women better than men (later onset and better premorbid)
good social support+regular schedule=do better
Estimated 15-45% of American homeless
5% suicide rate (especially early in illness)
Schizoaffective Disorder Overview
mood disorder integrated w/ active phase schizo sx
bipolar type or depressive type
Episode, remission, and severity specifiers
Not due to substance or medical condition
Major suicide risk
Schizoaffective Disorder Epidemiology
Lifetime prevalence <1%
M=F in bipolar type
F>M in depressive type
Female later than male
Bipolar type more common yng adl
Depressive type more common older adults
Schizoaffective Disorder Etiology
similar to schizophrenia with mood symptoms
, mood disorder with psychotic symptoms
, or concurrent expression of both.
Perhaps a group of heterogenious disorders.
likely variable and multifactorial
Schizoaffective Disorder Treatment:
Like Mood Disorders and Schizophrenia
both pharm & psycho etc therapy
Pharm-multi: antipsychotics, antidepressants, mood stabilizers, etc.
In some cases, ECT
Schizoaffective Disorder Course and Prognosis:
similar to mood disorder, according to type
or to schizophrenia, if positive psychotic symptoms are prominent.
Prognosis generally better than Schizophrenia but worse than mood disorder.
Schizophreniform Disorder: Clinical Features
Schizophrenia sx duration is 1-6 months.
r/o psychosis caused by substances or medical condition.
High comorbidity with mood and anxiety disorders.
Schizophreniform Disorder Treatment
Hospitalization often necessary
ECT may be indicated for depressed, catatonic patients
Respond quicker to antipsych than schiphren pt
3-6 month course of antipsychotic medication.
Schizophreniform Disorder: Course and Prognosis
Time limited episode with significant symptoms
60-80 additional episodes & progress to schizophrenia disorder.
Some experience 2-3 episodes (usually with a declining level of functioning)
Only few experience a single episode
Delusional Disorder - overview
Primarily a thought content disorder
The delusion, (fixed false belief) is usually systematized and possible (not bizarre and impossible like in schizophrenia)
Common delusions include:
being loved by a celebrity, being persecuted, being infected/poisoned, unfaithful partner
Be careful not to assume that all unlikely situations are delusions.
Delusional Disorder Epidemiology
0.2-0.3% prevalence in US
Delusional disorder Risk factors
elderly, sensory impairment,
isolation, recent immigration, lower socioeconomic status
Rarely seek treatment
Men more likely to have paranoid delusions
Women more likely to have delusions of love
Mean age of onset >40
etiology unknown but likely to have both biological and psychosocial factors.
A psychosocial stress may occur at the onset of a delusional disorder.
Need to rule out substances, neurological disorders, and other medical causes for mental status change with delusions.
Delusional Disorder Treatment
Generally regarded as treatment resistant
Focus on managing the impact of the delusion on the patient's life.
Medical intervention, antipsychotic medication, and hospitalization as needed.
If there is a shared delusional disorder, those who share the delusion must be seperated
Delusional Disorder Course and Prognosis
Sudden onset common (often accompanied by psychosocial stressor)
Patients with delusional disorder usually experience an increase in their delusion over time.
They seek help from police, FBI, lawyers, medical and surgical physicians for help with what they believe rather than mental health professionals because of their belief that the delusion is truth rather than a mental disorder.
Brief Psychotic Disorder
Sudden onset of psychotic condition
Lasts one day to one month
Most common in young adults
More common in women than men
May be seen in patients with certain personality disorders who may have biological and psychological predisposition
histrionic, narcissistic, paranoid, schizotypal, and borderline personality disorder
Brief Psychotic Disorder Diagnosis:
Psychotic symptoms for at least one day but less than one month
Not associated with mood disorder
Not caused by substance or medical disorder
1. presence of a stressor
2. absence of a stressor
3. postpartum onset
Brief Psychotic Disorder
If symptoms persist longer than a month consider other diagnosis:
Mood disorder with psychotic features
Psychotic disorder- unspecified
Psychotic disorder- substance induced
What is Domestic Violence?
pattern of abusive behaviors
used to manipulate and control an intimate partner or other family member
Initial treatment: support, talk, education about coping
Pharm: SSRIs 1st line; TCA antidepressants also supported
Psychotherapy: focus on support, education, development of coping skills, and acceptance of event
Psychodynamically oriented psychotherapy
Group and Family therapies
Other treatment modalities PTSD & acute stress
Relaxation and stress management
Eye movement desensitization and reprocessing (EMDR)
Relatively new, somewhat controversial
Patient focuses on the lateral movement of the clinician's finger while maintaining a mental image of the trauma allowing the patient to work through the trauma while in a state of deep relaxation. It is supported by patients and clinicians who have used it successfully.
Sx develop in as short as 1 week
may take up to decades
last at least 1 month, but often much longer.
Symptoms can fluctuate & intensify during times of stress.
Good prognosis: rapid onset and short duration (<6 mo),
good premorbid function, good social support
absence of other psychiatric, medical, or substance use disorders.
Very young and very old have more difficulty with trauma.
This diagnosis is widely used in clinical practice.
characterized by an emotional response to a stressful event
stress often financial or social
Adjustment d/o epi/eti
2-8% of general population
F 2x > M
Single women are at the highest risk
Frequently diagnosed in adolescents (male and female)
School problems, family issues, parental divorce
Etiology: stressor(s) involved, by definition.
Psychodynamic, Family, and Genetic factors also contribute (biopsychosocial)
Adjustment d/o Clinical Features
Appearance of emotional or behavioral symptoms
after, but within 3 months, of a stressor.
Sx don't always subside after the stress resolves.
If stressor continues, the disorder may become chronic.
Can occur at any age.
Physical symptoms most common in children and the elderly.
Symptoms vary considerably.
Depressed, anxious, and mixed features are common in adults.
Treatment for Adjustment Disorder
1Psychotherapy: Primary treatment
2Group therapy: similar stressor(s); e.g. cancer groups
~~With hospitalization is suicidality is high
~~With frequent contact outpatient; may involve case management
4Pharmacotherapy: Only for tx of specific sx for brief times.
CAM: in pt resisting psych intervention
Adjustment d/o Course and Prognosis
Txd pts return to normal level fx w/in 3m
Some develop mood disorders or substance use: mc teens
Risk for suicide is high in adolescents
50% had suicide attempts just prior to hospitalization
60% during hospitalization
Comorbid substance use disorders and personality disorders increase risk for suicide
unconscious defense mechanism
segregate any group of mental or behavioral processes from the rest of the person's psychic activity.
can disrupt memory, perception, consciousness, or motor fx
memory loss; the inability to recall something previously known.
Coded differently based on cause
sudden, unexpected travel with the inability to recall some or all of one's past,
may be accompanied by confusion about one's identity or assumption of a new identity.
persistent or recurrent feeling of detachment or estrangement from one's self.
feelings of unreality or of being detached from one's environment.
inability to recall important personal information
too severe to be explained by normal forgetfulness.
Dissociative amnesia Epi/eti
reported in 2-6% of the general population
usually reported in late adolescence and adults
Etiology: Psychosocial with high emotional or conflictual circumstances.
May be related to trauma, betrayal, or other psychosocial stress.
Dissociative amnesia Classic Presentation
dramatic, overt, florid presentation
brought quickly to medical attention
May include somatic or conversion symptoms, altered consciousness, depersonalization, derealization, trance, or age regression.
Depression and suicidal ideation are common.
History of abuse or trauma, often.
Dissociative amnesia Nonclassic Presentation
present with depression, mood swings, anxiety, ED, PD, or other problems .
may be experienced for self-harm/violent episodes.
Ie don't remember cutting self
MSE Questions to ask for dissociative amnesia
Do you ever have blackouts, blank spells, or memory lapses?
Do you ever "lose time" or have gaps in time?
Have you ever traveled a significant distance and not remembered getting there?
Do people tell you things you said or did that you don't recall?
Do you find objects in your possession that you don't remember acquiring?
Have you ever been told you have talents or abilities you do not know you have?
Do your preferences for food, music, clothes, etc. fluctuate?
Do you have gaps in your memory of major events or times in your life?
Do you notice that you tune out, not hearing all or part of what's said?
Dissociative Amnesia: Treatment
1 Cognitive Therapy: Identifying the cognitive distortions based in trauma may provide entry for the patient into the lost memory.
2Hypnosis: Used to contain, modulate, and titrate the intensity of symptoms; to aid controlled recall of dissociated memories; to provide support and ego strengthening ; and finally to promote working through and integration of the dissociated material.
3Somatic Therapies: no known pharmacotherapy however pharmacologically facilitated interviewing, done carefully, may be helpful in some cases.
4Group Psychotherapy: helpful in cases associated with PTSD
Dissociative Amnesia Course & prognosis
frequently resolves spontaneously when the person is removed from the traumatic or overwhelming circumstances and feels safe.
Chronic forms of generalized, continuous, or severe localized amnesia can occur and they can be profoundly disabling and require high levels of social support with intensive family caretaking or extended care facility.
If lost memories can be restored to consciousness , it is less likely the repressed memory will form a nucleus in the unconscious around which future amnestic episodes might develop.
after traumatic experiences or intoxication commonly resolve spontaneously.
If sx of mood, psychotic, or anxiety disorder-remits w/ tx of primary do
may have an episodic, relapsing and remitting, or chronic course.
often refractory to treatment.
Dissociative Identity Disorder
two +distinct identities or personality states (alters, self-states, alter identities, or parts).
can experience all of the symptoms of the other dissociative disorders (amnesia, fugue, depersonalization, derealization, and others).
Distinct IDs recurrently assume control of the person's behavior, mood, thoughts
each may have a specific age, gender, and other distinguishing characteristics.
Dissociative Identity Disorder epi/eti
Considered extremely rare, little epidemiological data exists. However it is estimated:
Female to Male ratio is anywhere from 5-9:1
Etiology: strongly linked to severe early childhood trauma,
usually physical or sexual abuse, reported in 85-97% of cases.
No evidence currently of genetic factors.
Dissociative Identity Disorder sx
>1 distinct personalities
wide variety of other symptoms including symptoms also found in PTSD, mood, somatic, anxiety , psychotic and obsessive-compulsive disorders.
Mental Status- many findings similar to other (above) disorders
Memory and Amnesia- lost time, black out spells, gaps in knowledge of personal history
Dissociative Alterations in Identity- "we" or "they" or "the angry one" or "the wife" or "the son" (rather than "my son")
Dissoci id Differential
Affective disorders; Psychotic disorders
Anxiety disorders; PTSD
Personality DO; Neurocognitive DO
Somatic Symptom; Factitious DO
Other Dissociative; Deep-trance
Dissociative id Treatment
Psychotherapy: requires a therapist comfortable with a range of interventions including:
psychoanalytic psychotherapy, cognitive therapy, behavioral therapy, hypnotherapy, and treatment of trauma survivors
Pharm: by sx/comorbid including antidepressants, anticonvulsants, and BZDs.
Electroconvulsive therapy (ECT): for some patients with refractory mood symptoms.
Adjunct therapies: group, family, self-help groups, art, music, occupational therapies and Eye Movement Desensitization and Reprocessing (EMDR)
Dissociative id Course and Prognosis
Little is known of the course of untreated
Some are thought to continue to live in a traumatic culture
Many are believed to die by suicide or as a result of high risk behavior.
Prognosis is particularly poor if patient has comorbid psychotic serious medical, refractory substance use, or eating disorder, antisocial personality features, current criminal activity, or ongoing abuse.
Reqr by all animals for normal brain fx
Adults req 6-9/24 hours
restorative, homeostatic, thermoregulation, & energy conservation
active, not passive process-high amt brain activity
phases quantitatively and qualitatively different from each other
Excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts (5 or more of the following 8)
1Needs to be center of attention
2Inappropriate sexually seductive or provocative behavior
3Rapidly shifting and shallow expression of emotions
4Consistently uses physical appearance to draw attention to self
5Speech is excessively impressionistic and lacking in detail
6Shows self-dramatization, theatricality, and exaggerated expression of emotion
7Is suggestive, i.e. easily influenced by others or circumstances
8Considers relationships to be more intimate than they actually are
Narcissistic PD DSM-5 (Table 22-7)
Grandiose thoughts or behaviors, need for admiration, lack of empathy (needs 5)
1Has a grandiose sense of self-importance
2Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3Believes that he or she is "special" and unique
4Requires excessive admiration
5Sense of entitlement
6Takes advantage of others
8Envious of others or believe others envy them
Avoidant PD DSM-5 (Table 22-8)
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, (need 4)
1Avoids activities involving interpersonal contact, due to fears of criticism, disapproval, or rejection
2Unwilling to get involved with people unless certain of being liked
3shows restraint within intimate relationships because of a fear of being shamed or ridiculed
4Preoccupied w/being criticized/rejected in social situations
5Inhibited in new interpersonal situations due to feelings of inadequacy
6Views self as socially inept, personally unappealing, or inferior to others
7Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
Dependant PD DSM-5 (Table 22-9)
A pervasive/excessive need to be taken care of; submissive, clinging behavior & fears of separation, begins early adulthood; (needs 5)
1 Difficulty making everyday decisions
2 Needs others to assume responsibility for most major areas of his or her life
3Difficulty expressing disagreement with others
4Has difficulty doing things on his or her own because of a lack of self-confidence
5Excessive lengths to obtain nurturance and support from others
6Discomfort or helpless when alone
7Urgently seeks another relationship when a close relationship ends
8 Is unrealistically preoccupied with fears of being left to take care of himself or herself
OC PD DSM-5 Criteria (Table 22-10)
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, begins early adulthood; presents several contexts, (need four):
1Perfectionist; interferes w/task completion
2Preoccupied with details, rules, lists, order, organization, or schedules; major point of the activity is lost
3Excessively devoted to work and productivity; excludes leisure activities/friendships
4Inflexible about matters of morality, ethics, or values
5Unable to discard worn-out or worthless objects
6Reluctant to delegate tasks or to work with others
7Adopts a miserly spending style toward both self and others
8Shows rigidity and stubborness
Somatic Symptom Disorder
A. At least one somatic symptom that is distressing and results in disruption of life
B. Excessive thoughts, feelings, or behaviors related to the symptom with at least 1 of
1) Disproportionate & persistent thoughts of it
2) Persistent high anxiety about it
3) Excessive time and energy spent on it
C. Although any 1 symptom may not be continuously present, the state of being symptomatic is, usually > 6 months
A. Preoccupation with having or acquiring a serious illness
B. Somatic sx are absent or if present , mild.
C. High level of anxiety about health
D. Performs excessive health related behaviors or exhibits maladaptive avoidance
E. Preoccupation last > 6 months
F. not better explained by another disorder
A. Dissatisfaction with sleep quality or quantity with
B. Causes clinically significant distress or impairment
C. Occurs at least 3 nights/week
D. Present for at least 3 months
E. Occurs despite adequate opportunity for sleep
F. -H not caused by other disorder, substances etc
Specifiers (see Table 16.2-4 for complete criteria)
hypersomnolence DSM-5 Diagnostic Criteria
A. Self-reported excessive sleepiness despite sleeping 7 hours
and at least one of the following:
1. Recurrent periods of sleepiness or lapses into sleep with in the same day
2. Prolonged main sleep episode > 9 hours that is nonrestorative
3. Difficulty being fully awake after abrupt awakening
B. Occurs at least 3x/week for at least 3 months
C. Significant distress or impairment
D. -F not other causes/explanation
Specify: if with another condition; if acute, subacute, or persistent; current severity (mild, moderate, or severe)
Narcolepsy DSM-5 Criteria (Table 16.2-7)
A. Recurrent irrepressible need for sleep, lapsing into sleep, or napping in the same day; 3x/week; 3 months
B. The presence of at least one of the following:
1. cataplexy, either a. or b., at least a few times a month
2. hypocretin deficiency (measured in cerebral spinal fluid)
3. REM latency (measured on nocturnal sleep polysomnograph)
Specifiers for above (see DSM-5) w/ or w/out above
Specify current level of severity
Cataplexy type a&b
a. in longstanding dz, brief episodes of sudden bilateral loss of muscle tone, maintained consciousness, precipitated by laughing or joking
b. in children, or within 6 mo. onset, grimaces, jaw-opening with tongue thrusting, or global hypotonia, without any emotional triggers
Exposure to actual/threatened death, serious injury or sexual violence by:
~~witnessing it as it occurred to others
~~learning of violent or accidental trauma to family member or friend
~~repeated or extreme exposure to details (such as experienced by 1st responders)
Four symptom clusters (required symptoms from each) >1month :
1) Re-experiencing (at least one): flashback/dream/memory
2) Avoidance & numbing (at least one)
3) Negative alterations in mood and cognition (at least two)
4) Alterations in arousal (at least two) jumpy etc
Acute Stress Disorder Criteria
Exposure to actual or threatened death, serious injury, or sexual violation
(in one of 4 ways-same as PTSD).
9 or more (of 14) symptoms from any of 5 categories
Duration of disturbance is 3 days to one month
It causes clinically significant distress or impairment
A. Development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
B. Symptoms are clinically significant with marked distress
and/OR significant impairment in functioning
C. not meet criteria for other d/o; not exacerbation
D. Not normal bereavement.
E. sx don't persist>6m after stress/consequence stopped
Specify if: depressed, anxious, mixed, disturbance of conduct, emotions and conduct, or unspecified.
Inability to recall important autobiographical information,
usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. (usually either localized for specific events or generalized for identity or life history)
B. Causes clinically significant distress or impairment in important areas of function
C. Not attributable to the effects of a substance or a neurological /medical condition
D. Not better explained by dissociative identity disorder, PTSD, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
Specify if with dissociative fugue
apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or other important autobiographical information.
Presence of persistent or recurrent experiences of depersonalization, derealization, or both.
1. depersonalization- feeling detached from one's self
(perceptual alterations, time distortion, emotional/physical numbing)
2. derealization- feeling detached from one's environment (dream-like)
B. During these experiences, reality testing remains intact.
C. Causes clinically significant distress or impairment.
D. Not attributable to the effects of a substance or other condition.
E. Not better explained by another mental disorder such as schizophrenia, panic disorder, major depressive disorder, PTSD, acute stress disorder, or another associative disorder. (these must be specifically ruled out)
as schizophrenia, panic disorder
major depressive disorder,
PTSD, acute stress disorder
another associative disorder
Dissociative ID disorder
A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession.
involves marked discontinuity in sense of self and sense of agency,
accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning.
may be observed by others and reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
E. Not attributable to the effects of a substance or another medical disorder.
impairment in memory
thinking and it's many domains: attention, executive function, learning, memory, language, perceptual-motor, and social
acute, life threatening, potentially reversible disorder of the CNS
characterized by a change in cognition and decline in the level of consciousness.
major neurocognitive disorders
serious cognitive impairment that disrupts performance of daily activities
neurocognitive disorder which involves multiple cognitive deficits
minor neurocognitive disorders
cognitive impairment w/ mild-moderate dec in fx
does not impair daily functioning
(some consider the cognitive changes of normal aging to fall in this category).
Nerocog d/o Clinical Evaluation
Detailed history: (multiple sources if possible)
Physical Exam and screening lab tests
Detailed Mental Status Exam
EEG, CT, and MRI when indicated
Brain biopsy by steriotactic needle - rarely
Neuropsychological testing - initial assessment and reevaluation of cognitive abilities
acute onset & time limited
change in cognition and confusion
Delirium subtypes based on etiology
1. general medical condition (e.g. infection, electrolytes)
antisocial personality disorder is common in illicit
depressive/anxiety disorders- with alcohol use
major risk factor for suicide! 20x more
15% of people with alcohol use disorder - suicide
self-medication for untreated mental illness is the most significant risk for suicide in the United States
see Table 20.1-1 in Synopsis of Psychiatry
Know the definitions of all these terms.
Also be aware that the DSM-5 has moved away from the abuse and dependency and has incorporated both into substance use disorders and then specify if there is tolerance, withdrawal, or compulsive use and apply a severity index. (ICD 10 has retained the terms of abuse and dependence)
Substance Related Disorders types
Substance Use Disorders
Substance Induced Disorders
Substance Use disorders
Term applied, naming the specific substance,
at least 2 of 11 criteria are met within 12 months.
1. recurrent use->failure to meet major obligations
2. recurrent use in hazardous situations (e.g. driving)
3. continued use despite adverse social or relationship consequences
4. tolerance: (a.) incr amts needed for effect or (b.) diminished effect from same amount
5. withdrawal: (a.) experience characteristic withdrawal symptoms or (b.) a similar substance is taken to avoid
6. substance used in larger amounts or longer time than intended
7. persistent desire or unsuccessful attempts to cut down or control substance use
8. much time is spend in obtaining, using, and recovering from use of the substance
9. give up important recreational/social/work activities in order to continue use
10. continue use despite known physical or emotional problems related to use
11. craving/strong desire/ urge to use substance
2 Y =investigate further
"needed to Cut down on your drinking?"
" Annoyed you by criticizing your drinking?"
"Have you ever felt Guilty about drinking?"
"Eye-opener) to steady your nerves or to get rid of a hangover?"
ssx of recent intake of a particular substance and includes:
development of reversible substance-specific syndrome
significant maladaptive behavioral or emotional changes due to the effects of the substance on the CNS developing during or shortly after use
symptoms not due to or better explained by a general medical condition or mental disorder
substance-specific syndrome due to reduction or cessation of substance
=> significant distress or impairment in social, occupational, or other functioning
sx not d/2 general med or mental d/o
symptoms are not due to or better explained by a general medical condition or mental disorder
Substance Induced Disorders
This is a major "rule out" in many of the other disorders!
Alcohol induced depressive disorder
LSD induced psychotic disorder
alcohol induced depressive disorder
some people who have abused alcohol in the past but have been sober for years can have ongoing depressive symptoms which were caused by neurobiological changed due to their past alcohol use.
LSD induced psychotic disorder
some people who abuse hallucinogens develop psychotic (mood or anxiety) disorders
guarded because relapse is common.
75% of people with Alcohol Use Disorders with severe dependence will relapse within 1 year of early remission.
2 million injuries/year; including 22,000 deaths
causes acute neurochemical changes: depression, anxiety, and psychosis can result
causes chronic medical complications: potentially fatal withdrawal; liver, heart, nutritional, etc.
causes significant social consequences: broken relationships, loss of jobs, homelessness
90% of US population drinks
>40% have temporary problems related to alcohol
>10% of Males - abuse
>5% of Females - abuse
10% of Males - dependence
3-5% of Females - dependence
20-30% of psychiatric patients - abuse or dependence
Genetic Factors may account for 60% of the risk
Environmental Factors may account for 40%
Again we see a combination of nature and nurture.
Fhx=more at risk
Alcohol use Comorbidity
other substance related disorders (often more than one drug is used)