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  1. How is ADHD diagnosed?
    • A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
    • 1. Inattention:.a. fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities. b. Often has difficulty sustaining attention in tasks or play activities (e.g., has diffi­culty remaining focused during lectures, conversations, or lengthy reading).c. does not seem to listen when spoken to directly. d. does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace. e. has difficulty organizing tasks and activities .f. avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort .g. loses things necessary for tasks or activities .h. Is easily distracted by extraneous stimuli.  i. Is forgetful in daily activities.
    • 2. Hyperactivity and impuisivity: a. Often fidgets with or taps hands or feet or squirms in seat.b. Often leaves seat in situations when remaining seated is expected .c.runs about or climbs in situations where it is inappropriate. d. unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor” .f. talks excessively. g. Often blurts out an answer before a question has been completed h. has difficulty waiting his or her turn i. interrupts or intrudes on others 
    • .B.  prior to age 12 years.
    • C. present in two or more set­tings (e.g., at home, school, or work; with friends or relatives; in other activities)
  2. What is the course of ADHD?
    • In preschool, the main manifestation is hyperactivity.
    • Inattention becomes more prom­inent during elementary school.
    • During adolescence, signs of hyperactivity (e.g., running and climbing) are less common and may be confined to fidgetiness or an inner feeling of jitteriness, restlessness, or impatience.
    • In adulthood, along with inattention and restless­ness, impulsivity may remain problematic even when hyperactivity has diminished
  3. What are the RF for ADHD?
    • Genetic of dopamine, serotonin and glutamate related genes
    • Reversed or absent asymmetry of the caudate nucleus, smaller cerebral and cerebellar volume, smaller posterior corpus callosum regions.
    • Smaller prefrontal cortical volumes and reduced thickness of the anterior cingulate cortex, as well as cortical thinning in bilateral superior frontal brain regions
    • Reduced global activation and reduced local activation in the area of the basal ganglia and anterior frontal lobe.
    • ADHD is characterized by atypical frontal-striatal function and that methylphenidate affects striatal activation differently in ADHD than in healthy children.
    • Impaired executive functions and/or difficulties with response inhibition which are consistent with structural and functional abnormalities in prefrontal structures and basal ganglia regions
    • Prenatal exposure to tobacco
    • VLBW
  4. What are the functional consequences of ADHD?
    • Academic deficits, school-related problems, and peer neglect tend to be most associ­ated with elevated symptoms of inattention,
    • whereas peer rejection and, to a lesser extent, accidental injury are most salient with marked symptoms of hyperactivity or impulsivity.
  5. What are the ADHD comorbidities?
    • ODD--> MC
    • CD
    • Learning disability
    • Anxiety 
    • Depression
  6. What are the benefits of each type of medication for ADHD?
    • stimulants have a rapid onset of action and long record of safety and efficacy--> DOC
    • Atomoxetine may be more appropriate than stimulants for patients with a history of illicit substance use or FH of drug abuse (slow onset of action)
    • Alpha-2-adrenergic agonists as third choice
  7. What are the major problems with ADHD drugs?
    • Poor growth
    • Insomnia
    • Poor appetite
  8. How is specific learning disorder diagnosed?
    • A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties:
    • 1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incor­rectly or slowly and hesitantly, frequently guesses words, has difficulty sounding out words).
    • 2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings of what is read).
    • 3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
    • 4. Difficulties with written expression (e.g., makes multiple grammatical or punctua­tion errors within sentences; employs poor paragraph organization; written expres­sion of ideas lacks clarity).
    • 5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of arithmetic computation and may switch procedures).
    • 6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying math­ematical concepts, facts, or procedures to solve quantitative problems)
    • B. The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, and cause significant interference with academic or occupational performance, or with activities of daily living, as confirmed by individu­ally administered standardized achievement measures and comprehensive clinical assessment.
    • C. The learning difficulties begin during school-age years
  9. What is the diagnosis of developmental coordination disorder?
    • A. The acquisition and execution of coordinated motor skills is substantially below that ex­pected given the individual’s chronological age and opportunity for skill learning and use. Difficulties are manifested as clumsiness (e.g., dropping or bumping into objects) as well as slowness and inaccuracy of performance of motor skills (e.g., catching an object, using scissors or cutlery, handwriting, riding a bike, or participating in sports).
    • B. The motor skills deficit in Criterion A significantly and persistently interferes with activ­ities of daily living appropriate to chronological age (e.g., self-care and self-mainte­nance) and impacts academic/school productivity, prevocational and vocational activities, leisure, and play.
    • C. Onset of symptoms is in the early developmental period.
    • MC comorbidity-->ADHD
  10. How is Stereotypic Movement Disorder diagnosed?
    • A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body).
    • B. The repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury.
    • C. Onset is in the early developmental period.
    • Begin<3 years (tic between 5-7 and variable)
    • Deficits of social communication and reciprocity manifesting in ASD are generally absent in stereotypic movement disorder, and thus social interaction, social communication, and rigid repetitive behaviors and interests are distinguishing features.
  11. What is tic?
    A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.
  12. Tourette’s Disorder
    • A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently.
    • B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
    • C. Onset < 18 years.
  13. Persistent (Chronic) Motor or Vocal Tic Disorder
    • A. Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal.
    • B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset.
    • C. Onset is before age 18 years.
  14. What are the types of tics?
    • Tics can be either simple or complex.
    • Simple motor tics are of short duration (i.e., milli­seconds) and can include eye blinking, shoulder shrugging, and extension of the extrem­ities. Simple vocal tics include throat clearing, sniffing, and grunting often caused by contraction of the diaphragm or muscles of the oropharynx.
    • Complex motor tics are of lon­ger duration (i.e., seconds) and often include a combination of simple tics such as simul­taneous head turning and shoulder shrugging. Complex tics can appear purposeful, such as a tic-like sexual or obscene gesture (copropraxia) or a tic-like imitation of someone else's movements (echopraxia). Similarly, complex vocal tics include repeating one's own sounds or words {palilalia), repeating the last-heard word or phrase (echolalia), or uttering socially unacceptable words, including obscenities, or ethnic, racial, or religious slurs (coprolalia).
  15. What are the associated comorbidities with tic disorders?
    • ADHD
    • OCD
  16. How is delusional disorder diagnosed?
    • A. The presence of one (or more) delusions with a duration of 1 month or longer.
    • B. Criterion A for schizophrenia has never been met.Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).
    • C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd

    • Can be of several types
  17. What are the features of jealous subtype of delusional disorder?
    • In jealous type, the central theme of the delusion is that of an un­faithful partner.
    • This belief is arrived at without due cause and is based on incorrect infer­ences supported by small bits of "evidence" (e.g., disarrayed clothing).
    • The individual with the delusion usually confronts the spouse or lover and attempts to intervene in the imagined infidelity
  18. What are the features of somatic subtype of delusional disorder?
    Most common is the belief that the individual emits a foul odor; that there is an in­festation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are misshapen or ugly; or that parts of the body are not functioning
  19. What are the diagnostic features of catatonia?
    • A. The clinical picture is dominated by three (or more) of the following symptoms:
    • 1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
    • 2. Catalepsy (i.e., passive induction of a posture held against gravity).
    • 3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
    • 4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
    • 5. Negativism (i.e., opposition or no response to instructions or external stimuli).
    • 6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
    • 7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
    • 8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
    • 9. Agitation, not influenced by external stimuli.
    • 10. Grimacing.
    • 11. Echolalia (i.e., mimicking another’s speech).
    • 12. Echopraxia (i.e., mimicking another’s movements).
  20. What are considered neurodevelopmental disorders?
    • ADHD
    • ASD
    • Learning disorder
    • Intellectual disability
    • developmental coordination disor­der, stereotypic movement disorder, and tic disorders
    • Communication disorders
  21. How is disruptive mood dysregulation disorder diagnosed?
    • A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or be­haviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
    • B. The temper outbursts are inconsistent with developmental level.
    • C. The temper outbursts occur, on average, three or more times per week.
    • D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).
    • E. Criteria A-D have been present for 12 or more months. Throughout that time, the indi­vidual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D.
    • F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.
    • G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.
    • H. By history or observation, the age at onset of Criteria A-E is before 10 years.
    • Note: This diagnosis cannot coexist with oppositional defiant disorder (DMDD must be made only), intermittent ex­plosive disorder (only DMDD), or bipolar disorder (persistent irritability in DMDD/ grandiosity and elated mood in BMD)
  22. What is the major significance of DMDD?
    • High comorbidity rate (more than other childhood disorder)
    • highest overlap with ODD
  23. Premenstrual dysphoric disorder
    • A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.
    • B. One (or more) of the following symptoms must be present:1. Marked affective lability (e.g., mood swings: feeling suddenly sad or tearful, or in­creased sensitivity to rejection)
    • 2. Marked irritability or anger or increased interpersonal conflicts. 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.
    • C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).2. Subjective difficulty in concentration.3. Lethargy, easy fatigability, or marked lack of energy.4. Marked change in appetite; overeating; or specific food cravings.5. Hypersomnia or insomnia.6. A sense of being ovenwhelmed or out of control.7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain
    • all symptoms for most cycles during the preceding year
  24. What is the mc comorbid condition with  PMDD?
  25. Depression with mixed feature
    • A. At least three of the following manic/hypomanic symptoms are present nearly every day during the majority of days of a major depressive episode:1. Elevated, expansive mood.2. Inflated self-esteem or grandiosity.3. More talkative than usual or pressure to keep talking.4. Flight of ideas or subjective experience that thoughts are racing.5. Increase in energy or goal-directed activity (either socially, at work or school, or sexually) 6. Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual in­discretions, foolish business investments).7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia).
    • B. Mixed symptoms are observable by others and represent a change from the per­son’s usual behavior.
    • C. For individuals whose symptoms meet full criteria for either mania or hypomania, the diagnosis should be bipolar I or bipolar II disorder
  26. Depression with melancholic feature
    • A. One of the following is present during the most severe period of the current epi­sode:1. Loss of pleasure in all, or almost all, activities.2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).
    • B. Three (or more) of the following;1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.2. Depression that is regularly worse in the morning.3. Early-morning awakening (i.e., at least 2 hours before usual awakening).4. Marked psychomotor agitation or retardation.5. Significant anorexia or weight loss.6. Excessive or inappropriate guilt
  27. Depression with seasonal pattern
    • A. There has been a regular temporal relationship between the onset of major depres­sive episodes in major depressive disorder and a particular time of the year (e.g., in the fall or winter).Note: Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors (e.g., regularly being unemployed every winter).
    • B. Full remissions (or a change from major depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring).
    • C. In the last 2 years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined above and no nonseasonal major de­pressive episodes have occurred during that same period.
    • D. Seasonal major depressive episodes (as described above) substantially outnum­ber the nonseasonal major depressive episodes that may have occurred over the individual’s lifetime
  28. Separation anxiety disorder
    • A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures
    • 2. Persistent and excessive worry about losing major attachment figures or about pos­sible harm to them, such as illness, injury, disasters, or death.3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.7. Repeated nightmares involving the theme of separation.8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nau­sea, vomiting) when separation from major attachment figures occurs or is antici­pated.
    • B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
    • C. The disturbance causes clinically significant distress or impairment in social, aca­demic, occupational, or other important areas of functioning.
  29. What is the mc anxiety disorder in children?
  30. What are the RF for separation anxiety?
    • Genetic
    • life stress
  31. In children, separation anxiety disorder is highly comorbid with ...........................
    generalized anxiety disorder and specific phobia.
  32. Selective mutism
    • A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.
    • B. The disturbance interferes with educational or occupational achievement or with social communication.
    • C. The duration of the disturbance is at least 1 month (not limited to the first month of school).
    • D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
  33. What is the mc comorbidity with selective mutsim?
    Social anxiety disorder> separation anxiety and specific phobia
  34. OCD
    • A. Presence of obsessions, compulsions, or both:
    • Obsessions are defined by (1) and (2):1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
    • Compulsions are defined by (1) and (2):1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to per­form in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or dis­tress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neu­tralize or prevent, or are clearly excessive.

    B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  35. What is the epidemiology of OCD?
    • Chronic
    • F slightly more than M
    • <35 y
  36. What are OCD RF?
    • Greater internalizing symptoms, higher negative emotionality, and behavioral inhibition
    • Stressful life events
    • monozygotic of 60%
    • Dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum 
    • The abnormal activity was found to increase during symptom provocation, and to normalize with successful treatment
    • abnormalities in glutamatergic signaling in cortico-striatal pathways
  37. What are the comorbidites of OCD?
    • MC--> other axniety
    • MDD
    • Tic
    • OCPD
  38. How is OCD diagnosed from other disorders?
    • The recurrent thoughts that are present in GAD (i.e., worries) are usually about real-life concerns, whereas the obsessions of OCD usually do not involve real-life concerns and can include content that is odd, irrational, or of a seemingly magical nature; moreover, compulsions are often present and usually linked to the obsessions
    • In BDD, the obsessions and compulsions are limited to concerns about physical appearance; and in trichotillomania (hair-pulling disorder), the compulsive behavior is limited to hair pulling in the absence of obsessions.
    • Hoarding disorder symptoms focus exclusively on the per­sistent difficulty discarding or parting with possessions, marked distress associated with discarding items, and excessive accumulation of objects.
    • A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization (e.g., eye blinking, throat clearing). A stereotyped movement is a repetitive, seemingly driven, nonfunctional motor behavior (e.g., head banging, body rocking, self-biting). Tics and stereotyped movements are typically less complex than compulsions and are not aimed at neutralizing obsessions. Whereas compulsions are usually preceded by obsessions, tics are often preceded by premonitory sensory urges
    • Obsessive-compulsive personality disorder is not characterized by in­trusive thoughts, images, or urges or by repetitive behaviors that are performed in re­sponse to these intrusions; instead, it involves an enduring and pervasive maladaptive pattern of excessive perfectionism and rigid control.
  39. What is the treatment for OCD?
    • CBT
    • SSRI (high dose)
    • if not--> clomipramine, or venlafaxine
    • Augmentation with risperidone
  40. Hoarding disorder
    • A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
    • B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
    • C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).
    • D. The hoarding causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning (including maintaining a safe environ­ment for self and others).
    • Excessive acquisition by buying or collecting items discarded by others is common
    • Indecisiveness
    • Comorbid MDD or anxiety
  41. Trichotillomania (Hair-Pulling Disorder
    • A. Recurrent pulling out of one’s hair, resulting in hair loss.
    • B. Repeated attempts to decrease or stop hair pulling.
    • comorbid with MDD excoriation (skin-picking) disorder.

    Individuals with OCD and sym­metry concerns may pull out hairs as part of their symmetry rituals, and individuals with body dysmorphic disorder may remove body hair that they perceive as ugly, asymmetri­cal, or abnormal;
  42. Excoriation disorder (skin picking)
    • A. Recurrent skin picking resulting in skin lesions.
    • B. Repeated attempts to decrease or stop skin picking.
    • Comorbid with OCD and trichotillomania
  43. Reactive Attachment Disorder
    • A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregiv­ers, manifested by both of the following:1. The child rarely or minimally seeks comfort when distressed.2. The child rarely or minimally responds to comfort when distressed. 
    • B. A persistent social and emotional disturbance characterized by at least two of the following:1. Minimal social and emotional responsiveness to others.2. Limited positive affect.3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
    • C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
    • 2. Repeated changes of primary caregivers that limit opportunities to form stable at­tachments (e.g., frequent changes in foster care).3. Rearing in unusual settings that severely limit opportunities to form selective at­tachments (e.g., institutions with high child-to-caregiver ratios).
    • D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Cri­terion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
    • E. The criteria are not met for autism spectrum disorder.
    • F. The disturbance is evident before age 5 years.
    • G. The child has a developmental age of at least 9 months.
  44. What is the only RF for reactive attachment disorder?
    Serious social neglect
  45. How is reactive attachment disorder differentiated from ASD?
    • The restricted interests and repetitive behaviors characteristic of autism spectrum disorder are not a feature of reactive attachment disorder
    • No history of social neglect in ASD
  46. What are the comorbidities of RAD?
    • cognitive delays, language delays, and stereotypies
    • Malnutrition
  47. Disinhiblted Social Engagement Disorder
    • A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:1. Reduced or absent reticence in approaching and interacting with unfamiliar adults.2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.4. Willingness to go off with an unfamiliar adult with minimal or no hesitation.
    • B. The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyper- activity disorder) but include socially disinhiblted behavior.
    • C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.2. Repeated changes of primary caregivers that limit opportunities to form stable at­tachments (e.g., frequent changes in foster care).3. Rearing in unusual settings that severely limit opportunities to form selective at­tachments (e.g., institutions with high child-to-caregiver ratios).
    • D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Cri­terion A (e.g:, the disturbances in Criterion A began following the pathogenic care in Criterion C).
    • E. The child has a developmental age of at least 9 months.
  48. Somatic symptom disorder
    • A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
    • B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.2. Persistently high level of anxiety about health or symptoms.3. Excessive time and energy devoted to these symptoms or health concerns.
    • C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
  49. What are the features of somatic symptom disorder?
    • MC-> pain
    • May co-occur with medical illness particularly in the elderly
    • In children, the most common symptoms are recurrent abdominal pain, headache, fa­tigue, and nausea
    • Comorbid anxiety and depression (neuroticism)
    • Attention focused on somatic symptoms
    • Attribution of normal bodily sensations to physical illness (possibly with catastrophic interpretations)
    • Fear that any physical activity may damage the body
  50. What are some DDx with somatic symptom disorder?
    • Illness anxiety disorder: excessive worry about health but no somatic symptoms
    • Somatic subtype of delusional disorder: delusional belief of somatic disorder
    • Conversion disorder: In conversion disor­der, the presenting symptom is loss of function (e.g., of a limb), whereas in somatic symptom disorder, the focus is on the distress that particular symptoms cause.
  51. Illness anxiety disorder
    • A. Preoccupation with having or acquiring a serious illness.
    • B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or dispro­portionate.
    • C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
    • D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doc­tor appointments and hospitals).
    • E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
    • Two subtype: care seeking/care avoidant
  52. What are some DDx of illness anxiety disorder?
    • Adjustment disorder: <6 m
    • GAD: worry about multiple events, situations, or activities, only one of which may involve health
    • OCD: in illness anxiety disorder, the preoccupations are usually focused on having a disease, OCD, the thoughts are intrusive and are usually focused on fears of getting a disease in the future
  53. True or false: psychosomatic disorders can have delusional belief or bizarre delusions
  54. Conversion Disorder (Functional Neurological Symptom Disorder)
    • A. One or more symptoms of altered voluntary motor or sensory function.
    • B. Clinical findings provide evidence of incompatibility between the symptom and recog­nized neurological or medical conditions.
    • With wealcness or paralysis/ With abnormal movement/ With swallowing symptoms/ With speech symptom/ With attacks or seizures/ With anesthesia or sensory loss/ With special sensory symptom
  55. What are some examples of incompatibility with neurological symptoms?
    • Hoover's sign, in which weakness of hip extension returns to normal strength with con­tralateral hip flexion against resistance.
    • Marked weakness of ankle plantar-flexion when tested on the bed in an individual who is able to walk on tiptoes;
    • Positive findings on the tremor entrainment test. On this test, a unilateral tremor may be identified as functional if the tremor changes when the individual is distracted away from it. This may be observed if the individual is asked to copy the examiner in making a rhythmical movement with their unaffected hand and this causes the functional tremor to change such that it copies or "entrains" to the rhythm of the unaffected hand or the functional tremor is suppressed, or no longer makes a simple rhythmical move­ment.
    • In attacks resembling epilepsy or syncope ("psychogenic" non-epileptic attacks), the occurrence of closed eyes with resistance to opening or a normal simultaneous electro­encephalogram (although this alone does not exclude all forms of epilepsy or syncope).
    • For visual symptoms, a tubular visual field (i.e., tunnel vision).
  56. What are some features of conversion disorder?
    • Preceding stress
    • Dissociative symptoms
    • Maladaptive personality traits
    • Childhood abuse
    • The presence of neurological disease that causes similar symp­toms is a risk factor 
  57. What are the DDx for conversion disorder?
    • Neurological (most important)
    • Somatic symptom disorder--> not incompatible with pathophysiology
    • Factitious disorder and malingering: The diagnosis of conversion disorder does not require the judgment that the symptoms are not intentionally produced (i.e., not feigned), because assessment of conscious intention is unreliable. However definite evidence of feigning (e.g., clear evidence that loss of function is present during the examination but not at home) would suggest a diagnosis of factitious disorder if the individual's apparent aim is to assume the sick role or malingering if the aim is to obtain an incentive such as money.
  58. What are the comorbidities of conversion disorder?
    • Anxiety disorders, especially panic disorder, and depressive disorder
    • Neurological
    • Somatic symptom disorder
    • Personality disorder
  59. Psychological Factors Affecting Other Medical Conditions
    • A. A medical symptom or condition (other than a mental disorder) is present.
    • B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways:1. The factors have influenced the course of the medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition.2. The factors interfere with the treatment of the medical condition (e.g., poor adher­ence).3. The factors constitute additional well-established health risks for the individual.4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention.
    • C. The psychological and behavioral factors in Criterion B are not better explained by an­other mental disorder (e.g., panic disorder, major depressive disorder, posttraumatic stress disorder)
  60. What are some examples of psychological factors affecting other medical conditions?
    • Psychological or behavioral factors include psychological distress, patterns of interper­sonal interaction, coping styles, and maladaptive health behaviors, such as denial of symp­toms or poor adherence to medical recommendations.
    • Common clinical examples are anxiety-exacerbating asthma, denial of need for treatment for acute chest pain, and manipulation of insulin by an individual with diabetes wishing to lose weight.
    • The adverse effects can range from acute, with imme­diate medical consequences (e.g., Takotsubo cardiomyopathy) to chronic, occurring over a long period of time (e.g., chronic occupational stress increasing risk for hypertension).
    • Af­fected medical conditions can be those with clear pathophysiology (e.g., diabetes, cancer, coronary disease), functional syndromes (e.g., migraine, irritable bowel syndrome, fibro­myalgia), or idiopathic medical symptoms (e.g., pain, fatigue, dizziness).
  61. What are some DDx of psychological factors affecting other medical conditions
    Adjustment disorders. Abnormal psychological or behavioral symptoms that develop in response to a medical condition are more properly coded as an adjustment disorder (a clin­ically significant psychological response to an identifiable stressor). For example, an indi­vidual with angina that is precipitated whenever he becomes enraged would be diagnosed as having psychological factors affecting other medical conditions, whereas an individual with angina who developed maladaptive anticipatory anxiety would be diagnosed as hav­ing an adjustment disorder with anxiety
  62. Factitious Disorder
    • Factitious Disorder Imposed on Self
    • A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. B. The individual presents himself or herself to others as ill, impaired, or injured.C. The deceptive behavior is evident even in the absence of obvious external rewards.
    • Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy) A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.B. The individual presents another individual (victim) to others as ill, impaired, or injured.C. The deceptive behavior is evident even in the absence of obvious external rewards.
    • Note: The perpetrator, not the victim, receives this diagnosis.
  63. What are some examples of factious disorder?
    • report feelings of depression and suicidality following the death of a spouse despite the death not being true or the individual's not having a spouse;
    • decep­tively report episodes of neurological symptoms (e.g., seizures, dizziness, or blacking out);
    • manipulate a laboratory test (e.g., by adding blood to urine) to falsely indicate an abnor­mality;
    • falsify medical records to indicate an illness;
    • ingest a substance (e.g., insulin or warfarin) to induce an abnormal laboratory result or illness;
    • or physically injure them­selves or induce illness in themselves or another (e.g., by injecting fecal material to produce an abscess or to induce sepsis)
  64. What are some DDx of factious disorder?
    • Caregivers who lie about abuse injuries in dependents solely to protect themselves from lia­bility are not diagnosed with factitious disorder imposed on another because protection from liability is an external reward
    • Malingering. Malingering is differentiated from factitious disorder by the intentional re­porting of symptoms for personal gain (e.g., money, time off work). In contrast, the diag­nosis of factitious disorder requires the absence of obvious rewards.
    • Conversion disorder (functional neurological symptom disorder). Conversion disorder is characterized by neurological symptoms that are inconsistent with neurological patho­physiology. Factitious disorder with neurological symptoms is distinguished from con­version disorder by evidence of deceptive falsification of symptoms
  65. Pica
    • A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
    • B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.
    • C. The eating behavior is not part of a culturally supported or socially normative practice.
    • D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder], autism spectrum disorder, schizophre­nia) or medical condition (including pregnancy), it is sufficiently severe to warrant ad­ditional clinical attention
    • Associated with ASD and MR
  66. Rumination disorder
    • A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
    • B. The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).
    • C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
    • No disgust or nausea or retching is present
    • Infants with rumination disorder display a characteristic position of straining and arching the back with the head held back, making sucking movements with their tongue.
  67. Avoidant/Restrictive Food Intake Disorder
    • A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoid­ance based on the sensory characteristics of food; concern about aversive conse­quences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).2. Significant nutritional deficiency.3. Dependence on enteral feeding or oral nutritional supplements.4. Marked interference with psychosocial functioning.
    • B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
    • C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced
  68. What are some comorbidities of Avoidant restrictive food intake disorder?
    Anxiety, OCD, ASD
  69. How is Avoidant restrictive food intake disorder diagnosed from anorexia nervosa?
    Restriction of energy intake relative to requirements leading to sig­nificantly low body weight is a core feature of anorexia nervosa. However, individuals with anorexia nervosa also display a fear of gaining weight or of becoming fat, or persis­tent behavior that interferes with weight gain, as well as specific disturbances in relation to perception and experience of their own body weight and shape. These features are not present in avoidant/restrictive food intake disorder, and the two disorders should not be diagnosed concurrently
  70. What are the complications associated with AN or BN?
    • AN--> myocardial atrophy, mitral valve prolapse, pericardial effusion, bradycardia, functional hypothalamic amenorrhea, antenatal and postpartum problems, osteoporosis, gastroparesis, and constipation, arrhythmia
    • BN--> dehydration, hypokalemia, menstrual irregularities, Mallory-Weiss syndrome, ipecac-induced myopathy, and erosion of dental enamel
  71. Binge eating disorder
    • A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
    • B. The binge-eating episodes are associated with three (or more) of the following:1. Eating much more rapidly than normal.2. Eating until feeling uncomfortably full.3. Eating large amounts of food when not feeling physically hungry.4. Eating alone because of feeling embarrassed by how much one is eating.5. Feeling disgusted with oneself, depressed, or very guilty afterward.
    • C. Marked distress regarding binge eating is present.
    • D. The binge eating occurs, on average, at least once a week for 3 months.
    • E. The binge eating is not associated with the recurrent use of inappropriate compensa­tory behavior as in bulimia nenvosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa
  72. Enuresis
    • A. Repeated voiding of urine into bed or clothes, whether involuntary or intentional.
    • B. The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
    • C. Chronological age is at least 5 years (or equivalent developmental level).
    • D. The behavior is not attributable to the physiological effects of a substance (e.g., a di­uretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder)
  73. What are RF for enuresis
    • delayed or lax toilet training and psychosocial stress.
    • delays in the develop­ment of normal circadian rhythms of urine production, with resulting nocturnal polyuria or abnormalities of central vasopressin receptor sensitivity, and reduced functional blad­der capacities with bladder hyperreactivity (unstable bladder syndrome)
    • Genetic
  74. Encopresis
    • A. Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether in­voluntary or intentional.
    • B. At least one such event occurs each month for at least 3 months.
    • C. Chronological age is at least 4 years (or equivalent developmental level).
    • D. The behavior is not attributable to the physiological effects of a substance (e.g., laxa­tives) or another medical condition except through a mechanism involving constipation.
  75. Hypersomnolence
    • A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:1. Recurrent periods of sleep or lapses into sleep within the same day.2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).3. Difficulty being fully awake after abrupt awakening.
    • B. The hypersomnolence occurs at least three times per week, for at least 3 months.
    • C. The hypersomnolence is accompanied by significant distress or impairment in cogni­tive, social, occupational, or other important areas of functioning.
    • R/o other causes
  76. What are the RF for hypersomnolence?
    • Viral infection
    • Genetic
  77. PSG in hyperomolence
    • Normal to prolonged sleep duration
    • short sleep latency
    • normal to increased sleep continuity.
    • The distribution of rapid eye movement (REM) sleep is also normal.
    • Sleep efficiency is mostly greater than 90%.
  78. DDx of hypersomnolence
    • "Long sleepers" (i.e., individuals who require a greater than average amount of sleep) do not have excessive sleepiness, sleep inertia, or automatic behavior when they obtain their required amount of nocturnal sleep. Sleep is reported to be refreshing
    • Breathing- related sleep disorders are suggested by a history of loud snoring, pauses in breathing during sleep, brain injury, or cardiovascular disease and by the presence of obesity, oro­pharyngeal anatomical abnormalities, hypertension, or heart failure
    • Narcolepsy: Individuals with hypersom­nolence typically have longer and less disrupted nocturnal sleep, greater difficulty awakening, more persistent daytime sleepiness (as opposed to more discrete "sleep at­tacks" in narcolepsy), longer and less refreshing daytime sleep episodes, and little or no dreaming during daytime naps. By contrast, individuals with narcolepsy have cataplexy and recurrent intrusions of elements of REM sleep into the transition between sleep and wakefulness (e.g., sleep-related hallucinations and sleep paralysis). 
  79. Circadian Rhythm Sleep-Wake Disorders
    • A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule.
    • B. The sleep disruption leads to excessive sleepiness or insomnia, or both.
    • C. The sleep disturbance causes clinically significant distress or impairment in social, oc­cupational, and other important areas of functioning
    • Delayed sleep phase type: A pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or convention­ally acceptable earlier time
    • Advanced sleep phase type: A pattern of advanced sleep onset and awakening times, with an inability to remain awake or asleep until the desired or con­ventionally acceptable later sleep or wake times
    • Irregular sleep-wake type: A temporally disorganized sleep-wake pattern, such that the timing of sleep and wake periods is variable throughout the 24- hour period
    • Non-24-hour sleep-wake type: A pattern of sleep-wake cycles that is not synchronized to the 24-hour environment, with a consistent daily drift (usually to later and later times) of sleep onset and wake times.
    • Shift work type: Insomnia during the major sleep period and/or ex­cessive sleepiness (including inadvertent sleep) during the major awake period asso­ciated with a shift work schedule (i.e., requiring unconventional work hours).
  80. What are the comorbities of circadian rhythm disorder?
    • Delayed sleep phase type is strongly associated with depression, personality disorder, and somatic symptom disorder or illness anxiety disorder.
    • Advanced--> mental disorder associated with early morning awakening
    • Irregular sleep-wake type is often comorbid with neurodegenerative and neurodevelopmental disorders
    • Blindness is often comorbid with non-24-hour sleep-wake type, as are depressive and bipolar disorders with social isolation.
    • Shift work type has been associated with increased alcohol use disorder, other substance use disorders, and depression and physical disorder
  81. Circadian rhythm disorders are diagnosed by .......
    sleep diary
  82. Parasomnia
    Include abnormal physiological, behavioral or experiential event occurring in  association with sleep or its stages
  83. Non-Rapid Eye Movement Sleep Arousal Disorders
    • A. Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following:1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual has a blank, staring face; is relatively un­responsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty. 2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually be­ginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.
    • B. No or little (e.g., only a single visual scene) dream imagery is recalled.
    • C. Amnesia for the episodes is present.
    • D. clinically significant distress or impairment of functioning.
  84. What are some RF associated with NREM sleep disorder?
    • Genetic
    • Sedative use, sleep deprivation, sleep-wake schedule disruptions, fa­tigue, and stress
  85. NREM sleep arousal disorders arise most commonly from........
    3rd and 4th stage of NREM in the first third of the night
  86. What are DDx of NREM sleep arousal disorders?
    • Nightmare disorder. In contrast to individuals with NREM sleep arousal disorders, in­dividuals with nightmare disorder typically awaken easily and completely, report vivid storylike dreams accompanying the episodes, and tend to have episodes later in the night. NREM sleep arousal disorders occur during NREM sleep, whereas nightmares usually oc­cur during REM sleep. Parents of children with NREM sleep arousal disorders may misinterpret reports of fragmentary imagery as nightmares
    • REM sleep behavior disorder. REM sleep behavior disorder may be difficult to distinguish from NREM sleep arousal disorders. REM sleep behavior disorder is characterized by episodes of prominent, complex movements, often involving personal injury arising from sleep. In contrast to NREM sleep arousal disorders, REM sleep behavior disorder oc­curs during REM sleep. Individuals with REM sleep behavior disorder awaken easily and report more detailed and vivid dream content than do individuals with NREM sleep arousal disorders. They often report that they "act out dreams.
  87. What are the comorbidities of NREM sleep arousal disorders?
    • Adult-->MDD, OCD
    • Children--> neurotic traits
  88. Nightmare disorder
    • A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical in­tegrity and that generally occur during the second half of the major sleep episode.
    • B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.
    • C. clinically significant distress or impairment of functioning.
    • D. Not caused by other problems or substance
  89. What are the comorbidites of nightmare disorders?
    • CAD
    • Cancer
    • Parkinson
    • Pain
    • Most mental disorder
  90. How is nightmare diagnosed from REM sleep behavior disorder?
    The presence of complex motor activity during fright­ening dreams should prompt further evaluation for REM sleep behavior disorder, which occurs more typically among late middle-age males and, unlike nightmare disorder, is as­sociated with often violent dream enactments and a history of nocturnal injuries. The dream disturbance of REM sleep behavior disorder is described by patients as nightmares but is controlled by appropriate medication.
  91. What are comorbidities with REM sleep behavioral disorder?
    • PD
    • MSA
    • Lewy Body
    • Narcolepsy
  92. Rapid Eye Movement Sleep Behavior Disorder
    • A. Repeated episodes of arousal during sleep associated with vocalization and/or com­plex motor behaviors.
    • B. These behaviors arise during REM sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later por­tions of the sleep period, and uncommonly occur during daytime naps.
    • C. Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented.
    • D. Either of the following:1. REM sleep without atonia on polysomnographic recording.2. A history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (e.g., Parkinson’s disease, MSA, LBD).
  93. RLS
    A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by all of the following:1. The urge to move the legs begins or worsens during periods of rest or inactivity.2. The urge to move the legs is partially or totally relieved by movement.3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night.
  94. What are some RF for RLS?
    • FH
    • Iron deficiency
    • Uremia
    •  BTBD9 genetic variant-->80% excess risk
    • SSRI can aggravate
    • Disturbances in the central dopa­minergic system and disturbances in iron metabolism. 
  95. What is the main comorbidites with RLS?
    • Depressive disorders, anxiety disorders, and attentional disorders 
    • Main medical --> CVD (also many others)
  96. What is the treatment of RLS?
    • Pramipexole
    • Ropinirole
    • Rotigotine (transdermal patch)
  97. Gender dysphoria in children
    • A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1):
    • 1. A strong desire to be of the other gender or an insistence that one is the other gen­der (or some alternative gender different from one’s assigned gender).
    • 2. In boys (assigned gender), a strong preference for cross-dressing or simulating fe­male attire: or in girls (assigned gender), a strong preference for wearing only typ­ical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
    • 3. A strong preference for cross-gender roles in make-believe play or fantasy play.
    • 4. A strong preference for the toys, games, or activities stereotypically used or en­gaged in by the other gender.
    • 5. A strong preference for playmates of the other gender.
    • 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (as­signed gender), a strong rejection of typically feminine toys, games, and activities.
    • 7. A strong dislike of one’s sexual anatomy.
    • 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
  98. Gender Dysphoria in Adolescents and Adults
    • A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:
    • 1. A marked incongruence between one’s experienced/expressed gender and pri­mary and/or secondary sex characteristics (or in young adolescents, the antici­pated secondary sex characteristics).
    • 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics be­cause of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated second­ary sex characteristics).
    • 3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
    • 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
    • 5. A strong desire to be treated as the other gender (or some alternative gender dif­ferent from one’s assigned gender).
    • 6. A strong conviction that one has the typical feelings and reactions of the other gen­der (or some alternative gender different from one’s assigned gender).
  99. onset of cross-gender behaviors is usually between ages...........and......... years.
    2 and 4
  100. What are RF for gender dysphoria?
    • high degree of atypicality of gender behavior makes the development of gender dysphoria and its persistence into adolescence and adulthood more likely
    • Having older brothers in males
    • No endocrine finding in male
    • Increased androgen levels in female
    • In gender dysphoria associated with a disorder of sex development, the likelihood of later gender dysphoria is increased if prenatal production and utilization (via receptor sensitivity) of androgens are grossly atypical relative to what is usually seen in individuals with the same assigned gender
  101. DDx of gender dysphora
    • Nonconformity to gender roles--> differentiate by distress and impairment in dysphoria
    • Transvestic disorder. Transvestic disorder occurs in heterosexual (or bisexual) adoles­cent and adult males (rarely in females) for whom cross-dressing behavior generates sex­ual excitement and causes distress and/or impairment without drawing their primary gender into question.
  102. What are the comorbidities of gender dysphoria?
    anxiety, depression, disruptive and impulse-control
  103. ODD
    • A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following cate­gories, and exhibited during interaction with at least one individual who is not a sibling.
    • Angry/Irritable Mood
    • 1. Often loses temper.2. Is often touchy or easily annoyed.3. Is often angry and resentful.
    • Argumentative/Defiant Behavior
    • 4. Often argues with authority figures or, for children and adolescents, with adults.5. Often actively defies or refuses to comply with requests from authority figures or with rules.6. Often deliberately annoys others.7. Often blames others for his or her mistakes or misbehavior.
    • Vindictiveness
    • 8. Has been spiteful or vindictive at least twice within the past 6 months.
  104. Features of ODD
    • Comorbid with CD and ADHD
    • Sequence : ADHD-->ODD (preschool)-->CD
    • RF are high levels of emotional reactivity, poor frustration tolerance/ bad child-rearing/
    • Also comorbid with anxiety and MDD
  105. What are DDx of ODD?
    • Conduct disorder: The behaviors of ODD are typically of a less severe nature than those of conduct disorder and do not include aggression toward people or animals, destruction of property, or a pattern of theft or deceit. Furthermore, ODD includes problems of emotional dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct disorder.
    • ADHD: In ADHD individual's failure to conform to requests of others is solely in situations that demand sustained effort and attention or demand that the individual sit still
    • Disruptive mood dysregulation disorder: ODD shares with dis­ruptive mood dysregulation disorder the symptoms of chronic negative mood and temper outbursts. However, the severity, frequency, and chronicity of temper outbursts are more severe in individuals with disruptive mood dysregulation disorder than in those with ODD. When the mood disturbance is severe enough to meet criteria for disruptive mood dysregulation disorder, a diagnosis of ODD is not given, even if all criteria for oppositional defiant disorder are met
  106. Intermittent Explosive Disorder
    • A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following;1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not re­sult in damage or destruction of property and does not result in physical injury to animals or other individuals.
    • 2. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occur­ring within a 12-month period.
    • B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors.
    • C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/ or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation).
    • At least 6 years of age
  107. Neurobiology of intermittent explosive disorder
    • Serotonergic abnormal­ities, globally and in the brain, specifically in areas of the limbic system (anterior cingulate) and orbitofrontal cortex
    • Enhanced Amygdala responses to anger stimuli
  108. What are the DDx of IED?
    • Diagnosis should not be made if behavioral outbursts occur only during other mental disorder 
    • Disruptive mood dysregulation disorder. In contrast to intermittent explosive disorder, disruptive mood dysregulation disorder is characterized by a persistently negative mood state (i.e., irritability, anger) most of the day, nearly every day, between impulsive aggressive out­bursts. Also DMDD only diagnosed if first symptom< 10 year and is not diagnosed after 18
    • Antisocial personality disorder or borderline personality disorder: the level of impulsive aggression in individuals with antisocial personality disorder or borderline personality disorder is lower than that in individuals with intermittent explosive disorder.
    • ADHD, conduct disorder, ODD. Individuals with any of these childhood-onset dis­orders may exhibit impulsive aggressive outbursts. Individuals with ADHD are typically impulsive and, as a result, may also exhibit impulsive aggressive outbursts. While indi­viduals with conduct disorder can exhibit impulsive aggressive outbursts, the form of ag­gression is proactive and predatory. Aggression in ODD is typically characterized by temper tantrums and verbal ar­guments with authority figures, whereas impulsive aggressive outbursts in intermittent explosive disorder are in response to a broader array of provocation and include physical assault
  109. CD
    • A. A repetitive and persistent pattern of behavior in which the basic rights of others or ma­jor age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the cate­gories below, with at least one criterion present in the past 6 months:
    • Aggression to People and Animals
    • 1. Often bullies, threatens, or intimidates others.2. Often initiates physical fights.3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people.5. Has been physically cruel to animals.6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).7. Has forced someone into sexual activity.
    • Destruction of Property
    • 8. Has deliberately engaged in fire setting with the intention of causing serious damage.9. Has deliberately destroyed others’ property (other than by fire setting).
    • Deceitfulness or Theft
    • 10. Has broken into someone else’s house, building, or car.11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering: forgery).
    • Serious Violations of Rules
    • 13. Often stays out at night despite parental prohibitions, beginning before age 13 years.14. Has run away from home overnight at least twice while living in the parental or pa­rental surrogate home, or once without returning for a lengthy period.15. Is often truant from school, beginning before age 13 years.
    • B. The disturbance in behavior causes clinically significant impairment in social, aca­demic, or occupational functioning.
    • C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.
  110. Features of CD
    • ODD is a precursor
    • Higher risk of persistence if early onset
    • RF: difficult temperament, lower IQ, bad family, bad peer group, genetic, Slower resting heart rate, Reduced autonomic fear conditioning, particularly low skin conductance
    • Abnormal functional imaging of affect regulatory and affect processing areas (frontotemporal-limbic connections involving the brain's ventral prefrontal cortex and amygdala)
  111. Difference between male and female CD
    • Males exhibit fighting, stealing, vandalism, and school discipline problems.
    • Females exhibit lying, truancy, running away, substance use, and prostitution.
  112. DDx of CD
    • ODD: ODD do not include aggression toward individuals or animals, destruction of property, or a pattern of theft or deceit. Furthermore, ODD in­cludes problems of emotional dysregulation (i.e., angry and irritable mood)
    • ADHD: ADHD behavior does not by it­self violate societal norms or the rights of others.
    • Intermittent explosive disorder. the aggression in individuals with inter­mittent explosive disorder is limited to impulsive aggression and is not premeditated, and it is not committed in order to achieve some tangible objective (e.g., money, power, intim­idation). Also, the definition of intermittent explosive disorder does not include the non­aggressive symptoms of conduct disorder
    • Adjustment disorders (with disturbance of con­duct or with mixed disturbance of emotions and conduct) should be considered if clinically significant conduct problems develop in clear association with the onset of a psychosocial stressor and resolve within 6 months of the termination of the stressor (or its consequences). Conduct disorder is diag­nosed only when the conduct problems represent a repetitive and persistent pattern
  113. Pyromania
    • A. Deliberate and purposeful fire setting on more than one occasion.
    • B. Tension or affective arousal before the act.
    • C. Fascination with, interest in, curiosity about, or attraction to fire and its situational con­texts (e.g., paraphernalia, uses, consequences).
    • D. Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
    • E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideol­ogy, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual de­velopmental disorder], substance intoxication).
    • F. The fire setting is not better explained by conduct disorder, a manic episode, or anti­social personality disorder.
  114. Kleptomania
    • A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
    • B. Increasing sense of tension immediately before committing the theft.
    • C. Pleasure, gratification, or relief at the time of committing the theft.
    • D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
    • E. The stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder
  115. Gambling disorder
    • A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the fol­lowing in a 12-month period:1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
    • 2. Is restless or irritable when attempting to cut down or stop gambling.
    • 3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
    • 4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).
    • 5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
    • 6. After losing money gambling, often returns another day to get even (“chasing” one’s losses).
    • 7. Lies to conceal the extent of involvement with gambling.
    • 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
    • 9. Relies on others to provide money to relieve desperate financial situations caused by gambling.
    • B. The gambling behavior is not better explained by a manic episode.
  116. Major neurocognitive disorder
    • A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and mem­ory, language, perceptual-motor, or social cognition) based on:
    • 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and 2. A substantial impairment in cognitive performance, preferably documented by stan­dardized neuropsychological testing or, in its absence, another quantified clinical assessment.
    • B. The cognitive deficits interfere with independence in everyday activities (i.e., at a min­imum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications).
    • C. The cognitive deficits do not occur exclusively in the context of a delirium.
  117. Mild neurocognitive disorder
    • A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual motor, or social cognition) based on:1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and 2. A modest impairment in cognitive performance, preferably documented by stan­dardized neuropsychological testing or, in its absence, another quantified clinical assessment.
    • B. The cognitive deficits do not interfere with capacity for independence in everyday activities (i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required).
    • C. The cognitive deficits do not occur exclusively in the context of a delirium.
  118. What are the strongest RF for major and mild neurocognitive disorder?
  119. NCD increases the risk of.......
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2013-10-28 08:42:24

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