Pseudo Disorders



|Somatoform Disorders |

| |Somatization |Conversion |Pain |Hypochondriasis |Body Dysmorphic |Factitious |Malingering |

|Definition |Experience physical |Symptoms affecting motor |One or more sites of pain|Preoccupation with fears |Preoccupation with |Intentional production of|Intentional production of|

| |symptoms due to mental |or sensory function |causing impairment |of disease based on |imagined appearance |symptoms |false symptoms |

| |conflict | | |bodily sensations |defect | | |

|Associated Features |Seeking medical attention|Symptoms do not match | |Poor insight despite | |Few visitors; knowledge |[psychosis] |

| |for symptoms |anatomic pathways | |medical evaluation | |of medical lingo | |

| |AKA hysteria & briquet |“La belle indifference” | |Doctor shopping | | | |

|Age |Onset before age 30 | | | | | | |

|DSM-IV Criteria & |4 pain |Psychological factors | |At least 6 months |Frequent inspection |Motivation for primary |Aware for secondary gain |

|Duration |2 GI |must be involved | | |leading to suicide |gain but not for | |

| |1 sexual | | | | |secondary gain | |

| |1 pseudoneuro | | | | | | |

| |Not intentional |Not intentional |Not intentional | | |Intentional |Intentional |

|Comorbidity |High comorbidity with |Associated with trauma |Associated with |Serious childhood illness| |“Munchausen by proxy” | |

| |personality disorders | |psychological factors | | |(Parent hurt child for | |

| | | | | | |gain) | |

|Female:Male |More common in women |More common in women; | |Equally common in men & | | | |

| | |rural populations; poor | |women | | | |

| | |people | | | | | |

|Not Due To GMC But Cause Functional Impairment |

|Dissociative Disorders |

| |D. Amnesia |D. Fugue |D. Identity |Depersonalization |Derealization |

|Definition |Inable to recall personal |Sudden, unexpected travel away |Two or more distinct |Feeling detached from body |Feeling the external world is |

| |information |from home & retrograde amnesia |personalities | |unreal |

|Frequency |One or more episodes | |Transitions via stress | | |

|Associated Features |Associated with traumatic event |Associated with traumatic event |At least two personalities take |Reality testing is intact |Can occur with |

| | | |control regularly | |depersonalization |

| |Self limited: resolve in days |Confusion about personal identity |Inable to recall personal |Occur in people without psychiatric |People seem unfamiliar or |

| | | |information |pathology |mechanical |

| | |Assume new identity |History of childhood physical or |Not psychotic episode |Size and shape of world seems |

| | | |sexual abuse | |altered |

|Female:Male |Common in men & women | |Common in adult females |Common in mild form | |

Euthymia: normal range of mood states with no depression or elevated mood

Anhedonia: loss of interest in regular and pleasurable activities

Expansive mood/affect: expression of feelings without restraint; associated with grandiosity

Euphoria: Intense feelings of grandeur

Dysphoria: Unpleasant mood

|Mood Episode Guidelines |

| |Major Depressive Episode |Manic Episode |Mixed Episode |Hypomanic Episode |

|Duration |At least 2 weeks |At least 1 week | |At least 4 days |

|Emotions |Feeling depressed or anhedonia |Feeling euphoric, expansive, irritable |Both mania and depression at same time |Feeling euphoric, expansive, irritable |

| | |with mania | |with mania |

|Associated Features |Significant functional impairment |Significant functional impairment | |Change in function from baseline |

| |Can’t be due to drugs or GMC |Psychotic symptoms | |Not psychotic |

| | |Danger to self | |Not dangerous to self |

|Mood Disorders |

| |Major Depressive Disorder |Dysthymic |Depression NOS |Bipolar Type I |Bipolar Type II |Cyclothymic |Bipolar NOS |

|Definition |Recurrent depressive |Chronic, low grade |Not enough information |Recurrent mania & |Recurrent hypomania & |Chronic fluctuations |Type I vs. Type II |

| |episodes with functional |depression | |depression |major depression |b/w minor mood episode |vs. Cyclothymia |

| |problems | | | | | | |

| |At least 2 weeks of | |Premenstrual dysphoric |At least one manic or |No manic or mixed episode| |GMC is not ruled out|

| |depression OR anhedonia + | |disorder |mixed episode | | | |

| |symptoms | | | | | | |

|Episode Frequency |One ore more MDD episode |Two or more years of | |One manic or mixed | |Two or more years | |

| | |depression | |episode needed | | | |

| |Chronic episodic |Never goes more than 2 | |Good inter-episode |Good inter-episode |Never symptom-free more| |

| | |months without symptoms | |recovery |recovery |than 2 months | |

|Epidemiology |More in females |More in females | |Equal in female/male | | | |

| |15% commit suicide |Co-morbid with personality| |Earlier onset than MDD |Rarely require | | |

| | |types | | |hospitalization | | |

|Etiology |Abnormal NorEpi, serotonin,| | | | |Many hypomanic and | |

| |dopa, & Acetylcholine | | | | |minor depressive | |

| | | | | | |episodes | |

|Psychology |Loss of parent before age |Low energy | | | | | |

| |11 | | | | | | |

| |Trauma during development |Low self worth | | | | | |

| |Poor coping with |Poor concentration | | | | | |

| |personality disorders | | | | | | |

|Subtypes |Melancholia: anhedonia with| | |Postpartum psychosis = | | | |

| |decreased sleep | | |bipolar | | | |

| |Atypical depression: | | |Seasonal affective | | | |

| |excessive sleep | | |disorder | | | |

| |Psychotic depression: | | |Rapid cyclers = 4 or more| | | |

| |hallucinations | | |episodes per year | | | |

| |Postpartum depression | | | | | | |

Anxiety: apprehensive anticipation of danger (unpleasant & somatic symptoms)

Phobia: persistent, excessive, or irrational fear of specific things or situation

Fear response: 1. cognitive appraisal 2. physiologic danger 3. behaviors

Panic attack: period (10 minutes or less) of intense fear with four or more of the symptoms (ie. Choking, chest pain, sweating, numbness)

|Anxiety Disorders |

| |Panic Disorder |Social Phobia |OCD |Generalized Anxiety Disorder |PTSD |

|Definition |Recurrent unexpected panic |Fear of embarrassing situations or |Recurrent unwanted & distressing |Excessive worry about real life |Reexperiencing, hyperarousal, |

| |attacks |places |thoughts or behaviors |problems |emotion numb |

|Symptoms |Anticipation, worry, and change | |Distress & interfere with daily |3 or more anxiety symptoms |** Response involve fear, |

| |in behavior | |function (ego-dystonic) |(restless, tension, fatigue) |helplessness, & horror ** |

|Associated Features |With or without agoraphobia (open|Exposure to situation provoke anxiety|Not pleasurable but reduce anxiety |Seek help for somatic concerns |[psychosis] |

| |places) | | | | |

| | |Good insight into excessive nature |Insight present [psychosis] |2nd most common disorder | |

| | |Co-morbidity with alcohol and |Chronic & disabling |Co-morbidity with other | |

| | |depression | |psychiatric disorders | |

|Female : Male |3x more in women |Higher in women & strong genetics |Equally in men & women |Higher in women |Higher in veterans |

| | | | |2:1 | |

|Onset | | |Half is childhood onset | |Last more than 1 month |

|Psychotic Disorders |

| |Schizophrenia |Schizophreniform |Brief Psychotic |Delusional |Shared Psychotic |Schizoaffective |

|Duration |At least 6 months |1-6 months |1 day - 1 month |At least 1 month |Develop delusions with | |

| | | | | |relationship partner | |

|AKA |Pre-senile dementia | | | | | |

|Symptoms |Social/occupational |Good prognostic features: |Eventual return to premorbid|Non-bizarre delusions | |Mood symptoms for |

| |dysfunction | |functioning | | |substantial part of illness |

| | |Female | | | | |

| | |Co-morbid mood disorder | | | | |

| | |Late & acute onset | | | | |

| | |Insight preserved | | | | |

| | |No family history of | | | | |

| | |pyschosis | | | | |

| |Disorganized speech/ | | |Preceded by psychosocial | |Delusions/Hallucinations |

| |thought/ behavior | | |stressor | |persist at least 2 weeks in |

| | | | | | |absence of mood symptoms |

| |Psychic ambivalence | | | | | |

| |Loosening of associations | | | | | |

|DSMIV Criteria |At least 1 month of | |Sudden onset of at least 1 |No impairment of function or|Delusions of both are |Major mood episode while |

| |Bizarre Delusions | |positive characteristic |bizarre behaviors |similar in content |experiencing characteristic |

| |OR | |symptom | | |symptoms of schizophrenia |

| |Hallucinations | | | | | |

| |(auditory then visual) | | | | | |

|Epidemiology |Episodic with gradual | | |Onset at 40 | | |

| |decline | | | | | |

| |50% attempt suicide | | | | | |

|Prevalence |1% | | |0.03% | |Less than 1% |

|Distribution |Equal in men/women | | | | | |

| |Earlier onset in men | | | | | |

| |Common in lower status: | | | | | |

| |“downward drift” | | | | | |

|Abnormalities & Subtypes |Decreased brain volume & | | |Erotomanic type | |Depressive type: only major |

| |increased lateral ventricles| | |Grandiose type | |depressive episodes |

| | | | |Jealous type | | |

| | | | |Persecutory type | | |

| | | | |Somatic type | | |

| |Smaller prefrontal cortex | | | | |Bipolar type: manic or mixed|

| |with loss of asymmetry | | | | |episodes |

| |between left & right brain | | | | | |

| |CD PUR subtypes | | |“Shh” therapy works | | |

Psychosis: gross impairment in reality testing or ego boundaries

Schizophrenic disorders: delusions, hallucinations, disorganized speech & behavior

Psychosis due to GMC: delusions & hallucinations without insight

|Personality Disorders |

|A |B |C |

|Odd, eccentric, guarded, reserve |Dramatic, impulsive, attention, seeking/getting |Compulsive, fearful, timid |

|Paranoid |

|Dysfunctions |Disorders |Symptoms |

|Sexual Desire |Hypoactive sexual Desire | |

| |Sexual aversion |Dislikes & avoids all genital contact with partner |

|Sexual Arousal |Female sexual arousal |Patient can’t lubricate enough to complete sexual activity |

| |Male erectile |Patient can’t keep or get erection to complete sexual activity |

|Orgasmic |Female orgasmic |Normal sexual excitement phase, but orgasm is delayed or absent persistently |

| |Male orgasmic |Normal sexual excitement phase, but orgasm is delayed or absent persistently |

| |Premature ejaculation |Minimal sexual stimulation cause early ejaculation |

|Sexual Pain |Female dyspareunia |Genital pain with sexual intercourse not due to inadequate lubrication or vaginismus |

| |Female vaginismus |Repeated spasms of vaginal muscles interfering with sex |

|Substance-induced | |Symptoms develop within 1 month of drug use OR medications cause symptoms |

|Due to GMC | |PE or lab findings show direct physiological effects of GMC AND not due to mental disorder |

*All cause marked distress or interpersonal problems

** All not caused by GMC or substance abuse

Paraphilias: recurrent, intense sexual urges or behaviors involving unusual situations

Cause significant distress or impairment

At least 6 months

|Paraphilias |

| |Exhibitionism |Fetishism |Frotteurism |Pedophilia |Masochism |Sadism |Transvestic Fetishism |Voyeurism |

|Duration |At least 6 months |At least 6 months |At least 6 months |At least 6 months |At least 6 months |At least 6 months |At least 6 months |At least 6 months |

|Symptoms |Exposure of genitals at|Involves use of |Touching & rubbing |Sex with prepubescent |Real act of being |Real acts of |Heterosexual male |Observing an |

| |unsuspecting stranger |nonliving objects |against non-consenting |child (13 or younger) |humiliated, beaten, |psychological or |cross-dressing |unsuspecting person |

| | | |person | |bound, or made to |physical suffering of| |who is naked, |

| | | | | |suffer |victim | |disrobing, or having |

| | | | | | | | |sex |

|Criteria |Cause distress & | |Cause distress & |Cause distress & |Cause distress & |Cause distress & |Cause distress & |Cause distress & |

| |impairment | |impairment |impairment |impairment |impairment |impairment |impairment |

| | |Not limited to | |Person is at least 16 | |Act on non-consenting|Gender dysphoria | |

| | |female clothing or | |years old & 5 years older | |person |(discomfort with | |

| | |devices | |than victim | | |gender identity) & | |

| | | | | | | |frequent in males | |

| | | | |Exclusive or nonexclusive | | | | |

Gender identity disorder NOS

Intersex conditions & gender dysphoria

Transient cross-dressing

Preoccupation with castration or penectomy without desire to acquire sex characteristics of other sex

|Atypical Antipsychotics |

|Block Serotonin more than Dopamine receptors |

|Drug |Treatment |Side Effects |Cautions |

|Clozapine |Treat TD & refractory cases |Anticholinergic |Seizures |

| | |Sedation |Agranulocytosis |

| | |Hypersalivation | |

| | |Orthostasis | |

| | |Weight gain | |

|Risperidone | |EPS | |

| | |Risk of stroke | |

|Olanzapine | |Somnolence | |

| | |Increased appetite & weight | |

|Quetiapine | |Cataracts in beagle dogs | |

|Ziprasidone | | |Cardiac conduction problems |

|Aripiprazole |Newest |Well tolerated | |

Thought – mood – anxiety – psychosis – personality – agitation disorders

Traditional antipsychotics

Dopamine blockade D2

Anticholinergic = Anti-SLUDGE

Anti-Histamine – Cardiotoxicity – Orthostasis – Pigmentary changes – Photosensitivity – Sexual dysfunction – Lower seizure threshold

Antipsychotics

Haloperidol

Fluphenazine

Thiothixene

Perphenazine

Clorpromazine

Thioridazine

|Antidepressants Classes |

| |TCA |MAOI |SSRI |SNRI |

|Mechanism |Block reuptake of serotonin & norepinephrine |Block catabolism of serotonin, NE, dopamine, |Block serotonin reuptake |Block serotonin & norepinephrine reuptake |

| | |& monoamines | | |

|Side effects |α-1 blockade (sexual dysfunction) |Hypertensive crisis |Anxiety & akathisia | |

| |Histamine blockade |Serotonin syndrome |Insomnia vs. sedation | |

| |Acetylcholine blockade | |GI upset | |

| | | |Anorexia | |

| | | |Sexual dysfunction | |

|Overdose |Delirium | |Risk of suicide | |

| |Cardiotoxicity | |Serotonin syndrome | |

| |Lower seizure threshold | | | |

|Drugs |Desipramine |Approved for depression: |Citalopram |Venlafaxine |

| |Amitriptyline | |Fluoxetine |Mirtazapine |

| |Nortriptyline |Phenelzine |Fluvoxamine |Duloxetine |

| |Imipramine |Tranylcypromine |Paroxetine | |

| | | |Sertraline | |

| | | |S-Citalopram | |

|Onset |3-4 Weeks | | | |

MAOIs

Effective for depression & anxiety

Monoamine hypothesis = depression caused by low serotonin & norepinephrine

Serotonin syndrome

Mental status change

Autonomic instability

Neuromuscular abnormalities

SSRIs

First-line for depression & anxiety

Safe overdose & better tolerated

Serotonergic agents

Trazadone

Priapism

Nefazadone

Uncommon sexual dysfunction

Acute hepatoxicitiy

Dangerous drug interactions

Buproprion

Increase Dopamine, Norepinephrine, little on serotonin

Effective with atypical depression

FDA for smoking cessation

No sexual dysfunction

Seizure risk & agitation

Venlafaxine

Blood pressure elevations

Mirtazapine

Sometimes block serotonin receptors = prevent SSRI side effects

Histamine blockade = weight gain & sedation

Low sexual side effects

Duloxetine

Increase serotonin & NE like TCAs

|Mood Stabilizers |

| |Lithium |Valproic Acid |Carbamazepine |Lamotrigine |

|Type | |Anticonvulsant |Anticonvulsant |Anticonvulsant |

|Mechanism |Increase Dopamine, Ne, serotonin, Ach, & |Increase GABA |Decrease sodium influx |Block sodium channels (& calcium) |

| |GABA | |Modulate GABA-B receptors |Increase glutamate |

|Onset |1-3 weeks | | | |

|Indications |Classic Bipolar (mania) |Bipolar (mania) |Trigeminal neuralgia |FDA for bipolar depression |

| |Unipolar depression |Epilepsy |Bipolar | |

| |Personality disorders |Personality disorder |Epilepsy | |

| |PTSD |PTSD & GAD |Alcohol & benzodiazepine withdraw | |

| | |Alcohol abuse | | |

| | |Migraine prophylaxis | | |

| | | | | |

|Uses |Augment antidepressants |Favorable side effect than Li | | |

| |Augment antipsychotics |Effective in atypical bipolar | | |

| |Reduce suicidal behaviors |Wider therapeutic index | | |

|Side Effects |Tremor |Weight gain & sedation |Sedation |Life-threatening rash |

| |Acne |Tremor |Cognitive dulling |Double vision |

| |Weight gain & sedation |Alopecia |GI upset |Dizziness |

| |Cognitive dulling |Diarrhea |Clumsiness |Ataxia |

| |Diarrhea |Ataxia | | |

| |Diabetes insipidus | |SIADH | |

| |Lower seizure threshold | |Rash | |

| |Granulocytosis | |Hepatic failure & pancreatitis | |

| |Renal complications | | | |

|Cautions |Pregnancy = Ebstein’s anomaly |Pregnancy = Neural tube defects |Pregnancy = craniofacial, neural tube, | |

| |In breast milk |In breast milk |fingernail, & development | |

| | | | | |

| |ECG prolongation |Increase liver function |Autoinduction of P450 system | |

| |Hypothyroidism |Agranulocytosis |Cardiac conduction delay | |

| |Leukocytosis |Fatal hepatoxicity & pancreatitis |Leukopenia | |

Benzodiazepines = increased GABA-A

Alprazolam = addictive (Xanax)

Clonazepam

Diazepam = addictive (Valium)

Lorazepam

Triazolam

Midazolam

Chlordiazepoxide

Anxiolytic at low doses

Sedative at high doses

Mental Retardation

IQ less than 70

Delays in self care & communication

Pervasive Developmental Disorders

Autistic Disorder

Impaired reciprocal social interaction

Mental retardation & seizures

Impaired verbal & nonverbal communication

Restricted activities

Treatment

Alpha-2 Agonists

Clonidine

Risperidone

Asperger’s Disorder

High functioning autisms

Retts Disorder

Normal growth for first months

Decelerated head growth b/w 4-8 months

Females only

Incoordination

Childhood Disintegrative Disorder

Normal development for first years

Loss in (2 or more) language – social skills – bladder control – play – motor skills

Before age 10

PDD NOS

Impairment in development but not met for specific PDD

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