Diagnosis Final Exam

cognitive restructuring

(Used for treating PTSD) type of CBT a therapeutic approach that teaches clients to question the automatic beliefs, assumptions, and predictions that often lead to negative emotions and to replace negative thinking with more realistic and positive beliefs -can be used to make sense of the event, and instill a realistic perspective to the event.

schizoid personality disorder

(cluster A) Characterized by a pervasive pattern of detachment from social relationships. These individuals don't desire or enjoy social relationships of any sort, family, friends, romantic involvement, and are indifferent to the criticism of others. This is not due to autism, or schizophrenia.

Paranoid personality disorder

(cluster A) Individuals afflicted with this condition are very distrusting and suspicious overall. They commonly bear unprovoked grudges on individuals uninvolved with their life. often perceive attacks on their character from others who have no intention of doing so. As a result of this, they can have difficulty establishing and maintaining jobs, relationships etc.

schizotypal personality disorder

(cluster A) Think of an individual with the traits Schizoid personality (detached socially) that also experiences occasional perceptual distortions (belief in telepathy, clairvoyance), exhibits strange behaviors, but does not meet the criteria for Schizophrenia.

borderline personality disorder

(cluster B) A pattern of unstable interpersonal relationships, impulsivity, and poor self image. These individuals are also impulsive, often destructive to themselves, and have a marked fear of abandonment. They often oscillate between idolization and devaluing -more common in women

narcissistic personality disorder

(cluster B) A pervasive pattern of self grandiosity, need for admiration, and lack of empathy. They believe they are special, and can only be understood, or should associate with high status people. They are arrogant with a sense of entitlement, can be exploitive, and very envious. They lack empathy, similar to an antisocial, but are often able to assimilate, and do well in the corporate world. -more common in males

histrionic personality disorder

(cluster B) This is characterized by exaggerated emotionality and attention seeking. Individuals will strive to be the center of attention, consider relationships more intimate than they really are, display rapidly shifting shallow emotion, dress provocatively, and are very suggestable. -more common in women

antisocial personality disorder

(cluster B) referred to as individuals who don't interact with others. An antisocial personality will interact with others in order to exploit or deceive them. Antisocial personalities have no regard for the respect or well being of others. They are unable to follow direction/authority, hold a job, or maintain any financial obligations. are often impulsive, reckless, and physically aggressive. A very common diagnosis in the corrections system. -more common in males

avoidant personality disorders

(cluster C) -A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. As a result, they are unable to form intimate relationships due to fear of being shamed/ridiculed. They are also preoccupied with being criticized in social situations, and they view themselves as inept.

obsessive-compulsive personality disorder

(cluster C) A preoccupation with orderliness, perfectionism and mental/interpersonal control at the expense of flexibility, openness, and efficiency. In these individuals the rules and details are more important than the activity that they are engaging in. They are very hyper-vigilant, perfectionist to the point where it interferes with the completion of the task. They are also rigid and stubborn, and display some hoarding traits (won't throw out worn out things, often stockpile money). They don't meet the criteria for OCD as they don't cycle through obsessions, compulsions, and anxiety.

dependent personality disorder

(cluster C) Individuals display an excessive need to be cared for, which often leads to submissive and clinging behavior. They have great difficulty making decisions, initiating projects, taking responsibility for major areas of their life, and constantly seek the nurturance of others. -More common in women

excessive acquisition

(hoarding disorder specifier) If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no additional space is present in 80-90% of Hoarding Disordered individuals. It's more or less the hallmark of the disease. Great anxiety results when the individual is unable to or is prevented from acquiring items.

systematized amnesia

(symptoms of dissociative amnesia) inability to recall events relating to a specific category of information, such as one's family or one particular person or event

eye movement desensitization reprocessing (EMDR)

(treatment for PTSD) an exposure treatment in which clients move their eyes in a rhythmic manner from side to side while flooding their minds with images of objects and situations they ordinarily avoid In this, an individual re-experiences the trauma while focusing on a back and forth moving object. The focus may distract them and ultimately desensitize the reactivity associated with the memories.

Depersonalization/Derealization Disorder.

**can experience both! Depersonalization: Experiences of unreality, detachment, or being outside observer with respect to one's thoughts, feelings, sensations, body, or actions (perceptual alterations, distorted sense of time, unreal or absent self, emotional and or physical numbing). An out of body experience Derealization: Experiences of unreality or detachment with respect to surroundings (individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted) *During the depersonalization or derealization experiences, reality testing remains intact -The symptoms result in distress/impairment of social, occupational functioning -These individuals often feel detached from their entire being to where they feel "I am no one" and/or "I have no feelings", or "My head is full of cotton". -They may also feel robotic, as if they are being moved by a machine, not themselves. -Individual also often have difficulty describing their symptoms and feel like they are having the quintessential "nervous breakdown" or "going crazy." -These symptoms are not uncommon to the general public, but most individuals experience them as a transient phenomenon. -PREV is listed at 2% in DSM V with an equal male/female ratio. -childhood trauma is often a precipitator. -The symptoms most commonly begin in adolescence but can emerge in young adulthood. DIFF DIAG can include depression, anxiety, psychotic disorders, and substance abuse disorders. TREATMENT CBT/DBT

somatization disorder

-One or more somatic symptom (pain, GI, muscular, urogenital) that is distressing and or results in significant disruption of daily life. -These symptoms generate anxiety, and consume much of the individuals time. -These last for six months and have no discernable medical findings. -PREV is 5-7% and is more common in females.

conversion disorder

-One or more symptoms of altered voluntary motor or sensory function (blindness/deafness, paralysis/weakness, dysphagia, seizures, dysphonia), with no significant medical findings. -"Hysterical blindness." -While there is concern/anxiety over somatic symptoms in somatization disorder, individuals with conversion disorder usually have very little concern over their symptoms and the phrase "la belle indifference." -PREV numbers were not listed in DSM but it appears to be relatively rare at approximately 2-5 cases/100,000 per year. -This is 2-3x more common in females.

Treatment of opiate addiction

-Opiate meds are used to treat pain (morphine, demerol, oxycontin). -Heroin is also an opiate. This has no medical indications and is the "street drug" of abuse. They can be used IV or po (by mouth). Heroin is frequently inhaled as well. -These drugs can decrease pain by binding to naturally occurring opioid receptors and decrease the sensation of pain. Our bodies make beta endorphins that bind to these receptors and help us cope with pain naturally. -Opiate drugs help us decrease pain, but they will result in dependence if used for extended periods, and are likely to be fatal in overdose, as they decrease the action of the respiratory center of the brain (medulla oblongata). -They also potentiate this action in other drugs (alcohol, benzodiazepines, barbiturates, some sleep aids). -these opiate drugs, heroin or prescribed pain meds, all have the potential to be addicting -Step 1: detoxify the addicted individual. This is done in most cases, with a drug called buprenorphine (subutex). This drug is an opiate agonist and is given in gradually decreasing doses. This process is done over a period of some 5 days in a hospital. -Once discharged there are a few ways the treatment may proceed. Some individuals do fine with just a drug treatment program. Unfortunately, a number of individuals relapse on opiates while in the program. After a few relapses, the individual is usually recommended to partake in some type of MAT (medically assisted treatment). The oldest MAT is methadone. (This is nothing more than an opiate substitute.) Over time (months to years), the dose is ideally to come down in order to get the patient ultimately off the opiate. -newer form of MAT is with a drug called suboxone, which is a combination of two drugs, buprenorphine and naloxone (at a ratio of 4:1). -Buprenorphine was mentioned earlier and is an opiate agonist. -Naloxone is narcan, the opiate overdose rescue drug. Naloxone is what's called a competitive antagonist meaning it has the ability of removing opiates already taken in by the individual, off their receptors. This is why it is used as the opiate overdose rescue drug. -This can be prescribed by any physician, physicians assistant, advance practice nurse that has completed an approved training program. -It is harder to overdose on suboxone due to the mix of naloxone in it. It is very dangerous to -take with other sedatives (benzos, some sleep aids, alcohol) however. -The philosophy is the same as methadone in that ideally, the individual will eventually come off of the suboxone. -Suboxone is less stigmatized as one does not have to go to a "methadone clinic" but still carries the risk of abuse, and overdose. Please note narcan is sold on it's own in individual injectable units to rescue opiate overdose victims. -Another type of MAT is with a medication called Naltrexone (Revia or in long acting injection vivitrol, oral revia). Naltrexone is an opiate antagonist, not competitive so it's not used for treatment of overdose but it is often used after an individual is detoxified. -It can decrease the craving for opiates as well as alcohol in alcoholics! -The advantage with naltrexone is there is no risk of overdose or disastrous reactions with other sedative medications. -The vivtrol injection is often sought after as it is given once a month and the individual does not need to take medications daily

treatment of alcohol abuse

-Some type of a genetic link, as well as a pattern of learned behavior, but we are far from figuring out what makes someone an alcoholic. -It can be even harder for one to admit they have an alcohol problem addiction. -An alcoholic has no ability to control their drinking behavior. -They inevitably have poor or even disastrous outcomes from drinking (legal, personal, career). -Alcohol is produced via the process of fermenting fruits or grains. There are various forms and concentrations of this. There are any number of horror stories involving individuals taking in alcohol from non-consumable sources (hand sanitizer, vanilla extract, grain alcohol). -Consumable alcohol, (liquor, beer, wine) is used by most members of society at some point in their lives. Aside from the brief era of prohibition (1920-1933) it has been legal. -on a pharmacologic level, alcohol functions as a central nervous system depressant. -Similar to benzodiazepines, alcohol binds to GABA receptors, holds chloride channels open on the membranes of our neurons, and hyperpolarizes neurons, decreasing their rate of firing. Acute effects of alcohol involve: a decreasing of reaction time, -impairment in motor movements as well as visual impairments. These can be subtle at first, and have a negative impact on an individual without them being conscious of it. High enough levels of consumption will result in impaired judgement/disinhibited behaviors. When used on a chronic/ongoing basis, can result in -liver disease (cirrhosis/cancer/ascities), -anemia from a variety of gastrointestinal bleeding, -dilated cardiomyopathy. -Neurodegenerative diseases/various forms of dementia can also result from chronic alcohol use (Werneke's syndrome from decreased B12 , Alzheimer's dementia) as well as neuropathies. **must be detoxified if chronic use** -can later experience life threatening withdrawal syndrome · symptoms start with tremors, sweats, nausea and lead up to fever, inc blood press, agitation and even hallucinations (delirium tremens). -In order to avoid this, the individual is given gradually decreasing doses of a benzodiazepine, usually Librium, as it has a long half life. -This detoxification process is carried out over some 3-5 days. MAINTAINING SOBRIETY: involves a comprehensive approach (Subs abuse treatment program, AA meetings, ind/family therapy). Also there are medications which may relieve the alcohol craving. Naltrexone (revia/vivitrol) serves an opiate antagonist and somehow decreases the alcohol craving. Vivitrol is the long acting, monthly injection. Disulfiram (Antabuse)- (older drug) This drug inhibits the action of the enzyme aldehyde dehydrogenase, which is essential in the breakdown of alcohol. If an individual taking disulfiram drinks alcohol, as a result the inhibition of aldehyde dehydrogenase, they will build up a noxious compound, acetaldehyde (similar to formaldehyde). This results in palpitations, nausea, sweats, dizziness. In this sense it is a form of aversion training. Acamprosate- An old medication said to decrease the craving for alcohol. Its mechanism is unclear. Current theories believe it to have some impact on NMDA receptors and Calcium channels. ***Please remember it is essential to effectively treat any psychiatric/psychological comorbidity in order to maintain sobriety.***

Avoidant/Restrictive Food Intake Disorder

"picky eater" without anorexia individual has a lack of interest in food, and is concerned about aversive consequences of eating, as manifested by failure to meet nutritional needs. It is associated with one or more of the following: -Significant weight loss -Significant nutritional deficiency -Dependence on enteral feeding or nutritional supplements -Marked interference with psychosocial functioning the disturbance is not explained by a lack of food, a cultural practice, or Anorexia Nervosa/Bulimia Nervosa -usually develops in childhood and can persist into adulthood. -Often by adulthood, the individual knows how to regulate it and can function in an adjusted manner overall. I believe whatever problems are to ensue from this are usually caused by the parent-child interaction when the picky eating is first presented. DIFF DIAG -reactive attachment disorder, -autism spectrum disorder, -anxiety disorder, -major depression, -OCD, -anorexia nervosa. TREATMENT -nutritionist -CBT

dissociative fugue

The sudden loss of memory for one's personal history, accompanied by an abrupt departure from home and the assumption of a new identity; wandering and travel during dissociation

Reactive attachment disorder

A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by: -The child minimally seeks comfort when distressed, and the child minimally responds to comfort when distressed Persistent social and emotional disturbance characterized by at least two of the following: -Minimal social and emotional responsiveness to others, -limited positive affect, -episodes of unexplained irritability, -sadness, or -fearfulness that are evident even during nonthreatening interactions with adult caregivers. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: -Persistent social neglect or deprivation by caregiving adults, -repeated changes in primary caregivers, -rearing in unusual settings that severely limit opportunities to form attachments (high volume orphanage). *These are usually what precipitates the behaviors exhibited by children with this condition.* **A child diagnosed with this cannot meet the criteria for Autistic spectrum disorder**. -This condition is evident before age 5 years. -It is unclear whether reactive attachment disorder occurs in older children and, if so, how it differs from its presentation in older children. -As a result, the diagnosis should be made with caution in children older than five years. DIFF DIAG.: -autism spectrum disorder, as there is a significant amount of social aberration. -Intellectual disability -depressive disorders. NO SPECIFIC TREATMENT In general, attempts can be made to stabilize the home environment, get consistent caregivers that are more responsive to the needs of the child, and educate the caregivers as to what these needs are. -Play therapy, art therapy, fam therapy Medication use is usually limited due to the age of the children diagnosed with this. Fortunately, children often display resilience and can develop into adjusted, functional adults with reasonable intervention.

illness anxiety disorder

A preoccupation with having or acquiring a serious illness • Somatic symptoms often absent and if present, are mild • There is a high-level anxiety about health and the indiv. is easily alarmed about their health status Indiv. preform excessive health related behaviors (self-exam, checking), or exhibits maladaptive avoidance of medical appointments (although there is a care seeking/non-care seeking specifier

anorexia nervosa

A very serious condition. One of the, if not the most potentially fatal psychiatric diagnoses. Affected individuals are dangerously underweight, to wear basic biological functions are not be carried out effectively (grossly decreased muscle mass, amenorrhea in females, cardiac failure from low critical electrolyte levels). This coupled with the increased risk of suicide due to mental illness! The criteria is as such: -Restriction of energy intake relative to requirements leading to significantly low body weight -Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even with a significantly low body weight -Disturbance in the way in which one's body weight is experienced, that is undue influence of body weight or shape on self-evaluation/worth, or lack of recognition of the seriousness of the current low body weight -Codes for restricting type, binge-eating/purging type Severity specifier involves the calculation of BMI (body mass index) -Mild: BMI> or equal to 17 -Moderate: BMI 16-16.99 -Severe: BMI 15-15.99 -Extreme BMI<15 Most commonly occurs in Caucasian females PREV is about 0.4% Gender rate skewed to females at approximately 10:1 ratio quite often very driven, hypervigilant, high functioning individuals Symptoms often are not seen until adolescence or even young adulthood. Not necessarily repulsed/averse to food. They often enjoy preparing meals for others. Physical traits in addition to being thin include hypotension, bradycardia, hypothermia, amenorrhea in females, and lanugo. DIFF DIAG includes -depression, -anxiety disorders, -body dysmorphic disorder, -avoidant/restrictive food intake disorder. COMORBID with -Depression, -anxiety, -bipolar dis, -substance abuse, -PTSD, -personality disorders TREATMENT -medicating co-morbid symptoms, -CBT, DBT or dynamic therapy, -family/group therapy. (a lot of dynamic distress related to conflicted family relationships, abuse or even incest with anorexia nervosa.) -nutritionist there are specialized clinics -Renfrew, -Center for Discovery and -Princeton House The severity of the symptoms determines the level of care (inpatient, residential, ambulatory)

somatic symptom and related disorders

These include conditions based in an individual's feelings/behaviors (anx/dep), related to perceived physical symptoms (pain, GI, muscular, urogenital) -somatic symptom disorder -illness anxiety disorder -conversion disorder -facticious disorder -

Post traumatic stress disorder (PTSD)

This is a condition where the symptoms are based in some type of stressful/traumatic event, either personally witnessing such, or being directly involved in such an event. -natural disasters such as hurricanes, earthquakes, global pandemics, or manmade situations such as wars, car accidents, assaults/robberies, etc. -The commonality as that the individual has no way, or is perceived to have no means of escape. -This can also result from learning that a loved one experienced one of the above stressors. -can also originate from repeated exposure to adverse details of traumatic events (first responders collecting human remains, police officers exposed to the results of violent crimes). The diagnosis is made through a combination of symptoms among four symptom groups: *One or more intrusion symptoms below*: -Recurrent, involuntary, intrusive distressing memories -Recurrent, distressing dreams of the event -Dissociative reactions in which the individual feels/acts as though the event were recurring -Distress upon exposure to internal/external cues that resemble part of the event -Marked physiologic reactions to these cues (an automobile accident survivor beginning to sweat profusely upon sensing the smell of burning rubber) *One or both of these avoidance symptoms*: -Avoidance/efforts to avoid distressing thoughts, memories, feelings associated with the event -Avoidance/efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories of the event. *Two or more negative cognition/mood symptoms*: -Inability to remember important aspects of the event -Persistent/exaggerated negative beliefs -Persistent, distorted cognitions about the causes or consequences of the event, guilt or blaming of others -Persistently negative emotional state (fear, horror, anger, shame, guilt) -Diminished interest/participation in significant activities -Feelings of detachment or estrangement from others -Persistent inability to experience positive emotions Two or more alterations in arousal/reactivity symptoms: -Unprovoked irritable/angry outburst -Reckless or self-destructive behaviors -Hypervigilance -Exaggerated startle response -Problems with concentration -Sleep disturbance ALL OF THE ABOVE SYMPTOMS PERSIST FOR ONE MONTH -Prior to one month of duration, this collection of symptoms is given the diagnosis of acute stress disorder. -this collection of symptoms must cause significant disruption of social, academic and occupational functioning. There is a dissociative symptom specifier that includes: Depersonalization & Derealization COMORBID WITH depression, anxiety, dissociative disorder, substance abuse ETC. -CHILDREN tend to dissociate with a slightly higher occurrence in adults. It makes sense, where else can a child escape aside from an unreal world. -Substance abuse is very common in adults, as this can serve to numb the negativity/mental pain associated with this. -It is not clear why some individuals manifest PTSD where other individuals exposed to trauma do not. Perhaps level of functioning, support and overall level of cognitive resilience. TREATMENT medications (none specific to PTSD) but there are so many associated symptoms that medications may help with (insomnia, irritability, anxiety, depression). -SSRIs (paxil, Prozac, Zoloft) are commonly given. -Its important to try to avoid sleep aids/anxiolytics with the potential for addiction (benzodiazepines such as Xanax, Ativan, valium) in this population.*** -CBT in particular exposure therapy, where the individual re-experiences a part of the trauma in a safe, controlled environment to decrease the reactivity to the trauma. -cognitive restructuring -eye movement desensitization reprocessing (EMDR).

Autism Spectrum Disorder

a disorder that appears in childhood and is marked by significant deficiencies in communication and social interaction, and by rigidly fixated interests and repetitive behaviors all levels of severity are placed under the umbrella of autism spectrum disorder rather than autism, asperger's , etc. Deficits in social communication and interaction, are manifested by the following:::: -Failure to engage in back and forth conversations, reduced sharing of interests, emotions, or failure to initiate or respond to social interactions. -Deficits in nonverbal communicative behaviors such as poor use of body language, eye contact, facial expressions, and a lack of comprehending these when used by others. -Deficits in developing, maintaining, and understanding relationships. Restricted, repetitive patterns of behavior and interests are manifested by at least two of the following::: -Stereotyped or repetitive motor movements, use of objects or speech. This such as tapping or flipping toys, repeating phrases, hand tapping. On some occasions rocking, or even self destructive behaviors can develop. -Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior. -Highly restricted, fixated interests that are abnormal in intensity or focus (being infatuated with a clothespin collection). -Hypo or hyper-reactivity to sensory input or unusual interest in sensory aspects of the environment (apparent indifference to pain/temperature or adverse response to specific sounds or textures. All of the above must be present in the early developmental period, but in some instances are not evident until social demands exceed their limited capacities for such. Usually starting school is the ultimate challenge. As always, these symptoms must not be caused by another mental illness, intellectual disability or medical condition, and will severely impair social and occupational areas of functioning. **Severity specifiers refer to the level of support needed in order to live.** (Level 1-3) condition is diagnosed in childhood Many adults without family support wind up in state run group homes as they often, are unable to live independently in the community. A number of individuals with autism spectrum disorder also have intellectual impairment (not causing their autism, but in addition to it) increased risk of seizure disorder in children with autism spectrum disorder With regard to developmental course, the symptoms are usually evident within the second year of life, but can develop later if they are more subtle/less severe. PREV is1%. DIFF DIAG -selective mutism, -language disorders, -intellectual disability, -ADHD -schizophrenia TREATMENT -No medications are approved to manage autism specifically -Antipsychotics (Haldol, Zyprexa, Seroquel) and anti-epileptic meds (Depakote, trileptal) are sedating and can make their behaviors less destructive and more manageable. -Management programs that are a set up format with as much routine consistency/repetitiveness (albeit constructive) as possible -goal is to support yet gently challenge them at the same time -Art and play therapy can help channel or find a skill or talent that perhaps can be built up. -Parent management training and family support can also be helpful as with ADHD.

PICA

an abnormal craving or appetite for nonfood substances, such as dirt, paint, or clay that lasts for at least 1 month , inappropriate for the developmental level of the individual. not part of a common cultural practice soap, paint chips, hair, string, clay, charcoal, starch or ice. The diagnosis is made when the above criteria are met this is much more common in the adult population afflicted with an Intellectual Disability and Autism Spectrum Disorder. COMORBID with -trichotillomania -excoriation, and -avoidant/restrictive food intake disorder.

Cluster B personality disorders

antisocial, borderline, histrionic, narcissistic tend to be dramatic, over emotional, or erratic.

dissociative disorders

are characterized by a disruption of or a discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Dissociative symptoms are experienced as intrusions into awareness and behavior, with accompanying losses of continuity in subjective experience.

Cluster C personality disorders

avoidant, dependent, obsessive-compulsive tend to be anxious or fearful (evenly distributed between both males and females besides dependent)

obsessive-compulsive related disorders

body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation

Trauma and Stressor Related Disorders

All precipitated by some type of exposure to a traumatic/stressful event. The events have a great deal of variability, as do the diagnoses. -The events can include sudden, unexpected events, or chronic/subtle, routine events. -The reactions can range from introverted/internalizing depression-like, to disinhibited, externalizing, aggressive behaviors. INclude: 1) Reactive attachment disorder, 2) Disinhibited social engagement disorder, 3)Posttraumatic stress disorder and 4) Acute stress disorder. · *TIME is the difference between acute and PTSD*

Feeding and Eating Disorders

Characterized by a persistent disturbance of eating behavior, leading to altered consumption or absorption of food that significantly impairs physical health and/or psychosocial functioning have the highest potential for the fatality of all psychiatric disorders.

ADHD (Attention-Deficit Hyperactivity Disorder)

Defined by a persistent pattern of inattention and/or hyperactive-impulsivity that interferes with functioning or development This is characterized by 1) Inattention OR 2) Hyperactivity/impulsivity 1. Inattention: six or more of the following symptoms have persisted for at least 6months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Only five are required for adolescents age 17 or adults:::: -Fails to give close attention to details or makes careless mistakes in schoolwork/work -Difficulty sustaining attention in tasks or play activities, conversations, or reading -Does not seem to listen when spoken to directly -Does not follow instructions and fails to finish schoolwork, chores, or work responsibilities -Difficulty organizing tasks/activities -Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort -Frequently loses things necessary for tasks/activities (books, pencils, tools etc.) -Is easily distracted by extraneous stimuli -Frequently forgetful in daily activities (chores. errands, appointments) 1. Hyperactivity/Impulsivity: Six or more of the following symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social/academic/work activities (five for adolescents age 17 or adults)::: -Fidgets/taps hands/feet, squirms in seat -Often leaves seat in situations where remaining seated is expected -Often runs about or climbs in situations where it is inappropriate -Often unable to play or engage in leisure activities quietly -Often on the go as if driven by a motor -Often talks excessively -Blurts out answers before the question is completed -Difficulty waiting their turn Often interrupts or intrudes on others Also required are the following: -Several inattentive or hyperactive/impulsive symptoms were present prior to age 12 years -Several inattentive or hyperactive symptoms are present in AT LEAST TWO OR MORE SETTINGS! (school, home, little league, cubscouts, church) -These clearly have a negative impact on social, school, work performance There are specifiers for predominantly inattentive, predominantly hyperactive/impulsive, or combined presentations. Also mild, moderate, or severe. These symptoms always begin in childhood. Often ADHD co-occurs with mild delays in language, motor or social development. Low frustration tolerance, irritability, and mood lability, are also seen with ADHD. PREV is 5% in children and 2.5% in adults. (some children may "outgrow it") This is more common in males at a ratio of approx. 2:1. The females that get this are usually more of the "inattentive" type. There is a genetic component DIFF DIAG -oppositional defiant disorder, -disruptive mood dysregulation disorder, -bipolar disorder, -intermittent explosive disorder, -anxiety disorder TREATMENT -Medications are commonly used. These are mainly stimulants (Ritalin, Adderall, vyvanse), which are closely regulated by the DEA due to potential abuse/sales of it -can also suppress a child's apetite Therapy, -play therapy, -art therapy -CBT can help channel the child's energy and improve their concentration focus. -Family Therapy (Often the child with ADHD can make it difficult for siblings to feel they are getting their needs met by their caregivers.) ***Parent Management Training*** Coaching the parent with how to deal with the child's symptoms, way to constructively channel the child's energy, and accept realistic expectations can avert abuse of the child and minimize the distress felt by the parent/caregiver.

binge eating disorder

Defined by recurrent episodes of binge eating. These episodes are characterized by: -Eating, in a discrete period of time, an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. -A lack of control over eating during the episode -Also, the binge eating episodes are associated with three or more of the following: -Eating more rapidly than usual -Eating until uncomfortably full -Eating large amounts of food when not feeling hungry -Eating alone because of feeling embarrassed by how much one is eating -Feeling disgusted with oneself, depressed or guilty afterwards Also, marked distress regarding binge eating is present -binge eating occurs, on average, at least once/week for three months -binge eating is not associated with inappropriate compensatory behaviors -Most individual afflicted with this are normal weight, overweight, or obese individuals. -Mostly obese individuals enter treatment. -Females of multiple races are afflicted with this most commonly (1.6%), where males of all races show a prevalence of 0.8%. -PREV is much higher in the weight loss seeking population. Once again symptoms usually first show in late adolescence/early adulthood. DIFF DIAG -bulimia, -borderline personality, -depression/bipolar disorders COMORBID includes similar conditions along with substance abuse TREATMENT -CBT/DBT, -medicating any co-morbid symptoms, -nutritional/exercise training to emphasize a healthy all around life style. -nutritionist

Pseudocyesis

False belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy, may include: Abdominal enlargement, reduced menstrual flow, amenorrhea, sensation of fetal movement, nausea, breast engorgement/secretions and labor pains

Compulsions vs. Obsessions

Obsessions are unwanted, intrusive thoughts, images, or urges that trigger intensely distressing feelings. (inappropriate sexual acts, acts of violence, screaming inappropriate vulgarities,) Compulsions are behaviors an individual engages in to attempt to get rid of the obsessions and/or decrease his or her distress. (locks, windows, faucets, stove), counting random objects, organizing things in a fastidious manner, asymmetry, washing/cleaning (which can look like a germ phobia!)

SSRIs

Paxil, Zoloft, Prozac, Luvox, Lexapro drugs that are typically used as antidepressants in the treatment of the major depressive disorder, anxiety disorders, and other psychological conditions.

Depersonalization

Persistent or recurrent experiences of feeling detached from one's body or mental processes (a dream like state, an unreality where time moves slowly, like an outside observer of one's life)

hoarding disorder

The diagnostic criteria include -persistent difficulty discarding or parting with possessions, regardless of their actual value. This is due to a perceived need to save these items and due to distress associated with discarding them. The end result of this is a severely congested/cluttered home which interferes with ADLs (activities of daily living) such as cooking, cleaning, washing, sleeping. • Any relief of this, (clearing of clutter), is usually provided by family members, hired help or authorities. • The resultant clutter causes significant impairment in social occupational or academic functioning. • They have trouble leaving the house, finding important documents, clothing etc. Their homes are often fire hazards as a result of their symptoms/behaviors. Insight Specifiers: -Fair/good insight-Individual recognizes that hoarding related beliefs and behaviors are problematic -Poor insight-Individual is mostly convinced that hoarding related beliefs/behaviors are not problematic despite evidence to the contrary -Absent insight/Delusional beliefs-Individual is completely convinced that hoarding related behaviors are not problematic despite evidence to the contrary There is another specifier associated with Hoarding Disorder: -Excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no additional space (80-90% of individuals) -Anxiety also becomes marked when individuals try to get rid of these seemingly useless items. These items can be almost anything. As mentioned in my example newspapers, magazines, toys, clothing, tools, car/machine parts. -some individuals hoard live animals. Animal control frequently is called upon to deal with situations where way too many dogs/cats or even larger animals are kept in a dwelling severely unfit for that number of animals/people. Prevalence is listed at 2-6% in the USA and Europe -higher prevalence in males, others in females. appears more in older individuals aged 55-94 years as opposed to younger individuals 34-44yrs. It is said to get worse with increased age. DIFFERENTIAL DIAGNOSIS l includes OCD, -Neurodevelopmental disorders (Autism), -Schizophrenia, -Major Depression, -Neurocognitive Disorders (Alzheimer's Dementia). TREATMENT is very difficult for this. It often involves involvement of authorities (Animal Control, Fire Marshall) as well as behavioral health to get the individual in a safe environment. -Desensitization and exposure therapy may be used. -Medications are used, but as with Body Dysmorphic Disorder, no medications are indicated for the treatment of Hoarding Disorder per se. The medications used are usually determined by any comorbid symptoms or conditions that may be present.

derealization

The individuals surroundings take on a dreamlike, unreal state

conversion disorder (Functional Neurologic Symptom Disorder)

criteria • One or more symptoms of altered voluntary motor or sensory function • Incompatibility between the symptoms and the recognized neurologic conditions • Blindness, aphonia, paralysis/weakness, seizures or anesthesia/sensory loss • Symptoms less than 6 months-acute, > 6mo, chronic • This condition is often associated with dissociative symptoms/stressful life events/personality disorders • there is often little anxiety or concern over their symptoms (as opposed to Somatic Symptom Dis), "La belle indifference" is the historical phrase used to describe this. • Relatively rare, 2-5 cases per 100,000/year are recorded • 2-3x more common in females

Antiepileptic drugs

depakote and trileptal (For autism)

Benzodiazepines

drugs that lower anxiety and reduce stress alprazolam (Xanax) chlordiazepoxide (Librium) clonazepam (Klonopin) clorazepate (Tranxene) diazepam (Valium) estazolam (Prosom) flurazepam (Dalmane) lorazepam (Ativan)

Obsessive compulsive disorder

is based in obsessions, which are defined as recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted. Also present are compulsions or repetitive behaviors or mental acts that an individual feels drive to perform in response to an obsession or according to rules that must be applied rigidly Many times the compulsive behavior is driven by the preoccupation. For instance, Joey Ramone has to check to see if his windows are locked fifty times before he can leave his house or else he will scream loud vulgarities in public. other conditions involve more specific behaviors and preoccupations, (hair pulling, skin picking, preoccupation with body parts) but are placed in this overall category. Diagnostic criteria includes: -Presence of obsessions, compulsions or both (as defined above) · -Some examples of obsessions can include inappropriate sexual acts, acts of violence, screaming inappropriate vulgarities, -Some examples of compulsions include checking behaviors (locks, windows, faucets, stove), counting random objects, organizing things in a fastidious manner, asymmetry, washing/cleaning (which can look like a germ phobia!) Also, these obsessions/compulsions must consume one hour each day OR cause significant stress in social, occupational, or academic functioning -Individuals afflicted with this commonly have troubles leaving their home. They frequently miss or are markedly late for events that they are primarily responsible for such as work or family related functions. Of particular importance is the insight specifier: -With fair to good insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true -With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true -With absent insight/delusional beliefs: The individual is completely convinced that the obsessive-compulsive disorder beliefs are true One more specifier states if the afflicted individual has a current or past history of a tic disorder, that is the tic specifier DIFF DIAGNOSIS can include a -specific phobia -delusional disorder. -GAD or really any type of anxiety disorder. -Tic disorder -eating disorders PREV: 1.2% in the USA and 1.1-1.8% worldwide -Males develop symptoms more commonly in childhood, where females more commonly develop their symptoms in adulthood. -Males are more likely to have a related tic disorder and obsessions related to forbidden thoughts and asymmetry. -Females are more likely to have symptoms /compulsions related to cleaning. TREATMENTS **It is particularly difficult with poor and absent insight.** -An individual with fair to good insight may benefit from CBT, exposure or desensitizing therapies. Medications commonly used include SSRI antidepressants such as Zoloft, Prozac, Luvox etc. The doses used to treat OCD are notably higher than those generally effective for depression. Atypical antipsychotics (Seroquel, Risperdal, Geodon etc) are used in some severe cases, particularly those with a delusional quality

Disinhibited Social Engagement Disorder

it is precipitated by persistent social neglect/deprivation, repeated changes in primary caregivers, and rearing in unusual settings that severely limit opportunities to form attachments. The difference is in the symptoms manifested by the child. These include: -Reduced or absent reservations/reticence in approaching unfamiliar adults, -overly familiar verbal or physical behavior, -diminished or absent checking back with adult caregiver, -willingness to go off with an unfamiliar adult with minimal or no hesitation. · The above symptoms are not caused by impulsivity (as in ADHD)...ADHD would be in the differential diagnosis however. NO SPECIFIC TREATMENT In general, attempts can be made to stabilize the home environment, get consistent caregivers that are more responsive to the needs of the child, and educate the caregivers as to what these needs are. -play therapy, art, and fam therapies Medication use is usually limited due to the age of the children diagnosed with this. Fortunately, children often display resilience and can develop into adjusted, functional adults with reasonable intervention.

neurodevelopmental disorders

neurologically based disorders that are revealed in a clinically significant way during a child's developing years -anxiety/stress disorders -ADHD -Autism

Cluster A personality disorders

odd/eccentric paranoid, schizoid, schizotypal

somatic symptom disorder

psychological disorder in which the symptoms take a somatic (bodily) form without apparent physical cause •One or more somatic symptom (pain- GI, muscular, urogenital) that is distressing and or results in significant disruption of daily life This along with excessive thoughts, feelings, or behaviors related to these somatic symptoms: As evidenced by at least ONE of the following: -Disproportionate/persistent thoughts about the seriousness of one's symptoms -Persistently high anxiety about one's health/symptoms • Excessive time and or energy devoted to these symptoms • Also, although one of the somatic symptoms may not be persistent, the state of being symptomatic is • This symptom set lasts at least six months • must be no discernable medical findings • PREV is 5-7% in DSM V • More common in females • Familial link among this and Antisocial personality disorder • Studies have found that a family with an indiv. affected with Somatic symptom dis is more likely to have another family member with Antisocial personality dis • They may share a genetic polymorphism causing dec. 5HT production (serotonin)

personality disorders

psychological disorders characterized by inflexible and enduring behavior patterns that impair social functioning these disorders are grouped into clusters and then classified further with each individual diagnosis. · TREATMENT -Behavioral therapy is usually targeted at a particularly problematic behavior within the symptom set, so as to maximize the individuals functionality. -Borderlines can occasionally benefit from the structure of Dialectic Behavioral Therapy DBT. -CBT can be targeted to a specific behavior with some of the others. -Medications are not approved for use in any personality disorder, but are frequently used to deal with any comorbid depression, anxiety or impulsivity experienced with them. COMORBID with depression/anxiety

Trichotillomania (Hair-Pulling Disorder)

recurrent pulling out of one's hair, resulting in hair loss. This in spite of repeated attempts to stop or decrease this behavior. This ultimately results in impairment in social, occupational, and academic functioning. PREV at 1-2%. -This is more common in females at a ratio of approximately 10:1. These numbers may be swayed by the fact that more females seek out treatment for this where with males, hair loss in more acceptable. DIFF DIAG -neurodevelopmental disorders (tic disorder), -psychotic disorder (schizophrenia etc.), -and other OCD related disorders. Once again, this condition is often seen with other OCD related disorders. TREATMENT is usually approached in the same manner as other OCD related disorders. CBT to change the hair pulling behaviors, medications to perhaps treat any comorbid anxiety/depression.

Excoriation (skin picking) disorder)

results from picking at one's skin forming skin lesions. This, in spite of attempts to stop. we see the obligatory impairments in social, occupational, and academic functioning. PREV is listed at 1.4% -more females are afflicted with this (approx. 75% females). This condition in particular, can have medical complications related skin infections (impetigo) from the excoriation. DIFF DIAG is similar to trichotillomania with some minor exceptions: is seen the neurodevelopmental condition Prader-Willi Syndrome (not tic disorder). TREATMENT -CBT

Rumination disorder

there is repeated regurgitation of food over a period of at least one month. The food may be re-chewed, re-swallowed, or spit out. The repeated regurgitation is not caused by a medical condition or another eating disorder. -this disorder occurs at a much higher rate in the population with Intellectual disabilities. -This can be associated with malnutrition and growth delay in children. -Medical workups are of utmost importance to r/o medical problems (GI obstruction, pyloric stenosis).

Facticious Disorder

• Falsification of physical or psychological signs/symptoms, or induction of injury or disease, associated with identified deception • The indiv. presents themselves to others as ill impaired/injured • This version is Imposed on the self Factitious Disorder Imposed on another: Falsification of physical/psych symptoms, or induction of injury/disease in another, associated w/identified deception; The individual presents another individual (victim) to others as ill, impaired or injured • Whether imposed on self or another, there is no obvious external reward • This distinguishes it from malingering, where there are obvious external rewards (mostly money!) • Factitious dis usually presents in intermittent episodes. Persistent and single episodes are less common • DSM V estimates the prevalence as 1% in the hospital setting • Munchausen syndrome Pseudocyesis- False belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy, may include: Abdominal enlargement, reduced menstrual flow, amenorrhea, sensation of fetal movement, nausea, breast engorgement/secretions and labor pains TREATMENT Much like the treatment of Personality Disorders, treatment is indeed challenging • It must be individualized as the combination of symptoms/comorbidity -Meds of course for any comorbidities potentially responsive to meds • CBT is a potential help in some cases • DBT in particular can be helpful as there is much comorbid personality disorders • A strong provider/patient relationship is particularly helpful in these cases as a delicate combination of empathy/honesty is required • This can be difficult to establish in the large clinic (CMHC) or hospital environment • The most important factor is somehow maintaining one's own mental health, composure and objectivity when dealing with these cases!

bulimia nervosa

Recurrent episodes of binge eating as defined by both of the following- -Eating, in a discrete period of time, an amount of food that is definitely larger than what most individuals would eat in a similar period of time under normal circumstances. -A sense of lack of control over eating during the episode. -Also, recurrent inappropriate compensatory behaviors in order to prevent weight gain (induced vomiting, laxatives, diuretics, fasting or excessive exercise -The eating/compensatory behaviors both occur on average at least once/week for 3 months. -Again, self evaluation is unduly influenced by body weight. -Most individuals with bulimia nervosa are again Caucasian females. -usually within the normal BMI range. -fatality rate is not as high as with anorexia, but still esophageal tears and gastric rupture with fatality have been reported. -The gender ratio is again approx.. 10:1. -PREV is listed at 1-1.5% -symptoms also begin in adolescence/young adulthood. DIFF DIAG -binge eating disorder -borderline personality -depression, -anxiety disorders, -body dysmorphic disorder, -avoidant/restrictive food intake disorder. COMORBID -borderline personality. -Depression, -anxiety, -bipolar dis, -substance abuse, -PTSD, -personality disorders TREATMENT -specialized clinics. -medicating co-morbid symptoms, -involving family in treatment, -CBT/DBT, -group therapy -nutrionist

Level 2 Autism Spectrum Disorder

Requires substantial support- Similar to #3 but the individual can speak in simple sentences, and may express some narrow interests and displays odd nonverbal communication when doing so. Behaviors are inflexible, coping with change is difficult but not as severe as in #3. Changing attention focus is difficult as well.

Level 3 Autism Spectrum Disorder

Requires very substantial support- The social deficits leave the individual unable to speak more than a few words of intelligible speech, and will almost never initiate interaction. Their behavior is inflexible with extreme difficulty coping with change, and great difficulty changing focus or action.

Level 1 Autism Spectrum Disorder

Requiring support- The individual can speak complete sentences but needs supports in place for this to happen. They also have the potential to change their focus, but would not do so without supports in place.

antipsychotic medications

Risperdal Zyprexa Seroquel Haldol Geodon. (SEROQUEL, RISPERDAL, GEODON OCD) (SEROQUEL, RISPERDAL, ZYPREXA BODY DYS.) (HALDOL, SEROQUEL, ZEPREXA FOR AUTISM)

Body Dysphoric Disorder

criteria includes: -A preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others · -at some point in the disorder, the individual has performed repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance seeking, comparing their appearance with others) in response to the appearance concerns -the above preoccupation results in significant distress or impairment in social, occupational or academic functioning This condition has identical insight specifiers as OCD. Another specifier is muscle dysmorphia. This is when the individual is preoccupied with the idea that his or her body build is too small. Often these individuals will weight train excessively Afflicted individuals believe they are "unattractive", "not right" or "hideous". The focus can be with any part of the body, skin, teeth, hair, the nose, eyes to name a few! Their preoccupations with mirrors, grooming, and checking can impact the individual similar to one with OCD. PREVALENCE is listed as 2.4% in the USA with females having only a slightly higher percentage than males PREV was found to be -9-15% among Dermatology patients, -7-8% among cosmetic surgery patients in the USA and -3-16% among international cosmetic surgery patients, -8% in orthodontic patients, 10% among oral/maxillofacial surgery patients Most individuals with this condition begin to show symptoms in early adolescence DIFFERENTIAL DIAGNOSIS eating disorder, major depression, an anxiety disorder, or a psychotic/delusional disorder TREATMENTS is similar to ODC in the sense that it is determined by the amount of insight displayed by the individual. -Supportive psychotherapy can perhaps build the self-esteem of an individual with fair/good insight. -CBT may assist an individual with fair/good insight in rethinking and replacing the checking/grooming behaviors. -Medications can be used but there are no meds indicated for this condition per se, often the medications will be directed at any comorbid symptoms/conditions. -Antidepressant meds (Prozac, Zoloft, Lexapro etc) for individuals with comorbid depression. Seroquel, Zyprexa, Risperdal) for individuals with prominent delusions. This can be very resistant to treatment unfortunately.

dissociative identity disorder

criteria: -Disruption of identity characterized by two or more distinct personality states, (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/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. *These symptoms cause impairment in social, occupational, or other important areas of functioning · Some individuals show predominantly possessive (identity symptoms) while other show predominantly dissociative amnestic symptoms This condition is frequently found in the aftermath of a trauma. -There is some overlap of the symptoms of PTSD. -On occasion, non-epileptic or "Pseudo-seizures" may occur. -Self-injurious behavior is common in this population. -These episodes of possession and or amnesia, are frequently precipitated by some type of distressing event or conflict. -The source is frequently some type of childhood abuse. -The symptoms can develop from childhood into adulthood. -The prevalence is listed at 1.5% in DSM V with relatively equal distribution among genders. DIFF DIAG/COMORBID -depression, bipolar, PTSD, psychotic disorders, substance abuse disorder, personality disorder, conversion disorder (pseudo-seizures) and malingering. TREATMENT is designed to fit the individual and can often involve re-experiencing any past trauma in a safe, supportive environment similar to treatment for PTSD. -CBT/DBT to improve coping, and medications for any treatable form of co-morbidity (depression, bipolar) can be effective.

dissociative amnesia

criteria: -An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. -The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning. IMportant specifier With dissociative fugue: An apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information. · The amnesia can be localized, that is specific for events that occur during a circumscribed time. · This is the most common form of dissociative amnesia. If it is selective, the individual may be able to recall some events during this time period. · In generalized amnesia, the memory loss is more severe. · This is more rare mercifully. It can leave the individual in a dumbfounded state to where they don't know who or where they are, to the point where they are picked up by police or EMS. · This type of amnesia is more common in combat veterans and sexual assault victims. -In systematized amnesia, the individual loses memory for a specific category of information (memories related to a specific person, one's family, or childhood sexual abuse). Individuals afflicted with this have often been abused as children, and they display similar self-injurous behaviors as individuals with DID. -PREV is listed as 1.8% in DSM V. -Females are affected twice as frequently as males. DIFF DIAG -DID, PTSD, Neurocognitive disorders (organic brain pathology), amnesia due to brain injury (physical trauma), Substance abuse disorder, Seizure disorders, and malingering COMORBID -depression, PTSD, somatic disorder, conversion disorder, and personality disorder (particularly dependent, borderline and avoidant). TREATMENT is individual and is similar to DID.(CBT/DBT)

medically assisted treatment (MAT)

using a medicine as a secondary treatment to augment the counseling that is the primary treatment of substance use disorders (for opiate treatment) The oldest MAT is methadone. (This is nothing more than an opiate substitute.) It is dispensed by a specialty clinic licensed to do so, the individual either attends the drug treatment program there as well, or goes to another facility for drug treatment. T the theory is to keep the individual on a controlled, safe dose of opiate, prevent frequent relapse, and avoid all the disaster that accompanies the addictions lifestyle (criminal behavior, assault, overdose/contaminated street drugs etc.). Over time (months to years), the dose is ideally to come down in order to get the patient ultimately off the opiate. -newer form of MAT is with a drug called suboxone, which is a combination of two drugs, buprenorphine and naloxone (at a ratio of 4:1). Buprenorphine was mentioned earlier and is an opiate agonist. Naloxone is narcan, the opiate overdose rescue drug. -Suboxone is less stigmatized as one does not have to go to a "methadone clinic" but still carries the risk of abuse, and overdose. Please note narcan is sold on it's own in individual injectable units to rescue opiate overdose victims. -Another type of MAT is with a medication called Naltrexone (Revia or in long acting injection vivitrol, oral revia). -Naltrexone is an opiate antagonist, not competitive so it's not used for treatment of overdose but it is often used after an individual is detoxified.