SpecDis- Psych

What are the 2 types of change required for successful adaptation during development?

assimilation- incorporation of challenge into existing organizational structures

accommodation- reorganization of our structures to meet demands of environment

*must be in balance*

What is the orthogenetic principle?

development moves from undifferentiated and stereotypical → greater complexity and individualized responses

each period of development characterized by adaptational challenges from environmental demands and emerging internal influences

challenges → change and demand for adaptation → development

How can biologic, psychological, and social factors can lead to psychopathology?

interaction of biologically-based predispositions with psychosocial stressors can cause psychopathologic outcomes

Identify major life transition points and describe how they can contribute to psychopathology.

critical period- first 3 years of life due to rapid development of nervous system and less neural plasticity in subsequent years

other major life transitions that are high-risk periods for psychopathology: entry to formal schooling, puberty and transitions to junior high, HS graduation, entering workforce, marriage, birth of children, death of loved ones

What is the moderator effect?

moderating factor reduces risk factor's effect on a person developing a disorder

moderators are "protective" or "buffering" factors

How is classical conditioning used in clinical practice?

progressive relaxation- alternately tense and relax different muscle groups in systematic fashion → profound relaxation (new conditioned response), very effective for anxiety-based disorders

systematic desensitization- successive degrees of exposure to feared object or stimulus, very effective for phobia and anxiety-based disorders

How are learning theories used in clinical practice?

majority of behavior directed toward higher needs (self-fulfillment and psychological needs)

token economy- treatment based on conditioning reinforcers

What is insight?

awareness that symptoms or disturbed behaviors are normal or abnormal

How are cognitive and cognitive-behavioral interventions used in clinical practice?

cognitive therapy- errors in thinking can be found in each of major types of psychopathology, produce change by having patient monitor changes in mood and relate those changes to ongoing flow of automatic thoughts → use own behavior to test accuracy of these beliefs

*not as effective in substance use, marital distress, conduct disorder, or formal thought disorders*

When is exposure-based treatment superior to medication?

when treating social phobia

Cognitive therapy is as effective as medication for all but _________?

the most severe depression

Define the 3 main types of psychotherapy and differentiate between them

dynamic: focuses on the psychological roots of emotional suffering, self-reflection and self-examination, consciously making better choices in relationships, trying to minimize defense mechanisms

experiential-humanistic: focuses on acceptance and fosters growth, focuses on person not the symptoms, targets conscious processes instead of unconscious processes

cognitive-behavioral: patient is encouraged to test irrational perspectives/distorted thoughts and replace them with more realistic beliefs that can be validated

Neurochemical causes of eating disorders?

↑ serotonin reuptake in anorexia and bulimia= ↓ appetite, ↑ release of serotonin during binging

↑ PYY (satiety peptide) in gut with anorexia and bulimia= ↓ appetite

↑ baseline and post-prandial CCK (satiety peptide) w/ anorexia= ↓ appetite

ghrelin (hunger hormone)- dysfunctional with binge eating

What personality characteristics may be more associated with eating disorders?

overall sense of anxiety, difficulty coping with stress, awkwardness with interpersonal relationships, low self esteem, lack of assertiveness

A 17-year-old girl presents with a 20lb weight loss in the past year. Her BMI is now 16.8. When you ask her about her diet, she reports she has a very restrictive diet to avoid eating anything "unhealthy." Physical exam reveals bradycardia, skin dryness, orthostatic hypotension, and hypothermia. Dx?

Anorexia nervosa

Types of anorexia nervosa?

Binge/purge: unable to refrain from binge eating and purging; frequently abuse alcohol and drugs, stimulants, or laxatives; evident by continued weight loss

Restrictive: limit intake to as little as 300-600 cal/day, limited food selection, obsessive and compulsive symptoms regarding food, eating habits, and exercise

During a 16-year-old girl's annual physical, you notice she has calluses on her knuckles and some tooth erosion. She has a normal BMI. When asked about her eating habits, she reports she often feels "out of control" while eating and feels she has to engage in compensatory behavior afterwards to prevent weight gain. Dx?

Bulimia nervosa

Compensatory behaviors: purging (self-induced vomiting), laxative abuse, diuretics, fasting, excessive exercise

What is the female athlete triad?

disordered eating (restrictive dieting, overexercising, weight loss, lack of body fat), amenorrhea, osteoporosis

Medical complications of bulimia nervosa?

anemia, irregular HR, weakened heart muscle, low pulse and BP, dehydration, hypokalemia, hyponatremia, hypomagnesemia, dry skin, fatigue, stomach ulcers, tooth erosion, metabolic acidosis from diarrhea, metabolic alkalosis from vomiting

Treatment for eating disorders?

Referral to psychotherapist or psychiatrist- CBT is cornerstone of treatment

Referral to dietician

School involvement for accomodations

SSRIs- may have some benefit in decreasing frequency of binging and add benefit to CBT

What is diabulemia?

eating disorder behavior associated with T1DM

patients deliberately skip or reduce insulin dose → hyperglycemia, glucosuria, DKA, rapid weight loss

What does the DSM-5 classify insulin omission as?

purging behavior

if pt is binging then restricting insulin= bulimia

if pt is eating normally then restricting insulin= purging disorder

if person is both severely restricting food and insulin= anorexia

DSM-5 criteria for binge eating disorders?

recurrent episodes of binge eating characterized by eating in a discreet period of time an amount of food larger than what most would eat and a sense of lack of control over eating during the episode

*no compensatory behavior so they gain weight*

at least once a week for 3 months

Risk factors for major depressive disorder?

family history

personality traits- insecure, worried, introverted, stress sensitive, obsessive, unassertive, dependent

early childhood trauma- loss, disruptive, hostile/negative environment (abuse or neglect)

recent negative life event

postpartum

lack of interpersonal relationships

anxiety disorder

At her annual physical, one of your patients reports she has been feeling empty and gloomy lately. She feels unable to enjoy her usual activities. She has also lost 15 lbs, has trouble falling and staying asleep, has difficulty concentrating and remembering things, and overall feels like she has no energy. Her feelings are so severe that she has been avoiding spending time with friends and family recently. She reports these symptoms started 3 months ago when her mother died. Dx? Tx?

Major depressive disorder

Tx: mild- CBT

moderate/severe- antidepressants (at least 6 months to prevent relapse)

severe/intractable- hospitalization w/ electroconvulsive therapy

DSM-5 criteria for major depressive disorder?

≥5 symptoms during same 2 week period:

depressed mood most of day/every day, loss of interest/pleasure (anhedonia) in all or almost all activities, weight loss or weight gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive/inappropriate guilt, diminished ability to think or concentrate, recurrent thoughts of death

*at least 1 must be depressed mood or loss of interest/pleasure*

*NO manic or hypomanic episode*

A patient reports feelings of inadequacy, low self-esteem, pessimism, despair and hopelessness for the past 2 years. He is often fatigued, and not very productive at work. He reports no sleep changes, no changes in appetite, no loss of libido, does not feel "slowed down," and has no suicidal ideations. Dx? Tx?

Persistent depressive disorder (dysthymia)

Tx:

1. SSRIs

2. TCAs (require continued treatment for at least 6-12 months)

DSM-5 criteria for dysthymia?

depressed mood for most of day, more days than not, as indicated by either subjective account or observation by others, for at least 2 years

≥2 of following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness

during 2-year period, patient has not been without sx for more than 2 months at a time

True or false: if full criteria for a major depressive episode have been met at some point during current episode of illness for dysthymia, the patient should instead be given a diagnosis of major depressive disorder.

True

True or false: depression has a stronger genetic component than bipolar disorder

False- bipolar disorder has very strong genetic component (2/3 have family hx of unipolar and/or bipolar disorders)

What is atypical depression?

shares many of typical symptoms of MDD but patients experience mood reactivity (improved mood in response to positive events)

Sx: weight gain/appetite increase, hypersomnia, heavy/leaden feelings in arms or legs, oversensitivity to interpersonal rejection

A 20-year-old female reports she has been experiencing episodes of abnormal behavior. During these episodes, she feels uncontrollably excited, a decreased need for sleep, racing thoughts and speech, and she paces her room for hours making grandiose and unrealistic plans. Despite all this increased energy, she is unable to work efficiently during these episodes. These episodes typically last 2 weeks, and are usually followed by a periods of feeling down, sad, and hopeless. Dx? Tx?

Bipolar I disorder

Tx:

acute mania- antipsychotics, lithium, or valproic acid

acute depression- lamotrigine, quetiapine, olanzapine +/- SSRIs

maintenance- lithium, valproic acid, lamotrigine or atypical antipsychotics

DSM-5 criteria for bipolar I disorder?

≥1 manic episode lasting at least 1 week and present most of day, nearly every day (any duration if hospitalization is necessary)

≥3 symptoms: inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual, flight of ideas or racing thoughts, distractability, increase in goal-directed activity, excessive involvement in risky activities

True or false: a full manic episode that emerges during antidepressant treatment but persists at fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I diagnosis

True

True or false: major depressive episodes are required for bipolar I diagnosis

False- only requirement is at least 1 manic episode

How is hypomania different from mania?

hypomania- abnormal and persistently elevated, expansive or irritable mood lasting at least 4 days, does not require hospitalization, not associated with marked impairment of social/occupational function, no psychotic symptoms (delusions, hallucinations), no severe racing thoughts or marked psychomotor agitation

at least 3 manic symptoms

A male patient reports he has been experiencing frequent "mood swings." He reports that for 4 or 5 days (but less than a week), he has an elated mood, a lot of energy, a decreased need for sleep, and is the most productive at work that he has ever been. This is followed by periods where he feels extremely depressed, has a decreased interest in daily activities, insomnia, loss of appetite, and decreased ability to concentrate. Dx? Tx?

Bipolar II disorder

Tx:

1. atypical antipsychotics

2. lithium or valproic acid + atypical antipsychotic

DSM-5 criteria for bipolar II disorder?

≥1 hypomanic episode (lasting at least 4 consecutive days) and ≥1 major depressive episode (lasting 2 weeks)

NO manic episodes

What is rapid-cycling bipolar disorder?

four or more affective episodes per year

patients with rapid-cycling bipolar disorder tend to have longer and more refractory illness

80-95% are women

DSM-5 criteria for cyclothymic disorder?

for ≥2 years (≥1yr in children and adolescents), numerous periods w/ hypomanic symptoms that do not meet criteria for hypomanic episode and numerous periods w/ depressive symptoms that do not meet criteria for major depressive episode

individual has not been without the symptoms for ≥2 months at a time

A 22-year-old girl presents with mood fluctuations. Since she started college 4 years ago, she has not felt like herself. She reports fairly constant alternation between 2-3 days feeling "on top of the world, everything is great, very motivated, and getting lots of stuff done" and 3-5 days of feeling more sad, hopeless, upset, and unmotivated. Dx? Tx?

Cyclothymic disorder

Tx: low dose SSRIs, bupropion or MAOis PLUS lithium or other mood stabilizers (NO TCAs)

Discuss the normal sleep cycle.

~90 minutes long

non-REM: decreased physiological and psychological activity

REM: associated with dreaming, length decreases as we get older

rhythm governed by SCN in hypothalamus- tells adrenal glands to release cortisol when time to wake (light) and tells pineal glands to release melatonin when time to sleep (darkness)

Which neurotransmitters are involved in arousal from sleep?

acetylcholine- turns on during REM sleep and starts wake cycle

norepinephrine, serotonin and histamine- turn off REM sleep and keep us awake

orexin- stabilizes wake/sleep switch and reinforces wake cycle.

Which neurotransmitters are involved in sleep initiation?

adenosine- builds up as brain tires during day, triggers release of GABA and galanin

GABA and galanin- inhibit arousal areas in hypothalamus and pons- turn on non-REM sleep

A female patient presents with fatigue, headaches, and poor concentration. She reports she has problems falling asleep, wakes up constantly throughout the night, and when she wakes up in the morning, she doesn't feel rested. She says this has been going on for the past 5 months. Dx? Tx?

Insomnia disorder

Tx:

non-pharm: CBT-I and sleep hygiene education, counseling for acute stressors

pharm: 1. non-BZD hypnotics (Z drugs) 2. DORAs 3. doxepin low dose

*no BZDs unless very short term and no risk of abuse*

What is the safest medication to prescribe for insomnia?

ramelteon- melatonin agonist, "addiction-proof"

DSM-5 criteria for insomnia disorder?

≥1 symptom: difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening with inability to return to sleep

occurs ≥3 nights/week, present for ≥3 months, occurs despite adequate opportunity for sleep, coexisting mental disorders and mental conditions do not adequately explain the insomnia

Which medications can cause nightmare disorder?

1st generation antihistamines, beta blockers, SSRIs, corticosteroids, donazepil, amantadine, statins

A teenager reports she has been having frequent scary dreams. She remembers them when she wakes up and the memory of them distresses her throughout the day. She does not get up or move around during these nightmares, but she sometimes wakes up screaming and her heart is racing. Her mother witnessed one of these nightmare episodes and said the girl appeared asleep with her eyes closed. Dx? Tx?

Nightmare disorder

Tx: if severe, can suppress REM with MAOIs or other antidepressants

A 60-year-old man with PMH of Parkinson's presents with a hand injury he sustained when he whacked his hand against his bed frame in his sleep. His wife says he has been punching, kicking, and yelling in his sleep recently. The man reports he has dreams where he is being attacked and needs to defend himself. During these episodes, the man appears asleep with his eyes closed; he wakes up clearly and rapidly afterwards, and has memory of these events. Dx? Tx?

REM sleep behavior disorder

Tx: sleep hygiene, maintain safe environment, consider clonazepam, D/C any serotonergic antidepressants

How to distinguish whether a sleep disorder is occuring during REM sleep or not?

REM sleep: eyes closed

non-REM sleep: eyes open

A mother brings her 5-year-old child into the office because recently he has been having episodes in the middle of the night where he gets out of bed, starts screaming and thrashing around, and appears very agitated and sweaty. His eyes are open during these episodes, but he is difficult to arouse and when he does wake up, he is confused and disoriented. The boy has no memory of these episodes. Dx? Tx?

Sleep terror disorder

Tx: sleep hygiene

if severe- consider BZDs or low dose tricyclics

reassure parents- children do not suffer b/c they don't recall them, symptoms decrease with age

Does sleep walking disorder occur during REM sleep or non-REM sleep?

non-REM sleep so eyes will be open, patient will have no memory of event, they will be difficult to arouse and confused upon awakening

Tx: sleep hygiene

A young man presents with excessive daytime sleepiness, sudden loss of muscle tone when he laughs, and brief paralysis when he starts to fall asleep. His friends say he dozes off often when they are hanging out. A sleep study shows a sleep latency <8 minutes and spontaneous awakenings during polysomnography. Dx? Tx?

Narcolepsy

Tx: scheduled naps, REM sleep inhibition, modafinil

DSM-5 criteria for narcolepsy?

irrepressible need to sleep, lapsing into sleep, or napping occurring with in same day- occurs ≥3x/week over past 3 months

≥1 of the following: cataplexy, hypocretin deficiency, polysomnography showing REM sleep latency ≤15 min or multiple showing mean sleep latency ≤8 min

Pathophysiology of narcolepsy?

loss of orexin-producing neurons= loss of stabilization of wakefulness

also lose ability to keep from falling into REM and non-REM sleep

Signs and symptoms of alcohol intoxication?

disinhibition, depression, slurred speech, impaired judgment and somnolence

ataxia, impaired attention or memory

labile mood- erratic behavior, aggression

Neurochemical effects of alcohol?

inhibits glutamate- impairs learning and memory

increases GABA activity

increases dopamine activity

Signs and symptoms of alcohol withdrawal? Management?

increased CNS activity- nausea/vomiting, headache, anxiety, paroxysmal sweats, tactile disturbances, visual disturbances, auditory disturbances, tremors, agitation, and disorientation/clouding of sensorium

can progress to withdrawal seizures and delirium tremens

Tx: IV benzos- potentiate GABA-mediated CNS inhibition

Effects of cannabis? Withdrawal symptoms?

S/sx- euphoria, sedation, hallucinations, temporal distortion, dry mouth, conjunctival erythema, tachycardia, hypotension

Withdrawal- hyperemesis syndrome, irritability, insomnia, restlessness

Effects of hallucinogens (MDMA)?

dry mouth, bruxism, light and sound sensitivity, hyperactive, mydriasis, diaphoresis, rhabdomyolysis (from electrolyte imbalances), hypertension, tachycardia, hyperthermia

can precipitate serotonin syndrome

Pathophysiology of hallucinogens?

increase net release of monoamine neurotransmitters (serotonin, norepinephrine, dopamine)

Signs and symptoms of opioid intoxication?

pupillary constriction (miosis), altered mental status and respiratory depression, bradycardia, hypotension, nausea, vomiting, flushing, constipation, hypothermia

Signs and symptoms of opioid withdrawal?

lacrimation, hypertension, pruritus, tachycardia, nausea, vomiting, abdominal cramps, goose bumps, pupil dilation (mydriasis), flu-like symptoms- rhinorrhea, joint pains, myalgias *unpleasant but not life-threatening*

Signs and symptoms of benzodiazepine intoxication?

impaired motor coordination, tremors, slurred speech, altered vision, vertigo, bradypnea, bradycardia, nausea and vomiting, pupil dilation

Symptoms of benzodiazepine withdrawal?

anxiety, panic attacks, agitation and restlessness, insomnia, muscular spasms or cramps, dizziness, tachycardia, hypertension, nausea and vomiting, SEIZURES (can be lethal)

Physical manifestations of methamphetamine abuse?

tachycardia, hypertension, tachypnea, diaphoresis, mydriasis, hyperactivity, agitation, paranoia, delusions, psychosis, dental erosions, dermal lesions (skin scratching), rapid eye movements

Signs and symptoms of cocaine abuse?

Sx- elevated or euphoric mood, psychomotor agitation, pressured speech

may progress to respiratory depression, arrhythmias, hypertension, seizures, skin picking, hallucinations, MI, stroke, intracranial hemorrhage

Physical exam- increased motor activity, tremor, flushing, hyperthermia, cold sweats, dilated pupils

Neurochemical effects of methamphetamine?

increases serotonin, dopamine and norepinephrine activity

Neurochemical effects of cocaine?

blocks reuptake of dopamine, norepinephrine, and serotonin

blocking dopamine is most important for drug's stimulating, reinforcing and addictive properties

Neurochemical effects of nicotine?

increases release of acetylcholine, serotonin, dopamine, norepinephrine

affects mesolimbic dopamine pathway- gives rewarding or pleasure feeling that reinforces use

Symptoms of nicotine withdrawal? Treatment?

restlessness, anxiety, irritability, sleep abnormalities, headaches, depression, increased appetite and weight gain

Tx: CBT, nicotine replacement therapy, bupropion or varenicline

Neurochemistry of behavior addictions?

Dysregulated dopamine systems- involved with learning, motivation, and salience of stimuli and rewards

Increased dopamine levels may serve a "double deficit" function by reinforcing PG behavior through increasing excitement levels while simultaneously reducing inhibition of risky decisions

A female patient with PMH of depression and anxiety presents with abdominal pain, dizziness, and chronic pelvic pain. She reports the severity of these symptoms wax and wane, but she seriously worried that something is wrong. She has seen multiple specialists over the past year. Her labs all come back within normal limits. Dx? Tx?

Somatic symptom disorder

Tx: treat comorbid mental disorders, psychotherapy, validate feelings, schedule frequent follow up

How long does one need to have distressing somatic symptoms to be considered somatic symptom disorder?

>6 months

Signs and symptoms of illness anxiety disorder?

high anxiety about health- excessive "checking" for signs of illness, may avoid healthcare settings, give extremely detailed health histories, misinterpret normal bodily sensations as something more serious

*physical symptoms are not present or only mild*

symptoms wax and wane over time, exacerbated by stressors

Tx: CBT, SSRIs may be effective

True or false: neuroimaging can show decreased activity in areas of brain affected in patients with conversion disorder

True

A female patient presents with left arm paralysis, abnormal movements, and left facial paralysis. Her neurological exam is normal. She mentions these symptoms started when her husband left her last week. Dx? Tx?

Conversion disorder

usually triggered by unresolved conflict or traumatic events

Tx: can resolve spontaneously or to suggestive techniques, chronic- need behavioral modification techniques and try to modify environment

*do not treat with actual medical therapy for physical symptom b/c can lead to permanent invalidism*

What is "la belle indifference?"

inappropriate lack of concern for symptom found in conversion disorder

Signs and symptoms of factitious disorder?

intentional falsification or exaggeration of signs and symptoms of medical or psychiatric illness for primary gain- hypoglycemia, anemia, GI bleeds, dermatological conditions, blood dyscrasias

usually pick one symptom and stick with it- multiple hospitalizations, then go to different hospital and repeat cycle

Signs and symptoms of Munchausen syndrome?

usually lying more so than inducing injury or disease on self

typically present to ED late at night/weekends when less experienced clinicians are there, traveling a lot

usually mimics PTSD, bereavement, dementia, amnesia, schizophrenia, seizures, brain tumors or other cancers

Signs and symptoms of Munchausen syndrome by proxy?

mother brings in child for medical treatment of a simulated or factitiously produced disease, mother is intensely involved in care, child starts to improve when mother not there

*must be reported as child abuse*

What is malingering?

intentionally falsifying or grossly exaggerating psych or physical symptoms for secondary gain (external incentives)- money, time off from work, drugs, evading criminal prosecution

A female patient presents with muscle aches, fatigue, impaired concentration, and insomnia. She reports she feels persistent worry about her health, work, and her relationships with others, and it makes her restless. Dx? Tx?

Generalized anxiety disorder

Tx: CBT, antidepressants, buspirone, no BZDs unless short-term

DSM-5 criteria for generalized anxiety disorder?

excessive anxiety and worry for ≥6 months, difficult to control the worry, associated with ≥3 symptoms: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbances

DSM-5 criteria for panic disorder?

recurrent unexpected, spontaneous attacks w/ ≥4 symptoms: palpitations, sweating, trembling or shaking, SOB, feelings of choking, chest pain, nausea, dizziness, chills or heat sensation, paresthesia, derealization/depersonalization, fear of losing control, fear of dying

at least 1 attack followed by ≥1 month of persistent concern/worry or maladaptive change in behavior related to attacks

Tx: CBT

DSM-5 criteria for specific phobia?

marked fear or anxiety about specific object/situation, object/situation is actively avoided or endured w/ intense fear/anxiety, fear/anxiety is out of proportion to actual danger posed by object/situation, fear/anxiety lasts ≥6 months

Tx: CBT, SSRIs, beta blockers for blood/illness/injury phobias

DSM-5 criteria for social anxiety disorder?

marked fear or anxiety about 1 or more social situations where individual may be exposed to possible scrutiny by others (social interactions, being observed, performing in front of others)

social situations are avoided or endured with intense fear or anxiety

fear/anxiety/avoidance is persistent- lasts ≥6 months, is out of proportion to actual threat posed by the social situation

A male patient is supposed to give a big presentation at work, but is extremely anxious about it because fears he will humiliate himself and poop his pants in front of everyone. This happens to him every time he has to speak publicly- he experiences an immense amount of anxiety and has difficulty sleeping the entire week leading up to the speaking. Dx? Tx?

Social anxiety disorder

Tx: CBT, SSRIs- paroxetine or sertraline, propranolol

A male patient presents with insomnia, irritability, and issues with concentration. He reports that since he was in a severe car accident 4 months ago where his friend died, he has been having recurrent vivid nightmares of the accident, feels detached from others and emotionally numb, and tries to walk everywhere to avoid being in the car. He has a very flat affect. Dx? Tx?

Post-traumatic stress disorder

Tx: CBT and EMDR, antidepressants, prazosin for nightmares and insomnia

DSM-5 criteria for PTSD?

exposure to actual or threatened death, serious injury, or sexual violence

presence of ≥1 intrusion symptoms- distressing memories, distressing dreams, dissociative reactions (flashbacks), intense or prolonged distress to cues, marked physiological reactions to cues

persistent avoidance of stimuli associated w/ event

≥2 negative alterations in mood/cognition

≥2 alterations in arousal and reactivity

duration of disturbance is ≥1 month

How is acute stress disorder different from PTSD?

timing: 3 days-4 week duration vs >1 month

also need 3 dissociative symptoms: subjective sense of numbing/detachment/absence of emotional responsiveness, reduction in awareness of surroundings, derealization, depersonalization, dissociative amnesia

A 16-year-old male presents with excessive nervousness, tearfulness, sadness, and difficulty sleeping. His mother reports these symptoms began after she and the patient's father got divorced 1 month ago; her son was inconsolable and refuses to participate in any of his usual activites. Dx? Tx?

Adjustment disorder

Tx: psychotherapy, SSRIs, may consider sedative/hypnotics or anxiolytics for bedtime

DSM-5 criteria for adjustment disorder?

symptoms begin within 3 months of onset of stressor(s)

once stressor or its consequences have terminated, the symptoms do not persist for >6 months

An 11-year-old girl is brought into the clinic by her parents, who are distraught over her behavior. They state that over the past several months she has started to act oddly, combing the hair of her toy dolls for hours without stopping and repetitively counting her steps in the house. She walks around the house 12 times before leaving "to keep her family safe." She is often brought to tears when confronted about these behaviors. She has occasional motor tics, but the remainder of the exam is benign. Dx? Tx?

Obsessive-Compulsive Disorder

Tx: CBT (most effective) and SSRIs (HD fluoxetine)

A 26-year-old male presents with insomnia. Although he is a very successful student, over the past few months he has become increasingly preoccupied with failing. He states he wakes up 10-15 times per night to check his textbooks for factual recall. He has tried unsuccessfully to suppress these thoughts and actions, and he has become extremely anxious and sleep-deprived. He has no past medical history and family history is significant for a parent with Tourette's syndrome. Dx? Tx?

Obsessive-Compulsive Disorder

Tx: CBT (most effective) and SSRIs (HD fluoxetine)

A 20-year-old woman presents to her PCP to discuss undergoing rhinoplasty. She says her nose looks "twisted" and "not symmetrical," and she wants surgery to correct it. When in public, she explains that she frequently tries to cover her nose with a scarf because she feels "embarrassed by the way it looks." Additionally, she also thinks her "skin tone is not even," and she feels that her friends' skin is much better than hers. Her friends and family say there are no issues with her nose or her skin, but she feels ashamed of her appearance. She reports checking the mirror every hour, which she says "consumes a lot of time" in her day. The patient is not reassured by the PCP's comments that her nose and skin appear healthy and symmetric, and she insists that she looks "ugly." Physical examination reveals skin picking in multiple areas of the patient's body. Dx? Tx?

Body dysmorphic disorder

Tx: SSRI and CBT

DSM-5 criteria for hoarding disorder?

persistent difficulty discarding or parting with possessions regardless of actual value

distress associated with discarding items

difficult discarding possessions results in accumulation of possessions that congest and clutter active living areas and compromise their intended use

Tx: CBT first line, cognitive remediation if no response to CBT

A female patient with PMH of anxiety presents with hair loss. She has hair thinning and bald patches with no inflammation. When asked about her hair loss, the patient reports she sometimes pulls out hairs when she is stressed out because she feels it releases tension. Dx? Tx?

Trichotillomania

Tx: CBT, clomipramine

A 15-year-old female presents with multiple skin excoriations on her face, hands, and chest that are variable in size. Her back is completely clear. She reports she has been concerned about her skin texture and cannot overcome her desire to pick her skin. Dx? Tx?

Excoriation (skin-picking) Disorder

Tx: CBT, consider involving derm for treating pruritis and wound care, SSRIs or atypical antipsychotics if unresponsive to CBT