on hospitalization or to termination of subsequent hospital visits. The infants frequently show none of the normal upset, fretting, or protest about hospitalization. Older infants usually show little interest in their environment. They may not play with toys, even if encouraged; however, they rapidly or gradually take an interest in, and relate to, their caregivers in the hospital. many children with reactive attachment disorder have disturbances of growth and development. Thus, establishing a growth curve and examining the progression of developmental milestones may be helpful in determining whether associated phenomena, such as failure to thrive, are present.

What are some examples of maltreatment that adolescents report occurred during their childhood? Sadock, p. 1314

the most common experiences were being left home alone as a child, (reported by 41.5 percent of the sample), physical assault (reported by 28.4 percent), physical neglect (reported by 11.8 percent), and sexual abuse (reported by 4.5 percent).