Disorders

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Disorders

• Personality disorders

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DSM-IV general PD

• Enduring, inflexible, pervasive (across diff.
  Fields of functioning), causes disress, diff.
  From cultural norms, starting in
  adolescence/early adulthood
• Cognitions
• Affectivity
• Interpersonal functioning
• Impulse control
• Not due to other mental or physical

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Cluster A

• Odd

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Paranoid
4/7 criteria
Mrs Norris runs her own embroidery business. She
doesn't want to work for others because she
believes that everyone is against her and are
constantly plotting against her. Her neighbour
complimented her work but she is sure there was a
hidden meaning or a threat in the way she said
it. A tradesman came to fix the plumbing. She
just couldn't trust him. She was sure he was
copying some of her designs for his wife (who he
was saying embroiders). She bears grudges
against her neighbours because they asked her to
remove her clothes from the line. She used to be
married but her husband just made her too
jealous. She just couldn't believe that he would
even consider fooling around with other women
when she was so talented. He called her a
self-important bitch and left.
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Schizoid
(4/7 criteria) Assoc. Professor Sphinx doesn't
like developing relationships with his
colleagues. He likes the solitary activities of
the laboratory to the chatter of the staff room.
He's never cared for sexual relations, though
there'd been more than a few young honours
students who would have had him owing to his good
looks. So much for sex in fact he never seems to
take pleasure in any activities.
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Schizotypal personality disorder
5/9 criteria Loopus has no friends. He gets
anxious in company because hes very suspicious
of people. No wonder they look funny at him
though. He behaves strangely. He seems to think
and speak oddly in a vague kind of way and his
facial expressions are always flat. Hes got so
much on his mind what with all the references to
him on TV, he doesnt mind not socializing. He
sometimes has these strange illusions which has
made him have some odd beliefs and magical
thinking.
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Personality disorders Cluster B

• Dramatic

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Antisocial personality disorder
3/7 criteria Mr Arsifice managed to get himself
into the army by being deceitful about his
history of law breaking and arrests. Hed fit in
well of course because hes totally reckless
about the safety of himself and others. Hes got
no remorse about hurting others and hes one
irritable and aggressive bully constantly getting
into fights. Just like everything else hes
joined up out of impulsivity being totally
irresponsible about the debts hes got back
home. Some psychiatrist said he had conduct
disorder long before he turned 15 but it wasnt
til he turned 18 that his true criminality was
realised.
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Borderline PD
5/9 criteria Hellraisa is one intense, angry,
woman. Shes the local drug dealers girlfriend,
for a week at a time anyway. Her relationships
are unstable and intense and she spends them
idealising and then devaluing the poor guy.
Funnily enough for all her antics she tries
really hard to avoid abandonment. It doesnt
help that she has these some major mood swings
and often ends up cutting up at the end of a
downer. Or she might do something impulsive that
ends in disaster. It just seems Hellraisa
doesnt know who she is, as if her sense of
identity is disturbed. No wonder she constantly
complains of emptiness. Not empty enough though,
shes sure got some weird transient,
stress-related paranoid ideation or severe
dissociative symptoms sometimes!
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Histrionic PD
5/8 criteria Paris is a model, which is just
fine since she cant handle being in situations
where shes not the centre of attention. Shes
always trying get everyones attention with her
appearance, her high drama and being sexually
provocative. Shes not worth talking to of course
because shes got a simple tongue and is all
emotional but her feelings somehow seem fake
shallow. Funnily enough shell think youre a lot
more intimate with her than you are and will be
very suggestible.
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Narcissistic PD
5/9 criteria Bigshot is one arrogant prick.
Hes just an ordinary accountant but is obsessed
with fantasies of unlimited success. He treats
everyone at the office with such self-importance
that youd think he was the top dog. He sure
thinks hes something special and only the boss,
who he envies, deserves his conversation. He
seems to think hes entitled to every promotion
thats going and exploits others to get there.
Hes got no empathy for those he tramples on his
way to the top. Youd think he thinks well enough
of himself not to need it but he sure is a sucker
for admiration.
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Cluster C

• The anxious

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Avoidant personality disorder
4/7 criteria Ms Peabody is one shy woman. She
works from home because she doesnt like jobs
where shes gotta talk to people because they
might criticize or reject her. She sees herself
as socially inept and is all inhibited in social
situations. She was all restrained in her her
last intimate relationship so the guy upped and
left. Poor think she was only worried about being
shamed or ridiculed. Shes decided she doesnt
want to get involved with people unless shes
sure theyll like her. She doesnt even want to
take risks shes so worried shell end up
embarrassed.
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Dependent personality disorder
5/8 criteria Mrs Plain got married again almost
as a matter of urgency once Arthur left her. She
was morbidly afraid she was gonna be left to look
after herself. She sure couldnt be left alone,
she feels so helpless even when her hubby goes
out for the odd night. She stores up all her
decisions until he backs home and wants him to
take all the responsibility. No wonder Arthur
left, he couldnt rely on her to initiate any
projects on her own. She was so submissive, he
used to wish she would disagree with him
sometimes. In the end it all got too much for
him, her wanting nurturance and support all the
time.
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Obsessive-Compulsive Personality disorder
4/8 criteria Procrustus is a pilot who loves
the order of things hes gotta do more than the
flying itself. He used to be such a perfectionist
with assignments he would never get them done in
time. The airline loves him though as hes
dedicated to his work. Unlike some other pilots
hes too morally rigid to be sleeping around with
the poor hostesses and cause legal troubles. His
colleagues of course hate his guts for being such
a stubborn prig. He cant work with anybody
because theyve gotta do things exactly his way.
He wouldnt go out for drinks with them either
because hes such a miser. Just like it was
money he doesnt throw anything else away either
even though they might be useless.
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Borderline controversies
Valid construct? Kendell 2002 review suggests
its not as too much overlap with Axis I
disorders Relationship with Mood
disorder Gundersun 1991 suggest imaging/other
neurobiological evidence that impulsivity rather
than true mood instability may be the underlying
problem 5HT dysregulation
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Borderline PD vs other PS

• Zanarini et al. 1991. These are the most specific
  features
• Four features in the interpersonal domain
• Abandonment/ engulfment/ annihilation concerns
• Demandingness/ entitlement
• Treatment regressions
• Ability to arouse inappropriately close and/or
  hostile responses in professional caretakers
• Two features in the impulsivity domain
• Deliberately self-destructive acts
• Manipulative suicide efforts
• One feature form the cognitive domain
• Quasi-psychotic experiences, which are transient
  (lt2days), circumscribed (involving only one or
  two aspects of their life), and / or atypical
  delusions or hallucinations.

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Admitting a patient with BPD
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Disorders

• Sleep disorders

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Normal sleep
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Sleep regulation
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Sleep disorders and the DSM
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Sleep walking disorder

• Associated with
• Family history
• Sleep deprivation
• Stress / recent life event
• Drugs - sedative/hypnotic
• Drugs antihistamine (e.g. promethazine
  phenergan)
• More common in young children (due to increased
  slow wave sleep)

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Sleep hygeine (SH)
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1º insomnia mgt
Long-term hypnotic use If dependent already
(gt4-6 months) If pain/GMC No adverse
effects/safety concerns e.g. falls/cog. In
elderly A trial of reduction has bee undertaken
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Other sleep disorder dx mgt
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Miscellaneous disorders
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Disorders

• Postnatal disorders

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Post natal disorders
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Post natal disorders mother-baby admissions
Problems with some insurance providers funding of
a two-person admission
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Post-natal blues
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Post-natal depression
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Post-natal depression
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Post-natal psychosis
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Psych sequelae of abortion
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? risk of post abortion ?
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Disorders

• Other disorders

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Adjustment disorder
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Breavement

• Bereavement the fact of loss through death.
• Bereavement reaction any psychological,
  physiological, or behavioral response to
  bereavement
• Bereavement process an umbrella term that refers
  to the emergence of bereavement reactions over
  time.
• Grief the feelings and associated behaviours,
  such as crying, accompanying the awareness of
  irrevocable loss.
• Grieving process the changing affective state
  over time.
• Mourning the social expressions of grief,
  including funerals, visitations, and rituals.

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Complicated bereavement reactionThe risks
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Abnormal grief reactions

• Chronic grief last long and the deceased is
  idealised
• Hypertrophic grief is abnormally intense and
  associated with loss of function
• Delayed grief initial denial/minimal reaction
  leading to anger and guilt with a later reaction

• Male mortality in 1st year following death of
  spouse
• Accidents
• CVS
• Suicide
• Some infections

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Working Definition of Dissociation

• DSM IV a disruption of the integrated
  functions of consciousness, memory, identity or
  perception of environment
• Presentations in which there are disturbances of
  connection with current time self and external
  and internal environment including emotions,
  memories and other mental processes resulting in
  a complex range of mental disturbances
  potentially affecting all areas of mental life

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Dissociation
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Trauma and Dissociation - Janet

• When people are terrified the usual cognitive
  schemata are inadequate to create a mental
  construct which places the experience in the
  perspective of prior knowledge schemes causing
  it to be left unintegrated and to persist as a
  psychological automatism

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And Kihlstrom ( 1990s)

• Dissociation is mediated by a disruption in the
  links between semantic representatives and their
  contextual features. The critical item to context
  link cannot be performed
• Failure to arrange the memory linguistically
  leaves it to be organised on a somatosensory or
  iconic (perceptual) level as somatic sensations,
  behavioural re-enactments, nightmares or
  flashbacks

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Psychological Automatisms

• Psychological Automatisms very similar to
  dissociation
• Psychological automatism is a state of semi
  automatic or at least not so consciously directed
  activity mental and or physical
• Psychological because it has a conscious
  component i.e. accompanied by sensibility and
  consciousness

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Partial and Total Automatism

• Partial automatism Consciousness not totally
  dominated but a dissociated state manifests in a
  number of possible ways which are disconnected
  from personal consciousness
• Total automatism consciousness is totally
  dominated by a dissociated state

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Partial Automatisms

• Mannerisms eg finger crossing, hand wringing,
  clenched fists
• Altered sensations anaesthesia, hypoaesthesia,
  hyperaesthesia eg burned throat
• Self harm eg picking at sores, automatic self
  cutting or burning

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Total Automatisms

• Dissociative state eg re-enactment of trauma
• Fugue states
• Dissociative identity disorders

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Vulnerability

• Genetic predisposition
• Adverse attachment experiences particularly
  disorganised attachment Alan Schore
• Trauma history
• Fatigue
• Illness, physical and mental
• Debility
• Intoxication

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Range of Dissociative Phenomena Disturbances of
.

• Consciousness - altered states e.g. narrowing,
  trance, depersonalisation, derealisation
• Memory e.g. amnesia, blocking, hypo or
  hypermnesia, flashbacks, somatic memories
• Perceptual hallucinatory phenomena
• Motor e.g. manneristic or stereotypic behaviours
  and self harm

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Presentation as a Dissociative Disorder

• Dissociative Amnesia
• Dissociative Fugue sudden travel, amnesia for
  past, identity confusion (occasionally assumption
  of new identity)
• Dissociative Identity Disorder
• Depersonalisation Disorder
• Dissociative Disorder NOS
• (Dissociative Trance Disorder)

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Dissociation in Psychiatric Disorders

• Acute reactions to trauma or stress eg in acute
  stress reactions
• A symptom of other disorders eg depression,
  anxiety or PTSD, schizophrenia
• A habitual response pattern conditioned by a
  trauma history and triggered by internal or
  external trauma related cues eg borderline
  personality disorders, complex ptsd
• One or more of the dissociative disorders

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Miscellaneous disorders

• Pathological or Problem Gambling

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Gambling
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Gambling DSM

• 5 of 10
• Relationship with gambling
• Pre-occupied with gambling
• Relief gambling to deal with dysphoria
• Money amount keeps increasing
• Restless irritable when not gambling
• Cut down attempts repeated unsuccessful
• Chases losses
• Relationship with others
• Lies about how much
• Illegal acts to get money e.g. defrauds others
• Relationships damaged
• Relies on others to get more money for gambling

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Gambling
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Colleges suggestions re gambling

• Odds be made public for all forms
• Gamblers be told of the psychological harm caused
  to them
• Gamblers be told where to get help
• That help be available
• Research be done into harm/treatment

The college is keen to work with the industry in
advisory role but not to be seen
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Amnestic disorders
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REM sleep behaviour disorder
REM sleep behavior disorder (RBD), a REM
sleeprelated parasomnia, is characterized by
intermittent loss of REM sleep atonia with dream
enactment. Patients usually have clear recall of
the dream, and witnesses can relate the activity
to the dream mentation. Events are more likely to
occur in the later half of the night and do not
have stereotypic behavior. Injury to self or bed
partner is common. The prevalence of RBD is
unknown but appears to be more common in older
men and may be a precursor to select degenerative
neurologic disorders such as Parkinson disease,
multisystem atrophy, or Lewy body dementia.
Patients may also develop RBD from structural
lesions affecting the REM atonia pathway.
Medications such as serotonin reuptake blockers
and norepinephrine reuptake blockers have been
cited to provoke RBD. The diagnosis is usually
suggested by history and confirmed by
polysomnography. Recordings show persistent
muscle tone and complex behaviors during REM
sleep. Most patients respond to clonazepam at
bedtime, but success has been reported with
melatonin and donepezil.