Psychiatry for Medical Students

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Psychiatry

• IMEC INC.

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Psycho-analytic Concept

• Freud and his daughter
• Ego, Id, Superego
• Symptom maladaptive defense, or defense breakdown
• Focus on unconscious mechanism free association
• Original acceptance of stories of trauma as true
  was reversed

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Principle of Psychodynamic Psychotherapy

• Interpretation of transference
• Therapist not self-revealing or directive
• Dream interpretation
• Counter transference requires self analysis and
  supervision

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Freudian Jargon

• Permeates mental health culture despite loss of
  dominance paradigm
• Transference in patients distorted gt feeling
  toward clinician
• Counter-transference in clinicians gt feeling
  toward patient

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Defense Mechanism

• Acting out
• Repression
• Suppression
• Reaction Formation
• Denial
• Projection
• Identification

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Behavior Therapy

• Skinner, Watson
• Operant Conditioning
• Modeling
• Social Learning
• Exposure and response prevention

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Social Psychiatry

• Jung did not see Psychiatry as a purely medical
  treatment of disease, but more of a mental and
  physical and spiritual quest for wholeness. He
  points to a sacred journey on which not just the
  sick, but all humanity should embark.

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Supportive Therapy

• Empathic listening, may involve some advice and
  problem solving. Idea is to support ego capacity

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Cognitive Therapy

• Belief systems and distorted Thinking
• Cognition effects Feeling
• Countered Learned Helplessness
• Controlled Studies show effective less in
  depression

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Interpersonal Therapy

• A structure short term therapy shown to be
  effective in controlled studies for depression
  
• Focus relationship on one specific problem over
  10-12 sessions

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Dialectical Behavior Therapy

• Develop by Masha Linneman, Phd
• Combined cognitive and behavioral psychodynamic
  and existential concepts in educational approach
• Documented effective for Para suicidal people and
  borderline personality

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Family Therapy

• Many schools of thought
• Clarify or interpret family dynamics
• Work with whomever in family will come
• Needs to be done by different clinician than
  individual therapist

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Group Therapy

• May be psycho-educational, like a class
• Or psych-dynamic, interpreting transference and
  resistances
• Or supportive

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Family Psycho-educational

• Includes family members and identified patient in
  educational problem solving classes on
  vocational, recovery, medical topics
• Seeks to maximize use community resources and
  support systems

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DSM IV System of Diagnostics
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Descriptive Diagnostic Criteria1970s

• Specific criteria to develop more homogenous
  research samples
• A move away from psycho-dynamics other theory
• Getting ready for managed care

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Expert Consensus plus field testing

• A big money maker for American Psychiatric Assn
• Attempts to coordinate the ICD system
• Attempts to fit subjective distress into the
  medical model which is criticized
• Some diagnosis is more reimbursable than others

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AXIS I

• Most Psychiatric Diagnosis are here
• Sometimes require for payment eligibility

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AXIS II

• Difference form Axis I questioned
• Mental Retardation Personality Disorder are
  stigmatized as unchangeable
• Some Axis II may be attributed to AXIS I spectrum
  of disorders

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AXIS III

• Non-psychiatric medical diagnosis
• Neurological, Dementia, Deliria and sleep
  disorders

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AXIS IV

• Psychosocial disorders that contribute to
  distress

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AXIS V

• Global Assessment of Function 1-100
• Psychological, social, and occupational
  functioning

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Appendix Adecision trees

• Helps to understand Hierarchal structure of
  DSM-IV diagnoses

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Appendix B Diagnoses for further study

• Hardly vestigial, this is the growing edge of DSM
• Premenstrual, Dysmorphic Disorder
• Post-psychotic depressive disorder of
  schizophrenia
• Minor and belief disorders
• Binge-eating disorder
• Neuroleptic malignant syndrome
• Other movement disorders due to medication

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Glossary (appendix C)

• Helpful in defining terms one might find on a test

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ICD-9 Codes(appendix H)

• Used by some insurance systems

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Anxiety and Adjustment Disorders
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Overview

• 15 of people have anxiety
• Abandonment, fear is Existential
• Freud classified this as Ego Malfunction with
  conflict
• Monozygotic concordance with Panic 85

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Panic Attacks in DSM IV

• First recognized in 19th century-Soldier Heart
• Clearly differentiated form chronic anxiety
  states in DSM-III
• Lactate and CO2 triggers became classic arguments
  for biological etiology
• 1-2 population has Panic Disorder, gt women
• Need to rule out cardiac disorder, hyperthyroid,
  pheocromocytoma , vestibular problems

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Phenomenological of Panic

• A discrete period of intense fear or discomfort
  in which 4 of the 13 symptoms appear rapidly and
  peak within 10 minutes
• Symptoms
• Palpitation
• Sweating
• Trembling
• SOB
• Choking
• Chest pain
• Nausea
• Dizzy
• Derealization
• Fear of loosing control
• Fear of Dying
• Chills/Hot Flashes
• Parasthesias

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Panic Disorder Criteria DSM IV

• Recurrent unexpected panic attacks
• One month or more of
• Persistent worry about attacks
• Worry about the consequences
• Persistent change in Behavior

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Behavioral Treatment of PANIC

• Cognitive Therapy
• Relaxation/breathing
• R/O ETOH, Caffeine
• Stress Management

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Medical Treatment of Panic

• SSRI
• TCAs
• MAOIs
• Benzodiazepines
• Relapse Rate varies with amount of education and
  psycho-therapy

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Agoraphobia in DSM IV

• Anxiety about being places or in situations where
  escape of help might not be available in case of
  panic
• Situations are avoided or endured with marked
  distress

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Treatment of Agoraphobia

• Exposure and response prevention
• Practice and Stopping Paradigms
• In Vivo Behavior Therapy

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Generalized Anxiety Disorder

• Excessive anxiety and worry more days than not
  for 6 months about several events or activities
• Difficult to control the worry
• Worry not part of another Axis I disorder
• Three or more of
• Restless/on edge
• Easy Fatigue
• Difficulty concentrating/mind blank
• Irritabilty
• Muscle Tension
• Sleep Disturbances

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Treatment of GAD

• Cognitive Behavior Therapy
• Most Antidepressants
• Benzodiazepines
• Buspirone
• Non-habit forming
• Slow acting-a couple of days
• Low in side effects

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Specific Phobia in DSM IV

• Unreasonable/excessive fear of specific object or
  situation
• Exposure provokes anxiety response, which could
  be panic
• Fear is recognized as unreasonable
• Treatment is exposure and response prevention
• Animal, Natural, environmental, blood etc.
• 2-1 female predominance

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Social Phobia in DSM IV

• Marked Fear or Social Performance
• Exposure provokes anxiety or Panic
• Fear unrecognized as excessive
• Situation are avoided or ended with distress
• If under age 18, must last 6 months
• Generalized or specific

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Treatment of Social Phobia

• Specific forms mostly fear of public speaking
• Responds to exposure and support-Toastmasters
• Beta blocker help
• Generalized Form more persistent
• May respond to SSRI
• CBT
• Possible overlap with personality disorder
• 3 in both men and women

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PTSD in DSM IV part 1

• Exposed to threat or death or serious injury of
  self/other
• Response of Fear, Horror, helplessness
• Trauma is re-experience persistently
• Intrusive or distressing thoughts
• Recurrent Bad Dreams
• Reliving Flashbacks of Events
• Intense distress at cues
• Physiological Reactivity with Cues

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PTSD in DSM-IVpart 2

• Persistent avoidance of cues and numbing
• Avoids thoughts, feeling, talk of event
• Avoids people, places, activities related to
  event
• Cant remember aspects of trauma
• Diminished interest/withdrawal
• Restricted affect
• Foreshortened future expected

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PTSD in DSM-IVpart 3

• Persistent Symptoms of Arousal with 2 below
• Insomnia
• Irritability
• Cant concentrate
• Hyper-vigilance
• Exaggerated startle response
• Disturbances must last 1 month
• Acute less than 3 months
• Chronic more than 3 months
• Delayed onset- gt 6 months later

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Treatment of PTSD

• May treat anxiety and depressive symptom with
  medication
• Support, group therapy with similar patients
• Gradual desensitization to and reorganization
  traumatic event memories
• PTSD may be unrecognized if co-occurring with
  other disorders
• 30 rape victims and Vietnam veterans have PTSD

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Acute Stress Disorder in DSM-IV

• Traumatic exposure as in PTSD
• Three or more during or after event
• Emotional numbing
• Dazed
• Derealization
• Depersonalization
• Dissociative amnesia
• Re-experienced regularly on cue exposure
• Avoidance of cue or recollection
• Marked symptoms of Anxiety/arousal
• Lasts 2-29 days---start within 29 day
• Lasts short-starts early

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Obsessive-compulsive DSM IV part 1

• Must have obsessions or compulsions
• Obsessions need ALL 4
• Intrusive thoughts that cause distress
• Not just real life worries
• Attempts to ignore, suppress or neutralize
• Recognized as a product of own mind

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OCD--continued

• Compulsions need both
• Repetitive behaviors that person feels driven top
  perform
• Aim is to prevent harm or dreaded event, but not
  in a realistic way
• Obsessions or compulsions recognized as
  unreasonable at some point
• Obsession/compulsions cause distress, take over 1
  hour, or mar routine
• Not just focused on other AXIS I issue.(food,
  hair, weight, drugs, sex, etc.)

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Treatment of OCD

• 1-3 of Population in US
• TLE, Pos-Streptococcal syndromes may mimic
• Exposure and response prevention
• WASHERS, CHECKERS, COUNTERS
• Medications partially helpful
• Clomipramine
• High-dose SSRI
• Possibly anti-psychotics if delusional

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General Psychiatric Co-morbidities with anxiety

• Depression?common with GAD
• Substance Abuse self-treatment
• Pyschosis

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Medical Co-morbidities with Anxiety

• Meds with side effectsXanthines to antibiotics
• Hypoxia
• Fear of Illness/Pain
• Post anesthesia syndrome

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Adjustment Disorder in DSM IV

• Emotional or Behavioral Symptoms in Response to a
  stressor within 3 months of onset
• Either
• Marked Distress in excess of expected response
• Significant social or occupational impairment
• Not bereavement
• Not an exacerbation of a previous Axis I disorder
• Acute if less lt 6 months
• Chronic if greater gt 6 months

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Sub-types of Adjustment Disorder in DSM IV

• With Depressed Mood
• With anxiety
• With mixed anxiety and depressed mood
• With disturbances of conduct
• With mixed disturbances of emotions and conduct
• Unspecified

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MOOD DISORDERS
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Major Depressive Episode DSM IV

• 5 Symptom for 2 weeks
• Must include depressed mood or anhedonia (or
  both)
• 5 weight change in a month or consistent
  appetite change
• Insomnia/Hyper-somnia
• Observed psychomotor agitation or retardation
• Persistent Fatigue or loss of energy
• Worthlessness inappropriate guilt
• Decreased concentration or indecisiveness

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Emil Kraepelin distinguished schizophrenia from
mood disorders in 1899. ECT developed by
Cerletti BiniJohn Cade discovered antimanic
properties of Lithium in 1949 Antidepressant
medications introduced in late 1950s
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Manic Episode in DSM IV

• Elevated, expansive or irritable mood for 1 week
• 3 symptoms (4 if irritable)
• Grandiosity
• Less sleep
• Pressured speech
• Racing thought/Flight of Ideas
• Distractibility
• Increased Goal directed activity or agitation
• Pursues pleasure at high risk
• Causes Marked impairment

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Hypo-manic Episode

• As Manic-less time around 4 days
• No Marked impairment

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Major Depressive Disorder DSM-IV

• No Mania Allowed
• With psychotic features
• With Catatonia-no response
• With Melancholia-everything is all right
• With Postpartum onsets within 4 weeks
• 10-25 women, half as many men
• Divorce increase risk
• First degree relatives 2-3X more likely to get it

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MDD with Catatonia DSM-IV

• 2 of the listed below-
• Catalepsy/waxy flexibility or stupor
• Excessive motor activity
• Negativism/mutism
• Posturing-stereotypy
• Echolalia/echopraxia (mimicking)

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MDD with Melancholia DSM-IV

• Must have Anhedonia-loss of pleasure
• 3 of the following
• Distinct changemood quality
• Early AM waking
• Psychomotor agitation
• Anorexia or Weight loss
• Excess Guilt

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MDD with Atypical Features in DSM-IV

• Mood Reactivity
• Two of the following
• Weight gain
• Hyper-somnia
• Leaden paralysis
• Rejection sensitivity

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MDD with Post-PartumDSM IV

• Must be within 4 weeks Postpartum

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MDD with Seasonal PatternDSM IV

• Episode and periods of remission follow seasonal
  pattern
• At least 2 episodes linked to season and none
  out of season within the last 2 years
• Lifetime episodes tend to be seasonal

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Rapid Cycling Mood Disorderin DSM-IV

• 4 Episodes in one year with 2 months remission
  between each

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Mixed Mood EpisodeDSM-IV

• Meets Criteria for both Manic and Major
  Depressive episode nearly every day for 7 days

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Dysthymic Disorder in DSM-IV

• Most days depressed for 2 years (adult) Children
  need to show irritability-1 year
• 2 symptoms from list
• Appetite disturbances
• Sleep disturbances
• Low energy/fatigue
• Low self-esteem
• Problems concentrating, decisions
• Hopeless feelings
• No MDE for 2 years
• No mania, hypomania, or cyclothymia
• No 2 month period between episodes
• Effects about 6 of people-women 2-3X men. Less
  than ½ develop MDD or Bipolar

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Double Depression (not DSM)

• Refers to superimposed Dysthymic Disorder and
  Major Depression
• Effects 25 with MDD
• Must be Dysthymic first

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Bipolar I II

• Bipolar I with Mania in DSM-IV
• Bipolar II with hypomania, requires some
  depressive episodes in DSM-IV
• More worse depression in Bipolar II
• Bipolar I gender neutral
• Bipolar I inherited at higher rate than MDD or
  Schizophrenia

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Cyclothymia in DSM-IV

• 2 years of hypomanic and depressive symptoms that
  do not make MDE
• No 2 month period of remission for 2 years
• No MDE first 2 years
• After 2 years, may occur with major mood disorder
• 1/3 Cyclothymics Progress to Bipolar
• 2/3 Remain Stable

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ECT for Depression and Mania

• Often works faster than medication
• Indication for psychotic depression
• Memory loss usually transient, not a therapeutic
  effect
• Stigma reduces access
• 8-12 sessions in most cases
• Bi-frontal stimulation

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Course Outcomes of Mood Disorders

• 10-15 of Mood disorders patients suicide
• Episodes get worse and more frequent over time if
  untreated
• 6 months therapy in first episode
• 50 bipolar do well on lithium
• 60-70 response in major depression to
  antidepressants
• Placebo better in depression than mania

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Antidepressants

• Tricyclics-late1950s
• (Tofranil,Pamalor, Doxapin)
• Dry mouth, Constipation, sedation are common
• Can cause mild withdrawal
• Toxic if overdose
• MAOIs
• Require care with diet, serotonergic medications
  and indirect acting stimulants contraindicated
• May be more effective with Bipolar Depression
• Weight gain, hypotension
• Avoid Tyramine (Wine, Cheese)
• P450 OXIDATION Decreased with MAOI

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Antidepressants Cont-SSRI

• Less toxic in overdose
• May be more effective in pre-menopausal women
• Cognitive and sexual side effect
• Rare but significant akithesia
• Interact with TCAs and MAOIs
• Serotonin Syndrome
• Increased TCA levels do to p450 effect
• Overlapping can cause mild Serotonin
  Syndromestiffness, nausea, diarrhea, fever
• SIGNIFICANT HYPERTHERMIA-

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Other Antidepressants

• Bupropian?Ziban or Wellbutrin (antichol)
• May reduce smoking---no wgt gain or sexual
  effects
• Caution regarding pro-ictal effects
• Venlafaxine
• Dual agent SSRI-like and Noradrenergic-May cause
  mild increase in BP
• Nefadozone
• Lack of sexual side effect (but significant p450)
• Bad with Statins
• Mirtazepine
• Newer

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Mood Stabilizers

• LITHIUM CARBONATE
• Weight gain, tremors, polyurea, THYROID disorders
• Toxicity confusion, diarrhea, delirium, nausea
• CARBAMEPAZINE (Tegretol)
• May cause rash, decreased WBCs
• High maintenance-revs up p450
• SODIUM VALPROATE
• Can be loaded fast
• Weight gain, amenorrhea, tremor
• Thrombocytopenia at HIGH doses

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Mood Stabilizers in Pregnancy

• Thorazine (Chlorpromazine)
• A phenothiazine with antiemetic properties no
  specifics known adversely for pregnancy
• Melleril (Thioridazine)
• Good in combative states-hyper excitability
• Also has antiemetic properties, phenothiazine
• Both dopamine blockade, are extrapyrimidal
  (another is Stelazine)

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Anti-psychotics a mood stabilizers

• Dopamine blocking neuroleptics can restrain mania
  acutely and chronically-long acting shots or
  oral versions
• SIDE EFFECT-TARTIVE DYSKINESIA
• New Atypical antipsychotics may have mood
  stabilizing effect
• Olanzapine
• Risperidone
• Quetiapine
• Ziprasidone
• These agents are very expensive compared to other
  mood drugs

78
Mood Stabilizers as Antidepressants

• Lithium, Carbamepazine, Lamotrigine all have
  antidepressant properties, especially in bipolar
  disorder

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DEPAKOTE (valproic acid)

• Primarily a seizure medication that can be used
  in absence seizure, as well as associated
  Migraines

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How long to treat bipolar disorder?

• Indefinitely, if clear recurrent symptoms
• Psychotherapy can help with acceptance of illness
• Strong relationships with support group
  counteracts loss of insight
• 50 usually dually diagnosed with substance abuse

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Stress, Sleep, and Substances

• All can exacerbate moods
• Normalizing sleep and addressing psychotic and
  suicidal thinking top priorities
• Get drugs and alcohol out of the way
• Steroids and thyroid can provoke manic picture

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Social Learning and Reinforcement Theories in
Depression

• Work, recreation, exercise may all have
  antidepressant effect
• Change in routine, loss of supports may trigger
  depression
• First episode of depression may be stressor
  related
• But recurrent episodes may be of kindling

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Schizophrenia and Dissociative Disorders
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DSM-IV criteria for Schizophrenia

• At least 2 of the following (6 months)
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms
• Running commentary (voices)-fixed

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DSM IV Schizophreniform

• Same criteria as schizophrenia, except symptoms
  last from 1-6 months
• Good prognostic features
• Psychiatric features begin within 4 weeks of
  behavioral change
• Confusion/perplexity with psychosis
• Good premorbid function
• Affect not flat or blunted
• Does not require a decline in function

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DSM IV Brief Psychotic Disorder

• One of the symptom list for schizophrenia other
  than negative symptoms
• Lasts one day to one month
• May specify with or without marked stressors, or
  post-partum if within 4 weeks of delivery

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OLD ANTI-PSYCHOYIC MEDS-NEUROLEPTICS

• D2 blocking neuroleptics
• Chloropromazine (Thorazine)
• Haldoperodol (Haldol)
• Thifluoroperazine (Stelazine)
• Fluphenazine (Prolixin)
• Molindone (Moban)
• Haldol and Fluphenazine may be given in long
  lasting injection

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Chlorpromazine (Thorazine)

• Phenothiazine with D2 blockade. 3 sedative
  effectvery moderate extra-pyramidal effects
• Used in psychosis and mania
• Also used in acute intermittent porphyria
• Migraine headache
• SE-SEDATION

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Haldoperol

• Heterocylic compound with low anticholinergic
  effects, yet high extra-pyramidal side effects
• Considered a butyrophenone-

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Perphenanazine (Trilafon)

• Phenothiazine with low to moderate
  anticholinergic and low to moderate
  extrapyrimidal
• D2 phenothiazine-
• Used with Hiccoughs
• Used in Hemi-ballismus
• Tourettes

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Fluphenazine (Prolixin)

• D2 Phenothiazine with low anticholinergic and
  high extra-pyrimidal side effects
• Can be given in long acting IV
• Considered a depot drug for Torrettes

92
Molindone (Moban)

• A heterocyclic compound with moderate
  anticholinergic and moderate extra-pyramidal
• Least likely to cause seizure

93
Side effects of Older Antipsychotics

• Akinethesia
• Dystonia
• Tardive Dyskinesia
• Neuroleptic Malignant Syndrome
• Parkinsonism
• Cognitive and mood disorders

94
Akithesia

• Subjective-inner restlessness
• Pacing-cant sit still
• Also associated with SSRIs
• Responds to Beta-blockers or benzodiazapines

95
Dystonia

• Opisthotnos, Oculgyric crisis common
• May effect any muscle group
• Anticholinergics and antihistimine may be given
  IM or IV
• Atropine or Neostigmine
• Life threatening if it effects the tongue or
  Respiration

96
Tardive Dykinesia

• Occurs in 50 of patients with chronic Dopamine
  D2 Blockade
• Spastic twitching of mouth, tongue, fingers, but
  may be truncal or ballistic
• Movement disorder may be part of another disorder
  as well
• May improve with lower doses or switch to an
  atypical

97
Parkinsonism

• Idiopathic
• Mask faces, stiff gait, reduced arm swing
• Need to distinguish from depression
• Very common with Thorazine
• Give Dopa/Carbidopa

98
Neuroleptic Malignant Syndrome

• May be life threatening
• Ridgitity, increased CPK
• Hyperthermia and confusion
• Possible common pathway in Catatonia
• GIVE DANTROLENE

99
Cognitive and Mood effects of Dopamine Blockers

• Dysphoria-mental slowing
• May be partially relieved by smoking tobacco
• Leads to discontinuation
• Reduces PLEASURE Principle

100
Newer Antipsychotic and Side Effects

• Clozapine-(Clozaril)
• Aplastic anemia, seizures, weight gain
• Olanzapine-(Zyprexa)
• Weight gain
• Resperidone-(Risperdal)
• Increased Prolactin
• Quetiapine-(Seroquel)
• Cataracts in Beagles
• Ziprasidone-(Geodan)
• QTc Interval worry

101
Other Interventions

• Mood Stabilizers
• Benzodiazapines-helpful in Catatonic State
• ECT-(First Year)
• Cognitive Therapy may be helpful

102
Mental Status in Schizophrenia Spectrum

• Affect may be flat, blunted or inappropriate
• Hallucinations, usually auditory, formed or
  unformed, like a sound, not just a thought
• Thought content may be delusional, ideas of
  reference
• Though form includes a word salad, echolalia,
  loose associations
• Orientation and memory usually intact
• Poor insight common

103
Prognosis of Schizophrenia

• Majority live independently in community
• Family, employment, housing, positive symptoms,
  late onset and female gender improve outcomes
• Improved medications more effective with less
  side effects
• Prognosis has improved relative to affective
  disorder
• Still, 15 die of suicide lifetime

104
Prognosis of Acute Psychotic Disorder

• Precipitating trauma or stressor is good sign
• Treatment improves prognosis
• Preserved affective tone is a good sign

105
About hallucinations

• Frequently are uniformed
• Usually auditory
• May be tactile, gustatory or visual
• May be experienced as coming inside or outside
  person
• May be the voice of a known person
• Hearing a name called or voice of a dead relative
• May be part of a normal religious experience
• There are false sensory perception

106
Affect vs. Mood

• Affect describes range of mood and how it is
  globally expressed to observer verbally or
  non-verbally
• Blunted, labile, shallow, flat
• Mood is specific feeling tone from sad to
  euphoric, may have a distinct abnormal quality in
  melancholia

107
Delusions

• False beliefs that reject evidence
• Organized persistent delusions tend to persist
  despite treatment
• Do not assume unlikely belief is false or without
  some truth

108
Illusions

• Misperception of normal sensory function
• Common in children and delirium

109
Recovery/Survivor Movement

• Government support in US
• Skeptical toward forced treatment
• Believes symptoms need not be barrier to work or
  independence
• Favors self help/mutual help
• Questions medical model
• Supports closing hospitals

110
Epidemiology of Schizophrenia Spectrum

• 50 monozygotic concordance
• 1 of population across cultures
• Schizotypal personality in families12 of 1st
  degree relative get schizophrenia
• Seasonal patterns of birth suggest infectious
  etiology
• Onset is later in women
• African-americans may be over-diagnosed

111
Psychological Theories

• Ambiguous parental communication largely
  discounted now
• High expressed emotionexacerbates endogenous
  condition
• Inadaquate ego development or stimulus
• Fundamental cognitive problems, neural networking
  under investigation now

112
Differential Diagnosis

• Mood disorders with psychosis
• Borderline Personality may hear voices, brief
  psychosis
• Schizotypal personality old mannerisms, thoughts
  short of criteria
• Paranoid disorder/personalitylack formal thought
  disordernot bizarre
• Drug induced disorders

113
Schizophrenia Terms

• Thought broadcasting others can hear/know pts
  thoughts
• Catatoniaecholalia
• Thought insertion another person thought in
  patients head
• Delusions of reference unrelated experience has
  special meaning
• Loose associations thoughts do not usually
  follow each other
• Clang associationswords associated by sound not
  meaning
• Neologism a made up word

114
Dissociative Identity Disorder DSM IV

• Two or more distinct personalities-Three Faces of
  Eve
• At least two take control of behavior at times
• Inability to recall extensive personal
  information
• Not due to alcohol, medical issues, or in
  children fantasies

115
Depersonalization DisorderDSM IV Criteria

• Feeling of being outside of self
• Intact reality testing
• Causes significant distress or problems in
  function
• Not part of other Medical or Psychiatric disorder

116
Dissociative Fugue DSM IV criteria

• Sudden travel away from home
• Forgetting past, taking on a new one in a new
  place
• Culture bound syndromes of AMOK, PIBLKLOG, GRISI
  SIKNIS fall into this category

117
Dissociative disorderNOS in DSM IV

• Dissociative trance disorder an unusual loss of
  identity interpreted as possession
• Dissociative states brought on by torture or
  brainwashing
• Situations where criteria for dissociative
  disorder is only partially met
• Derealization without depersonalization

118
Atypical Psychotic Syndromes

• Shared Psychotic disorder sicker one dominates
• Capgras syndrome delusions that people one
  knows are imposters
• Coutards syndrome nilhilistic delusions that
  the world or body parts are gone
• Autoscopic pyschosis illusion that ones own body
  part
• Koro delusion that genitalia are being absorbed
  into ones body

119
Delusional Disorder DSM IV

• Non-bizarre Delusions involving real life
  possibilities, lasting one month or more
• Does not meet criteria for schizophrenia
• Outside of delusions functioning not impaired
• Mood problems brief relative to periods of
  delusions

120
Types of delusions

• Erotomanic delusions that another loves them
• Grandiose delusions of wealth or inflated worth
• Jealous delusion that partner is unfaithful
• Somatic delusion of persecution
• Mixed form above
• Unspecified

121
Personality Disorder, Substance Abuse and Eating
Disorders
122
Overview of Personality Disorders

• Longstanding, stable pattern of behavior
• Causes Distress or impairment
• Not explained by Axis I disorder
• Pattern of inner experience and behavior deviates
  markedly from cultural expectation

123
Cluster A Odd

• Paranoid PD
• Schizoid
• Schizotypal

124
Paranoid PD Distrust and suspicion

• Need 4 from list
• Suspects other exploit or harm them
• Unjustified doubts about others loyalty
• Reluctant to confide in others
• Reads insults or threats into benign events
• Unforgiving
• Perceives attacks on reputation reacts
• Suspects infidelity of partner for no reason

125
Schizotypal PDOdd, Cognitive, distortions

• Need 5 from list (THINK OF STORY TELLER)
• Ideas of reference
• Odd or magical beliefs
• Perceptual distortions
• Odd thinking or speech
• Suspicious/paranoid ideas
• Inappropriate or constricted affect
• Eccentric Behavior
• Lacks Friends
• Social Anxiety

126
Schizoid PD Detached

• Needs 4 from list
• Does not desire relationships
• Solitary
• Little sexual activity
• Few pleasures
• Lacks friends
• Indifferent to critics
• Detached or cold

127
Cluster B

• Antisocial PD
• Histrionic PD
• Borderline PD
• Narcissistic PD

128
Antisocial PD Criminal

• After age 15, has 3 criteria
• Repeated law breaking
• Deceitful lies
• Impulsive
• Irritable and aggressive
• Disregard for safety
• Irresponsible
• No remorse

129
Borderline PD Unstable

• Needs 5 of these
• Frantic to avoid abandonment
• Unstable relationships
• Unstable identity
• Impulsive
• Suicidal/cutting
• Mood shifts
• Feels empty
• Inappropriate rage
• Brief Paranoia/Dissociation

130
Histrionic PDexcess emotion

• Needs 5 below
• Seeks attention
• Seductive
• Shallow mood shifts
• Uses physical appearance
• Vague speech
• Dramatic
• Suggestible
• Imagine intimacy

131
Narcissistic PD Grandiose

• Needs 5
• Self Important
• Fantasies of Glory
• Feels special
• Seeks admiration
• Entitled
• Exploitative
• Lacks empathy
• Envious
• Arrogant

132
Cluster C

• Obsessive-Compulsive
• Dependent
• Avoidant

133
Obsessive-Compulsive

• Needs 4 of list
• Preoccupied with details
• Perfectionism
• All work, no play
• Over scrupulous
• Cant delegate
• Miserly
• Stubborn

134
Dependent PD Clinging

• Needs help deciding
• Wants other responsible
• Cant say no
• Afraid to start things
• Seeks nurturance
• Feels helpless alone
• Always in relationship
• Fears solitude

135
Avoidant PD Fears risk

• Avoids activities or relationships that might
  involve rejection or criticism
• Low self-esteem

136
Treatment of Personality Disorder

• Medication may help depression, anxiety or mood
  stability
• Building insight through relationship with
  therapist
• Setting limits/confronting acting out/impulsive
  acts
• Borderline PD responds to dialectical behavior
  therapy
• Avoid Hospitalization

137
Eating Disorders

• Bulimia Nervosa
• Anorexia Nervosa
• Obesity

138
Bulimia Nervosa in DSM-IV

• Binging
• Eating too much in a specific time
• Lack of controlled eating
• Compensatory Behavior for weight purge, fasting,
  and exercise
• Behaviors occur twice a week for three months
• Focus on body shape weight
• Separate from Anorexia Episodes, if any
• Purging and non-purging types may be specified

139
Anorexia Nervosa in DSM IV

• Refusal to keep body weight at 85 or more
• Fear of gaining weight distorted awareness of
  body weight

140
Dementias
141
Dementia Types

• Alzheimers Dementia
• Vascular Dementia
• Picks Disease
• Creutzfield-Jakobs
• Huntingtons Chorea
• Parkinsons Disease
• Wilsons Disease

142
Alzheimers Dementia

• Memory loss that effects job skills
• Difficulty with familiar tasks
• Problems with language
• Disorientation to time place
• Problems with abstract thought
• Poor judgment
• Changes in personality, mood and behavior
• Loss of initiateve
• ACCULMULATION OF AMYLOID PLAQUES ON
  NEUROFIBRILTORY TANGLES

143
Vascular Dementia

• Patchy deterioration in cognitive function post a
  cerebovascular accident
• Men gt women
• 15 of all dementias
• Most prevalant between 60-70 Years

144
Picks Disease

• Atrophy of the frontal and temporal lobes
• Very rare
• Personality changes due to frontal lobe

145
Creutzfield-Jakobs

• Dementia causes by an unknown prion-some
  indicators suggest similarities with Mad Cow
  disease
• Rapidly progressive, onset in the 40s
• Fatal within 2 years

146
Huntingtons Chorea

• Autosomal dominant
• Defect in Chromesome 4
• Males Females
• BASAL GANGLIA AND CAUDATE
• Chorionic movements and dementia
• Onset between 30-40
• Psychosis progresses to infantile state
• Death in 15-20 years

147
Parkinsons Disease

• Decreased dopamine in substantia nigra
• Symptoms
• Bradykinesia
• Tremors
• Masklike face
• Shuffling gait
• Cogwheel rigidity
• TX- L-Dopa, Carbidopa, and deprnyl

148
Wilsons Disease

• Defect in Chromosome 13
• Ceruloplasmin deficiency
• Abnormal copper metabolism
• Kaiser-Fleischner rings

149
Defense Mechanism
150
Defense mechanism types

• Mature
• Altruism
• Humor
• Sublimation
• Suppression

151
Altruism

• Guilty feelings are subdued by honost unsolicited
  generosity of time and money to others

152
Humor

• Appreciating the amusing nature of an anxiety
  provoking stimuli

153
Sublimation

• Process where one replaces an unacceptable wish
  with one that fits ones moral beliefs

154
Suppression

• A voluntary (unlike other defense mechanisms) in
  which one withholds an idea or feeling awareness

155
Defense mechanism types

• Immature
• Acting Out
• Dissociation
• Displacement
• Fixation
• Identification
• Isolation
• Projection
• Rationalization
• Regression
• Repression
• Splitting

156
Acting Out

• Unacceptable feeling or thought are expressed via
  obtuse actions

157
Dissociation

• Temporary, changes in personality, consciousness,
  and memory, sometimes to a drastic level, in a
  avoidance of the emotional stressor

158
Displacement

• Avoidance of the awareness of some painful reality

159
Fixation

• Partially remaining at a more childish level of
  developement

160
Identification

• Modeling behavior after another person who is
  more powerful

161
Isolation

• Separation of the feelings from ideas of events

162
Projection

• An unacceptable internal impulse attributed to an
  external source

163
Rationalization

• To proclaim some sort of a logical reason for
  actions that would appear morally unacceptable,
  in order to actually a avoid self-blame

164
Reaction- Formation

• Warding off an idea or feeling which is replaced
  (unconsciously) with emphasis on the opposite
  idea or feeling

165
Regression

• Turning back to a lesser mature state or earlier
  time to deal with stressor in todays world

166
Repression

• Involuntary withholding an idea from conscious
  awareness. The precursor mechanism to other
  immature defences

167
Splitting

• Belief that people are either good or bad, ie
  saying all physicians are cold and insenstitive

168
THE END