Diagnostic & Statistical Manual IV (DSM IV)

Major Axes of Diagnosis:

Axis I: Clinical disorders: e.g. schizophrenia, affective disorder, anxiety, somatoform disorders. Also includes anorexia nervosa, bulimia nervosa, sexual disorders, sleep disorders, autism

Axis II: Personality disorders and mental retardation

Axis III: Physical conditions & disorders

Axis IV: Psychosocial & environmental problems including primary support group, social occupation, education, housing, economics, health care services, and legal issues

Axis V: Global assessment of functioning (GAF) scored on descending scale of 100 to 1, where 100 represent superior functioning, 50 represent serious symptoms, and 10 represent persistent danger of hurting self or others

1. Example of multi-axial diagnosis

Axis l: Dysthmic disorder

            Reading disorder

Axis ll: No diagnosis

Axis lll: Influenza

Axis IV: Victim of child neglect

Axis V: GAF=44 (current)

Disorders usually diagnosed in Childhood

1. Mental retardation

• Scored on axis ll
• Fetal alcohol syndrome (FAS) most common known cause
• Down and Fragile-X syndromes most common genetic causes

Classification

Level                           IQ                                Functioning     

Mild	75-50	Self-supporting with some guidance– 85% of retarded. Two time as many are male. Usually diagnosed first year in school
Moderate	49-35	“Trainable,” benefits from vocational training, but needs supervision. Sheltered workshops
Severe	34-20	Training not helpful, can learn to communicate, basic habits
Profound	Below 20	Needs highly structured environment, constant nursing care supervison

2. Pervasive developmental disorders:

Autism

• Scored on Axis l
• Usually diagnosed in infancy (30 month)
• Clinical signs:

                                                              i.      Problems with reciprocal social interactions, decreased repertoire of activities and interest

                                                            ii.      Abnormal or delayed language development, impairment in verbal and nonverbal communication

                                                          iii.      No separation anxiety

                                                          iv.      Oblivious to external world

                                                            v.      Fails to assume anticipatory posture, shrink from touch

                                                          vi.      Preference to inanimate objects

                                                        vii.      Stereotyped behavior and interest

• Male-female ratio 4:1
• Linked to chromosome 15
• Occurs in four of every 10,000 births
• Monozygotic concordance is greater than dizygotic concordance
• 80% have IQ below 70
• potential causes

                                                              i.      Association with prenatal and perinatal injury, e.g. rubella in first trimester

                                                            ii.      Failure of apoptosis (normal pruning of neuronal circuits)

• Treatment: behavioral techniques (shaping)

Attention deficit hyperactivity disorder (ADHD)

• Approximately 10% of lower class males and 5% of middle class
• Male to female ratio is 10:1
• More common in first born males
• Overtreatment appears common; differentiate from a child who is simply “overactive”
• Treatment: methylphenidate, dextroamphetamine, or pemoline

Schizophrenia

1. General overview

1.      Criteria

o   Bizarre delusions

1.      Delusions: false beliefs not shared by culture

2.      Illusions: misperceptions of real stimuli

3.      Hallucinations: sensory impressions, no stimulis

o   Auditory hallucinations in 75%

1.      Impaired concentration

2.      Note: not visual hallucinations

o   Blunted affects

o   Loose association

o   Deficiency in reality testing, distorted perception

o   Disturbances in behavior and form and content of language and thought

o   Changes in pscychomotor behavior; loss of prosody

2.      “Differential”

o   Schizophreniform if symptoms less than 6 month in duration

o   Brief psychotic disorder

1.      Presence of delusions, hallucinations, or disorganized speech & behavior

2.      From 1 – to 30 days

3.      Return to full former functioning

4.      Not cultural response pattern

5.      Not due to substance abuse or organic cause

3.      Potential causes

o   Trinucleotide repeat amplification

o   Birth trauma (hypoxia likely if early onset)

4.      Epidemiology

o   Onset: male, age 15-24; female, age 25-34

o   Prevalence 1% of population cross culturally. However less chronic and severe in developing countries than in developed countries

o   Downward drift to SES

o   Over 50% of schizophrenics do not live with their families. Nor are they institutionalized

5.      Genetic contribution

o   Rates for monozygotic twins reared apart = rates for MZ twins raised together (47%)

o   Dizygotic concordance 13%

o   If two schizophrenic parents: 40% incidence

o   If one parent or one sibling 12%

6.      Related terms:

o   Schizophrenogenic family: highly critical, negative emotions, double messages. Linked to schizoid personality disorders, not linked to development of schizophrenia

o   Hig expressed-emotion families: relapse rate four to five times higher

o   Vocabulary:

1.      Amhedonia

2.      Clang associations

3.      Echolalia

4.      Echopraxia

5.      Flight of ideas

6.      Loose associations

7.      Mannerism

8.      Mutism

9.      Neologism

10.  Perseverations

11.  Poverty of speech

12.  Pressure speech

13.  Veberbigeration

7.      Subtypes

o   Paranoid

1.      Delusions of persecution or grandeur

2.      Often accompanied with hallucinations (voices)

3.      Older onset than other types with less regression of mental faculties and emotional response

o   Catatonic

1.      Complete stupor or pronounced decrese in spontaneous movements

1.      May be mute

2.      Often negativism, echopraxia, automatic obedience

3.      Rigidity of posture; can be left standing or sitting in awkward positions for long period of time\brief outburst of violence without provocation

4.      Waxy flexibility

2.      Alternatively, can be excited and evidence extreme motor agitation

1.      Incoherent and often violent or destructive

2.      In their excitement, can hurt themselves, or collapse in exhaustion

3.      Repetitious, stereotyped behavior

o   Disorganized

1.      Incoherent, primitive, uninhibited

2.      Unorganized speech and behavior

3.      Active, but aimless

4.      Poor personal appearance

5.      Little contact with reality

6.      Pronounced thought disorder

7.      Explosive laughter

8.      Silliness

9.      Incongruous grinning

o   Undifferentiated

1.      Psychotic symptoms

2.      Does not fit paranoid, catatonic, or disorganized diagnoses

o   Residual

1.      Previous episode, but no prominent psychotic symptoms at evaluation

2.      Some lingering negative symptoms

8.      Important conditions

o   Positive symptoms (type l)

1.      What schizophrenic persons have that normal do not, e.g. delusions, hallucinations, bizarre behavior

2.      Associated with dopamine receptors

o   Negative symptoms

1.      What normals have, that schizophrenics do not, e.g. flat affect, motor retardation, apathy, mutism

2.      Associated with muscarinic receptors

o   Schizoaffective disorders

1.      Concurrent symptoms of schizophrenia and depression or mania

9.      Predictors for good prognosis

1.      Paranoid or catatonic

2.      Late onset (female)

3.      Quick onset

4.      Positive symptoms

5.      No family history of schizophrenia

6.      Family history of mood disorders

7.      Absence of structural brain abnormalities

8.      Schizoaffective form

10.  Neurochemistry

o   The dopamine hypothesis is based on

1.      The effectiveness of neuroleptic medications in ameliorating the symptoms of schizophrenia

2.      The correlation of clinical efficacy with drug potency in dopamine receptor antagonists

3.      Findings of increased dopamine receptor sensitivity in postmortem studies

4.      PET scan studies of sch compared with controls

o   Other neurotransmitters have come under increased scrutiny because of the limitations of the dopamine hypothesis. E.g. serotonine, glutamate, norepinephrine, and related excitatory amino acids, and the neuropeptides cholecystokinin and neurotensin

o   Role of serotonine (5-HT)

1.      Genes involved in serotoninergic neurotransmission are implicated on the pathogenesis of schizophrenia

2.      LSD affect serotonin and can produce a psychotic like state

3.      Newer antipsychotics (clozapine) have high affinity for serotonin receptors

4.      Serotonin rises when dopamine falls in some areas of the brain

o   Role of glutamate

1.      Major neurotransmitter in pathways key to schizophrenic symptoms

2.      N-methyl-D-aspartate (NMDA) receptors

o   Regulates brain development and contols apoptosis (pruning)

o   Phencyclidine and ketamine block NMDA channel: can create positive and negative psychotic symptoms identical to schizophreina

o   2-(aminomethyl)-phenylacetic acid (AMPA) receptors

§  Abnormally sparse in temporal lobes of schizophrenics

§  ampakines (new dugs) selectively enhance transmission and improve memory in patients

11.   Attention & information processing deficits

o   smooth pursuit eye movements (SPEM)

1.      the capacity of the eye to follow slow moving target is impaired in sch patients

2.      normal persons perform this task without errors, up to 80% of sch patients and half of their relatives show saccadic eye movements and deficit at this tracking task

o   Backward masking: two images shown in rapid succession

1.      If shown one-half second apart, later image “masks” the former for the sch

2.      For normals, less than one-fourth second is necessary for effect

3.      Explanation: schizophrenics are slower to fix impressions in short term memory

o   Event-related potentials (ERP)

1.      Sch is associated with diminished amplitude of auditory P300) ERP

2.      P300 component is elicited by task-relevant stimuli

3.      Abnormalities may be associated with impaired selective attention, therefore, sch patients do not conduct involuntary information processing normally

4.      Diminished P300 amplitude is also observed in healthy family members of schizophrenics

o   Prefrontal cortex (PFC) impairment

1.      Faced with cognitive task, increased activity is found in the prefrontal cortex of normal individuals

2.      Sch show decreased physiologic activity in prefrontal lobes when faced with tasks

3.      Impaired performance on the Wisconsin Card Sort (WCST), a test sensitive to prefrontal dysfunctions

4.      Clinical profile has similarities with patients with frontal lobe injury (e.g. cognitive inflexibility), problem-solving difficulties, and apathy).

o   Brain structural and anatomic abnormalities

1.      Cortical abnormalities

1.      Larger ventricle size and ventricular brain ratios (VBRs)

2.      Cortical atrophy

3.      Smaller frontal lobes

4.      Atrophy of temporal lobes

5.      Association with specific clinical and cognitive correlates, including deficit symptoms, cognitive impairment, and poor outcome

o   Correlation between ventricle size, type and prognosis of illness

o   More dilation with negative symptoms

o   However, dilated ventricles also reported among patients having unipolar, bipolar, and schizophrenic disorders (sensitive, but not specific indicator)

o   Subtle anomalies in limbic structures

1.      Limbic system seen as the site of the primary pathology for schizophrenia

2.      Changes in hippocampus, parahypocampal gyrus, entorhinal cortex, amygdala, cingulate gyrus

1.      Smaller volume of hyppocampus and amygdala

2.      Same found in high risk but non symptomatic patients

3.      Changes within basal ganglia, thalamus, corpus callosum, and brainstem neurotransmitter systems.

4.      Loss of inhibitory neurons in second layer of anterior cingulated gyrus

12.  Log-term course

·         Antipsychotic medications reduce acute (positive) symptoms in 75% versus 25% with placebo

·         Relapse rates

o   40% in 2 years if on medication

o   80% in 2 years if off medication

·         Prognosis

o   33% of patients lead normal life

o   33% of patients experience symptoms but functions in society

o   33% of patients frequent hospitalizations

·         If no first-year relapse and medication are taken, 10% relapse thereafter

Mood disorders

Depression and elation are normal human emotions. Disorder is when it gets too long-term or too extreme

	Mild	Extreme
Stable	Dysthymia	Unipolar (major depression)
Alternating	Cyclothymia	Bipolar (manic-depression)

1. Basic subtypes:

1. Dysthymia (nonpsychotic depression)

                                                                                                                                      i.      Depressed mood

                                                                                                                                    ii.      Loss of interest or pleasure (anhedonia)

                                                                                                                                  iii.      Chronic (at least 2 years)

                                                                                                                                  iv.      Not severe enough for hospitalization

                                                                                                                                    v.      Lifetime prevalence 45 in 1,000

                                                                                                                                  vi.      30 to 50% alcoholics have secondary depression

                                                                                                                                vii.      May be associated with:

1.      Increased or decreased appetite

2.      Fatigue

3.      Decreased self-esteem

4.      Hopelessness

5.      Lowered concentration

                                                                                                                              viii.      Patient is functional, but a suboptimal level

2. Cyclothymia (nonpsychotic bipolar)

                                                                                                                                      i.      Alternating states

                                                                                                                                    ii.      Chronic

                                                                                                                                  iii.      Often not recognized by the person (ego-syntonic)

                                                                                                                                  iv.      Lifetime prevalence <1 o:p="">

3. Seasonal affective disorder (SAD)

                                                                                                                                      i.      Depressive symptoms during the winter months

                                                                                                                                    ii.      light

                                                                                                                                  iii.      Atypical symptoms

a.       Increased sleep

b.      Increased appetite

c.       Decreased energy

                                                                                                                                  iv.      Caused by abnormal melatonin metabolism

                                                                                                                                    v.      Treatment bright light (not melatonin tablets)

4. Unipolar depression (major depression)

1.      Symptoms for at least two weeks

2.      Must represent a change from previous functioning

3.      May be associated with

a.       Anhedonia

b.      Lack of motivation

c.       Feeling of worthless

d.      Decreased concentration

e.       Weight loss or gain

f.       Depressed mood

g.       Recurrent thoughts (rumination)

h.      Insomnia or hypersomnia

i.        Psychomotor agitation / or retardation

j.        Somatic complaints/delusions

k.      Delusions or hallucinations (mood congruent!)

l.        Loss of drive

4.      Diurnal improvement as day progress

5.      Suicide

a.       60% of depressed have suicidal ideas

b.      15% of depressed die of suicide/ 50% of suicide related with depression

6.      biologic correlates

a.       PET scan shows abnormally high glucose metabolism in amygdala

b.      Smaller hippocampus, atrophy is greater if depression prolonged

c.       Linked to abnormally high level of glucocorticoids

7.      Decreased level of most hormones

8.      Neurochemical changes:

a.       Decreased norepinephrine

b.      Decreased serotonin

c.       Decreased dopamine

d.      Metabolites of all above also decreased

9.      Sleep correlates:

a.       Increased REM in first half of sleep

b.      Decreased REM latency

c.       Decreased stage 4 sleep

d.      Increased REM time overall

e.       Early morning awakening

5. Bipolar disorder (manic-depression)

                                                              i.      Symptoms of major depression plus symptoms of manic period of abnormal and persistent elevated, expansive, or irritable mood

                                                            ii.      Alternates between depression and mania

                                                          iii.      Subtypes:

1.      Bipolar 1: mania more prominent

2.      Bipolar ll: recurrent depressive episodes plus hypomaniac episodes

3.      If alternates within 48-72 hours, called “rapid cycling bipolar disorder”

                                                          iv.      Manic symptoms

1.      Increased self esteem or grandiosity

2.      Low frustration tolerance

3.      Decreased need for sleep

4.      Flight of ideas

5.      Excessive involvement in activities

6.      Weight loss or anorexia

7.      Erratic and uninhibited behavior

8.      Increased libido

                                                            v.      Neurochemical changes:

1.      Increased norepinephrine (NE)

2.      Increased serotonin

3.      Slight increase in dopamine

                                                          vi.      Sleep correlates:

1.      Multiple awakenings

2.      Markedly decreased sleep time

Epidemiology of mood disorders:

	Unipolar	Bipolar
Point prevalence	Men 2 to 3%, women 5-9%	Men & women less than 1%
Gender difference	Women 2x men (stress of childbirth, hormonal effects, abused as children)	Rates are effectively equal
Lifetime prevalence	Men 10%, women 20%	Men & women 1%
Onset	Mean age 40	Mean age 30
SES	Low SES more likely	Higher SES more likely
Relationships	More prevalent among those with no close relationships, separation, divorce	More prevalent among single and divorced (casual?)
Family history	Higher risk if parents depressed or alcoholics; increased risk if parental loss before age 11	Higher risk if parent(s) has bipolar

                                                        vii.      Corollaries of mood disorders

1.      Persons with multiple sclerosis have 13x rate of bipolar disorder compared with general population

2.      50 to 60% in remission from bipolar or unipolar disorder will have recurrences

3.      80% with either unipolar or bipolar do not get proper treatment

4.      Evidence of genetic bipolar link stronger than unipolar

a.       If both parents: 50 to 70% for bipolar

b.      If both parents: 20-25% for unipolar

c.       Bipolar concordance rates: MZ twins=70%, DZ twins-20%

5.      Younger persons are more at risk for unipolar disorder

Ages                                  Annual incidence

18-44                                                                  3,4%

45-64                                                                  2,2%

65+                                                1,0%

6.      Children of depressed mothers are

a.       Less involved and more resentful of children

b.      Two times more likely to abuse children.

c.       Attempted suicide 12 times more likely

d.      Children have higher risk of depression (1.6 x) and substance abuse (2,3x)

7.      Smokers are 2x as likely to develop depression

a.       Depressed smokers have more trouble quitting and 40% less likely to succeed

b.      Doxepin (cyclic antidepressant) seems help even nondepressed smokers to quit

c.       Zayban used for quit smoking

8.      Lab tests & depression

a.       3-methoxy- 5-hydroxy-phenyl-glucol (MHPG)

                                                                                                                                      i.      CNS metabolite of norepinephrine

                                                                                                                                    ii.      Depressed patients with low levels of MHPG are more likely to respond to imipramine than to amitriptyline

b.      Dexamethason suppression test (DST)

                                                                                                                                      i.      Introduced in 1981

                                                                                                                                    ii.      Focuses on hypothalamic-pituitary-adrenal axis

                                                                                                                                  iii.      Some depressed patients have high serum cortisol levels that are not suppressed in response to exogenous corticosteroid administration

                                                                                                                                  iv.      DST is only 50% sensitive (although 70% sensitivity for depression with psychotic features)

                                                                                                                                    v.      Not high specificity, yields too many fals positive results (*anorexia, Cushing, Schizophrenia)

                                                                                                                                  vi.      Suppression of cortisol level is good predictor of response to cyclic medications

Eating Disorders

1. Bulimia nervosa

1. Compulsive, rapid ingestion of food followed by self-induced vomiting, use of laxatives, or exercise: binge & purge (type)
2. Personality: outgoing & impulsive
3. Roughly 4% females and 0.5% males; 5 to 10% of women experience it at some point during their lives
4. Clinical signs:

                                                              i.      Scars on back of hand

                                                            ii.      Esophageal tears

                                                          iii.      Enlarged parotid gland

                                                          iv.      Cooking preoccupation

                                                            v.      Minimal public eating

5. Often associated with taking on responsibility (leaving home, getting a job)
6. Low baseline serotonin concentration (repeated bingeing raises serotonin)
7. One third have drug or alcohol problem
8. Serotonine / norepinephrine implicated
9. Treatmen: imipramine, SSRI, insight, & group th

2.  Anorexia nervosa

1.  self imposed dietary limitations, significant weight loss (15-25% below the ideal body weight); self starvation
2. fear of gaining weight
3. “feel fat” even when very thin (body image disturbance)
4. appearance of lanugo (baby fine hair)
5. dental cavities
6. amenorrhea
7. serotonine / norepinephrine implicated
8. prevalence:

a.       0.5% of population, 2% of adolescent females

b.      ages 10 to 30 (85% between 13 and 20); uncommon in women older than 40

c.       95% female

9. mortality 5-18%
10. predisposing factors

                                                              i.      family dynamics linked to relationship with father; harsh mother    

                                                            ii.      mother with history; 50% of susceptibility inherited

                                                          iii.      50% of anorexics also have binge & purge

                                                          iv.      40 t0 80% seriously depressed

11. treatment

                                                              i.      usually resistant to treatment (denial of illness)

                                                            ii.      stabilizing weight than family & individual therapy

                                                          iii.      ECT

                                                          iv.      Pharmacologic treatment: cyproheptadine, chlorpromazine, amitriptyline

             

Anxiety disorders

1.      Most common disorders in women of all age. For men, substance abuse is most common

2.      Rule out coronary heart disease and hyperthyroidism

3.      Anxiety can become a self generating spiral

Subtypes:

1. Generalized anxiety disorder (GAD)

1. Over a 6 month period symptoms exhibited more days than not.
2. The anxiety is a universal emotion. The issue here is one of degree
3. Lack of structure is frequent contributing factor, e.g. “Sunday neurosis,” Planned activities bind anxiety
4. Symptoms

                                                              i.      Motor tension (fidgety, jumpy)

                                                            ii.      Autonomic hyperactivity (heart pounding, sweating, chest pains), hyperventilation

                                                          iii.       Apprehension (fear, worry, rumination), difficulty concentrating

                                                          iv.      vigilance and scanning (impatient, hyperactive, distracted)    

                                                            v.      Fatigue and sleep disturbances common, especially insomnia and restlessness

2. Phobias

1. General:

1. Prevalence: 4% men; 9% women

                                                              i.      Public speaking is the No 1 phobia

2. Specific phobias: fear of specific objects, e.g. spiders, snakes

                                                              i.      Anxiety when faced with identifiable object

                                                            ii.      Phobic object avoided

                                                          iii.      Fear must be persistent and disabling

2. Agoraphobia

                                                              i.      Fear of open spaces

                                                            ii.      Sense of helplessness and humiliation

                                                          iii.      Manifest anxiety, panic like symptoms

                                                          iv.      Travel restricted

                                                            v.      Often occurs with panic disorder

3. Social phobia

                                                              i.      Fear of feeling being stupid, shameful

                                                            ii.      Leads to dysfunctional circumspect behavior, e.g. inability to use public washrooms

                                                          iii.      Prevalence 1% of general population

                                                          iv.      May accompany avoidant personality disorder

                                                            v.      ‘Discrete performance anxiety’ (stage fright): most common phobia, treat with atenolol or propranolol (beta blocker) or paroxetine (SSRI)

                                                          vi.      ‘generalized social anxiety’ treat with phenelzine (MAO inhibitor) or paroxetine (SSRI)

4. Obsessive-compulsive disorder (OCD)

                                                              i.      Obsession: focusing on one thought, usually to avoid another

                                                            ii.      Cumpulsion: repetitive action shields person from thoughts, action “fixes” bad thought

                                                          iii.      Common defenses:

1.      Isolation

2.      Undoing

3.      Reaction formation

                                                          iv.      Typically recognized by patient as absurd and attempts to resist

                                                            v.      Primary concern of patient is to not lose control

                                                          vi.      Epidemiology:

§  1.5% have disorder; 3% lifetime prevalence

§  50% remain unmarried

§  males = females

§  major depression among 2/3 over lifetime

                                                        vii.      increased frontal lobe metabolism

                                                      viii.      increased activity in the caudate nucleus

                                                          ix.      Treatment:

1.      Fluoxetine; fluvoxamine; or other SSRI

2.      Clomipramine

3.      Avoid neuroleptics

5. Panic disorder

                                                              i.      Three attack in 3-week period

                                                            ii.      No clear circumscribed stimulus

                                                          iii.      Abrupt onset of symptoms, peak within 10 minutes

                                                          iv.      Epidemiology

1.      Onset early 20s

2.      1.5% of population has disorder, 4% lifetime prevalence

3.      70 to 80% are women

4.      10 to 14% of cardiology patients have panic attacks

                                                            v.      Clinical signs

1.      Great apprehension and fear

2.      Palpitations, trembling, sweating

3.      Extreme fear of dying or going crazy

4.      Hyperventilation, “air hunger”

5.      Sense of unreality

                                                          vi.      Premenstrual period: heightened vulnerability

                                                        vii.      Recurrent attacks leave patients demoralized, hypochondriacal, agoraphobic, depressed

                                                      viii.      Can induce panic attacks by hyperventilation, carbon dioxide, yohimbine, sodium lactate, epinephrine (panicogens)

                                                          ix.      Treatment

1.      Alprazolam (NIMH study)

2.      TCA-s (imipramine)

3.      Clonazepam

4.      Any SSRI

5.      Carbon dioxide for hyperventillationa

                                                            x.      Relapse is common; keep on medication for 6-12 months

Somatoform disorders, Factitious disorder, And Malingering

Somatoform disorders

1. Somatization disorder

                                                              i.      Set of eight or more number of symptoms (four pain, two GIT, one sexual, one pseudoneurologic)

                                                            ii.      Onset before age 30

                                                          iii.      Symptoms can occur over a period of years

                                                          iv.      20 to 1 female-male ratio

2. Conversion disorder

                                                              i.      One or more “serious” symptoms

                                                            ii.      Altering of physical functioning, suggesting physical disorder

                                                          iii.      Usually skeletal, muscular, sensory, or some peripheral nonautonomic system, e.g. paralysis of the hand, loss of the sight

                                                          iv.      Loss of functioning is real and unfeigned

                                                            v.      Look for ‘la belle indifference

3. Hypochondriasis

                                                              i.      Unrealistic interpretation of physical signs as abnormal

                                                            ii.      Preoccupation with illness or fear of illness when none present

                                                          iii.      Preoccupation persist in spite of reassurance

                                                          iv.      At least 6 month duration

                                                            v.      Treat by simple palliative care and fostering relationship

4. Somatoform pain disorder

                                                              i.      Severe, prolonged pain

                                                            ii.      No cause found

                                                          iii.      Pain disrupt day to day life

                                                          iv.      Rule out of depression

                                                            v.      Look for secondary gain

5. Body dysmorphic disorder

                                                              i.      Preoccupation with unrealistic negative evaluation of personal appearance and attractiveness

                                                            ii.      Sees self as ugly or horrific when normal in appearance

                                                          iii.      Preoccupation disrupt day-to-day life

                                                          iv.      Not accounted for by other disorder (e.g. anorexia nervosa)

                                                            v.      May seek multiple plastic surgeries or other extreme interventions

Differential diagnosis

1.      Somatoform disorders:

a.       Unintentional or unconscious symptom production

b.      Unconscious motivation to be ill

c.       Both primary and secondary gain

2.      Malingering: everything conscious

a.       Intentional symptom production

b.      Conscious motivation

c.       Symptoms purely for secondary gain, e.g., to avoid court date, military induction, or school

3.      Factitious disorder: some conscious some unconscious

a.       Intentional illness production

b.      Unconscious motivation, therefore, a compulsion

c.       Patients aware of manufacturing their symptoms but unaware of why they go to such lengths

d.      Both primary and secondary gain

e.       Munchausen syndrome or polysurgical addiction: chronic factitious

Post-Traumatic Stress Disorder

1. Manifestations
1. Re-experience of the event as recurrent dreams or recollections (flashbacks)
2. Avoidance of associated stimuli
3. Sleep disruption / or excess
4. Irritability; loss of control; impulsivity
5. Headache; inability to concentrate
6. Repetition compulsion
2. Symptoms must be exhibited for more than 1 month; if less, diagnose acute stress disorder
3. Following psychologically stressful event outside the range of normal human experience
1. Most commonly, serious threat to life, family, children, home, or community
2. Common reaction to rape for women
4. Often long latency period, e.g. abused as a child, manifest symptoms as adult
5. Quicker onset correlates with better prognosis
6. Increased vulnerability if:
1. Prior emotional variability; excessive autonomic reactions is a predictor of occurrence
2. Prior cocaine/opiate use
7. Adults recover quicker; very young and very old have harder time to cope
8. Prevalence 0,5% in men, 1,2% in women
9. Sleep changes: increase in REM latency; decrease in amount of REM and stage 4 sleep
10. Increased urinary secretion of norepinephrine
11. Treatment: group therapy to facilitate working through normal reactions blocked by disorder; seeking cathartic release. SSRI can improve patient’s functional level.

Adjustment disorder

1. Residual category, use only if no other Axis 1 applies
2. Criteria:
1. Presence of identifiable stressor within 3 month of onset
2. Symptoms last less than 6 month after end of stressor
3. Symptoms are clinically significant, with significant social, occupational and/or academic impairment
4. Not a grief response

Dissociative disorders

1. Symptoms similar to temporal lobe dysfunctions (temporal lobe epilepsy)
2. Reaction often precipitated by emotional crisis
1. Primary gain: anxiety reduction
2. Secondary gain: solution to the crisis (avoidance)
3. Subtypes
1. Fugue

                                                              i.      Sudden unexpected travel

                                                            ii.      Inability to recall one’s part

                                                          iii.      Confusion of identity or new identity

2. Amnesia

                                                              i.      Inability to recall important personal information

                                                            ii.      Linked to trauma

3. Dissociative identity disorder (multiple personality)

                                                              i.      Presence of two or more distinct identities

                                                            ii.      At least two identity control behavior

                                                          iii.      Inability to recall important personal information

Personality disorders

1.      General characteristics

a.       Inflexible

b.      Inability to adapt

c.       Lifelong

d.      All areas of life affected

e.       Maladaptive responses to stress and responses to social context

f.       Can thrive if situation right

g.       Interactive, interpersonal disorders

                                                              i.      Patients really annoy others

                                                            ii.      Symptoms are ego syntonic

                                                          iii.      Patients seek to change the world, not self

h.      Overall, 10-to 15% prevalence (Nova Scotia and Manhattan studies)

i.        Concordance rate for MZ twins three times that of DZ twins

2.      Cluster A: odd or eccentric

·         Higher prevalence in biologic relatives of schizophrenics, higher prevalence in males

1.      Paranoid

                                                                          i.      Long-standing suspiciousness or mistrust of others: a base line of mistrust

                                                                        ii.      Preoccupied with issues of truth

                                                                      iii.      Reluctant to confide in others

                                                                      iv.      Reads hidden meaning into common events

                                                                        v.      Carries grudges

                                                                      vi.      Differentiate from:

1.      Paranoid schicophrenic has hallucinations and formal thought disorders; paranoid personality disorder not

                                                                    vii.      Delusional disorder, paranoid type has fixed, focal delusions; paranoid personality disorder not

                                                                  viii.      Defense = projection

2.      Schizoid

                                                                          i.      Lifelong pattern of social withdrawal, and like it that way

                                                                        ii.      Seen by others as eccentric, isolated withdrawn

                                                                      iii.      Restricted emotional expression

                                                                      iv.      Prevalence 7,5% of population

                                                                        v.      Males 2x than females

3.      Schizotypal

                                                                          i.      Very odd, strange, weird

                                                                        ii.      Magical thinking (Including ESP and telepathy), ideas of reference, illusions

                                                                      iii.      Idiosyncratic meanings

                                                                      iv.      Social anxiety (paranoid)

                                                                        v.      Lack of close fiends

                                                                      vi.      Incongruous affects

                                                                    vii.      Odd speech

                                                                  viii.      Social isolation

                                                                      ix.      Collections ( e.g., ball off barbed wires)

                                                                        x.      Ill-fitting or mismatched clothing

     3. Cluster B: Dramatic and emotional –

often associated with addictions and Somatization disorders

a)      Histrionic

§  Colorful

§  Dramatic

§  Extroverted

§  Inability to maintain long-lasting relationships

§  Attention-seeking, constantly wanting in the spotlight

§  Seductive behavior

§  Defense =

o   Regression

o   Somatization

o   Conversion

o   Dissociation

b)      Narcissistic

§  Increasing recognition and reported cases

§  Grandiose sense of self-importance

§  Preoccupation with fantasies of unlimited wealth, power, love

§  Demands constant attention

§  Fragile self esteemÞ

§  Prone to depression

§  Criticism met with indifference or rage

§  Genuine surprise and anger when others don’t do as they want

§  Can be charismatic

§  Fixation subphase at separation - individuation

c)      Borderline

§  1 to 2% of population

§  Females 2X> males

§  Very unstable affects, behavior, self image

§  In constant state of crisis, chaos

§  Self detrimental impulsivity

§  Promiscuity, gambling, overeating

§  Substance abuse

§  Unstable but intense interpersonal relationships

§  Very dependent & hostile, love/hate

§  Great problems with being alone

§  Self-mutilation

§  History of sexual abuse

§  Usual defense: splitting

§  Passive- aggressive

§  Particularly incapable of tolerating anxiety

§  Often coupled with mood disorder

§  5% commit suicide

§  Defense =

o   Splitting

o   Projective identification

o   Dissociation

d)      Antisocial

§  2% males 1% females

§  Continual criminal acts

§  Inability to conform social norms; truancy, delinquency, theft, running away

§  Cant hold job,

§  No enduring attachments,

§  Reckless, aggressive

§  Onset before 15: - if younger than 18; diagnose conduct disorder

§  3X greater in areas of social disintegration

§  75% of prison population

§  5X more common among relatives with disorder

§  Superego lacunae

4. Cluster C: Anxious and fearful    (behaviors associated with anxiety & fear)

                                   

a)      Avoidant

§  Extreme sensitivity to rejection

§  Sees self as socially inept

§  Excessive shyness

§  High anxiety levels

§  Social isolation

§  Intense desire for affection and acceptance

§  Tend to stay in the same job, same life situation, same relationship

§  Defense = avoidance

b)      Obsessive compulsive

§  Orderliness, inflexible, perfectionist

§  More common in males, first born, harsh discipline upbringing

§  Loves lists, rules, order

§  Unable to discard worn-out objects

§  Doesn’t want change

§  Excessively stubborn

§  Lacks sense of humor

§  Wants to keep routine

§  Differentiate form obsessive-compulsive anxiety disorder. The anxiety disorder has obsessions and compulsions that are focal and acquired. Personality disorders are life long and pervasive

§  Defense =

o   Isolation

o   Reaction formation

o   Undoing

o   Intellectualization

c)      Dependent

§  Gets others assume responsibility

§  Subordinates own needs to others

§  Cant express disagreement

§  Great care of having to care for self

§  May be linked to abusive spouse