MOOD DISORDERS

MOOD DISORDER Affective Disorder

o Normal Reaction: Grief
o Trauma & Stressor: Adjustment Disorder w/ Depressed Mood
o Depressive Disorders
Major Depressive Disorder (MDD)
Persistent Depressive Disorder (Dysthymia, Dysthymic Disorder)
Premenstrual Dysphoric Disorder
Substance or Medication Induced Depressive Disorder
Depressive Disorder due to GMC
Unspecified Depressive Disorder
o Bipolar & Related Disorders
Bipolar I Disorder (just has a manic episode)
Bipolar II Disorder (must have hx of depression)
Cyclothymic Disorder (not sure yet)
Substance or Medication Induced Bipolar & Related Disorder
Bipolar & Related Disorder due to GMC
Unspecified Bipolar & Related Disorder
MANIC EPISODE
o Duration is > 1 week or any hospitalization
o DIGFAST (3 of the following or 4 of the following if mood is irritable)
D Distractibility (7s, months of year, spell world backward)
I Irrationality/Irresponsible behaviors
G Grandiosity
F Flight of Ideas FOIs (racing thoughts)
A Activity Increased
S Sleep Decreased (dont need sleep)
T Talkativeness/Pressured Speech
o Not caused by a medical condition or substances
o Psychotic features may be present (must be severe)
HYPOMANIA
o Abnormally/persistent elevated, expansive, irritable mood, at least 4 days
o DIGFAST (3 of the following or 4 of the following if mood is irritable)
o Unequivocal change in functioning uncharacteristic of the individual
o Not severe enough to impair in social/occupational or hospitalization
MAJOR DEPRESSIVE DISORDER Episode
o Depressed mood or Loss of interest/pleasure / Duration is > 2 weeks
o SIGECAPS (> 5 of the following): Sleep, Interests, Guilt, Energy, Concentration, Appetite , Psychomotor, Suicidal
o Causes impairment in social or occupational functioning
MIXED EPISODE = Manic Episode + Major Depressive Episode
GRIEF
o Emptiness, loss / Pain w/ positive emotions / Self-esteem preserved

o !
ADJUSTMENT DISORDER W/ DEPRESSED MOOD
o Emotional/behavioral symptoms in response to identifiable stressor
Stressor occurs within 3 months of symptom onset
Does not last longer than 6 months after stressor
o Low mood, tearfulness, hopelessness for Depressed Mood Specifier
o Includes at least 1 of the following:
Marked distress out of proportion to severity/intensity of stress
Impairment in social, occupational, etc. areas of functioning.

o Does not meet criteria for another disorder / Does not represent normal
o Most common dx (usually 50%) of hospital psychiatry consult
o Increased risk of suicide attempts & completed suicides.
MAJOR DEPRESSIVE DISORDER
o Meets criteria for at least 1 Major Depressive Episode
o Single: 1 episode / Recurrent: interval of at least 2 consecutive months
o Severity: Mild, Moderate, Severe
o Onset: Increases with puberty; usually in 20s
o Prevalence:
10-25% risk of MDD in women / 5-12% risk of MDD in men
Marked differences in gender groups (Females 1.5-3x higher)
18-29 year old age group is 3x than individuals > 60 yo age group
5-10% risk with single episode MDE developing mania
o Inheritance: If a family member has MDD, there is a 1.5 to 3 times higher likelihood of having MDD in their 1st degree biological
relatives

o !
PERSISTENT DEPRESSIVE DISORDER (Dysthymia or Dysthymic Disorder)
o Less severe, but long lasting form of depression, often unremitting
o Duration is > 2 yrs (> 1 yr in children) / > 2 of the following:
Poor appetite, Insomnia/hypersomnia, Low energy/fatigue
Low self-esteem, Poor concentration/difficulty making decisions
Feelings of hopelessness
o Significant distress or impairment in social, occupational, or other
o 75% of individuals with Dysthymia develop MDD within 5 years

o !
BIPOLAR I DISORDER
o Meets criteria for at least 1 manic episode
o MDEs, usually experienced, NOT necessary for Bipolar 1 Disorder Dx
o Rapid cycling > 4 episodeS/yr (major depresS, manic, or hypomanic)
o Remission: 2 months without sx of disturbance
o Onset: bimodal (18yr, 60yr)
o More common in high-income than low income countries
o Suicide Risk: 15 times greater than the general population

o !
BIPOLAR II DISORDER
o Meets criteria for at least one hypomanic episode AND at least one MDE
o There has NEVER been a Manic episode
o Presentation: usually present to physician in MDE
o Onset: mid-20s (later than Bipolar I, earlier than MDD)

o !
CYCLOTHYMIC DISORDER
o Less severe form of Bipolar II Disorder
o Numerous periods with hypomanic sx & depressive symptoms
Criteria for manic, hypomanic, or MDE have NEVER been met
o Duration is > 2 yrs (> 1 year in children)
o Significant impairment in social, occupational, or other
o 15-50% risk of developing Bipolar I or II Disorder

o !
SUIDICE
o Screen ALL patients: SADPERSONS
o S - Sex M > F
A Age Elderly > Younger
D Depression
P Previous attempts
E Ethanol (alcohol) abuse
R Rational thinking lost
S Social Support lacking
O Organized plan
N No spouse (widowed, divorced, separated)
S Sickness (Comorbid chronic medical illness)
TREATMENT
o Grief: None
o Adjustment Disorder: No meds, Hospitalize acute risks, Psychotherapy
o MDD / Persistent Depressive Disorder
Anti-depressant (SSRIs > SNRIs > NDRIs > a-antagonist, SARI, TCAs, MAOIs)
Augmentation Meds, Atypical anti-psychotics, Mood Stabilizers
Psychotherapy, ECT, TMS
o Bipolar I or II Disorder / Cyclothymic Disorder
Lithium > VA, Lamictal, Carbamazepine, Oxcarbamazepine
Anti-psychotics (usually 2nd generation)
Augmentation Meds, Atypical anti-psychotic, Psychotherapy, ECT
Anti-depressants CI in Bipolar Disorders ! could induce mania.
Only substance that doesnt induce mood disorder = marijuana
What class notoriously causes mood disorders = beta-blockers
Medical disorder that may cause manic state = thyroid
Tx catatonia = Ativan, ECT

PSYCHOTIC DISORDERS

SCHIZOPHRENIA
o 2+ of following during 1 month period:
Delusion, hallucination, disorganized, catatonic, negative symptoms (affective flattening, alogia, avolition)
o Social/occupational dysfunction
o Duration: Continuous signs of the disturbance persist for at least 6 months
o Onset: late teens mid-30s (onset for men early than women)
o High rates of comorbidity with substance disorders, especially nicotine
Affects blood level of antipsychotics
o Causes: infection (more born in winter/spring), prenatal exposure to influenza, environment (urban)
Biochemical Factors: NE, GABA, glutamate, Ach, nicotine, MHC
o Neural Circuits: prefrontal cortex, limbic system
+ symptoms: ant. cingulate basal ganglia thalamocortical circuit
symptoms: dorsolateral prefrontal circuit (usually less severe)
o Bleulers Sx: Association defect, Autism, Ambivalence, Affect disturbance
o Schneiderian Sx: Auditory hallucination, Delusional, Passive delusions, Alienation delusions
o Bipolar Type: if disturbance includes a Manic or a Mixed Episode
More in young adults

Depressive Type: if disturbance only includes Major Depressive Episode

More in older adults

BRIEF PSYCHOTIC DISORDER

o Pre-existing personality disorders may predispose patients
o Occurs more among younger patients
o Most frequently with low SES or experienced disasters or cultural changes
Precipitating stressors events w/ significant emotional distress
Dont confuse this with a typical cultural reaction
o Episode MUST resolve in 1 month cant diagnosis it until theyre better
o Half of those dx go on to develop chronic psychiatric syndromes

DELUSIONAL DISORDER
o Erotomanic Type: delusions that another person, usually of higher status, is in love with the individual
o Grandiose Type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person
o Jealous Type: delusions that the ones sexual partner is unfaithful (men)
o Persecutory Type: delusions that the person is being malevolently treated
o Somatic Type: delusions that one has some physical defect/medical issues
o Mixed Type: delusions characteristic of more than one of the above types
o Unspecified Type
o Possible causes: Hearing deficiency, severe psychosocial stressors, low SES
o Slight predominance in women

SHARED PSYCHOTIC DISORDER

o Delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established
delusion
o Also known as Folie a Deux
o Person with the original psychotic disorder = the inducer
o More common in women
o When left alone, the course is usually chronic
o Separation was thought to be curative in the past
Patients may require hospitalization or antipsychotics
o A psychosocial stressor may accompany onset

PSYCHOTIC DISORDER
o Prominent hallucinations or delusions
o Evidence that the disturbance is the direct physiological consequence of a general medical condition.
o Disturbance is not better accounted for by another mental disorder.
o Disturbance does not occur exclusively during the course of a delirium.
o Code based on predominant symptom:
o With Delusions: if delusions are the predominant symptom
o With Hallucinations: if hallucinations are the predominant symptom
o May be transient or reoccurring

SUBSTANCE-INDUCED PSYCHOTIC DISORDER

o Prominent hallucinations or delusions
Do not include hallucinations if person knows they are induced
o Sx during, or within a month of Substance Intoxication or Withdrawal
Or medication use is etiologically related to the disturbance
o Odd symptoms or odd age for symptoms

PSYCHOTIC DISORDER NOT OTHERWISE SPECIFIED

o Psychotic symptomatology (i.e., delusions, hallucinations, disorganized speech, grossly disorganized, catatonic) with inadequate info
to make a dx
o Examples include
Postpartum psychosis that does not meet criteria
Psychotic symptoms that have lasted for less than 1 month but that have not yet remitted
Persistent auditory hallucinations in absence of other features
Persistent nonbizarre delusions with periods of overlapping mood episodes
Psychotic Disorder is present, but is unable to determine whether it is primary, due to a general medical condition, or
substance

PHARMACOLOGY
o Typical Antipsychotics (Haldol, prolixin, thorazine)
High potency ! low anticholinergic & hypotensive; high EPS
Low potency ! high anticholinergic & hypotensive; low EPS
Risk of tardive dyskinesia, prolactin elevation
o Atypical Antipsychotics = first line
All have Black Box Warning with antipsychotics (risk of CV, infection, aspiration)
Clozapine (SE: agranulocytosis, low seizure threshold, drooling)
Risperidone (most dopamine blockade)

Greater risk of EPS, prolactin elevation, OH

Olanzapine (SE: weight gain, metabolic syndrome, diabetes)
Ziprasidone (SE: increase QT; favorable metabolic profile)
Quetiapine (least EPS, SE: sedation, OH, weight gain, metabolic)

Quetiapine XR
Aripiprazole (dopamine agonist/antagonist; SE: akathisia)
Paliperidone (active metabolite of Risperdal, time-release form)
Iloperidone (recently approved, efficacy w/ schizoprenia)
Asenapine (recently approved, similar to Zydis & Risperdal)

EPS ! dystonia, akathisia, Parkinsonian, dyskinesias

o Tx: anticholinergics
o Acute dystonia tx: IM anticholinergics
o Most at risk: young, muscular males

NMS ! lead pipe rigid, autonomic change, fever, renal fail, confusion, elevated CPK
o Can happen with any antipsychotic
o Tx: Dantrolene, Bromocriptine

TD ! risk: female, elderly, mood disorder, long use of antipsychotic

o Tx: Vitamin E

ANXIETY DISORDERS

ANXIETY DISORDERS
o Most develop in childhood, persist into adulthood if not treated
o NOT caused by substances/meds or other mental/medical conditions
o Impairment in social, academic, occupational, or other important areas
o Comorbid with other mental disorders
o Female: Male Ratio [2:1]

ADJUSTMENT DISORDER W/ ANXIETY

o Emotional/behavioral symptoms in response to an identifiable stressor
Nervousness, worry, jitteriness, or separation anxiety
o Stressor(s) occurs within 3 months of onset of symptoms
o Includes at least 1 of the following:
Marked distress is out of proportion to the severity of stressor
Significant impairment in social, occupational, or important areas
o Does not meet criteria for another anxiety disorder
o Does not last longer than 6 months after stressor

ACUTE STRESS DISORDER

o Duration of sx are < 1 month after exposure.
o Significant impairment in social, occupational, or important areas
o NOT caused by medical condition or substances.
o Similar criteria as PTSD except duration is < 1 month

PTSD
o
o
o
o
o
o

o
o

Duration of sx are > 1 month after exposure.

Causes significant impairment in social, occupational, or important areas
NOT caused by medical condition or substances.
Exposure to actual or threatened death, serious injury, or sexual violation either directly, by witnessing the event, learning that the
event occurred to a family/friend, or through experiencing repeated or extreme exposure
Note: This does NOT apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.
Intrusion (> 1)
Recurrent, involuntary, intrusive distressing memories

Child ! repetitive play with themes of events

Recurrent distressing dreams are related to event

Child ! frightening dream w/o recognizable content

Dissociative reactions (flashbacks) where the individual feels or acts as if the traumatic event is recurring

Complete loss of awareness can occur

Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues
Avoidance (> 1)
Avoid distressing memories, thoughts, feelings about event
Avoid external reminders that arouse distressing memories
Negative alterations in cognitions & Negative mood (> 2)
Inability to remember an important aspect of the traumatic event (dissociative amnesia)
Persistent & exaggerated negative beliefs or expectations
Blaming oneself for the event, persistent negative emotionals
Diminished interest or participation in activities
Feelings of detachment or estrangement from others

Persistent inability to experience positive emotion

Arousal (> 2)
Sleep disturbance
Irritable behavior / angry outbrusts with little or no provocation
Hypervigilance
Problems with concentration
Exaggerated startle response
Reckless or self-destructive behavior

SEPARATION ANXIETY DISORDER

o Development Inappropriate fear/anxiety concerning separation
o Duration: > 4 weeks in children & > 6 months in adults
o > 3 of the following sx:
Distress when anticipating or experiencing separation
Worry about losing attachment figures or about possible harm
Worry about experiencing untoward events (getting lost, kidnapped, having an accident, being ill) that causes separation
Reluctance or refusal to go out away from attachment figures
Fear about being alone or without attachment figures at home
Refuse to sleep away from home or go to sleep w/o being near
Repeated nightmare involving separation
Complaints of physical symptoms when separated

SELECTION MUTISM
o Consistent failure to speak in specific social situations where there is an expectation for speaking (school) despite speaking in other
situations
o Interferes educational/occupational achievement or social communition
o Duration is > 1 month
o Not due to lack of knowledge or comfort with the spoken language
o Not due to communication disorder or other childhood mental disorder

SPECIFIC PHOBIA
o Marked fear or anxiety about a specific object or situation
Children ! fear expressed via crying, tantrums, freezing, clinging
o The object or situation always:
Provokes immediate fear or anxiety
Is actively avoided
Provokes fear out of proportion to the actual danger
Provokes fear that is persistent (duration is > 6 mths)

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)

o Marked fear or anxiety about social situations where exposed to scrutiny
EX: conversations, meet unfamiliar people, observed eat/drink, performing in front of others (give a speech)
Performance Only Specifier: restricted to only speaking/perform
o Fear that they will be negatively evaluated ! rejection or offending others
o The social situation almost always:
Provokes immediate fear or anxiety
Is actively avoided
Provokes fear out of proportion to the social situation
Provokes fear that is persistent (duration is > 6 mths)

PANIC DISORDER
o Recurrent, unexpected panic attacks
o At least 1 attack has been followed by > 1 month of:
Concern about additional panic attacks or their consequences
Behaviors designed to avoid panic attacks
o Not caused by another mental disorder, a medical condition, or substances.
o Panic Attack: abrupt surge of intense fear/discomfort that reaches a peak within minutes, and during which > 4 of the following
symptoms occur
o Derealization: feelings of unreality
o Depersonalization: being detached from one self

AGORAPHOBIA
o Marked fear or anxiety about > 2 of the following situations:
Using public transportation (buses, trains, planes)
Being in open spaces (parking lots, marketplaces)
Being in enclosed places (shops, theaters)
Standing in line or being in a crowd
Being outside the home alone
o Fears or avoids the situations b/c of thoughts that escape might be difficult or help might not be available if panic-like symptoms occur
or other embarrassing symptoms (fear of falling or incontinence) occur.
o These situations

Always provoke fear or anxiety.

Actively avoided, require presence of a companion, intense fear.
The fear or anxiety
Is out of proportion to the actual danger
Is persistent, lasting > 6 months typically
Clinically significant distress in social & occupational functioning
Is excessive to any other medical condition that is present
Not better explained by mental disorder, condition, substances

GENERALIZED ANXIETY DISORDER

o Excessive anxiety & worry, > 6 months about a # of events or activities
o Individual finds it difficult to control the worry
o Associated with > 3 of the following:
Restlessness or feeling keyed up or on edge
Easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle Tension
Sleep Disturbance
o Cause significant distress in social or occupational functioning
o Not due to another mental disorder, a medical condition, or substances

OBSESSIVE-COMPULSIVE DISORDER
o Presence of obsessions, compulsions, or both.
o Obsessions:
Recurrent, persistent thoughts, urges, images that are intrusive.
Attempts to suppress with other thought or action (compulsion)
o Compulsions:
Repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the
person feels driven to perform in response to an obsession
Prevent/reduce anxiety or distress, or preventing some dreaded event; behaviors not connected in a realistic way with what
they are designed to neutralize or prevent, or are clearly excessive
Time consuming (> 1 hr /day) or cause clinically significant distress in social, occupational, or other areas of functioning.
Not due to mental disorder, a medical condition, or substances
o Treatment: Clomiprimine

TREATMENT
o Education
o Psychotherapy is the most effective treatment with less relapse
o Combo of psychotherapy + medication management is recommended
o 1st Line Medication Treatment
o SSRIs (see Mood Disorders Lecture for more information on SSRIs)
o Start at low doses for anxiety disorders.
o OCD patients often take longer (8-12 weeks) to respond to medications.
Often require higher doses, partial reduction is typical response
o Other Treatments
SNRIs
Benzodiazepines
1 Partial Agonists
Anti-histamines
o Only SSRI dont approved for depression = Fluvoxitine (for OCD)

DSMV EATING DISORDERS

ANOREXIA NERVOSA
o Morbid fear of fat, distortion of body image, unrelenting pursuit of thin
o Begins in adolescence (10-30yrs) ! go to extremes to lose weight
o Misperception of internal body cues Tend to think in terms of absolutes
o TYPES:
Binge Eating/Purging Type: alternate b/w fasting and binging; binges w/ vomiting, huge laxatives, diuretics, diet pills

Generally have Cluster B traits

Restricting Type- drastically cut caloric intake while engage in rigorous and incessant exercise beyond the point of
emaciation

Generally have Cluster C traits

o PSYCHIATRIC CO-MORBIDITY
66% = at least one mood disorder on presentation
60% = suffer from Major Depressive Disorder
Alcohol and amphetamines are commonly abused
33% = suffer from anxiety disorders

50% of anxiety disorders = OCD

80% = personality disorders

COMPLICATIONS:
Amenorrhea or oligomenorrhea
Premenarcheal ! short stature and delayed breast development
Osteoporosis
Vomit, constipation, cold, HA, polyuria, sleep disturbance
LABS:
Low ESR & fibrinogen
Low FSH and LH
Decreased GFR
Low estrogen
Hypercholesterolemia
Abnormal cortisol
Hypomagnesemia
Reduced T3
Hypophophatemia
High BUN/Creatinine
Anemia
Leukopenia
Thrombocytopenia
Can lead to DEATH (10-22%)
Self induced vomitting ! metabolic hypokalemic alkalosis
EKG- inverted T waves, ST depression, increased intervals
Refeeding edema complicates treatment ! leads to CHF
Sudden death may result from laxative and/or diuretic abuse
Starvation ! pneumonia, arrhythmia, CHF, renal failure, suicide

BULIMIA NERVOSA
o Episodic uncontrolled binge eating of lots of food over a short time
o Recurrent compensatory behaviors aimed at weight gain prevention
o Binges/compensatory behaviors occur at least once per week for 3 months
o Disturbance does not occur exclusive during episodes of anorexia nervosa
o Sx: Uncontrolled gorging in a short period of time
Unaware of hunger, do not stop when satiated
Binges end only when extreme nausea or abdominal pain severe, when interrupted, fall asleep, or induce vomitting
o PSYCHIATRIC CO-MORBIDITY
80% = affective disorders w/ major depression most common
60% = anxiety disorders (PTSD, panic disorder, social phobia)
22%-77% = personality disorders
Cluster B disorders are MC, but Cluster C is also seen
o COMPLICATIONS:
CV effects of fluid and electrolyte imbalances ! arrhythmias
Dental caries and erosion of tooth enamel is common
Benign enlargement of parotid and salivary glands
Cardiomyopathy from emetine poisoning from ipecac syrup
Bulimics are at increased risk for developing seizure disorders
o LABS:
Hypokalemia / Hypomagnesemia / acid-base unbalanced
Elevated serum amylase!!! (common board question)
EKG ! ST depression & U waves

PICA
o
o

Persistent (> one month) ingestion of nonnutritive substances inappropriate for developmental age and unacceptable as cultural
EX: toddlers eat paint chips, pregnant women eat starch/clay, severely MR eat feces, anxious adults who chew finger nails

RUMINATION DISORDER
o Rare syndrome of infancy in which swallowed food is repeatedly returned to mouth, pleasurably sucked/re-chewed, and swallowed
again
o It is not due to GERD or pyloric stenosis
o It does not occur exclusively during the course of another eating disorder

PERSONALITY DISORDERS

Personality: stable & enduring set of characteristic behavioral & emotional traits
Freudian Tradition: Psychoanalysis
o Structural (Id, Ego, Superego)
o Topographic (unconscious, preconscious, conscious)
o Model of Personality
Grand Theories: Psychodynamic
o Unconscious forces strongly influence behavior
o Internal conflict plays a key role in personality disorder
o Early childhood experiences influence adult personality
Defense Mechanisms:
o Rationalization: creating a false but plausible explanation

o Repression: burying thoughts in unconscious

o Projection: attributing ones thoughts/motives to another
o Displacement: diverting emotions to a safe target
o Reaction Formation: behaving the opposite to feelings of anxiety
o Regression: reversion to childlike behavior
o Identification: shore up self esteem by becoming-like another
o Denial: refusal to acknowledge an obvious unpleasant reality
o Sublimation: channeling energy into a positive/creative outcome
Dimensional Factors
o Neuroticism: expression of negative emotions
o Extraversion: interest in interacting with other people
o Openness: willingness to consider and explore
o Agreeableness: willingness to cooperate and empathize with others
o Conscientiousness: persistent pursuit of goals, organization, dependability

PERSONALITY DISORDER
o Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals culture; 2+ of
these:
Affectivity
Interpersonal functioning
Impulse control
o Pattern is inflexible and pervasive across personal and social situations
o Pattern leads to clinically significant distress or impairment in functioning
o Pattern is stable and of long duration, back at least to adolescence
o Pattern is not better explained as another mental disorder.
o Pattern is not due to substance or another medical condition
o Epidemiology:
10-20% of general population ! Start during adolescence/early
Antisocial PD is the only PD that has an age requirement, 18 yrs
Antisocial is more common in men
Borderline, avoidant, and dependent more common in women
Prevalence about equal across sexes in schizoid, schizotypal, and obsessive-compulsive disorder

CLUSTER A: ODD & ECCENTRIC (WEIRD)

o PARANOID: pervasive distrust/suspiciousness, motives are interpreted as malevolent, beginning by early adult and present in many
contexts, 4+ of:
SUSPECT

Spouse fidelity suspected

Unforgiving (bears grudges)

Suspicious of others

Perceives attacks (and reacts quickly)

Enemy or friend (suspects associated and friends)

Confiding in others feared

Threats perceived in benign events

Tx: unlikely to initiate or establish trust in treatment
o

SCHIZOID: Detach from social relationships, restricted range of emotions

DISTANT

Detached (or flattened affect)

Indifferent to criticism and praise

Sexual experiences of little interest

Tasks (activities) done solitarily

Absence of close friends

Neither desires nor enjoys close relations

Takes pleasure in few activities

Tx: meds not helpful unless depressed

SCHIZOTYPAL PERSONALITY: pervasive pattern of interpersonal deficits and acute discomfort with relationships
ME PECULIAR

Magical thinking or odd beliefs

Experiences unusual perceptions

Paranoid ideation

Eccentric behavior or appearance

Constricted (or inappropriate) affect

Unusual (odd) thinking and speech

Lacks close friends

Ideas of reference

Anxiety in social situations

Rule out psychotic disorders

Contact w/ reality maintained, highly personalized/superstitious
Tx: low-dose antipsychotic agents (atypicals) for paranoia

CLUSTER B: ERRATIC, DRAMATIC, EMOTIONAL (WILD)

o ANTISOCIAL: Before 15, repeatedly violate rules, societal norms or rights
After 15, shown disregard for rights of others in many situations
CORRUPT

Conformity to law lacking

Obligations ignored

Reckless disregard for safety of self or others

Remorse lacking

Underhanded (deceitful, lies, cons others)

Planning insufficient (impulsive)

Temper (irritable and aggressive)

Biological Influence: Limbic system dysfunction, Left temporal lobe damage, Role of testosterone
Under-arousal Hypothesis: Low Cortical Arousal
Biological Influences: Low serotonin

Low 5HT in aggressive children predicts more severe aggression two years later

Found in ASPD and repeat violent offenders

o

BORDERLINE: by early adult life, unstable impulse control, interpersonal relationships, moods and self image
Potentially self damaging impulsiveness in at least 2 areas:

Eating, reckless driving, sex, spending, substances

A.M. SUICIDE

Abandonment

Mood instability (marked reactivity of mood)

Suicidal (or selfmutilating) behavior

Unstable and intense relationships

Impulsivity (in two potentially selfdamaging areas)

Control of anger

Identity disturbance

Dissociative (paranoid) sx that are transient/stress

Emptiness (chronic feelings of)

Mostly women or parasuicidal
Tx: antidepressants for mood stabilization (lithium, CBZ, SSRI)

Dialectical behavior therapy

HISTRIONIC: pervasive pattern of excessive emotional/attention seeking; self-centered, vain, over-concerned about approval
PRAISE ME

Provocative (or sexually seductive) behavior

Relationships (considered more intimate than they are)

Attention (uncomfortable when not center of attention)

Influenced easily

Style of speech (impressionistic, lacks detail)

Emotions (rapidly shifting and shallow)

Made up (physical appearance draw attention to self)

Emotions exaggerated (theatrical)

Tx: reassure but avoid rescue, avoid boundary violations

NARCISSISTIC: by early adult life, grandiosity (fantasized or actual), lack of empathy and need for admiration
SPECIAL

Special (believes he or she is special and unique)

Preoccupied with fantasies (success, power, brilliance)

Envious (of others or that others are envious of him)

Entitlement

Excess admiration required

Conceited (grandiose sense of self importance)

Interpersonal exploitation

Arrogant

Lacks empathy

CLUSTER C: ANXIOUS OR FEARFUL

o AVOIDANT: early adult life, social inhibition, hypersensitivity to criticism and feelings of inadequacy are present in a variety of
situations
CRINGES

Certainty (of being liked before getting involved)

Rejection (or criticism) preoccupies ones thoughts

Intimate relationships (fear of being shamed)

New interpersonal relationships (is inhibited in)

Gets around occupational activity

Embarrassment (potential) prevents new activity

Self viewed (as unappealing, inept, or inferior)

Tx: systemic desensitization, behavioral rehearsal

DEPENDENT: extreme dependence on others lead to submission/clinging

RELIANCE

Reassurance (required for decisions)

Expressing disagreement difficult (fear of lost support)

Life responsibilities

Initiating projects difficult (lack of self-confidence)

Alone (feels helplessness and discomfort when alone)

Nurturance (goes to excessive length to obtain support)

Companionship sought urgently when close other ends

Exaggerated fears of being left to care for self

OBSESSIVE COMPULSIVE: pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal
control, at the expense of flexibility, openness, and efficiency
LAW FIRMS

Loses point of activity (preoccupation with detail)

Ability to complete tasks (compromised by perfection)

Worthless objects (unable to discard)

Friendships excluded (due to preoccupation with work)

Inflexible, over conscientious (ethics, value, or morality)

Reluctant to delegate (unless other submit to guideline)

Miserly (toward self and others)

Stubbornness (and rigidity)

SOMATIC DISORDERS

SOMATIC SYMPTOM & RELATED DISORDERS

o Physical symptoms and signs which suggest a general medical condition but are not explained by a general medical condition, direct
effects of a substance, or by another mental disorder
o Most frequently encountered in primary care
o Can accompany diagnosed medical disorders
o Mental disorders may initially manifest with somatic symptoms

SOMATIC SYMPTOMS DISORDER

o 1+ somatic sx that are distressing or result in significant disruption of life
o Excessive thoughts, feelings, or behaviors related to somatic symptoms or associated health concerns, 1+ of following:
Disproportionate/persistent thoughts about seriousness of sx
Persistently high level of anxiety about symptoms
Excessive time and energy devoted to these symptoms
o State of being symptomatic is persistent (more than 6 months)
o Prevalence: is 5%-7% | Females > Males
o Risks: neuroticism, older age, uneducated, lower socioeconomic status
o Many report childhood abuse
o High overlap in anxious and depressed

ILLNESS ANXIETY DISORDER

o Preoccupation with having an illness
o Somatic symptoms are absent and the preoccupation is excessive
o High level of anxiety about health
o Individuals repeatedly check the body for signs of illness or avoids doctor
o Preoccupation has been present for at least 6 months
o Illness-related preoccupation not better explain by other mental disorder
o
Hypochondriac ! care-seeking type vs care-avoidant type
o Prevalence: is 1.3%-10%; Females=Males
o Childhood abuse is common
o Elevated risk for somatic symptom or personality disorder

CONVERSION DISORDER
o One or more symptoms of altered motor or sensory function
o Findings incompatible b/w symptoms & neurological/medical condition
o Deficits are not better explained by medical or mental disorder
o Symptoms cause significant distress
o TYPES:
With weakness or paralysis
With abnormal movements
With swallowing symptoms
With speech symptoms
With attacks or seizures

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o
o
o
o
o

With sensory loss

With mixed symptoms
Acute episodes last less than 6 months
Persistent episodes involve symptoms occurring for 6+ months
Onset: associated with a trauma or stressor
Prevalence: 5% of neurological referrals, 2-3x more common in females
Risks: Actual neurological disease
Maladaptive personality traits, hildhood abuse, anxiety, somatic symptoms, La belle indifference, and depressive disorders are
common

PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL CONDITIONS

o Medical symptoms or conditions are present
o Psychological factors adversely affect the medical condition in 1+ ways:
Influence the course of condition (exacerbation or recovery)
Interfere with the treatment such as adherence
Constitute additional risks for the individual
Influence underlying pathophys, precipitating or exacerbating sxs
o Psychological/behavioral factors not better explained by another disorder
o Prevalence: unclear, more common in Somatic Symptom Disorder
o Affect course of many diseases

FACTITIOUS DISORDER
o Disorder may be imposed on self or upon another
Falsification of signs or symptoms
Individuals present themselves or others as ill
Deception is evident with absence of external reward
Not better explained by another disorder
o Episodes can be single or recurrent
o Perpetrator receives the diagnosis if imposed upon another
o Prevalence: 1% of hospitalized pts meet criteria; single episode uncommon
o Induction of injury must be associated with deception
o EX: Adding blood to urine samples
Unwarranted injection of insulin
Ingestion of warfarin to alter lab data
Injection of fecal material to produce an abscess or induce sepsis
Heating thermometer in order to appear feverish

OTHER SPECIFIED SOMATIC SYMPTOM & RELATED DISORDERS

o Brief Somatic Symptom Disorder (<6 mos)
o Brief Illness Anxiety Disorder (<6 mos)
o Illness Anxiety Disorder without Excessive Health-Related Behaviors (Criterion D absent)
o Pseudocyesis: false belief of being pregnant associated w/ signs and sxs

UNSPECIFIED SOMATIC SYMPTOM & RELATED DISORDER

o Applies to presentations with characteristics of aforementioned disorders and should not be used unless there are decidedly unusual
situations where there is insufficient information to make a more specific diagnosis

MALINGERING
o Intentional production of symptoms motivated by external incentives
o Should be suspected if: medicolegal context, marked discrepancy between claimed stress/disability and objective findings, lack of
cooperation during diagnostic evaluation and in compliance, or presence of ASPD