Clinical Psychiatric Disorders

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DSM- IV Overview
Axis I: Clinical (Psychiatric) Disorders Axis II: Mental Retardation & Personality Disorders Cluster A Paranoid, Schizoid, Schizotypal Cluster B Antisocial, Borderline, Histrionic, Narcissistic Cluster C Avoidant, Dependent, Obsessive-Compulsive Axis III: Gen med conditions (may or may not be related to the mental disorder) Axis IV: Psychosocial and Environmental Stressors (not nec a focus of clinical attn) Axis V: Global Assessment of Functioning (0 to 100, 100 being the best)

Axis I: Clinical Disorders

(most of psychiatry is here)
Page 1 2 Disorders usu. 1st diagnosed in infancy, childhood, or adolescence Delirium Dementia Amnesic disorders Other cognitive disorders Schizophrenia Other psychotic disorders Mood Disorders Anxiety Disorders Need to know detailed criteria for the following: - Learning disorders - Pervasive developmental disorders - Attention & disruptive behavior disorders For each disorder in this section, the etiology is either: - General medical condition - Substance - Both - Schizophrenia - Delusional Disorder - Major depressive disorder - Bipolar I disorder - Bipolar II disorder - OCD - PTSD - Generalized Anxiety Disorder - Specific phobia - Social phobia - Somatization disorder - Hypochondriasis - Conversion disorder - Body Dysmorphic disorder (dysmorphophobia) - Pain disorder Sexual Dysfunctions (desire, arousal, orgasm, pain) Paraphilias Bulimia Nervosa Kleptomania (Subtype) with depressed mood

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Somatoform Disorders

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Factitious Disorders Dissociative Disorders Sexual & Gender Disorders Eating Disorders Sleep Disorders Impulse-Control Disorders NOC Adjustment Disorders

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Clinical Psychiatric Disorders

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Disorders usu. diagnosed in infancy, childhood, or adolescence

Learning Disorders o Achievement is substantially below what is expected for that age, schooling, and intelligence AND learning probs significantly interfere w/ academic achievement or activities of daily living o Can be Reading Disorders, Mathematic Disorders, Disorders of Written Expression, or LDs NOS

Pervasive Developmental Disorders o Autism o Qualitative impairments in social interaction Qualitative impairments in communication Restricted, repetitive, stereotypes pattern of behaviors & interests Onset: before age 3 NOT Retts or CDD

Aspergers Syndrome

Qualitative impairments in social interaction No communication problems Disturbance causes sig impairment in social, occupational, or other areas of FCN No sig general delays in language No sig delays in cognitive development, self-help, or curiosity about the environment Onset: later than autism onset Usually males!!

Retts Syndrome NOTE: Normal development up to 5-8 months! Onset: after 5-8 month period Slower head growth Loss of purposeful use of hands they wring their hands a lot!! Loss of social interaction

Clinical Psychiatric Disorders o Poorly coordinated gait or trunk movements Severely impaired languages!

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Usually females!! Severe or profound mental retardation

Childhood Disintegrative Disorder(CDD)

Normal development ~ 2 yrs Loss of previously acquired skills before age 10 (like lang, social skills, motor skills, bowel & bladder control) Usually males Severe mental retardation Usual ONSET ~ 3-4 yrs

Attention and Disruptive Behavior Disorders o Attention Deficit Hyperactivity Disorder (ADHD) [ Symptoms of inattention OR symptoms of hyperactivity-impulsivity ] AND present before 7 yo AND apparent in 2+ settings AND impairment in social, academic, or occupational functions. Note that ADHD doesnt exclude presence of other mental disorders Types of ADHD o Combined Inattentive Hyperactivity-Impulsive

Conduct Disorder Mild, moderate, or severe Basic rights of others and societal norms are violated AND significant impairments in social, academic, or occupational function AND (if the person is 18+ yo) the person does NOT have Antisocial Personality Disorder Has a childhood onset before age 10 and an adolescent onset after age 10!!

Oppositional Defiant Disorder Behavior is that negative, hostile, and defiant (Note that it doesnt grossly violate social norms) Onset usu. Before 8 yo

Clinical Psychiatric Disorders A lot of these cases progress to become conduct disorders

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Motor Skills Disorders Communication Disorders Feeding & Eating Disorders (Infancy or Early Childhood) Tic Disorders Elimination Disorders

Delirium, Dementia, Amnesic Disorders, & Other Cognitive Disorders

Cognitive Disorders: problems in memory, orientation, level of consciousness, & other cog FCNs - Abnormalities in neural chemistry or physiology (primary) or may be secondary to systemic illness - May show psychiatric problems (e.g., depression, anxiety), secondary to cog problems - * NOTE that for each disorder in this section, possible etiologies may include general med condition or substance-induced illness Delirium: - Hallmark: Impaired consciousness - Etiology: Can be *, multiple, or NOS - Develops quickly - Rapid shifts of emotion - Hallucinations, illusions possible Dementia - Hallmark: Memory impairment PLUS 1+ of the following o Apraxia (cant perform complex acts) o Aphasia (loss of lang) o Agnosia (loss of recognition, perception) o Loss of exec FCNing - Etiology: Can be *, multiple - Classifications o Dementia of the Alzheimers Type (DAT) dx post-mortem only Amyloid plaques (extracell) and neurofibrillary tangles (intracell) There are supportive treatments of DAT Maintaining familiar situations Maintenance of social environment Advance care directives o Vascular Dementia Multiple infarction Need step-wise course to treat vascular prob o Dementia of Depression (Pseudo-Dementia) occurs esp in the elderly! Really due to depression (e.g., spousal loss) or isolation Cognitive opportunities/ demands loss of secondary process thinking , (regression) VERY treatable!

Clinical Psychiatric Disorders Dementia Dementia of the Alzheimers Type (DAT) Slow onset Attempt to cover deficit - Denial - Confabulation - Humor (e.g., Who cares?) Try to answer Qs Supportive care Dementia of Depression (Pseudo-Dementia) Rapid onset Patient will emphasize deficits

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Respond I dont know Anti-depressants and/ or social situation

Amnesic Disorders - Hallmark: Memory impairment, absent or other significant cog impairments Other Cognitive Disorders - Etiology: Can be *, multiple, or NOS Mild Cognitive Impairment (MCI) - Early transitional condition: cog impairments beyond normal but Is NOT dementia - Daily activities not impaired - Self-reported complaint of memory o Memory performance will be 1.5 SDs below normal - Ask: What they had for breakfast that morning; how they got to the office

Schizophrenia & Other Psychotic Disorders

Schizophrenia: chronic, debilitating mental disorder characterized by: o Period of loss of touch with reality (psychosis) o Persistent disturbances of thoughts, behavior, appearance, and speech o Abnormal affect o Social withdrawal - Peak onset age: Men 15-25 yo and Women 25-35 - NOTE: PT has intact memory capacity, is oriented x 3, and has intact consciousness - Positive symptoms: hallucination, delusions, agitation, talkativeness - Negative symptoms: Lack of motivation, social withdrawal, flat affect, cognitive disturbances, poor speech content - 3 Phases: Prodromal Psychotic Residual - Dx: 6+ months of disturbance with 1+ months of active symptoms of the following: o Delusions o Hallucinations o Disorganized speech o Grossly disorganized or catatonic behavior - Subtypes o Paranoid o Disorganized o Catatonic o Undifferentiated o Residual

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Other Psychotic Disorders: all of these, at some point, are characterized by loss of touch with reality BUT they do not include all of the criteria required for schizophrenia dx Schizophreniform Disorder: same symptoms as Schizophrenia expect that its duration is < 6 months and there is no decline in FCNing Schizoaffective Disorder: mood episode and active-phase symptoms occurring together preceded by or follows 2+ weeks of delusions or hallucinations without mood symptoms Delusional Disorder: 1+ months of non-bizarre delusions WITHOUT other active symptoms of Schizophrenia Brief Psychotic Disorder: psychiatric disorder lasting longer than 1 day but less than 1 month Shared Psychotic Disorder: disturbance that developed in a person due to the influence of someone else with a similar delusional problem Psychosis due to gen med Psychosis due to substance use

Mood Disorders
Major depressive disorder - Recurrent depressive episodes, with each episode lasting 2+ weeks - Episodes are depressed mood or loss of interest, plus 4+ symptoms of SIGECAPS Bipolar I disorder - 1+ Episodes of mania & depression, each Bipolar II disorder - 1+ episodes of hypomania & depression, each Symptoms of Depression SIGECAPS Symptoms of Mania Feelings of grandiosity Irritability and impulsiveness Disinhibition Distractibility Racing thoughts Impaired judgments Delusions (re: grandiosity)

Dysthymia: 2+ years of depressed mood for more days than not - Relative to Major Depressive Disorder, this is less severe, non-episodic, chronic, and not in the least bit psychotic Cyclothymic: 2+ years of alternating periods of hypomania and dysthymia - Relative to Bipolar Disorder, this is less severe, non-episodic, chronic, and not in the least bit psychotic Seasonal Affective Disorder: a subtype of major depressive disorder associated with the short days of winter seasons Mood Disorder due to gen med condition

Clinical Psychiatric Disorders

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Mood Disorder due to substance use

Anxiety Disorders
Anxiety Disorders: person is frightened BUT the source of the danger isnt known, recognized, or it is inadequate to account for the symptoms - Physiological occurrence (think: symp ns) o Palpitation o Shakiness & seating o Tingling in extremities o Dizziness and syncope o GI and urinary disturbances o Mydriasis (pupil dilation) - NTs involved: GABA serotonin NE - Treatment 1. Anti-anxiety drugs e.g., benzodiazepines, blockers 2. Anti-depressants e.g., SSRIs 3. Psychological treatment - Classifications o Agoraphobia: anxiety of/ avoidance of places or situations where escape might be difficult (commonly referred to as fear of public places) o Panic Disorder1 2 w/o Agoraphobia o Panic Disorder w/ Agoraphobia o Agoraphobia w/o hx of Panic Disorder o o o Specific Phobia: irrational fear of certain things (e.g., elevators, snakes) Social Phobia (i.e., Social Anxiety Disorder): exaggerated fear of embarrassment in social situation (e.g., public speaking) Obsessive-Compulsive Disorder (OCD): Recurring, intrusive feelings, thoughts, and images that cause anxiety This anxiety is relieved by performing repetitive actions (compulsions) Common: fear of hand contamination; repeated checking of locked doors; counting objects PPL are usually aware that they are thinking and behaving irrationally Genetic factors involved Post-Traumatic Stress Disorder (PTSD)

A panic attack is a discrete period in which there is a sudden onset of intense apprehension, fearfulness, terror, & feelings of impending doom. Physiological symptoms SOB, palpitations, chest pain, choking or smothering sensations, fear of going crazy. 2 A panic disorder is characterized by recurrent panic attacks
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Symptoms occur usually after a catastrophic event affecting the PT or the PTs loved one(s) 4 subtypes of symptoms 1. Re-experiencing 2. Hyperarousal (e.g., startle response) 3. Emotional numbing (e.g., difficulty connecting w/ other ppl) 4. Avoidance (e.g., survivors guilt, social withdrawal, dissociation) Symptoms last 1+ months, and may have delayed onset (after the traumatic event) Acute Stress: same as PTSD, expect that the symptoms last more than 2 days but less than 4 weeks Generalized Anxiety: hyperarousal and worrying lasting 6+ months GI symptoms are common Onset: 20s Anxiety Disorder due to gen med condition Anxiety Disorder due to substance use Anxiety Disorder NOS

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Somatoform Disorders
Somatoform Disorders (General): physical symptoms without sufficiency organic cause ppl truly believe they are ill (DIFFERENT from those with Factitious Disorders or Malingering) o More common in women than in men o More important differential dx: Unidentified organic cause o MUST exclude: Factitious Disorder, Malingering, and Masked Depression! Classifications o Somatization (is polysymptomatic) Chronic hx of 2+ GI symptoms, 4 pain symptoms, 1 sexual symptom, 1 pseudo-neurological symptom Onset before 30 yo o Hypochondriasis Exaggerated concern w/ health and illness for 6+ months Goes doctor shopping ~ middle and old age Conversion Disorder: sudden dramatic loss of sensory or motor FCN, often associated with a stressful life event More common in unsophisticated adolescents and young adults PTs appear unworried Body Dysmorphic Disorder (Dysmorphophobia): excessive focus on minor or imagined physical defect Symptoms are NOT due to AN

Clinical Psychiatric Disorders o Onset: late teens

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Pain Disorder: acute or chronic pain not explained by physical disease Onset: 30s and 40s

Factitious Disorders
Factitious Disorder: person feigns mental or physical illness and in some cases, they induce physical illness o Different from Somatoform Disorders, in which ppl truly believe they are ill o Sometimes these ppl have worked in the medical field. At the very least, they know how to simulate illness o Note: Malingering psychiatric disorder Examples of feigned symptoms: abdominal pain, fever, hematuria, skin lesions, seizures Classifications o Factitious Disorder (formerly known as Munchausen) o Factitious Disorder by Proxy: illness is stimulated in other person, usually a child a form of child abuse! Must report! Malingering: conscious (thus not a psychiatric disorder) simulation of illness for financial or obvious gain!

Dissociative Disorders
Abrupt but temporal loss of memory (amnesia) or identity OR by feelings of detachment owing to psychological factor Usually related to disturbing emotional experiences in the PTs remote or recent past
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Classification Dissociative Amnesia

Dissociative Fugue Dissociative Identity Disorder (formerly known as Multiple Personality Disorder) Depersonalization Disorder

Characteristics Failure to important info about oneself Amnesia usually resolved in min or days, but may last years Amnesia + sudden wandering from home Adoption of a different ID 2+ personalities/ alters in a person More common in women Must exclude malingering and alcohol abuse Recurrent, persistent feelings of detachment from ones own body, the social situation, or the environmental (derealization)

Sexual & Gender Dysfunctions

Sexual dysfunctions: characterized by disturbance in sexual desire & in psychophysiological that characterize the sexual response cycle & cause distress and interpersonal difficulty Causes: biological, psychological, or interpersonal Classifications:

Clinical Psychiatric Disorders o o o o Desire (e.g., aversion, libido) Arousal (e.g., erectile dysfunction) Orgasm (e.g., rapid ejaculation) Dyspareunia (sexual pain) (e.g., vaginismus)

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Paraphilias: involve preferential use of unusual objects of sexual desire or engagement in unusual sexual activity o Exhibitionism o Fetishism o Necrophilia o Pedophilia most common paraphilia o Voyeurism Gender Identity Disorders: strong & persistent cross-gender identification + persistent discomfort with ones assigned sex

Eating Disorders
Bulimia Nervosa (BN): a major category of eating disorder o Etiology is unspecific: any of the 5 vertices of the ISM pentagram (biological, behavioral, sociocultural, cognitive, environmental) o Women at higher risk for eating disorders than men; more common in higher socioeconomic groups, and in the US o Commonly present @ older sage and have little, if any, weight loos o Feel hunger & urge to binge o Compensation either with dieting or excessive exercise (BN non-purging type) OR purging (BN-purging type) Purging: use of laxatives, diuretics, self-induced vomiting Different from Anorexia Nervosa (AN) o PTs may be normal weight or slightly over- or under-, while those with AN have body weight < 85% of norm o AN PTs: downregulation of the sympathetic ns so will have symptoms: emaciation, skin and hair , dry mucous membranes, hypotension, bradycardia, hypothermia o But people with AN or BN of the purging type will have electrolyte imbalances o People with AN will have amenorrhea of 3+ months, while those with BN may or may not present with menstrual irregularities

Sleep Disorders
Primary sleep disorders mean that the sleep disorder is not caused by (1) another mental disorder, (2) general med condition, (3) substance use Primary sleep disorders endogenous abnormalities o Dyssomnia (problems in timing, quality, or amount of sleep) e.g., insomnia, sleep apnea, narcolepsy o Parasomnia (problems in physiology or behavior associated with sleep) e.g., sleepwalking, sleep terror, nightmare disorders

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Impulse-Control Disorders NOC

Kleptomania - Recurrent failure to control the impulse to steal something the person does not need and easily could purchase. - Tension mounts before the act, and it is released while committing the act. Person will experience pleasure, gratification, or relief - Women have Kleptomania more often than men - Reinforcement: Tension is released upon stealing

Adjustment Disorders
Adjustment Disorders (DEF): short-term emotional or behavioral reactions to stressful life events Symptoms appear < 3 months (and last for < 6 mo) after precipitating stressor(s) and are severe enough to warrant clinical attn Stressors for adolescents: school problems, parental divorce, parental rejection, parental substance abuse Stressors for adults: marital difficulties, divorce, work, financial problems 3 factors contributing to development of adjustment disorder: 1. Precipitating stressor 2. Context & meaning of stressor 3. Predisposing vulnerabilities (due to past life experiences) Adjustment Disorders have 6 subtypes 1. With depressed mood: predominant symptoms are depressed mood, tearfulness, or hopelessness

2. 3. 4. 5. 6.

With anxiety With mixed depressed mood + anxiety With disturbance of conduct With mixed disturbance of conduct + emotion NOS