FOBS Test 2 Key Slides

Kristen Taylor
 Personality Disorder
General Criteria
(DSM IV)

The pattern is manifested in 2 (or more) areas:

1. Cognition how the pt perceives/interprets self, others,

events

2. Affectivity appropriate or inappropriate affect,lack of

affect, intensity of affect, range of emotions

3. Interpersonal functioning (between people)

4. Impulse control
Personality Disorder Clusters
A: Odd and Eccentric
- Paranoid -Schizoid
- Schizotypal

B: Dramatic, Emotional, Erratic

- Borderline -Histrionic
-Narcissistic -Antisocial

C: Anxious and Fearful

-Avoidant -Dependent
-Obsessive-Compulsive
 Paranoid Personality
Pervasive distrust and suspiciousness of
others
Prevalence: 0.5 1.5%
Etiology: shame-inducing experiences/
modeling of mistrust
- perceived/actual experiences of
mistreatment
Defenses: splitting/projection
Treatment: supportive psychotherapy/low
dose anti-psychotics
Approach in medical setting
- Trust is primary concern
- Explain all tests, treatment
 Schizoid Personality

Pervasive detachment from social

relationships
Prevalence: 0.5 1%
Treatment: supportive psychotherapy
Approach in medical setting
- Respect emotional distance
- Offer reassurance
 Schizotypal Personality

Present in higher rates in families with

schizophrenia
Prevalence: 1 3%
Thought to be a partial expression of
schizophrenia
Differs from schizoid/paranoid personality
disorder with cognitive distortions/oddness
Defenses: denial, distortion, projection, schizoid
fantasy
Treatment: supportive, reality-based therapy
- Low dose anti-psychotic medication
 Cluster B:
Dramatic, Emotional, Erratic

Borderline

Histrionic

Narcissistic

Antisocial
Borderline Personality Disorder

Pervasive pattern of instability in self image, interpersonal

relationships, affect and impulsiveness
Dramatic, self-destructive behavior
Recurrent suicidal behavior
Hallmark Feature: Impulsive
Most common personality disorder in clinical setting
Prevalence of 2%
High comorbidity
Defenses: splitting, projective identification, acting out
Etiology: history of abuse, abandonment
Treatment:
- Clear concise guidelines
- Simple, straightforward communication
- Maintain clear boundaries
- Be aware of impact of separation
Psychotherapy: multiple modalities
Psychotropics to treat symptoms
 Histrionic Personality Disorder
Prevalence: 2%
Etiology:
- Sexualization of parent of opposite sex
- Defense to deprivation of parent of same sex
Treatment:
Long-term psychotherapy (psychoanalytic)
Pervasive pattern of extreme emotionality and
attention seeking
- More common in females
- Treatment has been psychoanalytic methods
Approach in medical setting
- Support, reassurance, structured availability
- Firm, limit setting
- Reality-based education
Narcissistic Personality Disorder

Love of self: Pervasive pattern of grandiosity,

superiority, lack of empathy for others
Problematic anger-Envious of others-Requires admiration
WE use the non-confrontational approach, Supportive
therapeutic settings, Unlikely to seek treatment on their
own, because,there is nothing wrong with me, or my
behavior
Prevalence: less common
Etiology: disturbed parenting age 6 months- 2 years
- Unempathic, overcontrol, and neglect
- Potential for successful development undermined
Treatment:
- Psychoanalytic, supportive psychotherapy
Approach in medical setting
- Do not get into power struggle
- Clarify expectations, limits, your capacity to help
 Antisocial Personality Disorder
Pervasive pattern of exploiting others, disregard For the rights of others
and society
Does not learn from past
Evidence before 15
Irritable and aggressive
Lack of remorse
Reckless disregard for the safety of self or others
Considerations:
More common in males
Substance abuse, Depression, Suicide risk
Extremely difficult to treat
Most common co-morbid condition
-substance abuse
More common in men
Prevalence: 2-3%
Treatment:
- Avoid being manipulated
- Combination of individual/group therapy
Approach in medical setting
- Avoid power struggle
- Clarify roles, boundaries
- Agree to disagree
 Cluster C:
Anxious and Fearful

Avoidant
Dependent
Obsessive-Compulsive
 Avoidant Personality Disorder
Prevalence: .5 1%
Associated with social phobia, panic disorder
Etiology:
- Inborn temperamental tendency
- Suboptimal parental response
- Treatment: long-term psychotherapy
- Adjunctive use of anxiolytic/antidepressant
medication
Pervasive pattern of feelings of inadequacy,
hypersensitivity to any form of criticism, even if
minor in nature, and experiences extreme social
inhibitions
Approach in medical setting
- Provide empathy, support
 Dependent Personality Disorder

Pervasive pattern of excessive need to be

taken care or by others
Behavior is often very clinging and they
are fearful of separation
Will often times be submissive to others
Approach in medical setting
- Present as dependent clingers
- Offer appropriate limited availability
- reassurance, clarification, clear
expectations
 Obsessive Compulsive
Personality
Disorder
Pervasive pattern or preoccupation with
details at the expense of efficiency
Prevalence: 1%
Etiology:
- Temperment of attentional self-regulation
- Fixation in anal phase (age 3)
- Unconscious shame and guilt
Treatment/Management:
- Provide with as much control as possible
- Psychotherapy/analysis
Approach in medical setting
- Provide with as much control as possible
- Provide appropriate up to date information
Somatoform, Fictitious,
Malingering
Somatization Disorder

Formerly, hysteria or Briquets Syndrome

Women > than men-20:1

Lifetime prevalence: 0.4%

Point prevalence: 1-2%

Usually lower socioeconomic groups

Unconscious factors
Somatoform Disorder-
Somatization Disorder

Diagnosis: multiple somatic complaints of

several years consisting of:

- 4 pain symptoms

- 2 GI symptoms

- 1 sexual symptom

- 1 pseudoneurological symptoms
Conversion Disorder/Diagnosis

Monosymptomatic with symbolic relationship

between psychological conflict and physical
symptom

Symptom not intentionally produced (unconscious)

Symptom cannot be explained by general medical

condition
Somatoform Disorders-Pain Disorder

Pain is primary focus

Pain causes distress

Psychological factors judged to have role in

onset, severity, exacerbation, maintenance

Symptom not intentionally produced (unconscious)

 Hypochondriasis

Preoccupation with fear of having serious disease

Concern persists despite reassurance

Belief it is not of delusional intensity

Belief causes distress, impairment in life

Duration 6 months or greater

Unconscious motivation
 Somatoform Disorder -
Body Dysmorphic Disorder

Preoccupation with imagined defect in appearance

Belief causes significant distress, impairment in life

Onset typically in adolescence (range 6-33 years)

Possible female preponderance

Unconscious motivation
Body Dysmorphic Disorder (BDD)

High prevalence of major depression (50%)

May benefit from an SSRI

Pimozide

Individual/group cognitive therapy

 Factitious Disorders

Voluntary production of signs, symptoms,

diseases

The only goal is to achieve role of the patient

Conscious effort
 Factitious Disorders
Physical/Psychological
Symptoms
Typically socially conforming young women

Higher socioeconomic class

Intelligent, educated, employed in medically

related field

More common than once believed

 Factitious Disorders
Munchausens

Triad of simulation of disease, lying, wandering

Typically men of lower socioeconomic class

Socially maladjusted

Average age of 30
 Malingering
Intentional product of illness

Motivated by external goal:

- Financial
- Avoiding military
- Avoiding criminal prosecution
- Obtaining drugs
- Shelter
Delerium, HIV, Emergency
Delirium

Definition: reversible organic

mental disorder (however some
cases may progress to irreversible
brain failure)
Hallmarks: confusion & altered
level of consciousness
Delirium: Epidemiology

10-15% of general medical inpatients

are delirious at any given time
30-50% of acutely ill geriatric
patients become delirious at some
point during hospital stay
Frequent cause of psychiatric
consultations in the hospital
 Differential Diagnosis of Delirium
I WATCH DEATH

Encephalitis, meningitis, syphilis

Infectious

ETOH, barbiturates, sedatives

Withdrawal

Acute metabolic Acidosis, alkalosis, renal/hepatic

failure

Trauma
Heat stroke, severe burn, post-op

CNS pathology
Abscess, hemorrhage, seizure, stroke,
tumor, normal pressure hydrocephalus

Adapted from: Harvard Board Review

 Differential Diagnosis of Delirium
I WATCH DEATH (cont)
Anemia, CO poisoning, hypotension,
Hypoxia pulmonary/cardiac failure

Deficiencies Vitamin B12, niacin, thiamine

Hyper/Hypoadrenocortisolism,
Endocrinopathies
Hyper/Hypoglycemia

Acute Vascular Hypertensive encephalopathy, shock

Toxins or Drugs Medications

Heavy metals Lead, manganese, mercury

Adapted from: Harvard Board Review

 Acute Dystonic Reaction
Seen more common in young males, well
developed muscular males.
Common in people who have never taken
antipsychotics before.
See turning of the neck or eyes rolling back
in the head
Develop w/in few hrs of treatment
Respond quickly to benztropine
(anticholinergic), or benadryl
(antihistamines)
 Neuroleptic Malignant
Syndrome
stiffness, cogwheeling, autonomic instability (hi temp, they look
hot)
Occurs any time in treatment with antipsychotics
Most pronounced in pt with mental retardation or head injury
Requires immediate intervention very serious condition
More common in men
Mortality rate is up 20%
Initial treatment supportive care hydration and treat
hyperthermia.
Can also give DA agonist (bromocriptine) or dantroline (upper
motor neuron muscle relaxant)
More common in pts treated with high potency old antipsychotics
(e.g. haloperidol) less common now with new atypical
antipsychotics
 Akathesia 2ndary to GI
drugs
Compazine, phenergan, reglan can
cause akathisia look like anxiety
Pt c/o internal restlessness
Subjective feeling of motor restlessness
looks like anxiety but pt says he has no
reason to be anxious just cant sit still
Occurs 1-6 wks of treatment
Treated best by beta blockers or
antihistamines
Sedative-Hypnotics
Subunit Structure
Channel opens to Cl- ions when GABA
binds
Increased Cl- conductance inhibits
neural firing
Decreased Cl- conductance excites
neurons (seizures)
Benzodiazepines: Overview
Efficacious hypnotics; fast onset
SAFE by themselves
When combined with sedative-
hypnotics such as ethanol or
barbiturates, lethality is enhanced
Dependence is a serious problem
Long half-lives foster drug hangover
and next-day drug interactions
Diazepam (Valium)
-prototype
anxiolytic, hypnotic
muscle relaxant
pre-anesthetic (amnestic + above)
blocks convulsions in ethanol or
BZD withdrawal
long half-life (approx 50+ hrs)
Diazepam (Valium)
-prototype
terminates status epilepticus
given i.v.
Second choice agent behind lorazepam
Diazepam is much more lipid soluble than
lorazepam; so much so that diazepam
requires a special vehicle it precipitates
from aqueous solution unless the
concentration is very dilute. These
physicochemical properties have caused the
more water-soluble agent (lorazepam) to
take over this function.
not used as long-term therapy for
seizures
Oxazepam (Serax)
Final common pathway for diazepam and
chlordiazepoxide metabolism in the liver.
(See next slide)
Often see more reliable pharmacokinetics
in elderly for oxazepam as compared to
diazepam and chlordiazepoxide
Little change in Phase 2 metabolism
with aging (e.g. glucuronide
conjugation)
Significant changes in Phase 1
metabolism with aging (e.g., P450
oxidations)
BZD Dependence

Physical Dependence = an abstinence

syndrome when:
drug administration stops (spontaneous)
an antagonist is given (precipitated)
BZD Abstinence Syndrome
Withdrawal signs and symptoms
Signs
tremors
seizures
Symptoms
ANXIETY
insomnia
nausea
malaise
Zolpidem (Ambien)
As compared to BZDs, nearly as
efficacious in producing sleep
As compared to BZDs, much less:
anxiolytic
anticonvulsant
muscle relaxant
Zaleplon (Sonata)
Like zolpidem, binds BZD1 (omega1)
receptors and has same profile of effects
Shorter half-life than zolpidem (approx
1hr)
Being pushed for PRN, meaning take either
before bedtime or upon awaking in the
middle of the night (if more than 4 hr
remain in sleep cycle)
a treatment for those who awake mid-sleep
cycle
Melatonin
Pineal gland hormone that regulates
sleep/wake cycle
peaks about 2:00 a.m.
Particularly useful for sleep problems
related to jet-lag or changing
day/night working hours
Dose is variable (FYI, from 0.2 to 3.0
mg)
Depression or hx of depression is a
contraindication
BZDs vs Barbiturates
Both facilitate GABAs effects
Neither bind directly at the GABA
binding site on the receptor
At high doses, barbiturates
directly increase Cl- flux
In contrast, no dose of BZDs ever
directly affects Cl- flux. BZDs
only facilitate GABA.
Alcohol
BEC = 50 - 100 mg/dL
sedation; subjective high; increased reaction
times
2-4 quick drinks
BEC = 100 200
Impaired motor fcn, slurred speech, ataxia
BEC 200 300
Emesis, stupor
BEC 300- 400
Coma
BEC > 500 mg/dl
Respiratroy depression, death
 Units: % (g/dL) or mg % (mg/dL)
1-2 drinks produces a BEC of
~0.025 g/dL
= 0.025% or 0.25 mg%
Disulfiram
a. inH the MEOS ethanol metab. system
b. inH opioid mu recs (naltrexone)
c. inH alcohol DH
d. inH aldehyde DH
e. inH GABAa rec complex d
s/s: N/V, flushing, sweating, confusion
* By InH aldehyde DH build up of
ACETALDEHYDE wh/ + Vasodilation .: drops
there Blood Pressure
Naltrexone: opioid antagonist @ mu recs
classic to reduce cravings
* CI in impaired Liver fcn & CI in pts being
treated w/ opiods
Acamprosates: reduce cravings
Naloxone NOT orally active
Fomepizole: Methanol & Ethylene glycol
poisoning
The more you reduce the cravings the
better the patient can resist drinking
MOA of acamprosate
a. Activates GABAa rec and blocks NMDA rec
b. Blocks GABAa rec & acT NMDA rec
c. Blocks glutamatergic AMPA receptors
d. Activates glutaminergic kainate receptors
e. Selectively blocks GABA-A receptors

How is this related to ETOH?

facilitates GABAa rec transmission & normally (-) glutamate
transmission
acamprosate this has very weak actions vs.
ETOH
Adoption studies into the impact of
familial determinants on ETOHism
demonstrate
a. A reliable assoc. of ETOHism to specific genetic markers

b. That no sex diffs exist in the inheritance rates for

alcoholism - males at higher risk
c. An ETOHic adoptive parent markedly incrs. the risk of
alcoholism - NO
d. Biological sons of ETOHics (BSA) are at incr. risk of
psychiatric illnesses - yes
e. BSA are at an incr. risk of ETOHism d,e
50% and if
General prevalence = 10 15%
If psychiatric illness + ETOHic 90%
If 1 parent = 20%
2 parents = 20 50%
Which of the following signs is most
characteristic of korsakoffs syndrome
a. Anterograde amnesia
b. Tremor
c. Hallucinations - probably from the intoxication
itself
d. Seizures
e. Autonomic hyperreactivity a
COAT RACK
Korsakofs = retrograde & anterograde
amnesia, confabulations (pts DN know
they are lying)
Confusion, Opthalmoplegia, Ataxia =
Thiamine
Delirium tremens rare, but life-
threatening
- Mental confusion w/ fluctuating levels of
consciousness can have hallucinations
- Tremor
- Agitation
- Autonomic Overactivity
- FEVER, incr HR, BP, RR
Delirium part = pt doesnt know who they
are or where they are
ETOH withdrawal
Sxs include:
- hyperexcitability (tremulous)
- confusions
- toxic psychosis
- delirium tremens
* ETOHics know 3- 4am very well
As blood [ ] of drug of abuse drops,
withdrawal Sx begin and peaks when the
substance is completely gone
Starts BEFORE the drug is completely gone
from body
Drugs of Abuse
Reinforcing potency and
efficacy
Reinforcement: ability of drugs to increase
frequency of drug-taking (e.g., euphoric effects)
Abused drugs directly activate neural
reinforcement circuits (e.g., those activated by
food or sex), with no satiety equivalent
associated with natural reinforcers
Order of reinforcing potency for drugs of abuse is
similar in humans and animals
Most drugs of abuse can increase extracellular
dopamine (DA) in the nucleus accumbens (NA):
ethanol opioids amphetamine cocaine
nicotine others
Noradrenergic, serotonergic, and opioidergic
mechanisms may also be involved, but all
ultimately resolve to DA in the accumbens
Brain
monoamine
neurotransmi
tters and
their impact
on thought
and emotion
Pharmacokinetic Tolerance
Changes in distribution or metabolism of a
drug after repeated administration, such
that there is a diminished concentration of
drug at the site of action.

The most common mechanism is induction of

hepatic metabolism:
alcohol
barbiturates
benzodiazepines.
Pharmacodynamic Tolerance
Adaptive changes in target tissue occur with
repeated use such that there is a
diminished response to the same
concentration of drug.
Common mechanisms:
Reduced receptor density at the site of drug
action resulting in deceased agonist
sensitivity
(e.g., down-regulation of -opioid receptors
with chronic morphine)
Uncoupling of receptor to signal
transduction pathways.
Compensatory changes (e.g. up-regulation)
in systems mediating opposing
physiological effects
Learned Tolerance
A reduction in the effects of a drug due to learned
compensatory mechanisms:
Behavioral tolerance: skills developed through
experience with drug (often called learned
tolerance). Learning to walk a straight line during
alcohol intoxication is classic example. The same
phenomenon has been shown in simulated driving
experiments. Note: the legal system does not care
about learned tolerance.
Conditioned tolerance (situation-specific tolerance)
Based on pairing of drug administration with specific
environmental cues related to drug-taking. A
conditioned response that is opposite to the effects
of the drug occurs upon presentation of these
environmental cues prior to drug administration.
Mechanism is thought to be Pavlovian learning.
Acute Tolerance
Rapid tolerance developing with repeated use
on single occasion (e.g., cocaine binge)
Cocaine is often self-administered in a binge
pattern, with repeated doses over one to
several hours (often limited only by supply)
There is a decrease in euphoric response to
subsequent doses of cocaine during the
binge.
In contrast, there is little tolerance retained
from one binge session to the next.
Occurs with cocaine, methamphetamine,
nicotine
Cross-Tolerance
Tolerance conferred upon one or more other
drugs as a result of repeated use of a given
drug.
Involves drugs in the same structural and/or
mechanistic category
Can be based on similarity of
pharmacologic actions, target tissue effects,
or metabolic sources of the tolerance:
Tolerance to a naturally-occurring or
synthetic opioid results in cross-tolerance
to other opioids.
Tolerance to ethanol can produce
tolerance to other sedatives and general
anesthetics
Cocaine: Mechanisms
Reinforcing effects correlated best with
blocking DA transporter
one of the most reinforcing substances identified
in both humans and animals. It is thus
powerfully addictive.
20% of recreational users go on to serious heavy
usage with negative consequences.
NIDA estimates 25+ million Americans have
used cocaine. Use has declined considerably
from early 80s to the 90s
availability of free-base form (i.e., crack) has
influenced use
Also binds NE and 5-HT transporters
Reinforcing effects similar to i.v.
amphetamines
Amphetamine: Mechanism
Reinforcing effects correlate best with presynaptic
release of DA (amphetamine runs the re-uptake
transporter in reverse)
Some stimulants may have direct receptor effects
and/or inhibit MAO, but for amphetamine and
methamphetamine, these are minor actions
No local anesthetic effect (in contrast to cocaine);
thus, seizure potential is less with amphetamines
(although still a possibility)
Nicotine withdrawal
syndrome
Irritability, etc.
Anxiety
Dysphoria
Restlessness
Difficulty
concentrating Decreased HR
Increased appetite
and/or weight gain
Phencyclidine
PCP, angel dust, ozone, rocket fuel
Dissociative anesthetic, chemically related to
ketamine with similar effects. No therapeutic
application in humans
Mechanism: non-competitive blocker of NMDA
receptors
Route: smoking (marijuana laced with PCP), snorting,
oral. Tobacco cigarette laced with liquid (dip).
Psychotomimetic effects; profound tolerance
12-24 h half life; in overdosage may be prolonged to
72-h
Phencyclidine: Effects
Euphoria, staggering, disorientation,
paresthesia, nystagmus, slurred speech,
distortion of body image
Strength, power, invulnerability (insensitive
to pain); anger, rage
Depression; paranoid ideas; hostility
Moderate dose: Sympathomimetic effects
tachycardia, increased BP, mydriasis,
xerostomia
High dose:
Analgesia, anesthesia, decreased BP and
respiration. Combined horizontal and vertical
nystagmus is specific to PCP; horizontal seen in
ethanol and sedative hypnotics.
Amphetamines incr. SNS
acT
Acute effects of amphetamine
Alertness
Anti-fatigue DT NE at RAS
Anorexia
Emotionality
Toxic psychosis w/ chronic use
.: treat w/ anti-psychotics
SNS over activity
PCP resembles Ketamine
Ketamine: used for an anesthetic
(*also used in kids but get BAD dreams)
PCP: Mechanism: non-competitive blocker
of NMDA recs
Psychotomimetic effects; profound
tolerance
12-24 h half life
Always see: Nystagmus, High BP &
insensitivity to pain
Eating Disorders
Eating Disorders:
Anorexia Nervosa:
Central feature: misperception of
ideal body weight feels fat but is
not
Various means used to drive
weight well below optimal for
health
restriction
purging, laxative abuse, over-exercise
(hypergymnasia)
very resistant to feedback or
treatment
Eating Disorders:
Anorexia Nervosa:

Diagnostic Criteria:
Refusal to maintain minimally normal
weight
Intense fear of gaining weight or
becoming fat (although underweight)
Misperception of current weight
versus ideal
Amenorrhea (if post-menarche)
Min of 3 months
Eating Disorders:
Anorexia Nervosa:
Anorexia is misnomer appetite
is preserved but resisted
Rarely seek treatment brought by
worried families uncooperative
Physical exam: emaciation, lanugo
(fine, downy trunkal body hair)
may have signs of purging, if done
(see under Bulimia Nervosa)
amenorrhea obligatory
A syndrome of industrialized
societies where thinness is valued
Eating Disorders:
Anorexia Nervosa:
1-2% late adolescent/early adult
females uncommon in males
Mean age of onset = 17 yoa with
highly variable course
More severe presentation may
require inpatient treatment for
medical stabilization (starvation,
dehydration, electrolyte imbalance)
If severe, refer to specialized Rx
(and cross your fingers)
A normal weight young woman:
Weighing the evidence: B.N.
Normally active lifestyle
Menses continue
Normal weight or a little above
Hides problem but doesnt really
deny
Physical findings of purging seen
on exam
Eating Disorders:
Bulimia Nervosa:
Central feature: inability to control
appetite/eating leading to eating
binges
Inappropriate compensatory
methods follow to maintain
relatively normal weight
at least 2/wk X 3 mos
usually embarrassed, self-disparaging
purging, laxative abuse, over-exercise
(hypergymnasia) follow
Eating Disorders:
Bulimia Nervosa:
Ashamed but more likely to seek
Rx than anorectics
Signs: primarily 20 purging
Also more likely in industrialized
societies (like Anorexia)
1-3% late adolescent/young adult
females
> 90% females, < 10% males
More likely to remit than Anorexia
Eating Disorders:
Bulimia Nervosa:
May be treatable in office, or may
need specialized program
Appetite reduction/control may be
possible pharmacologically:
Fluoxetine approved (up to 60-80 mg QD
may be required more than for depression);
for suppressing appetites more than
elevating mood
Bupropion worked well but seizure risk too
high contraindicated now
Cannot use it because of Seizure risk
Already susceptible to Seizure without bupropion
appetite suppressants????
Trauma & Violence
Culture
Culture is learned.
Culture refers to systems of
meanings.
Culture acts as a shaping template.
Culture is taught and reproduced.
Culture exists in a constant state of
change.
Culture includes prescriptions and
proscriptions for human behavior.
88
Definitions

Child abuse: a child has suffered or there

is a substantial risk that a child will
imminently suffer physical harm, inflicted
non- accidentally by parents or caregivers
which causes a substantial risk of causing
disfigurement, impairment of bodily
functioning or other physical injury. (Fed.
Juvenile Justice Standard)

89
Definitions

Domestic Violence: intentionally

violent or controlling behavior of a currently
or previously intimate partner of a victim.
The goal is to coerce, assert power and
maintain control.

90
Definitions

Child neglect- failure to fullfill obligation

Physical neglect- refusal/delay in health
care, abandonment, inadequate
supervision
Educational neglect- permitted chronic
truancy, failure to enroll, inattention to
special education needs
Emotional neglect- inadequate affective
nurturance, exposure to abuse, refusal of
psychological care, permission to abuse
alcohol or drugs
91
Child Abuse- Epidemiology
1 million of children are abused per year
1,200 to 5,000 deaths/year mostly <1 yr
old
150,000 to 200,000 new cases of sexual
abuse
Severity of abuse varies with age
Prepubertal children: single parent, low
income ethnic minorities. Mother is the
abuser.
Adolescent: white, two parents family,
average income. Father is the abuser.
92
Abused Child- Characteristics

Premature, low birth, difficult

temperament, fussy, colicky or with
physical handicap
Child is perceived as slow or different
Physical resemblance to the rejecting or
abusive partner.
Certain developmental stages - toddler,
adolescent
1/3 of cases less than 5 years old
1/4 of cases 5-9 years old

93
 Child Abuser- Characteristics
Closest member of the family
More often mother than father
One parent active abuser and other parent passive
about abuse
Substance abuse/mental illness
Poverty/social isolation
History of victimization
Single young parents
Complicated pregnancies
30% to 59% of abusing mothers also being
battered
94
Sexual Abuse
Girls are sexually abused by men
92% of the time and lone women
(usually mothers) 6% of the time
Boys are sexually abused by men
80% of the time
Perpetrators of sexual abuse are
almost always known to the child
(less than 20% of cases involve
unknown offenders)
Elder Abuse- Epidemiology
1 million cases reported per year
Most cases are not reported
Abuser- closest member of the family with whom the
person lives and often supported financially by the elder.
Severity of the abuse directly proportional to age of the
elder
10% of people over 65 experience some form of abuse
Elder abuse includes:
physical abuse or sexual abuse
financial exploitation
Neglect
psychological abuse
medical abuse

96
 Domestic Abuse Epidemiology

85-95% of victims are women

95% abusers are men
Prevalence is about 3-4 million per year
Overall lifetime risk of abuse is 25% in US
Life time risk of severe violence is 9%
50% of all violent relationship include rape
25% of women who attempt suicide are
victims of domestic abuse

97
Childhood Psych
Psychological tests available
IQ tests check on the level of intelligence
of the child
Average IQ is 100 + or 15 points
2/3 of children fall into that range
95% are within 2 standard deviations or between
70-130 IQs

Mental Retardation requires 3 things in order to

achieve that diagnosis.
1. IQ less than 70.
2. Diagnosis made before age 18.
3. Deficits in more than one area of daily living skills.
Facts about Mental Retardation
Persons with IQs in the range of 71-84
have Borderline Intellectual Functioning.
Usually they have problems with the social
and economic demands of life.
Mild MR IQs 55-70 85% of cases
educable attend special education & can
work at some jobs
Moderate MR IQs 40-55 10% -
trainable
Severe MR IQs 25 - 40
Profound MR usually requires institutional
 Other facts about Mental
Retardation
It affects 1-2 % of the population.
Intellectual disability is the preferred term.
Male to female ratio is 2:1.
Mild MR is more common in lower SES.
Other levels of MR are equally distributed
in all social classes.
These children progress through normal
milestones but at a slower rate.
Etiology: Multifactoral & Polygenetic
Fetal alcohol syndrome = most FREQUENT
cause, also most PREVENTABLE
 MR continued -
Down syndrome most common CHROMOSOMAL cause
Fragile X syndrome most common HERITABLE cause
Inborn errors of metabolism Tay-Sachs disease and
untreated PKU are the most common ones identified
Other factors include:
A high rate of Down syndrome (trisomy 21) in older mothers
Maternal malnutrition, substance abuse, exposure to
radiation, maternal illness, abuse & neglect are all issues
Traumatic deliveries, exposure to toxins, infections, head
injuries, poor prenatal & perinatal care
Pervasive Developmental Disorders

Autism = CBS
Communication problems this usually shows up
early problems learning words/sentences.
Social impairments start at 3-6 months of age
They are aloof, withdrawn & detached.
Behaviors that are restricted or repetitive often self
stimulating rocking/head banging
Other disorders in this group include:
Retts disorder
Childhood disintegrative disorder
Aspergers disorder
See your text for full diagnostic criteria of Autistic disorder.
 Key Features of Autism
These children do not bond well with their parents.
They lack warmth, sensitivity & awareness.
Speech may be singsong or monotonous.
They want to maintain routines.
70% have some degree of mental retardation.
Some have extreme talents in music/math.
Make sure you check for metabolic disorders such
as PKU and karyotyping. Check hearing & vision
also.
25% have seizures so consider an EEG.
 Aspergers Disorder
Used to be known as high
functioning autism
Normal IQ usually
Socially awkward
Abnormal behaviors or
preoccupations
First described in 1994
Some complete college and have
good careers.
 Attention Deficit Hyperactivity
Disorder
Physically hyperactive
Inattentive trouble focusing or maintaining
attention
Impulsive
Usually improves with maturation but can persist
into adulthood.
3 types of ADHD
1. Predominantly inattentive
2. Predominantly hyperactive-impulsive
3. Combined type has a mixture of all symptoms
Must have 12 of 18 symptoms (See your text for full criteria)
 Conduct Disorder
A pattern of behavior that violates the rights of others with:
Aggression to people & animals
Destruction of property
Deceitfulness or theft
Serious violations of rules
Often become adults with Antisocial Personality Disorder
Early interventions are key to help these children develop
into healthy adults
Childhood onset type starts before age 10 (worse
prognosis)
Adolescent onset type starts around age 10 and up
See your text for full diagnostic criteria
 Facts about Conduct
Disorder
Up to 8% of boys and 3% of girls under 18
meet criteria
School is often not important to them at
all.
40% of boys and 25% of girls later have
antisocial personality disorders as adults.
The more aggressive they are, the worse it
is.
As they get older, their problems become
more serious and incarceration often
occurs.
Etiology MULTI-FACTORIAL Families
 Oppositional Defiant
Disorder
These children/teens have defiant qualities but
not as bad as conduct disordered behavior. They
are the children that other people might call
spoiled. (The type seen on shows such as Nanny
911 or Super Nanny.)
They often lose their tempers, argue with adults,
refuse to follow rules, and can be mean/spiteful.
(Examples can be seen on My Super Sweet 16 on
TV)
It is common. 5-10% of children. Boys > Girls
They often abuse substances.
Treatment is individual and family counseling.
Train the parents to set limits. Treat other
 Tourettes Disorder
Must have MOTOR & VOCAL tics.
Motor Tic Disorder has abnormal movements only.
(tongue protrusion, blinking, nodding, twitching
etc.)
Vocal Tic Disorder has abnormal grunting, barking
or shouting noises/words only.
You must have BOTH motor & vocal to make the
diagnosis.
(Classic example seen in Deuce Bigalow, Male
Gigalo movie.)

Patients are embarrassed by these symptoms but

can only stop them when they put effort into it for
 More Tourettes Facts
Affects 1-10/10,000 between ages 6-17.
Tics must occur many times a day nearly
everyday for a period of more than 1 year.
Medical professionals treat much sooner. (Dont
wait a year.)
Boy:Girl ratio is 3:1
Motor tics usually start between ages 3-8.Vocal
tics often come later. Severity often worsens in
the teens.
20% have a remission in their 20s. Tics often
decrease as the person gets older.
Separation Anxiety Disorder
Around 9 months of age, all children are
anxious when separated from their
caregivers.
This diagnosis is MUCH more than that.
This is a severe, disabling level of anxiety
where the child is fearful to be away from
the parent.
At least 3 of 8 symptoms must be present
for at least 4 wks
They often refuse to go to school or come
up with fake symptoms to come home.
 Rare Disorders in Children
Pica
Children who eat things
More common in children with lower IQs
Reactive attachment disorder
When the child has had a traumatic event and can
no longer attach to people. Two types:
Overly friendly disinhibited child will run up to
strangers at will. Super friendly because they are trying to
get something. No sense of stranger danger. Family and
child need immediate therapy.
Inhibited child the kid trusts no one. Lonely, sad,
doesnt like anyone. Wont be able to function in society.
Child needs to be taught who is safe, who to trust. Needs
attachment therapies.
Sexuality Disorders
Human Sexuality
Paraphilias
Definition

Paraphilias are problems with

controlling impulses that are
characterized by recurrent and
intense sexual fantasies, urges and
behaviors involving unusual objects,
activities, or situations not
considered sexually arousing to
others.
 Treatment
Satiation
Verbal After masturbation, the individual listens to an
audiotape of stimulating paraphiliac imagery for at
least 30 minutes. Or, he looks at stimulating material
while repeating a phrase over and over (for 20
minutes).
Masturbatory - The individual is first encouraged to
masturbate to ejaculation in response to socially
appropriate sexual fantasies with the concomitant
feelings of affection and tenderness. After this
experience the offender is required to masturbate to
deviant sexual fantasies. If the offender becomes
aroused, he or she is told to switch to an appropriate
fantasy or in some instances exposed to an aversive
stimulus such as ammonia.
Human Sexuality
Paraphilias

Treatment

Covert Sensitization attempts to pair sexual

feelings with emotional painful consequences.
The consequences are to be detailed
consequences of feelings of behavior, such as
public shame, humiliation, or imprisonment.

Aversion Therapy - involves the pairing of a

sexually arousing paraphilic stimulus with an
unpleasant image or odor (e.g., ammonia).
Human Sexuality
Paraphilias

Treatment

Social skills training is used with either

of the other approaches and is aimed at
improving a person's ability to form
interpersonal relationships.
 Human Sexuality
Paraphilias
Treatment
Cognitive Behavioral Therapy
Develop offense cycle
High risk situation Thoughts Emotions
Behavior
Identify and challenge cognitive
distortions
She was flirting with me. (about a 7-year old
girl)
I was just teaching her about love.
Develop new beliefs and thoughts
Sleep
 Narcolepsy
Oldest described sleep disorder first described in 1880
Incidence/prevalence - 1 in 2000
Age of onset teenage years but reported in children
as young as 2 yr of age
Classic tetrad of:
EDS
Sleep paralysis
Hypnagogic hallucinations
Cataplexy
Total loss of body muscle tone
Patients cannot move muscles voluntarily
No loss of consciousness
 Insomnia
Difficulty initiating sleep, maintaining sleep,
waking up too early, or nonrestorative sleep
Occurs despite adequate opportunity
Must have daytime complaint
Fatigue or malaise
Attention, concentration, or memory
impairment
Social or vocational dysfunction or poor
school performance
Mood disturbance or irritability
Daytime sleepiness
Motivation, energy, or initiative reduction
Proneness for errors or accidents at work or
while driving
Tension, headaches, or gastrointestinal
symptoms in response to sleep loss
Concerns or worries about sleep
 Insomnia
Treatment
Cognitive Behavioral Therapy for Insomnia
Consists of sleep restriction, stimulus control,
progressive muscle relaxation, and cognitive
restructuring
Most efficacious and long-lasting
Hypnotics
Ambien zolpidem
Sonata zaleplon
Rozerem ramelteon
Melatonin
 Sleep Related Movement Disorders
Treatment
RLS & PLMS
Ropinirole (Requip)
Gabapentin (Neurontin)
Old treatments: carbidopa-levodopa
opioids, benzodiazepines,
anticonvulsants
Suicide
Baseline / Distal Risk
Factors
Biochemical Factors
Biochemical abnormalities, particularly
in the serotonergic system, are
implicated in suicide.
These appear to relate to impulsivity
rather than to specific psychiatric
diagnoses.
You might
want to People who suicide using impulsive
remember and violent methods are more likely to
this have decreased levels of 5HIAA, a
metabolite of serotonin, in their CSF.
Follow-up of violent attempted
suicides with low 5HIAA finds them
more likely to subsequently die by
suicide than people with normal levels.
33
Baseline / Distal Risk
Factors
Mental Illness
Suicide Attempt
Of all known risk factors for suicide, a
nonfatal suicide attempt is the single best
You might predictor of future suicide:
want to
1% of all suicide attempters die of suicide in the
remember
year after an index attempt;
this
5% die of suicide within 10 years, if the suicide
attempt was medically serious;
19% of suicide attempters are dead with 12
years, most by suicide.

Among those requiring inpatient treatment

for an attempt, repetitive suicidal attempts
are common, with 1 in 4 making at least
one further attempt requiring admission in
the following 10 years.

30
 Physical Illness
You might Is found in half of all
want to
remember suicides, more so in older
this people (as in the general
population of older people).
HIV/AIDS, malignancies
(especially head and neck),
Huntingtons disease, MS,
peptic ulcer, renal disease,
spinal cord injury, SLE all
convey increased suicide
risks. 34
Proximal /Acute Risk Factors

Methods of Self-Injury
The ready availability of a way to self-
injury makes a suicidal act more likely.
Restricting access to particular
methods of suicide may reduce
suicides by that method and in some
cases may reduce total suicide rates.
The above statement is true for a
range of methods including firearms,
domestic gas, vehicle exhaust gas,
jumping sites, etc.
You might Suicidal persons should always be
want to
questioned about whether they have
remember
this
ready access to means, and if guns are
in the house, families should be told to
remove or secure them. 36
 Office and Clinic Protocols to Contain
the Risk of Self-Injury in Suicidal Patients

Office and clinic protocols have to be well thought and well-

rehearsed long before a reluctant, suicidal patient is convinced
to come in for care. These protocols can include:
1) Brief Triage and Risk Assessment Procedures Such protocols include:
(a)an immediate, brief evaluation of physical and mental status, (b)determination of
current mental capacity and level of consciousness, (c)evaluation of current
subjective distress, (d)identification of any psychopathology requiring immediate
management (e.g., impulsivity, psychosis), (e)need for involuntary treatment, and (f)
determination of the patients willingness to consent to care

2) Once the patient is in a safe environment, Comprehensive

Clinical Assessment of Suicide Risk Assessment of: (1)clinical status;
(2)diagnoses and co morbidity; (3)history of suicidal states; (4)current psychosocial
situation; and (5)patient strengths and vulnerabilities.

From a risk management perspective, once a high-risk suicidal state

has been identified, the patients immediate- and intermediate-
safety needs take priority over
term
everything else.
Addiction
What is Addiction? (1)
(descriptive)

An activity which initially provides

pleasure, and is relatively, and usually
harmless
Increases Hedonic Tone
The vulnerable recognize relief of
dysphoric feelings, and often report
feeling normal
What is Addiction? (1)
(neuro-biology)

An activity which initially stimulates

the limbic system, which results in
changes of neurotransmitter levels,
which are perceived as euphoria
(hedonic tone)
Tolerance
Reduction in the response to a drug after
repeated administrations. Key role in drug
abuse and dependence - leads user to
escalate dosage to achieve equivalent
high
May take form of a reduction in potency,
efficacy, or both.
Note: Tolerance may develop more rapidly to the
reinforcing effect than other effects of the drug
related to toxicity. This effectively decreases the
therapeutic index of the drug in a tolerant
individual, leading to higher probability of
accidental fatality.
e.g., opioids; respiratory depression

Tolerance is not limited to drugs of abuse

Screening for Alcohol
Addiction
CAGE
Cut down - tried to
Annoyed by someone criticizing your drinking
Guilty about your drinking
Eye-opener in the morning

compulsive use of the substance - you have to ask -

what, when, how much
continued use in spite of adverse consequences -
medical, legal, work, school, family, friends
loss of control of use - this differentiates abuse from
dependence
Stages of Change
Pre-contemplation - needs education
and encouragement
Contemplation - needs personalized
feedback
Decision - needs a plan for how to
proceed
Action - determine level of treatment
needed and begin the process of recovery
Maintenance - relapse prevention
Relapse - pick up where ever the person
has re-entered the cycle
(Prochaska & DiClemente)
Move one stage at a time
Precontemplation: Introduce
ambivalence
Contemplation: Resolve ambivalence
Preparation: Develop an action plan
Action: Solve problems
Maintenance: Consolidate gains
Relapse: Into action once again
Short-term residential
programs
Chemical Dependency (CD) Units,
"Minnesota Model" of treatment for
alcoholism.
3- to 6-week inpatient treatment phase
followed by extended outpatient therapy
or participation in 12-step self-help groups.
CD programs for drug abuse arose in the
private sector in the mid-1980s with
insured alcohol/cocaine abusers as their
primary patients.
Therapeutic Communities (TC)
40 years
hierarchical program residential
based
stepped program of increased social
and personal responsibility
peer mediated group settings
habilitation learning the behavioral
skills, attitudes, and values
associated with social living
Therapeutic Communities

Mutual self-help is also an important

aspect of this treatment partial
responsibility for the recovery of
others
12 24 months
dropout rate is high