SAZON, MARVA THERYSSE A.

PSYCH 136 – ABNORMAL PSYCHOLOGY

BS PSYCHOLOGY FINALS

1: SCHIZOPRHENIA SPECTRUM DISORDER

Symptoms and Diagnosis

 Five Domains of Symptoms:
 4 Types of Positive Symptoms:
1. Delusions
2. Hallucinations
3. Distorted thoughts (speech)
4. Disorganized or abnormal motor behavior
 Negative Symptoms

Schizophrenia
 A complex disorder with psychosis as its core diagnostic symptom.

Schizophrenia Spectrum
 Set of psychotic disorders that share similarities with Schizophrenia but are not as severe of persistent.

Positive Symptoms
1. Delusions
 Are ideas that an individual believes are true but are highly unlikely and often impossible.
 Types:
 Persecutory delusions
 Delusion of reference
 Somatic delusions
 Grandiose delusions
 Delusions of being controlled
2. Hallucinations
 Unreal perceptual experiences which tend to be more frequent, persistent, complex, and sometimes more bizarre and
often entwined with delusions.
 Types:
 Auditory hallucination
 Visual hallucination
 Tactile hallucination
 Somatic hallucination
 Asian culture: Common hallucinatory experience is ghost.
 Puerto Rican: Images of saints and virgins in the house, and images of Jesus.
3. Disorganized Thought and Speech
 Loose association or Derailment ─ Seemingly unrelated topic with little coherent transition.
 Word Salad ─ Totally incoherent.
 Neologism ─ The person may make up words that mean something only to him or her.
 Clangs ─ Make association of words based on sounds.
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 4. Disorganized or Catatonic Behavior
 Display unpredictable and apparently untriggered agitation, shouting, swearing, and pacing rapidly.
 This may occur as a response to hallucinations or delusions.
 Catatonia ─ Disorganized behavior that reflects unresponsiveness to the environment
 Negativism ─ Showing rigid and inappropriate posture to complete lack of response.

Negative Symptoms
 Restricted Affect ─ Severe reduction or absence of emotional response/expression.
 They may avoid contact.
 Avolition ─ Inability to initiate or persist common, goal-oriented activities. The person is unmotivated and physically slowed
down.
 Asociality ─ The lack of desire to interact with others.
 Makes recovery difficult.

Cognitive Deficits
 Basic cognitive functions: Attention, Memory, and Processing Speed.

Phases
 Prodromal Symptom
 Before the acute or active phase.
 Predominantly negative symptoms.
 Residual Symptom
 After the acute phase, they may be withdrawn and uninterested in others.

Prognosis
 Life expectancy is shorter by 10 years.
 It’s the most severe and debilitating mental disorder.
 10 to 15% commits suicide.
 Research shows 41% of these cases had complete recovery lasting for 1 year.

Gender and Age Factor

 Women had good prognosis than men.
 Women are hospitalized less often and for briefer period.
 Women show milder negative symptoms.
 They have better prior histories than men.
 Onset in women: Late 20s
Onset in men: Late teens
 Estrogen: Affects the regulation of dopamine favoring/protecting women.
 Prenatal brain development is slower in men.
 Generally, Schizophrenia improve with age.

Sociocultural Factors
 In underdeveloped countries, Schizophrenia is less debilitating because of social environment which facilitates adaptation an d
recovery.
 They also have broader and closer family systems surrounding the client.
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  Less hostility and criticism in underdeveloped countries.
 Developed countries resort to putting the client in mental seclusion.

Other Psychotic Disorders

1. Brief Psychotic Disorder
 Same criteria for Schizophrenia except that the duration would only last for less than a month.
2. Schizophreniform
 Symptoms typical of Schizophrenia but the duration is more than 1 month but less than 6 months.
3. Schizoaffective Disorder
 Symptoms of Schizophrenia are present but with major depressive/manic symptoms.
4. Delusional Disorder
 With delusions but does not meet the criteria for Schizophrenia.
5. Substance Induced Psychosis
 Symptoms are due to psychoactive substances.
6. Schizotypal Affective Personality Disorder
 Involves moderate symptoms resembling those of Schizophrenia but with a retained grasp on reality.

Biological Theories
 Genetic transmission.
 Structural and functional abnormalities in specific areas of the brain.
 History of birth complications or prenatal exposure to viruses which affect brain development.
 Neurotransmitter Theories: Excess level of dopamine, serotonin, GABA, and glutamate.

A. Structural Abnormalities
 Gross reduction in the gray matter in the cortex.
 Abnormal activity in prefrontal area (language, emotion, and expression). This is also connected to the limbic system
responsible for cognition and emotion, and to basal ganglia involved in motor movement; thus, the symptoms.
 Abnormal hippocampus responsible for information stored in the memory.
 Enlarged ventricles – Atrophy and deterioration in other brain tissue; they are less responsive to medication.

B. Birth Complications
 Perinatal hypoxia.
 History of obstetrical difficulties.
 Prenatal viral infection: Influenza, especially those exposed on the 2nd trimester.
 Those exposed to herpes simplex virus.
 Adoption Studies
 Increases the risk of Schizophrenia due to stressful environment; exposure to illogical thought, mood swings, and chaotic
behavior.

C. Neurotransmitters
 Dopamine Theory
 Supported by neuroleptics.
 Drugs that increase dopamine (amphetamines).
 Neuroimaging Studies: More dopamine in areas of the brain.

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  Different types of dopamine receptors and different levels in the various areas of the brain are accountable for the
symptoms of Schizophrenia.
 Serotonin neurons regulate dopamine neurons in the mesolimbic system.
 Interaction plays an important role in Schizophrenia.
 Abnormal levels of GABA and glutamate neurotransmitters.
 This contributed to the cognitive and emotional symptoms.

Psychosocial Perspectives
 Social Drift and Urban Birth
 Chronically stressful circumstances.
 Symptoms interfere with the person’s ability to complete education and hold a job.
 Urban birth – Overcrowding that exposes the mother to infectious disease (Flu, Herpes, Measles, etc.) .
 Stress and Relapse
 This does not cause Schizophrenia but triggers episode for people with disorder.
 Negative life events precede relapse (break up, loss of job, etc.) – social withdrawal.
 Psychodynamics theory
 Blames the Schizophrenogenic mother: Overprotective/rejecting moms.
 Communicating conflicting messages = Child cannot trust feelings or perception thus develops distorted views about self.
 Expressed Emotions
 Low warmth and high criticism.
 This creates stress for persons with Schizophrenia that overwhelms their ability to cope thus triggers episodes of psychosis.

Treatment
 Biological Treatment
 Insulin Coma Therapy
 Electroconvulsive Therapy
 Psychopharmacology
A. Typical Antipsychotics
• Dopamine Antagonists – Target the positive signs of Schizophrenia i.e. delusions, hallucinations, disturbed thinking,
and other psychotic symptoms but have no observable effect on the negative signs.
◦ Ex. Haloperidol (Haldol)
Chlorpromazine (Thorazine)
Levomepromazine (Nozinan)
◦ Side effects: Grogginess, dry mouth, blurred vision, drooling, sexual dysfunction, visual disturbances, menstrual
irregularities, and depression.
◦ Akinesia – Slowed motor activity, monotonous speech, and expressionless face.
◦ Pseudoparkinsonism – Freezing of facial muscles, tremors, and spasm in extremities.
◦ Akathesia – Agitation that causes the people to pace and unable to sit still.
◦ Tardive Dyskinesia – A neurological disorder that involves involuntary movements of the tongue, face, mouth, or
jaw; irreversible.
B. Atypical Antipsychotics
• More effective treatment because of lesser side effects.
• Treat also negative symptoms.
• Side effect:
◦ Agranulocytosis – Deficiency of granulocytes substance that fight infection.
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  Psychological and Social Treatments
 Help the client understand their disorder, appreciate the need to remain in their mediation, and cope more effectively with
the side effects of medication.
 Behavioral Treatment
 The use of operant conditioning and modeling.
 To teach the client skills such as initiating and maintaining conversation with others.
 Asking for information and help from physicians.
 Persisting in an activity such as cleaning or cooking.
 Family is taught to ignore symptoms (bizarre comments), and instead reinforce socially appropriate behavior by giving it
attention and positive emotional response.
 Token economies.
 Cognitive Therapies
 Helping client recognize and change demoralizing attitudes they may have toward illness so that they will seek help when
needed and participate in society to the extent that they can.
 Social Intervention
 Increasing contact between clients.
 Increasing support through self-help groups.
 They can learn problem solving skills through feedback and role playing of new skills.
 Family Therapy
 They are taught basic education on the disorder’s biological causes, symptoms, medications, and side effects.
 To reduce self-blame in family members, increase tolerance on symptoms, and help monitor side effects.
 They are also taught basics on communication to reduce harsh and conflicting interactions, and problem solving to help
manage issues in the family.
 Proven successful if combined with drug.
 Assertive Community Tx Program
 Provides comprehensive services relying on the expertise of medical professionals, social workers, and psychologists to meet
variety of patient’s need.
 The Lodge – Mental health professionals were available for help but residents ran the household and work with other
residents to establish healthy behaviors; they have their own employment agency.
 Skills training, vocational rehabilitation, and social support given to Schizophrenic patient.

Coping for Client With Schizophrenia

 Physical care
 Safety
 Deal with hallucinations:
 Accept that the client is hallucinating (real for the patient).
 Interrupt by initiating interaction.
 Do not argue; point out that you do not share the same perception.
 Move patient to a less stimulating environment.

Schizophrenia: Subtypes
1. Paranoid
 Characterized by one or more delusions/frequent auditory hallucinations.
 None of the following is prominent: Disorganized speech & behavior, affective flattening and catatonic behavior.

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2. Disorganized
 Characterized by disorganized speech, disorganized behavior, and flat/inappropriate affect.
 Does not meet the criteria for catatonic type.
3. Catatonic
 At least 2 of the following are present:
 Motor immobility, waxy flexibility, or stupor.
 Excessive motor activity (purposeless).
 Extreme negativity or mutism.
 Peculiar movement, prominent mannerisms.
 Echolalia or echopraxia.
4. Undifferentiated
 Symptoms in Criteria A are present but criteria for paranoid, catatonic, or disorganized subtypes are not met.
5. Residual
 Symptoms in Criteria A are no longer present; persistence of negative symptoms; Criteria A symptoms are in attenuated
form.

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 2: MOOD DISORDERS

 Mood refers to a sustained emotion that colors the way we view life.
 Mood disorders are common among those who are single and who have no significant other.
 It is more likely in someone who has relatives with similar problems.
 It is formerly called Affective Disorders.

3 Groups of Criteria Sets to Diagnose Problems Related to Mood

 Mood episode
 Mood disorder
 Specifiers describing the most recent episode and recurrent course

Mood Episodes
 Any period of time when a patient feels abnormally happy or sad.
 They are the building blocks from which any of the codable mood disorders are constructed.
 This is not a codable diagnosis.
 Major Depressive Episode – For at least 2 weeks, the patient feels depressed.
 Manic Episode – For at least 1 week, the patient feels elated and hyperactive; often patients must be hospitalized.
 Hypomanic Episode – Briefer and less severe than manic; no hospitalization is needed; can last for years without
hospitalization.

Depression
S – leep (increased/decreased)
I – nterest (decreased)
G – uilt/low self-esteem
E – nergy (decreased)
C – oncentration (decreased)
A – ppetite (decreased/increased)
P – sychomotor activities (decreased/increased)
S – uicidal ideation

Mania
 Mood is elated mixed with irritation and agitation.
 Unrealistically positive grandiose self-esteem.
 Speaks rapidly and forcefully conveying a racing stream of rapid thoughts.
 Symptoms last for 1 week.
 Engages in variety of impulsive behavior (e.g. sexual indiscretions and spending sprees).
 Often they pursue grand plans and goals.

Hypomania
 A milder episode of mania.
 Involves the same symptoms but not severe enough to cause impairment.
 No hallucinations and delusions and lasts for at least 4 days.

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Bipolar and Related Disorders
1. Bipolar I Disorder
 Includes at least 1 manic episode.
 Formerly called Manic-Depressive Illness.
 Men=Women; strongly hereditary.
 Bipolar I patients have a high likelihood of completing suicide; some reports suggest that they account for up to a quarter
of all suicides.
2. Bipolar II Disorder
 Principal distinction from Bipolar I is the degree of disability and discomfort.
 They are ill longer and spend more time in the depressive phase.
 Comorbidity is their way of life.

Bipolar I  One or more manic episodes usually accompanied by a major

depressive episode.
 Depressive episodes may vary from mild to moderate.
Bipolar II  One or more majo r depressive episodes accompanie d by at least
one hypomanic episode.

3. Cyclothymic Disorder
 Alternates episode of hypomanic and period of depressive symptoms for at least 2 years.
 Numerous episodes of hypomania and dysthymia that last chronically and do not affect social/occupational functioning.

Depressive Disorders
1. Disruptive Mood Dysregulation Disorder
 It showcases extremes of childhood.
 Child’s mood is persistently negative – depressed, angry, or irritable.
 80% will also meet criteria for Oppositional Defiant Disorder, in which case you will o nly diagnose DMDD.
2. Major Depressive Disorder
 A severe bout of depressive symptoms for 2 weeks.
 Depressed mood + Anhedonia must be present.
 A patient who has one or more depressive episodes and no manic or hypomanic episodes.
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  Females; strongly hereditary.
 Multiple episodes of depression greatly increase the likelihood of suicide attempts and completed suicide.
 In severe cases, they may have delusions and hallucinations (often negative).
 Ex. They have committed a sin and that they are being punished by their suffering.
 They may hear voices accusing them of having committed a crime or sometimes telling them to kill themselves.
 Subtypes:
 Anxious Distress – Prominent anxiety symptoms.
 Atypical Features – Positive mood reactions to some events, significant weight gain or increase in appetite,
hypersomnia and long standing sensitivity to interpersonal rejection.
 Melancholic Features – Inability to experience pleasure, depression is regularly worse in the morning, EMA,
psychomotor retardation, excessive guilt, and anorexia.
 Peripartum Onset – Onset of MDD is during pregnancy or in the 4 weeks after delivery.
 Psychotic Features – Presence of mood congruent or incongruent delusions and hallucinations.
 Mixed Features – Presence of 3 manic/hypomanic episodes but does not meet mania.
 Seasonal Pattern – History of 2 years in which MDD occurs during 1 season of the year (winter) and remit when the
season is over.
3. Persistent Depressive Disorder (Dysthymia)
 They are chronically depressed.
 Same symptoms with MDD except inappropriate guilt feelings and thoughts of death.
 They have an illness that is enduring but also relatively mild.
 Depression + 3 SIGECAPS
 Chronically depressed mood with a duration of at least 2 years.
 Does not affect social and occupational functions.
4. Premenstrual Dysphoric Disorder
 Women complain of varying degrees of dysphoric mood, fatigue, and physical symptoms that include sensitivity of
breasts, weight gain, and abdominal swelling.
 Experiences mood symptoms during an accumulated 8 years of her reproductive life.

Modifiers
 Severity Codes:
 Mild
 Moderate
 Severe
 Remission Codes:
 In Partial Remission – Patient formerly met full criteria but now has fewer required number of symptoms or had no
symptoms at all but for under 2 months.
 In Full Remission – For at least 2 months, the patient has had no important symptoms of the mood episode.
 Most Episode Patterns:
 With rapid cycling
 With seasonal pattern

Treatment and Prognosis

 Lifetime regimen of bipolar medications, often called Antimanic medications, and adherence to the treatment regimen.
 Lithium and other mood stabilizers.

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  If a client in the acute stage of mania or depression exhibits psychosis (disordered thinking, as seen in delusions, hallucin ations,
and illusions), an antipsychotic agent is administered in addition to the bipolar medication.
 Psychopharmacology:
 Antidepressant: SSRI, MAOI, and atypical antipsychotic.
 Mood Stabilizers: Lithium
 ECT
 Behavioral Therapy – Focus on increasing positive reinforcers and decreasing aversive experiences.
 CBT – To change negative patterns of thinking, followed by developing problem solving skills.
 IPT – Look for the problems such as grieving the loss of a loved one, interpersonal role disputes, role transitions, and deficits in
interpersonal skills.
 Family Focused Therapy – Reduce interpersonal stress by educating them in proper communication and problem solving skills.
 2 to 3 times common in women than men (suicide attempts).
 But men are 4 times likely to complete suicide than women.

Suicide
 Death from injury, poisoning or suffocation where there is evidence that the injury is self-inflicted and that the decedent
intended to kill the self.

Understanding Suicide
 Freud: Depressed people express anger at themselves instead of the people they feel have betrayed or abandoned them.
 Durkheim (Sociologist)
 Egoistic – Done by people who feel alienated from others.
 Anomic – Done by people who experience severe disorientation due to a major change in their societal role.
 Altruistic – Done by people who believe that taking their life will benefit the society (Ex. Vietnam war).
 Stressful Events – Sexual abuse and traumatic events link to suicidal thoughts and attempts.
 Loss of Loved Ones (Death and divorce).
 Suicide Contagion – Suicide becomes acceptable if it is done by popular people who can be identified with.

Personality and Cognitive Factors of Suicide

 Impulsivity – Tendency to act on one’s impulse than inhibit them.
 Hopelessness – The feeling that the future is bleak and there is no way to make it more positive.

Common Expression of Suicidal Individuals

 Cry For Help – Unable to handle the problem anymore.
 Escape – Abused, poverty, etc.
 Heroic – To gain respect, manly alternative to failure.
 Manipulation – Attempt to control.
 Martyrdom – “Everyone will be better off without me”.
 Rebirth – Fantasy of starting a new life.
 Redemption – Attempt to make up for a wrongdoing.
 Relief of Pain – Terminally ill.
 Retaliatory – To get even.
 Reunion – Joining a deceased loved one.

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Suicide Prevention
 Suicide hotlines and crisis intervention.
 Education of entire community.
 Presence of gun at homes increases suicide 3 times by mentally disordered client and 33 times by clients without mental
problems.

What to do with Suicidal Clients

1. Take the person seriously.
2. Get help.
3. Express concern.
4. Pay attention.
5. Ask direct question about suicidal plans.
6. Acknowledge the person’s feelings.
7. Reassure that things can get better.
8. Don’t promise confidentiality.
9. Make sure guns, medicines, and other means of self-harm are not available.
10. Don’t leave the person alone until she’s with the professionals.
11. Take care of yourself!
12. Make patient realize that the tendency to commit suicide is due to disturbance in brain chemistry and is treatable; therefore a
temporary condition.
13. Provide structured activities.
14. Mobilize support system and educate family and significant others to be aware of signs.

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 3: PERSONALITY DISORDERS

Personality
 Enduring patterns of perceiving, feeling, thinking about, and relating to oneself and the environment.

Personality Trait
 Aspect personality that is relatively consistent across time and situation i.e. outgoing, caring, compassionate, exploitative, and
impulsive.

Personality Disorder
 An enduring pattern of thinking, feeling, and behaving that is relatively stable over time and the particular personality
features must be evident by early adulthood.

Cluster A PDs
 Withdrawn, cold, suspicious, or irrational.

Cluster B PDs
 Theatrical, emotional, and attention-seeking; their moods are labile and often shallow. They often have intense interpersonal
conflicts.

Cluster C PDs
 Anxious and tensed, often over controlling.

 All humans have personality traits.

 PDs are collections of traits that have become rigid and may work to an individual’s disadvantage, to the point that they imp air
functioning or cause distress.
 These patterns of behavior and thinking have been present since early adult life and have been recognizable in the patient for a
long time.

All PDs have in common the following characteristics:

 A lasting pattern of behavior and internal experience that is clearly different from the patient’s culture.
 This pattern includes: Problems with affect, cognition, control of impulses, and interpersonal relationships.
 Remember the twin hallmarks of PDs: early onset (usually by late teens) and pervasive nature (disorder’s features affect
multiple aspects of work, personal, and social life).

CLUSTER A

1. Paranoid Personality Disorder

 “How little they trust” and “how much they suspect” others.
 Their suspicions are unjustified and they interpret untoward occurrences as the result of deliberate intent.
 Tends to harbor resentment for a long time, perhaps forever.
 Tends to be rigid, cold, calculating, guarded people who both avoid blame and intimacy.

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2. Schizoid Personality Disorder
 They are indifferent to the society or other people.
 Typically lifelong loners who show a restricted emotional range.
 Appears unsociable, cold, and reclusive.
 They succeed at solitary jobs that others may find difficult to tolerate.
 May daydream excessively, become attached to animals, and often do not marry or even form long-lasting romantic
relationships but they do retain contact with reality.

3. Schizotypal Personality Disorder

 Lasting interpersonal deficiencies that severely reduce their capacity for closeness with others.
 Have distorted or eccentric thinking, perceptions, and behaviors, making them odd.
 Often feels anxious when with strangers, they have almost no close friends.
 Their peculiarities of thought include magical thinking and belief in telepathy or other unusual modes of communication.
 They may talk about sensing a “force” or “presence” or have speech characterized by vagueness or unusual use of words.
 They may eventually develop schizophrenia.
 Their eccentric ideas and style of thinking place them at a higher risk of becoming involved with cults.
 Despite their odd behavior, many marry and work.

Management:
 Cognitive therapy focuses on increasing their sense of self-efficacy in dealing with difficult situations.
 Psychosocial treatments focus on increasing the person’s awareness of his or her own feelings, as well as increasing his or her
social skills and social contacts.
 Traditional neuroleptics such as haloperidol and thiothixene.
 Atypical antipsychotics.
 Antidepressants.

CLUSTER B

1. Antisocial Personality Disorder

 They chronically disregard and violate the rights of other people; they cannot or will not conform to the norms of society
 Some are engaging con artists; others graceless thugs, women may be involved in prostitution; most have heavy use of illicit
drugs.
 They seem superficially charming, many are aggressive and irritable.
 Besides substance abuse, there may be fighting, lying, and criminal behavior.
 They occasionally make suicide attempts but their manipulative interactions make it difficult to determine the genuineness of
the complaint.
 Before age 15, they must have a history that would support a diagnosis of Conduct Disorder.
 Lower socioeconomic status and runs in families.
 Childhood ADHD is a common precursor and childhood Conduct Disorder is a requirement.
 The diagnosis will not be warranted if the behavior happens in the context of substance abuse.
 Never make the diagnosis before age 18 because children sometimes do not escalate to the fuill adult syndrome.
 It is a serious disorder without known effective treatment. Thus, it is a diagnosis of last resort.

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2. Borderline Personality Disorder
 They appear unstable throughout their adult lives.
 Often at the crisis point with regards to their mood, behavior or interpersonal relationships.
 Many feel empty and bored, they attach themselves strongly to others then become intensely angry or hostile when they
believe they are being ignored or mistreated by those they depend on.
 May impulsively try to harm or mutilate themselves as expressions of anger, cries for he lp or attempts to numb themselves
from their emotional pain.
 It runs in families. These people are truly miserable to the point of having 10% complete suicide.
 Extreme emotional reactions to situations lead to impulsive actions.
 They tend to see themselves and other people as either all good or all bad and to vacillate between these two views, a
process known as splitting.
 Marked by instability, abuse, neglect, and parental psychopathology.
 Histories of physical and sexual abuse during childhood.
 Greater activation of the amygdala, which may contribute to the difficulty they have in regulating their moods.
 Low levels of serotonin.

Beautiful and talented Angelina Jolie voluntarily checked herself into a treatment facility in
the late 1990s, claiming she had experienced both suicidal and homicidal thoughts.
Although she had no intentions of acting on these thoughts, she realized that she needed
help.

3. Histrionic Personality Disorder

 A long-standing pattern of extreme attention-seeking and emotionalism that seeps into all areas of their lives.
 Their interest and topics of conversation focus on their own desires and activities.
 They continually call attention to themselves by their behavior, including speech.
 Overly concerned with physical attractiveness and express themselves extravagantly.
 Their need for approval can cause them to be seductive.
 Being insecure and having low tolerance for frustration can spawn temper tantrums.
 Quick to form new friendships and quick to become demanding.
 They don’t think very analytically so they have difficulty with tasks requiring logical thinking. They may however succeed in
jobs that set a premium on creativity and imagination.
 May run in families. Classic patient is female.

4. Narcissistic Personality Disorder

 A lifelong pattern of grandiosity, a thirst for admiration, and an absence of empathy.
 They regard themselves as unusually special; self-important individuals who commonly exaggerate their accomplishments.
 They have fragile self-esteem and often feel unworthy; even at times of great personal success, they may feel fraudulent or
undeserving.
 They remain overly sensitive to what others think about them and feel compelled to extract compliments.
 Often fantasize about wild success and envy those who have achieved it.
 They may choose friends they think can help them get what they want.
 Men.
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  Unrealistically positive assumptions about their self-worth as the result of indulgence and overvaluation by significant others
during childhood.
 Other people with this narcissistic personality disorder develop the belief that they are unique or exceptional as a defense
against rejection by important people in their lives.

Adolf Hitler. There has been much speculation about Hitler’s psychiatric profile over the years. In his
book, Hitler: Diagnosis of a Destructive Prophet, author Fritz Redlich concludes that the genocidal
leader showed strong symptoms of Narcissistic Personality Disorder.

Management:
 Antisocial Personality Disorder
 In psychotherapy , focus on helping the person gain control over his or her anger and impulsive behaviors by recognizing
triggers and developing alternative coping strategies.
 Lithium and atypical antipsychotics. The efficacy of these drugs in treating antisocial personality disorder is not yet clear.
 Borderline Personality Disorder
 Dialectical Behavior Therapy reduces depression, anxiety, self-mutilating behavior while increasing interpersonal
functioning.
 Antianxiety and antidepressant drugs.
 Histrionic and Narcissistic Personality Disorder
 Cognitive techniques can help these clients develop more realistic expectations of their abilities and more sensitivity to the
needs of others.

CLUSTER C

1. Avoidant Personality Disorder

 Feels inadequate, are socially inhibited, and overly sensitive to criticism.
 Their sensitivity to criticism and disapproval makes them eager to please others, which can also lead to marked social
isolation.
 They may misinterpret innocent comments as critical and often refuse to begin a relationship unless sure of being accepted.
 Avoid occupations that involve social demands.
 Other than family, they have few close friends.
 In an interview, they can appear tends and anxious.
 Many such patients marry and work although they may become depressed or anxious if they lose their support systems.

2. Dependent Personality Disorder

 Patients feel the need for someone else to take care of them.
 They desperately fear separation; their behavior becomes so submissive and clingy that it may result in others’ taking
advantage of them or rejecting them.
 Anxiety blossoms if they are thrust in a position of leadership; they feel helpless and uncomfortable when they are alone.
 Trouble in making decisions, starting projects and sticking to a job on their own.
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  They tend to belittle themselves and may also tolerate considerable abuse, even battering.
 Women.

David Beckham. According to at least one source, the handsome and famous soccer star
suffers from Dependent Personality Disorder. While certainly not financially dependent on
anyone, Beckham has shown excessive clinginess in his relationship, a low self-esteem, and
inability to cope with situations by himself.

3. Obsessive-Compulsive Personality Disorder

 Perfectionist, stiff, materialistic, and preoccupied with orderliness.
 They need to exert interpersonal and mental control.
 Many patients with OCPD have no actual obsessions or compulsions at all.
 Their rigid perfectionism often results in indecisiveness, preoccupation with detail, and insistence that others do things th eir
way.
 Often depressed and it interferes with their effectiveness.
 They are list makers who allocate their own time poorly, workaholics who must meticulously plan even their own pleasure.
 They resist the authority of others but insist on their own.
 Males. Runs in families.

Steve Jobs. The late CEO of Apple Computer Corporation suffered from OCPD. According to an
article in State Magazine, Jobs’ OCPD is “what made him great”.

Management:
 Dependent Personality Disorder
 Psychodynamic treatments
− Free Association
− Dream Interpretation
− Interpretation of the transference process
 Cognitive-behavioral therapy for dependent personality disorder includes behavioral techniques designed to increase
assertive behaviors and decrease anxiety, as well as cognitive techniques designed to challenge clients’ assumptions about
the need to rely on other.
 Nondirective and humanistic therapies.
 Obsessive-Compulsive Personality Disorder
 Supportive therapies.
 Behavioral therapies can decrease their compulsive behaviors.
 Relaxation techniques.

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 4: DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS

 These disorders entail problems with the regulation of behavior and emotions.
 Behaviors may occur on the spur of the moment or it may be planned; some are accompanied by efforts to resist.
 These acts are often illegal.
 Male predominate. Typically start in childhood or adolescence. Sometimes this is a progression.
 Children: Oppositional Defiant Disorder
Conduct Disorder
 Adults: Intermittent Explosive Disorder
Antisocial Personality Disorder

1. Oppositional Defiant Disorder

 Symptoms first show up around age 3 or 4.
 ODD and ADHD are strongly comorbid.
 Often angry and irritable. They disobey or argue with authority figures and may refuse to cooperate or follow rules—only
to annoy, not to violate the rights of others.
 Chronically negativistic, defiant, disobedient, and hostile.
 Defiant and obstinate = “Terrible Twos”.
 Boys: Physically aggressive; draw attention.
 Girls: Relational aggression; excluding peers, gossiping, and colluding to damage social status.
 Both: Likely to engage in stealing, lying, and substance abuse.
 High rates of depression.

2. Conduct Disorder
 This can happen as early as 5 or 6.
 4 categories:
 Aggression to people and animals.
 Destruction of property.
 Lying and theft.
 Serious rule violation.
 They chronically disrespect rules and other people’s rights.
 They use aggression to peers and even adults such as bullying, using dangerous weapons, showing cruelty to people or
animals, and even sexual abuse.
 DSM-5 Specifiers:
 Lack of remorse or guilt.
 Lack of empathy for others.
 Lack of concern about social performance/work.
 Shallow or deficient emotions to manipulate others.
 They are less reactive to fear and distress stimulus; less sensitive to punishment = “The Psychopaths”.
 With Limited Prosocial Emotions
 Co-behavior can take 2 forms:
1. The patient has trouble regulating powerful, angry, and hostile emotions. They tend to come from dysfunctional
families.

17
 2. The others lack empathy and guilt. They easily get bored so they prefer exciting and dangerous activities. They
typically report the four symptoms.
 Factors:
 Parents with antisocial behavior (genes and environment).
 Genes that are directly involved in regulation of certain neurotransmitters (low activity of amygdala).
 Environment that promotes abuse and maltreatment.
 Exposure to toxins (alcoholism and drugs in pregnancy).
 Low socioeconomic status.
 Neglect and low quality of parenting.
 Negative cognitions on social interactions – aggressive reactions.

Management:
 CBT – Aim to change children’s way of interpreting interpersonal interactions. “Self talk” to control impulsive behaviors.
 Teach them to take and respect the perspective of others.
 Recognize situations that trigger aggressive and impulsive behaviors.
 Family and parents should be involved through negative and positive reinforce ments of behaviors.
 Psychopharmacology: Lithium, antidepressants, and antipsychotics.

3. Intermittent Explosive Behavior

 Individuals age 6 and older who engage in frequent impulsive acts of aggression (verbal or physical) and must be grossly
out of proportion to the situation.
 The outburst is out of control as a result of anger and represents inability to inhibit impulse to be aggressive in the
immediate context of frustration and perceived stress that would not typically result In an aggressive outburst.
 Masked a passive-aggressive personality.
 They have periods of aggression that begin suddenly on little or no provocation.
 The stimulus can be quite benign then all hell breaks loose.
 The whole episode rarely lasts longer than half an hour and may end with the person expressing remorse.
 These outbursts are unplanned, have no goal, and are excessive for the provocation.

4. Pyromania
 An impulse-control disorder in which individuals repeatedly fail to resist impulses to deliberately start fires in order to
relieve tension or for instant gratification.
 Only when there is a typical history of yielding with relief to an irresistible impulse can the diagnosis be sustained.
 With interest in various aspects of fire. They will turn in false alarms, appear as spectators at fires, or collect the apparatus
used by firefighters.
 These patients may make advanced preparations, such as searching out a site and collecting combustibles.

5. Kleptomania
 An ICD characterized by an intense urge to steal things.
 The client may experience a compulsive urge to steal things usually of trivial value; often with OCD/Bulimia.
 Stealing occurs not as a result of need, or even necessarily of desire.
 When caught, they typically have enough money with them to pay for what they have taken.
 Once they left the scene undetected, they may give away or discard their loot.

18
Management:
 Psychotherapy – Focus on helping the client gain control over his impulsive behaviors by recognizing triggers and developing
alternative coping strategies.
 Mood stabilizers and atypical antipsychotics.
 No established cure or management.

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 5: NEURODEVELOPMENTAL DISORDERS

1. Intellectual Disability (Intellectual Developmental Disorder)

 Formerly called Mental Retardation.
 It has 2 sorts of problems:
 Fundamental deficit in their ability to think.
▫ Overall intelligence level is below average.
▫ IQ of less than 70.
 Patient’s ability to adapt to the demands of normal life—school, work, home—is impaired.
▫ A diagnosis is likely to be made earlier when there are associated physical abnormalities (such as Down Syndrome).
▫ The many causes of ID include genetic abnormalities and other biological causes.
 Significant Deficits in 3 Broad Domains of Daily Living:
 Conceptual Domain
▫ Skills in reading, writing, language, math, memory, and problem solving.
 Social Domain
▫ Awareness and understanding of others’ experiences.
▫ Interpersonal communication skills, regulating social reactions, judgment, keeping friends, and interactions.
 Practical Domain
▫ Deficits in managing personal care, finances, hygiene, cooking, recreation, and organizing themselves.
 4 Levels of Severity:
 Mild
▫ Cannot be distinguished from normal children until they attend school; they learn more slowly.
▫ Can develop academic skills equivalent to 8th grade level.
▫ Can work and live in the community if helped.
▫ Some may marry and have children.
 Moderate
▫ Can progress to about 2nd grade level in academic skills.
▫ By adolescence, they usually have good self-care skills i.e. eating, dressing, and going to the bathroom, and can
perform simple tasks.
▫ Most can work at unskilled or semiskilled jobs with supervision.
 Severe
▫ May learn to talk during childhood and develop basic self-care skills.
▫ In adulthood, they can perform simple tasks with close supervision.
▫ They often live in group homes or with their families.
 Profound
▫ Require constant care.
▫ Can understand some language but they have little ability to talk.
▫ Often have neurological condition that accounts for their retardation.
 Causes:
 Chromosomal and gestational disorders.
 Exposure to toxins during pregnancy and early childhood.
 Infections.
 Brain injury and malformations.
 Metabolism (Phenylketonuria: Phynelanine) –chon derivatives.
20
  Nutritional problems.
 Seizure disorders.
 Management:
 Restructure environment to meet the client’s needs.
 Repetition of instructions (Trainable: Reading, writing, and basic math).
 Role modeling.
 Typical antipsychotic – For aggression.
 Antidepressants – To reduce depressive symptoms, improve sleep, and help control injurious acts.
 Behavioral strategies involving caregivers.
 Social programs.
 The controversy of mainstreaming.

2. Autism Spectrum Disorder

 Usually recognized in childhood, it continues through adult life, though it may be greatly modified by experience and
education.
 Symptoms fall into three broad categories:
 Communication
 Socialization
 Motor behavior
 Communication
 Speech may be delayed by as much as several years.
 Deficits vary greatly—from those with Asperger’s disorder to those who can hardly communicate.
 They may fail to use body language or other nonverbal behavior to communicate.
 They have trouble beginning or sustaining conversation so they usually talk to themselves.
 They tend to ask questions over and over again even if they obtained repeated answers.
 Socialization
 Their social maturation occurs more slowly than normal kids.
 Parents are often concerned after 6 months when their child doesn’t make eye contact, smile reciprocally, or cuddle.
Instead, the baby arch away from a parent’s embrace and stare into space.
 Toddlers don’t point to objects or play with other children.
 They may not stretch out their arms to be picked up or no separation anxiety.
 It often results to tantrums and aggression.
 Motor Behavior
 Their motor milestones usually arrive on time but the type of behavior they cho ose marks them as different.
 They do compulsive or ritualistic actions (stereotypies) – Twirling, hand flapping, head banging, and maintaining odd
body postures.
 They tend to be preoccupied with parts of objects.
 They tend to resist change, preferring to adhere rigidly to routine.
 They may be preoccupied with smelling or touching things.
 Sensory abnormalities occur too, some hate bright lights or loud sounds.
 A small minority have special abilities in computation or music.
 Siblings of patients with ASD have a greatly elevated risk for the same disorder.
 A disorder characterized by impairment in social interactions and communication; usually diagnosed at the age 2; with
higher prevalence on boys and 50% of cases are accompanied by Mental Retardation.

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  Signs and Symptoms:
 Clinging to inanimate objects.
 Resist normal teaching method.
 Silly laughing/giggling.
 Echolalia, insensitive to pain, acts as deaf.
 No fear of danger, rocking or head banging.
 Some children do not speak at all, others speak in limited phrases or conversations, and some have relatively normal
language development.
 Repetitive play skills and limited social skills are generally evident.
 Unusual responses to sensory information i.e. loud noises and lights are also common.
 Management:
 Protect from injury (head banging).
 Assist in performance/completion of ADLs.
 Provide constant routine for the child.
 Educate family for the therapy and education of the child.
 Haloperidol – Symptomatic relief for hyperactivity, stereotypical, and self-destructive behavior.
 Goals of TX – To reduce behavioral symptoms and to promote learning and development, particularly the acquisition of
language skills.
 Comprehensive and individualized TX, i.e.:
▫ Special education
▫ Language therapy - Is associated with more favorable outcomes.

3. Attention-Deficit/Hyperactivity Disorder
 They tend to be impulsive, to say things that hurt the feelings of others, and to be unpopular.
 These behaviors usually decrease with adolescence.
 Adults may have continuing interpersonal problems, alcohol, or drug us, and personality problems.
 Adults may also complain of trouble with concentration, disorganization, impulsivity, quick temper, and intolerance to stress.
 Tends to run in families.
 Symptoms of ADHD:

Hyperactivity (6>) Impulsivity Inattention (6>)

 Is in motion as if “driven by a
motor”.
 Cannot stay seated.
 Squirms and fidgets.
 Talks too much.
 Runs, jumps, and climbs when this is
not permitted.
 Cannot play quie tly.
 Acts and speaks without thinking.
 May run into the street without
looking for traffic first.
 Has trouble taking turns.
 Cannot wait for things.
 Calls out answers before the question
is complete.
 Interrupts others.
 Has a hard time paying attentio n,
daydreams.
 Does not seem to listen.
 Is easily distracted from work or
play.
 Does not seem to care about details,
makes careless mistakes.
 Does not follow instructions or finish
tasks.
 Is disorganized.
 Loses a lo t of im portant things.
 Does not want to do things that
require ongoing mental effort.

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 Management:
 Nutrition: Finger foods.
 Safety: Environmental manipulation.
 Medication: Methylphenidate (Ritalin) – CNS stimulant (increases focus).
 Behavioral Therapy – Reward and punishment.
 Parents’ education.
 Play techniques (to channel energy).
 Dramatic play and play techniques.
 Environmental strategies in school and home (type of school).

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 6: NEUROCOGNITIVE DISORDERS

 Disorders that arise later in life.

 Results from medical conditions that cause impairment in cognition or from substance intoxication or withdrawal.

Problems
 Memory deficits
 Language disturbances
 Perceptual disturbances
 Impairment in executive function
 Failure to recognize/identify objects

Symptoms
1. Aphasia – Deterioration of language.
 Echolalia – Repeating what they hear.
 Papilalia – Repeating words over and over again.
2. Apraxia – Impairment of the ability in executing actions.
3. Agnosia – Failure to recognize objects or people.

Types of Dementia
1. Dementia of the Alzheimer’s Type
2. Vascular Dementia (Formerly called Multi-infarct Dementia)
 Blockage of blood in the brain, commonly known as stroke.
3. Dementia Associated with other Medical Conditions

1. Dementia of the Alzheimer’s Type

 It usually starts from mild memory loss but as the disease progresses, the memory loss and disorientation quickly be comes
profound.
 About 2 out of 3 Alzheimer’s patients show psychiatric symptoms, including agitation, irritability, apathy, and dysphoria.
 As the disease worsens, sufferers may become violent and
experience hallucinations and delusions.
 The disease usually begins after age 65, but there is an early-
onset type of Alzheimer’s disease that tends to progress more
quickly than the late-onset type.
 Brain Abnormalities in Alzheimer’s Disease
 Alois Alzheimer: Filaments within the nerve cells in his brain
were twisted and tangled.
 Neurofibrillary Tangles – The tangles, which are made up of a
protein called Tau, impede nutrients and other essential
supplies from moving through cells so that cells eventually die.
 Plaques – Accumulate in the spaces between the cells of the
cerebral cortex, hippocampus, amygdala, and other brain
structures critical to memory and cognitive functioning.

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  Shrinking of the cortex and enlargement of ventricles of the brain results from the
extensive cell death of the cortex in Alzheimer’s patients. The remaining cells lose
many of their dendrites.
 Causes of Alzheimer’s Disease
 Viral infection.
 Immune system dysfunction.
 Exposure to toxic levels of aluminum.
 Deficiencies of the vitamin folate.
 Head traumas.
* In current research, it focused on the genes that might transmit a vulnerability to
this disorder and on the beta-amyloid proteins that form the plaques found in the brains of almost all Alzheimer’s patients.

2. Dementia Associated with other Medical Conditions

 A variety of other serious medical conditions can produce dementia, including Parkinson’s Disease, the Human
Immunodeficiency Virus (HIV), and Huntington’s Disease.
 Parkinson’s Disease
 A degenerative brain disorder.
 Its primary symptoms are tremors, muscle rigidity, and the inability to initiate movement. The symptoms result from the
death of brain cells that produce the neurotransmitter dopamine.
 Human Immunodeficiency Virus (HIV)
 The virus that causes AIDS can cause dementia.
 Their mental processes slow—they may have difficulty following conversations or may take much longer to organize their
thoughts and to complete simple, familiar tasks.
 They may withdraw socially and lose their spontaneity, weakness in the legs or hands, clumsiness, loss of balance, and
lack of coordination are also common.
 If the dementia progresses, the deficits increase.
 HIV Associated Dementia
▫ Diagnosed when the deficits and symptoms become severe and global, with significant disruption of daily activities
and functioning.
▫ As more patients with HIV survive into older age due to these drugs, the number of people with HIV-related dementia
is increasing, particularly among people who abuse drugs or also had Hepatitis C infections.
 Huntington’s Disease
 A rare genetic disorder that afflicts people early in life, usually between the ages of 25 and 55.
 People with this disorder develop severe dementia and chorea—irregular jerks, grimaces, and twitches.
 Huntington’s Disease affects many neurotransmitters in the brain but which of these changes cause chorea and dementia is
unclear.
 Alcohol, Inhalants, and Sedatives, especially combines with nutritional deficiencies, can cause brain damage and
neurocognitive disorder.
 Alcohol-related neurocognitive disorder usually has a slow, insidious effect.
 Traumatic Brain Injury
 Caused by gunshots, closed head injuries, typically caused by impact to the head and/or concussive forces such as motor
vehicle accidents, explosion, or sport injury.

25
Treatment and Prevention
 Drugs for cognitive symptoms are:
 Cholinesterase Inhibitors – Donepezil (Aricept), Rivastigmine (Exelon), and Galantamine (Reminyl)
▫ Help prevent the breakdown of acetylcholine, which randomized trial shows that it has an effect on neurocognitive
disorder symptoms.
▫ Side effects are nausea, diarrhea, and anorexia.
 Memantine (Namenda)
▫ Regulates the activity of glutamate, which plays an essential role in learning and memory.
 Antidepressants and antianxiety
▫ Control emotional symptoms.
 Antipsychotic drugs
▫ Control hallucinations, delusions, and agitation.
 Behavioral Therapies
 Helpful in controlling outburst and emotional instability.
 Families are given behavioral therapies to help manage the patient’s symptoms.
 Reduces stress, emotional distress, and fewer behavioral problems.

Delirium
 Characterized by disorientation, recent memory loss and a clouding of attention.
 Most common psychiatric syndrome specifically in older people.
 High mortality rate on older people due delirium.
 Symptoms are: Difficulty focusing, sustaining, or shifting attention.
 Signs arise suddenly for hours or days and shift over the course of the day and often become worse at night (sundowning).

Common Progression of the Disorder

 In early phase:
 Mild symptoms
 Decreased concentration
 Irritability
 Restlessness, or;
 Depression
 Cognitive disturbance or perceptual disturbances or visual hallucination (in some)
 If worse:
 Disrupted orientation
 Sometimes onset of delirium is mistaken with normal personality trait.

Causes of Delirium
 Dementia is the strongest predictor of delirium, increasing the risk fivefold.
 Stroke, congestive heart failure, infectious diseases, high fever, and HIV infection, is associated with a risk of delirium.
 Intoxication with illicit drugs and withdrawal from these drugs or from prescription medications.
 Fluid and electrolyte imbalances, medications, and toxic substances.
 The level of acetylcholine affected by toxic substances, drugs, or other mental condition.
 Abnormalities on neurotransmitters such as dopamine, serotonin, and GABA.
 Can be due to the person’s medical disorder or the effect of medications.

26
Treatment
 Antipsychotic medications – To treat patient’s confusion.
 Nursing care.
* If another medical condition is associated with delirium, the condition must be treated first.

Amnesia
 Unlike the previous topic, amnesia only affects the memory.
 It often follows periods of confusion, disorientation, and delirium.
 Anterograde Amnesia – Inability to learn new information.
 Retrograde Amnesia – Inability to recall previously learned information or past events.

Causes of Amnesia
 Stroke
 Head injury
 Chronic nutritional deficiency
 Exposure to toxins (e.g. carbon monoxide poisoning)
 Herpes encephalitis
 Chronic substance abuse
 Korsakoff’s Syndrome
▫ An amnesiac disorder caused by damage to the thalamus, a part of the brain that act as a relay station for other parts
of the brain.
▫ This is also associated to chronic and heavy use of alcohol due to neglect nutrition that may develop thiamin deficiency.

Treatment
▫ First is to remove any possible condition associated with amnesia (e.g. alcohol use).
▫ Proper nutrition.
▫ Treat other health condition (e.g. hypertension).
▫ Present familiar environment.

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 7: FEEDING AND EATING DISORDERS

 Disorders characterized by persistent disturbance of eating or eating-related behavior that results in the altered consumption or
absorption of food.
 It impairs physical or psychological functioning.

1. PICA
 It is the eating of one or more nonnutritive, nonfood substances on persistent basis over a period of 1 month.
 Substances includes: Paper, soap, cloth, hair, string, soil, chalk, talcum powder, paint, charcoal, ash, or starch.
 To exclude a minimum age of 2 (developmentally normal mouthing of objects).
 Comorbidity:
 ASD
 Intellectual disability
 OCDs and trichotillomania/excoriation
 Diagnostic Markers
 Scan may reveal obstructions
 Blood test for poisoning

2. Rumination Disorder
 It is the repeated regurgitation of food occurring after eating or feeding over a period of at least one month.
 Weight loss and failure to make expected weight gain is expected despite excessive hunger.
 Some will avoid social eating due to undesirability.
 Risk factors:
 Problem with parent-child relationship
 Neglect
 Stressful life situations

3. Anorexia Nervosa
 Restriction of energy intake relative to requirements leading to low body weight in the context of age, sex, developmental,
and physical health.
 Intense fear of gaining weight despite significantly low weight.
 Persistent lack of recognition of the seriousness of the current body weight.
 Development and Course:
 Commonly begins in adolescence or young adults.
 Onset is usually associated with stressful events.
 Patients have a period of changed eating behavior prior to full criteria for the disorder being met.
 Some recovers after a single episode, with fluctuating weight gain followed by relapse, others expe rience chronic course
over many years.
 Comorbidity:
 Bipolar, depressive, and anxiety disorders commonly occur with anorexia nervosa.

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4. Bulimia Nervosa
 Characterized by recurrent episodes of binge eating.
 Binge Eating:
 Eating within 2 hour period, an amount of definitely larger than usual.
 Sense of lack of control over eating.
 Recurrent inappropriate compensatory to prevent weight gain (vomiting, misuse of laxatives, diuretics, fasting, or
excessive exercise).
 It occurs at least once a week in 3 months.
 Binge eating can be a way to deal with anxiety and purging behaviors are used to get rid of the food to avoid becoming
fat.
 Tooth enamel is lost because of recurrent vomiting and there is an increased incidence of dental caries and ragged or
chipped teeth.

Anorexia Nervosa Bulimia Nervosa

Description Intense fear of gaining weight. Does not want to gain weight but has no control
over eating urges.

Characteristics Dieters, extraneous exercising, may Binge eaters followed by self-induced vomiting,
become purgers, and uses laxatives. use of laxatives, and enemas.
Weight Less than 85% of normal. Normal or near normal.
Cognitive Thin but feels extremely fat. No control over binge eating.

Physical Dehydration, electroly te imbalances, Electrolyte imbalances, hoarseness, esophagitis,

Symptoms hormonal im balances, and lo ss of bowel dental carie s, halitosis, hormonal imbalances, loss
tone due to laxative abuse. of bowel tone due to laxative abuse, and
cuts/calluses on knuckles/back of hands.

Management:
 Clients are treatment-resistant d/t denial problems.
 Note for risk of suicide is significant.
 Outpatient is more likely to be effective for those who have been ill for less than 6 months, who are not binging and purging,
and who have parents who participate in family therapy.
 Medical management focuses on weight restoration, nutritional rehabilitation, rehydration, and correction of electrolyte
imbalances.
 Severely malnourished may require TPN or tube feedings, nutritionally balanced meals, and snacks are introduced and
gradually increase calories.
 Generally client is supervised during meals to ensure eating and after meals while using bathroom to prevent purging.
 Weight gain and adequate intake are often criteria for judging treatment effectiveness.
 Many drugs have been studied and tried but few show success. Amitripyline (Elavil) and cyprophetadine (Periactin) can
promote weight gain. Fluopxentine (Prozac) may help prevent relapse but only when weight has been gained because It can
cause weight gain.

5. Binge-Eating Disorder
 Binge-Eating Disorder is a serious eating disorder in which you frequently consume unusually large amounts of food.
 Deeply embarrassed about gorging and vows to stop.
 Occurs in normal-weight/overweight and obese individuals.
 Distinct from obesity.
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  Symptoms:
 Eating in a discrete period of time (e.g. within any 2-hour period).
 Lack of control over eating during the episode.
 Eating much more rapidly than normal.
 Eating until feeling uncomfortably full.
 Eating large amounts of food when not feeling physically hungry.
 Eating alone because of feeling embarrassed by how much one is eating.
 Feeling disgusted with oneself, depressed, and very guilty afterward.
 Severity:
▫ Mild: 1-3 binge-eating episodes per week.
▫ Moderate: 4-7 binge-eating episodes per week.
▫ Severe: 8-13 binge-eating episodes per week.
▫ Extreme: 14 or more binge-eating episodes per week.

6. Other Specified Eating Disorder

 Atypical Anorexia Nervosa
 Criteria of AN is met but the weight is normal.
 Bulimia Nervosa (Low Frequency)
 Criteria are met except the occurrence is less than once week or less than 3 months.
 Binge-Eating (Low Frequency)
 Occurrence is less.
 Purging Disorder
 Recurrent purging to influence weight or shape in absence of binge-eating.
 Night Eating Syndrome
 Eating after awakening from sleep or eating much after evening meal. There is disruption in normal functioning.
 Bigorexia
 A mental disorder characterized by a normal person’s obsession with an imagined defect in physical appearance.
 Also called muscle dysmorphia.
 Tends to be male because they are more pressured to be toned and muscular.
 10 Common Signs of Bigorexia:
1. Frequently looking at one’s self in the mirror.
2. Maintaining a strict high protein and low fat diet.
3. Wearing baggy clothes to hide the size of one’s body.
4. Using steroids or other body building products.
5. Missing social events, skipping work and ignoring one’s family in order to workout
6. Avoiding situations where one’s body might be exposed.
7. Working out even when injured.
8. Using excessive amounts of food supplements.
9. Never being satisfied with the muscular mass of one’s body.
10. Maintaining extreme workout methods.

Theories
 Families of girls with eating disorders have high levels of conflict, discourage the expression of negative emotions, and
emphasize control and perfectionism.
 Children with depression, anxiety disorders, and several other forms of psychopathology.
30
  Girls from troubled families who cannot completely ignore their hunger.
 Low parental warmth and high parental demands or control seems to distinguish girls an d women who develop binge-eating
disorder from those with other forms of psychopathology.
 History of binge-eating among other family members.

Differential Diagnosis
 Bulimia Nervosa
 Obesity
 Bipolar and Depressive Disorders
 Borderline Personality Disorder

Treatments
 Psychotherapy
 Cognitive-Behavioral Therapy
 Supportive-Expressive Psychodynamic Therapy
 Biological Therapies
 SSRI’s such as fluoxetine

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 8: ELIMINATION DISORDERS

 These all involve the inappropriate elimination of urine or feces and are diagnosed in childhood or adolescence.
 There is a specific minimum age requirement for diagnosis and is based on developmental age.
 It may be voluntary or involuntary.

1. Enuresis
 Repeated voiding of urine during the day or night into beds or clothes.
 Nocturnal enuresis happens during REM; the child may recall a dream involving urinating.
 Diurnal Enuresis – The child differs voiding until incontinence happen (d/t social anxiety or preoccupation with school
activities).
 Prognostic Factors:
 Delay/lax toilet training
 Psychosocial stress
 Physiological:
 Associated with delays in the development of normal circadian rhythms or urine production resulting in nocturnal polyuria.
 Unstable bladder syndrome.
 Genetic Heritability:
 The social impairment is through the limitation of the child’s social activities which may lead to social ostracism, negative
effect on self-esteem.

2. Encopresis
 Repeated passage of feces into inappropriate places (floor or clothing).
 It is often involuntary but sometimes also intentional.
 Involuntary:
 Constipation, impaction, and retention.
 Due to psychological reasons (anxiety, etc.) which may lead to avoidance of defecation.
 Risk Factors:
 Inadequate/inconsistent toilet training.
 Psychosocial stressors: Entering school, birth of sibling, etc.
 Painful defecation due to constipation as a result of taking medications (anticonvulsants, cough suppressants, etc.).
 Management:
 Monitoring fluid intake.
 Routine toileting (urine alarm).
 Treat comorbid constipation and other general medical condition.

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 9: SEXUAL DYSFUNCTIONS

 Sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically significant distu rbance
in a person’s ability to respond sexually or to experience sexual pleasure.
 The difficulty must be more than occasional and must cause significant distress or interpersonal difficulty.

4 Categories
1. Sexual Desire Disorders
2. Sexual Arousal Disorders
3. Orgasmic Disorders
4. Sexual Pain Disorders

Subtypes are Used to Designate the Onset of the Difficulty

 Lifelong
 Acquired
 Generalized
 Situational

Sexual Response Cycle

Sexual Desire Disorders

 Sexual desires can be manifested in a person’s sexual thoughts and fantasies, a person’s interest in initiating or participating
in sexual activities, and a person’s awareness of sexual cues from others.
1. Hypoactive Sexual Desire Disorder
 Recurrent lack of sexual fantasies and desire for sexual activity.
 This absence of fantasy and desire must produce marked personal and interpersonal distress.
 The distress can affect both partners.
 4 Types:
 Lifelong Hypoactive Sexual Desire Disorder
 Acquired Hypoactive Sexual Desire Disorder
 Generalized Hypoactive Sexual Desire Disorder
 Situational Hypoactive Sexual Desire Disorder

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 2. Sexual Aversion Disorder
 Recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.
 Individuals with this disorder actively avoid sexual activities.
 They may feel sickened by it or experience acute anxiety.
 Fear, revulsion, disgust, or similar emotions when the person with the disorder engages in genital contact with a partner.
 The aversion may take a number of different forms:
 Sight of the partner’s genitals
 Smell of his or her body secretions
 Kissing
 Hugging
 Petting
 Intercourse itself

Sexual Arousal Disorders

 People with sexual arousal disorders do not experience physiological changes that make up the excitement or arousal phase
of the sexual response cycle.
1. Female Sexual Arousal Disorder
 Recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling
response of sexual excitement.
2. Male Erectile Disorder
 Recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication -swelling
response of sexual excitement.

Orgasmic Disorders
1. Female Orgasmic Disorder (Anorgasmia)
 Recurrent delay in, or absence of, orgasm following normal sexual excitement phase.
2. Male Orgasmic Disorder (Impotence)
 Recurrent delay in, or absence of, orgasm following normal sexual excitement phase.
 Difference between ejaculation and orgasm:
 Ejaculation – Releasing semen
 Orgasm – Involuntary muscle spasms and letting go; the emotion side of the orgasm.
 The biggest indicator that male orgasmic disorder is a problem is the delay or absence of orgasm after adequate sexual
stimulation.
3. Premature Ejaculation
 Recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person
wishes it.
 Men with this disorder persistently ejaculate with minimal sexual stimulation before they wish to ejaculate.
 Premature ejaculation must cause significant distress or interpersonal problems before it is considered a disorder.

Sexual Pain Disorders

1. Dyspareunia (DSM-IV-TR)
 Recurrent genital pain associated with sexual intercourse in either a male or a female.
 Dyspareunia in Women
 Dryness of the vagina caused by antihistamines or other drugs, infection of the clitoris or vulva area, injury or irritation
to the vagina, or tumors of the internal reproductive organs.
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  Dyspareunia in Men
 Painful erections or pain during thrusting.
2. Vaginismus (DSM-IV-TR)
 In women, involuntary contractions of the muscles surrounding the vagina, which interfere with sexual functioning.
 Women with vaginismus may experience sexual arousal and have an orgasm when stimulated.
3. Genito-Pelvic Pain/Penetration Disorder (DSM-5)
 Differential Diagnosis
 Another medical condition.
 Somatic symptom and related disorders.
 Inadequate sexual stimuli

Causes of Sexual Dysfunctions

 Biological Causes
 Medical Illness
▫ Diabetes
▫ Cardiovascular disease, etc.
 In men, abnormally low levels of the androgen hormones, especially testosterone, or high levels of the hormones estrogen
and prolactin can cause sexual dysfunction.
 Vaginal dryness or irritation, which causes pain during sex and therefore lowers sexual desire and arousal can be caused
by antihistamines, douches, tampons, vaginal contraceptives, radiation therapy, endometriosis, and infections such as
vaginitis or pelvic inflammatory disease.
 Injuries during childbirth that have healed poorly, such as poorly repaired espisiotomy, can cause sexual pain in women.
 Prescription drugs:
▫ Antihypertensive drugs take by people with high blood pressure, antipsychotic drugs, antidepressants, lithium,
tranquilizers, and SSRIs.
 Many recreational drugs:
▫ Including marijuana, cocaine, amphetamines, and nicotine can impair sexual functioning.
 The use of alcohol.
 Psychological Causes
 Psychological disorders
 Attitudes and cognitions
 Performance concerns or performance anxiety
 Trauma

Treatments
 Biological Therapies
 Male Erectile Disorder: Sildenafil (trade name Viagra), Cialis, and Levitra.
 Bupropion appears to reduce the sexual side effects of the SSRIs and can itself be effective as an antidepressant.
 Mechanical interventions.
 Premature Ejaculation: Antidepressants can be helpful i.e. fluoxetine (Prozac), clomipramine (Anafranil), and sertaline
(Zoloft), etc.
 Hypoactive Sexual Desire Disorder: Hormone therapy (use of testosterone to increase sexual desire).

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 10: PARAPHILIC DISORDERS

 Paraphilia is a condition in which a person’s sexual arousal and gratification depend on fantasizing about and engaging in sexual
behavior that is atypical and extreme.
 Most paraphilias are far more common in men than in women.
 A paraphilia is distinguished by a preoccupation with the object to the point of being dependent on that object or behavior for
sexual gratification.
 Paraphilias are diagnosed when people have sexual fantasies, urges, or behavior that involve:
1. Nonliving objects
2. Non-consenting adults
3. Suffering or the humiliation of the person or the person’s partner
4. Prepubescent children

Diagnosis Object of Fantasies, Urges, or Behaviors

Fetishism Nonliving obje cts (e.g., female undergarments)

Transvestic fetishism Cross-dressing
Sexual sadism Acts (real, not simulated) in which the psychological or physical suffering
(including humiliation) of the victim is sexually exciting to the person

Sexual masochism Acts (real, not sim ulated) of being humiliated, beaten, bound, or
otherwise made to suffer
Voyeurism The act of observing an unsuspecting person who is naked, in the process
of undressing, or engaged in sexual activity
Exhibitionism Exposure of one’s genitals to an unsuspecting stranger

Frotteurism Touching and rubbing against a nonconsenting person

Pedophilia Sexual activity with a prepubescent child or children (generally age 13
years or younger)

Causes of Paraphilia
 Several lines of evidence suggest that alterations in the development of the nervous system may contribute to pedophilia.
 Men with pedophilia are more likely to have had head injury before age 13, to have cognitive and memory deficits, to have
lower intelligence, and to have differences in brain structure volume.
 Strong sex drive and masturbate often, providing many opportunities for the pairing of their fantasies with sexual
gratification.
 Few opportunities for other types of sexual reinforcement and has difficulty relating appropriately to other adults.
 Children whose parents frequently use corporal punishment and engage in aggressive, and perhaps sexualized acts towards
others as they grow older.
 Many people with pedophilia have poor interpersonal skills and feel intimidated when interacting sexually with adults.
 Childhood sexual abuse was a particularly strong predictor of pedophilia.
 Cognitive theorists have also identified a number of distortions and assumptions that people with paraphilia have about their
behaviors and the behaviors of their victims.

Treatments
 Treatment is often forced on those who are arrested after engaging in illegal acts including voyeurism, exhibitionism,
frotteurism, or pedophilia.
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  Simple incarceration does little to change these behaviors, and convicted sex offenders are likely to become repeat
offenders.
 Biological interventions generally are aimed at reducing the sex drive in order to reduce paraphilic behavior.
 Surgical castration, which almost completely eliminates the production of androgens, lowers repeat offense rates among sex
offenders.
 Behavior modification therapies commonly are uses to treat paraphilia and can be successful if people with a paraphilia are
willing to change their behavior.
 Aversion Therapy
 Desensitization
 Cognitive Interventions
 Group Therapy
 Cognitive-Behavior Therapy

Other Types of Paraphilia

 Telephone Scatalgia – Obscene phone call.
 Necrophilia – Sexual fantasies and acts involving a cadaver or corpse.
 Partialism – Exclusive sexual focus on a part of the body.
 Zoophilia – Sexual fantasies, acts with animals (rarest).
 Coprophilia – Smearing of feces, desire to defecate on a partner, to be defected on, or to eat feces.
 Urophilia – Smearing of urine.
 Klismaphilia – Sexual fantasies and arousal involving enemas.

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