CAM Psych 2 FINAL: Personality disorders; psychogenic nonepileptic seizure; dissociative disorders; somatic symptom and related disorders; sexual dysfunctions and paraphilic disorders

Cluster A personality d/o include

Schizoid

Schizotypal

Paranoid PD

Cluster A personality d/o - patients seem

Peculiar, eccentric, or withdrawn

SUSPECT mnemonic paranoid personality d/o

SUSPECT

Spousal infidelity suspected

Unforgiving (bears grudges)

Suspicious

Perceives attacks (and reacts quickly)

Enemy or friend? (suspects associates and friends)

Confiding in others is feared

Threats perceived in benign events

DISTANT mnemonic for schizoid personality disorder

DISTANT

Detached or flattened affect

Indifferent to criticism or praise

Sexual experiences of little interest

Tasks done solitarily

Absence of close friends

Neither desires nor enjoys close relationships

Takes pleasure in few activities

Schizoid =

AVOID

Difference b/e schizotypal and schizoid

Schizotypal PD has eccentric behavior or magical thinking,

Schizoid does not

Schizotypal PD tx

Psychotherapy with development of social skills

Cognitive-perceptual disturbances may benefit from low-dose second generation antipsychotic short-term

ME PECULIAR mnemonic schizotypal PD

ME PECULIAR

Magical thinking

Experiences unusual perceptions

Paranoid ideation

Eccentric behavior or appearance

Constricted or inappropriate affect

Unusual thinking or speech

Lacks close friends

Ideas of reference

Anxiety in social situations

Rule out psychotic or autism spectrum disorders

Cluster B personality disorders include

Antisocial

Borderline

Histrionic

Narcissistic

Cluster B personality disorders seem

Emotional

Inconsistent

Dramatic

Antisocial PD mnemonic: CORRUPT

CORRUPT

Cannot conform to law

Obligations Ignored

Reckless disregard for safety

Remorseless

Underhanded (deceitful)

Planning Insufficient (impulsive)

Temper (irritable and aggressive)

Antisocial PD begins in childhood as ___ d/o

Conduct d/o

- May have hx of hurting animals or starting fires

- Violations of law

Tx of Antisocial PD

Psychotherapy usually ineffective

Medication for comorbid conditions

Antisocial PD - inc morbidity d/t

SUD

Trauma

Suicide

Homicide

Antisocial pd - individual must be how old for dx?

18

What is the most commonly diagnosed personality disorder in psychiatric inpatients?

A.Antisocial personality disorder

B.Borderline personality disorder

C.Schizoid personality disorder

D.Schizotypal personality disorder

B.Borderline personality disorder

Tx of choice for BPD

Dialectical behavioral therapy (DBT)

Meds are adjunct—mood stabilizers and low-dose antipsychotic meds

- Of the personality disorders-- meds are most successful in BPD

IMPULSE mnemonic BPD

IMPULSIVE

Impulsive

Moodiness

Paranoia or dissociation under stress

Unstable self-image

Labile intense relationships

Suicidal gestures

Inappropriate anger

Vulnerability to abandonment

Emptiness (feelings of)

Histrionic PD defense mechanism of

REGRESSION -> revert to childlike behaviors

ACTRESS mnemonic Histrionic personality disorder

ACTRESSS

Appearance focused

Center of attention

Theatrical

Relationships (believed to be more intimate than they are)

Easily influenced

Seductive behavior

Shallow emotions

Speech (impressionistic and vague)

Describe the course of narcissistic PD

Chronic, higher incidence of depression in midlife due to their high value on power and youthfulness, depressed when do not get recognition they think they deserve

GRANDIOSE mnemonic for Narcissistic PD

GRANDIOSE

Grandiose

Requires attention

Arrogant

Need to be special

Dreams of success and power

Interpersonally exploitative

Others (unable to recognize feelings/needs of)

Sense of entitlement

Envious

What are the cluster c disorders

Avoidant

Dependent

Obsessive compulsive PD

in cluster C PD, Patients seem

fearful or anxious

Most effective tx for avoidant PD

Psychotherapy

Avoidant PD mnemonic: CRINGES

CRINGES

Criticism or rejection preoccupies thoughts in social situations

Restraint in relationships due to fear of shame

Inhibited in new relationships

Needs to be sure of being liked before engaging socially

Gets around occupational activities with need for interpersonal contact

Embarrassment prevents new activity or taking risks

Self viewed as unappealing or inferior

Problems with what in dependent personality d/o

employment - difficulty acting independently or w/o close supervision

Tx of choice for dependent personality d/o

Psychotherapy ToC

Others

- CBT with assertiveness and social skills training

- Meds for comorbid anxiety, depression

RELIANCE mnemonic for dependent personality d/o

RELIANCE

Reassurance required

Expressing disagreement difficult

Life responsibilities assumed by others

Initiating projects difficult

Alone (feels helpless and uncomfortable when alone)

Nurturance (goes to excessive lengths to obtain)

Companionship sought urgently when a relationship ends

Exaggerated fears of being left to care for self

Obsessive compulsive PD mnemonic SCRIMPER

SCRIMPER

Stubborn

Cannot discard worthless objects

Rule obsessed

Inflexible

Miserly

Perfectionistic

Excludes leisure due to devotion to work

Reluctant to delegate to others

Dissociative amnesia often after

trauma - stressful and traumatic events

Mainstay tx for dissociative amnesia

Psychotherapy

Meds not effective

Dissociative amnesia DSM - an inability to recall...

An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.

Dissociative amnesia- what is w/ dissociative fugue

Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information.

Characteristics of somatic sx disorder

Distressing somatic sxs:

- Abn thoughts

- Feelings

- Behaviors

- Multiple somatic sxs (pain is common)

Dx criteria for somatic sx d/o: one or more somatic sxs that are

Distressing or result in significant disruption of daily life

Dx criteria for somatic sx d/o: 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.

somatic sx d/o persistent specification is marked if duration is more than ___ months

6

Specification criteria for somatic sx d/o: Persistant and ____

With predominant pain: This specifier is for individuals whose somatic symptoms predominantly involve pain.

Tx for somatic sx d/o

- One PCP -> have regularly scheduled visits

- Address psychological issues slowly due to resistance for MH care

- Psychotherapy: CBT

- Pharmacotherapy: Dual action agents (5-HT and NE) TCA, SSRIs/SNRIs

Conversion d/o also known as

Functional Neurological Sx D/o

Tx conversion d/o

Education

CBT w/ or w/o PT

Common sxs of conversion d/o

Paralysis

Weakness

Blindness

Mutism

Sensory complaints (paresthesias)

Psychogenic nonepileptic seizures (PNES), globus sensation

Conversion d/o DSM: A. One or more symptoms of altered voluntary ____ or ___ function.

Motor or sensory

Difference b/e PNES and epileptic seizure

Illness anxiety d/o tx

- One PCP and regularly scheduled visits

- Psychotherapy-CBT

- Treat comorbid depression, anxiety—SSRIs, etc.

Illness anxiety d/o: ___ with having or acquiring a serious illness

Preoccupation

Are somatic sxs present in illness anxiety d/o

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.

Describe DSM for Illness anxiety d/o

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).

Facticious d/o - common deigned sxs

Hallucinations, depression,

fever,

infection, hypoglycemia, abdominal pain, seizures,

hematuria

Mgnt of factious d/o

Collect collateral info

Collaborate w/ other providers

non-threatening confrontation

Facticious d/o used to be known as

Munchhausen syndrome by proxy

Facticious disorder DSM - (A-C)

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.

is malingering considered a mental illness

no

What is malingering

The conscious feigning for sxs for some secondary gain

- Avoiding incarceration

- Monetary compensation

Mgnt of malingering

Neuropsych testing to assess further

TOMM (test of memory malingering)

Validity Indicator Profile (VIP)

Manage to pt underlying distress

Gentle confrontation may be necessary - pt may leave AMA

Gender dysphoria - the pathology is NOT the gender diversity itself, but rather the

Distress caused by incongruence b/e the gender a person was assigned to at birth and their identified gender

tx of gender dysphoria

- gender affirming psychotherapy

- Tx comorbid conditions with psychotherapy, meds as appropriate

- Family support

- Support patient in transitioning they desire (society, medical, surgical)

Surgical sex reassignment for gender dysphoria can be performed when

performed after living 1 year in the desired gender role and 1 year of continuous hormone therapy

At least how many months duration of gender dysphoria to get dx

6 months

tx for Female sexual interest disorder

- CBT, relationship therapy, trauma therapy depending on issues

- Education, Stimulation, Devices to increase erotic stimuli

- Meds - FDA approved two medications for hypoactive sexual desire d/o in premenopausal women - Filbanserin and Bremelanotide

Filbanserin is a

Serotonin receptor 1a agonist / serotonin receptor 2A antagonist

What inc hypotension and LOC if taken with Filbanserin

Alcohol

- skip dose if >3 drinks

Bremelanotide selectively activates

Melanocortin receptor NTs

SE of Bremelanotide

Inc BP

Decreasing HR

Focal hyperpigmentation

Nausea

Can you drink alc when on Bremelanotide

yes

How many sxs do you need to be dx with FSIAD

at least 3

tx for male hypoactive sexual desire d/o

CBT

Relationship therapy

Trauma therapy depending on issues

Stress reduction

Meds for male hypoactive sexual desire d/o

Testosterone therapy

Bupropion

Treatment of erectile dysfunction and premature ejaculation if present—

- Sildenafil (Viagra)

- Tadalafil (Cialis)

Treatment of premature ejaculation: SSRIs

Dx of male hypoactive sexual desire d/o

Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgment of deficiency is made by the clinician

what is paraphilic d/o

Engagement in unusual sexual activities and/or preoccupation with unusual sexual urges or fantasies for at least 6 months that are---acted on with a nonconsenting person or cause significant distress or impairment in functioning

MC paraphilic d/o

voyeuristic and pedophilic d/o

Poor prognostic for paraphilic d/o

Multiple paraphilias, onset at early age, comorbid SUD, high frequency of behavior, referral by law enforcement

Dx for paraphilic d/o

Difficult

Can use CBT

Social skills training

12 step programs

Group therapy

Controversial medications used to decrease sex drive and fantasies in paraphilic d/o

Antiandrogens, long-acting gonadotropin-releasing hormones, SSRIs, naltrexone

Fetishistic d/o

Sexual arousal from either the use of nonliving objects (pantyhose/shoes) or non genital body parts

Sexual masochism d/o

sexual arousal from act of being humiliated, beaten, bound, or made to suffer

Sexual sadism d/o

sexual arousal from the physical or psychological suffering of another

Exhibitionistic d/o

Sexual arousal from exposure of one's genitals to an unsuspecting person

Frotteuristic d/o

Sexual arousal from touching or rubbing against a nonconsenting person