Abby normal

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Bell Work • What markers would you look for to determine if someone has a learning disability?

Transcript of Abby normal

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Bell Work

• What markers would you look for to determine if someone has a learning disability?

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http://www.4degreez.com/misc/

personality_disorder_test.mv

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The following slides is info from the DSM IV

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Cautionary Statement• “The specified diagnostic criteria for each mental

disorder are offered as guidelines.” (emphasis added)• “The proper use of these criteria requires specialized

clinical training that provides both a body of knowledge and clinical skills.”– Essentially, do not try this at home

• Purpose of DSM is to provide information for clinicians to diagnose, communicate about, study, and treat people.

• “Clinical and research purposes” that may not meet “legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability.”

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Mental Disorder• The term “unfortunately implies a distinction between ‘mental’

disorders and ‘physical’ disorders that is a reductionistic anachronism of mind/body dualism.”

• They don’t have a substitute yet.

• “[A] clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom).”– Cannot be a socially or culturally acceptable response (think about different

response to the death of a loved one)– Regardless of cause, “it must currently be considered a manifestation of a

behavioral, psychological, or biological dysfunction in the individual)– Deviance, whether political/religious/sexual, in and of itself is not a mental

disorder. However, deviance can be a symptom.

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Key Concept: The DSM is not classifying people. It is classifying the disorders people have.

The DSM “avoids the use of such expressions as ‘a schizophrenic’ or ‘an alcoholic’ and instead uses the more accurate, but admittedly more cumbersome, ‘an individual with Schizophrenia’

or ‘an individual with Alcohol Dependence.’

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Limitations of the DSM• “A categorical approach to classification works best when

all members of a diagnostic class are homogenous, when there are clear boundaries between classes” (classes meaning the categories/labels, not classes of people), “and when the different classes are mutually exclusive.” But it is what it is.– Many of the diagnostic classifications can be a symptom of

another class or can appear to be another class.– As a result of all of this, it is essential for clinicians to use clinical

judgment and to document all data in case of incorrect diagnosis.• This is also why people without the years of medical and clinical

training should not pick up the DSM to try and diagnose themselves or others.– Even if you do have this training, it is not considered valid if you “diagnose”

yourself, family, friends—you need another professional and objective opinion

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Headings in the DSM• Diagnostic Features: Clarifications of symptoms and examples• Subtypes and/or Specifiers• Recording Procedures• Associated Features and Disorders• Specific Culture, Age, and Gender Features: General differentiations and

prevalence• Prevalence: Point and lifetime prevalence/risk

– Not based on above groups• Course: Typical presentation/evolution; typical age of onset, mode of onset

(e.g., abrupt, insidious); episodic vs. continuous; duration and progression (including general trend)

• Familial Pattern: Heritability and genetically-linked disorders• Differential Diagnosis: Which disorders look similar and how to tell them

apart

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Classification (Chapters)• Disorders Usually First

Diagnosed in Infancy, Childhood, or Adolescence

• Delirium, Dementia, and Amnestic and Other Cognitive Disorders

• Mental Disorders Due to a General Medical Condition Not Elsewhere Classified

• Substance-Related Disorders• Schizophrenia and Other

Psychotic Disorders• Mood Disorders• Anxiety Disorders

• Somatoform Disorders• Factitious Disorders• Dissociative Disorders• Sexual and Gender Identity

Disorders• Eating Disorders• Sleep Disorders• Impulse-Control Disorders

Not Elsewhere Classified• Adjustment Disorders• Personality Disorders

• Other Conditions That May Be a Focus of Clinical Attention

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Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

• Feeding and Eating Disorders of Infancy or Early Childhood– Pica (eat all the things!

[that shouldn’t be eaten])– Rumination Disorder (like

baby animals… eat, throw up, eat again)

• Tic Disorders– Tourette’s

• Elimination Disorders (Pooping Problems)

• Other Disorders of I/C/A– Separation Anxiety

Disorder (Early Onset)/Selective Mutism

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Bell Work

• What is the difference between Pica and Rumination Disorder?

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Multiaxial Assessment

• Axis I (Major Disorders Except Axis II)– Clinical Disorders– Other Conditions That May Be a Focus of Clinical Attention

• Axis II– Personality Disorders– Mental Retardation

• Axis III– General Medical Conditions

• Axis IV– Psychosocial and Environmental Problems

• Axis V (Clinician’s Judgment of Level of Impairment)– Global Assessment of Functioning

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NOS-Not Otherwise Specified

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Mental Retardation

• An IQ of approximately 70 or below with onset before age 18– Mild: IQ 50-55 to approx. 70– Moderate: IQ 35-40 to 50-55– Severe: IQ 20-25 to 35-40– Profound: IQ below 20-25

– Why do you believe there is a range within a range for the degrees of severity?

– “Mild” used to be referred to as “educable” retardation and “Moderate” used to be referred to as “trainable.” What is the problem with the outdated labels?

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Learning Disorders• Academic functioning that is substantially below:– What is expected from person’s chronological age– Measured intelligence– Age-appropriate education

• Reading• Written

Expression• Mathematics• NOS

(Not Otherwise Specified)

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Delirium, Dementia, and Amnestic and Other Cognitive Disorders

• Were once called “Organic Mental Syndromes and Disorders”– Suggested that “nonorganic” mental disorders do not

have a biological basis. Also, scientific community has drifted away from the misuse and overuse of the word “organic”

• Delirium-“characterized by a disturbance of consciousness and a change in cognition that develop over a short period of time.”

• Dementia-“characterized by multiple cognitive deficits that include impairment in memory.”

• Amnestic Disorder-“characterized by memory impairment in the absence of significant accompanying cognitive impairments.”

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Substance-Related Disorders

• Alcohol• Amphetamine• Caffeine• Cannabis• Cocaine• Hallucinogen• Inhalant (Volatile Substances)• Nicotine• Opioid• Phencyclidine (PCP)• Sedative, hypnotic, or anxiolytic• Polysubstance• Other or Unknown

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What is psychosis?

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• Narrowest definition of psychotic: delusions and/or hallucinations. Hallucinations occur without awareness that one is hallucinating.

• Broad: Includes those aware they are hallucinating, includes other positive symptoms of Schizophrenia (i.e., disorganized speech, grossly disorganized or catatonic behavior), extreme impairment of normal functioning, loss of ego boundaries, distance from reality

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Delusions vs. Hallucinations

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Schizophrenia and Other Psychotic Disorders

• Schizophrenia: Lasts at least 6 months, including 1-month of active-phase symptoms (two or more of: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms)

• Schizophreniform: Lasts 1-6 months; doesn’t necessarily result in loss of functioning

• Schizoaffective: Mood episode and active-phase symptoms of Schizophrenia occur together and preceded or followed by at least two weeks of delusions and/or hallucinations (no mood symptoms, except during mood episode—this is depression or mania)– Bipolar Type and Depressive Type

• Delusional Disorder: 1 month of non-bizarre delusions and no other active-phase Schizophrenia symptoms– What might constitute “non-bizarre delusions”?

• Brief Psychotic Disorder: Lasts 1 day to 1 month• Shared Psychotic Disorder: Psychosis influenced by someone else with the same

or similar delusion (this person’s delusion is longer-standing)– What cases/people might fit this disorder?

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Episodic with or without Interepisode Residual Symptoms

Single Episode

Continuous

Other/Unspecified Pattern

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Schizophrenia: Paranoid Type(Remember, these are generalizations)

• Prominent delusions (persecutory or grandiose; organized around a coherent theme) and/or auditory hallucinations (adhere to theme of delusion[s])

• Lack of disorganized speech/behavior, flat/inappropriate affect, catatonia

• Common Features: Anxiety, anger, aloofness, and argumentativeness

• Personality: superior, patronizing, formal, extreme intensity

• Paranoia predisposes individual to suicide or violence

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Schizophrenia: Disorganized Type• All of the following are prominent:

– Disorganized speech, disorganized behavior, flat or inappropriate affect• Silliness and laughter that isn’t related to the content of speech• Behavioral disorganization=lack of goal orientation; disrupts performance of daily living

activities (e.g., showering, dressing, preparing meals)

• Delusions/hallucinations uncommon—if present, fragmented and no coherent theme

• Features: Grimacing to silliness quickly• Usually has an early and insidious onset with few to no remissions

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Schizophrenia: Catatonic Type• Psychomotor disturbance: motoric

immobility (catalepsy—waxy flexibility, or stupor), excessive fine motor activity (purposeless and uninfluenced by external stimuli), extreme negativism (maintenance of rigid posture, resistant to outside forces), mutism, peculiarities of voluntary movement (voluntary assumption of inappropriate or bizarre postures or facial expressions), echolalia, echopraxia

• At-risk: Self-harm/harm of others with movement, malnutrition, exhaustion

• More rare diagnosis, as clinicians are encouraged to diagnose patient with different diagnosis if possible (substance-induced, GMC, Manic or Major Depressive Episode, etc.)

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Note activity in frontal

lobe

This Is Your Brain on Schizophrenia

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Undifferentiated Type

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Residual Type Diagnostic Criteria• Absence of prominent

delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior (although may have had an episode/disturbance of these things previously)

• There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more positive symptoms (not extreme symptoms) (e.g., odd beliefs, unusual perceptual experiences)

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Good Prognostic Features for Schizo- Disorders

• Two or more of the following:– Onset of prominent psychotic symptoms within 4 weeks of the

first noticeable change in usual behavior or functioning (rapid development generally means rapid remission)

– Confusion or perplexity at the height of the psychotic episode (demonstrates some awareness that what is being experienced is not normal)

– Good premorbid social and occupational functioning (good social/life skills before onset shows self-discipline and self-control)

– Absence of blunted or flat affect (downward change in affect generally means decline in brain function—think about stroke victims that have this change in affect)

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Delusional Disorder Subtypes• Erotomanic Type: Another person

is in love with patient.– Usually idealized romantic love and

spiritual union, not about sex– Person is usually of higher status

(e.g., celebrity or boss), but can be complete stranger

– Phone calls, letters, gifts, stalking/surveillance—sometimes just a secret

– Commonly females, males generally end up conflicting with law with their delusion (females sometimes do too)• “Misguided effort to ‘rescue’ him or her

from some imagined danger” (e.g., abusive relationship, but really it’s just their real relationship)

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Bell Work

• What is the difference between prognosis and diagnosis?

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Delusional Disorder Subtypes(What appears to be the central theme of delusion[s]?)

• Grandiose Type: “Conviction of having some great (but unrecognized) talent or insight or having made some important discovery.” Less common: special relationship, non-romantic, with a prominent person, or being a prominent person (actual person is an imposter) May have religious content.

• Jealous Type: Spouse/romantic partner is unfaithful

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Delusional Disorder Subtypes• Persecutory Type: “He/she is being conspired against,

cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.” Small offenses are exaggerated and may become the focus. Often feel that injustice must be remedied by legal action.

• Somatic Type: Involves bodily functions/sensations. Most common: a body part smells really bad; there is an internal parasite; body dysmorphia; body parts aren’t functioning – More extreme

• Mixed Type• Unspecified Type

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Psychotic Stressors• Loss of a loved one• Psychological trauma• Trauma from combat

• Without Marked Stressor(s)

• Postpartum Onset: within 4 weeks

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Mood Disorders

• Depressive Disorders• Bipolar Disorders

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Specifiers: Catatonia, Melancholia, Atypical, Postpartum, Seasonal Pattern, Rapid Cycling

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Mood Disorders: Depressive Disorders• Major Depressive Disorder:

Characterized by one or more Major Depressive Episodes (i.e., at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression

• Dysthymic Disorder: 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet criteria for a Major Depressive Episode

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Criteria for Major Depressive Episode• A. Five or more of the following within 2-week period (change from

previous functioning) (cannot be due to GMC or a symptom of a psychotic disorder [e.g., Catatonic Schizophrenia])– Must Include one of: depressed mood and/or loss of interest or pleasure– Depressed mood most of the day, nearly every day, indicated by self-report or

observations of others– Markedly diminished interest or pleasure in (almost) all activities – Significant weight loss or weight gain not caused by an intentional change in diet;

decrease/increase in appetite• Children: failure to meet growth milestones

– Insomnia/hypersomnia – Psychomotor agitation or retardation– Fatigue or loss of energy– Feelings of worthlessness, or excessive or inappropriate guilt (may be delusional)– Diminished cognitive abilities, indecisiveness– Recurrent thoughts of death, suicidal ideations with or without a plan, self-harm,

suicidal attempts

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Criteria for Major Depressive Episode• B. Do not meet criteria for

Mixed Episode• Symptoms cause clinically

significant distress or impairment in life-living

• Not directly due to physiological effects of a substance (drugs) or a GMC (e.g., thyroid)

• Not due to Bereavement – If the above criteria is met 2

months after the loss of the loved one, then it may be considered a Major Depressive Episode

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Criteria for Manic Episode

• A. Abnormally and persistently elevated, expansive, or irritable mood.– Lasts at least 1 week

• B. Mood disturbance must be accompanied by at least three additional symptoms (four if the mood is only irritable)– Inflated self-esteem or grandiosity (may be delusional)– Decreased need for sleep (e.g., feels rested after only 3 hours of sleep, as

opposed to insomnia/fatigue)– More talkative than usual or pressure to keep talking– Flight of ideas or subjective experience that thoughts are racing– Distractibility– Increase in goal-directed activity– Excessive involvement in pleasurable activities that have a potential for

painful consequences (e.g., buying sprees, sexual indiscretions, foolish business choices)

• D. Impairment in functioning

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Manic vs. Hypomanic Episode• 1 week vs. 4 days• Same Criterion B• Impaired functioning

(social, occupational, etc.) vs. No marked impairment (some even report that hypomanic episodes can be an asset)

• Hypomanic is mild or moderate mania

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Mood Disorders: Bipolar Disorders• Bipolar I Disorder: one or more

Manic, Hypomanic, or Mixed Episodes, accompanied by Major Depressive Episodes

• Bipolar II Disorder: One or more Major Depressive Episodes accompanied by at least one Hypomanic Episode

• Cyclothymic Disorder: At least 2 years of numerous periods of hypomanic symptoms that do not meet the criteria for a Manic Episode and numerous periods of depressive symptoms that do not meet criteria for a Major Depressive Episode.

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Bipolar I Disorder• At least one Manic, or Mixed

Episode.– Hypomanic Episodes may have

occurred in past• At least one Major Depressive

Episode• Mood symptoms cause clinically

significant distress, or impairment in social, occupational, or other important areas of functioning– The distress/impairment is usually

caused by the mania

• Generally about two months from episode to episode.

Bipolar I Prevalence: .4-1.6%Bipolar II Prevalence: .5%

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Bipolar II Disorder• A. One or more Major

Depressive Episode• B. At least one Hypomanic

Episode• C. There has never been a

Manic or Mixed Episode• D/E. Mood symptoms cause

clinically significant distress, or impairment in social, occupational, or other important areas of functioning– The distress/impairment is

usually caused by the depression

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Anxiety Disorders• Panic Disorder without

Agoraphobia• Panic Disorder with

Agoraphobia• Agoraphobia without History of

Panic Disorder• Specific Phobia (Type)• Social Phobia (Generalized

Social Anxiety Disorder)• OCD• PTSD• Acute Stress Disorder• Generalized Anxiety Disorder

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Anxiety Disorder Definitions• Panic Attack: Sudden onset of intense

apprehension, fearfulness, or terror, often associated with feelings of impending doom. Symptoms: shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, and fear of “going crazy” or losing control

• Agoraphobia: Anxiety about, or avoidance of, places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the even of having a Panic Attack or panic-like symptoms

• Phobia: significant anxiety provoked by exposure to a feared object or situation, often leading to avoidance behavior.

• Obsessive-Compulsive Disorder: Obsessions (which cause anxiety or distress) and/or by compulsions (which serve to neutralize anxiety)

• Generalized Anxiety Disorder: At least 6 months of persistent and excessive anxiety and worry

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PTSD Specifiers• Acute: Duration of

symptoms is less than 3 months

• Chronic: Symptoms last 3 months or longer

• With Delayed Onset: At least 6 months have passed between the traumatic event and the onset of the symptoms

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Specific Phobia Subtypes• Animal Type: Animals or insects. Generally has a childhood onset• Natural Environment Type: For example, storms, heights, or water. Things that occur

in the natural environment. Generally has a childhood onset.• Blood-Injection-Injury Type: Seeing blood or injury or by receiving an injection or

other invasive medical procedure. Highly familial and often characterized by a strong vasovagal response (fainting).

• Situational Type: Cued by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed places. (Manmade things unlike Natural Environment)

• Other Type: For example, fear of choking, vomiting, or contracting an illness; “space” phobia (the individual is afraid of falling down if away from walls or other means of physical support); and children’s fears of loud sounds or costumed characters (clowns)

• Having one phobia increases likelihood of having another phobia in the same subtype.

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Obsessions• Persistent ideas, thoughts, impulses, or images

that are experienced as intrusive and inappropriate and that cause marked anxiety or distress.– Note the difference between obsessions and

delusions– Ego-dystonic: individual’s sense that the content

of the obsession is alien, not within his/her own control, and not the kind of thought that he/she would expect to have

– They are not simply excessive worries about real-life problems and are unlikely related to a real-life problem

• Most common obsessions:– Contamination– Repeated doubts (Is the door locked?)– A need to have things in a particular order– Aggressive or horrific impulses (e.g., to hurt one’s

child or to shout an obscenity in church)– Sexual imagery (e.g., a recurrent pornographic

image)

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Compulsions• Repetitive behaviors (e.g., hand

washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification.

• By definition, compulsions are either clearly excessive or are not connected in a realistic way with what they are designed to naturalize or prevent. By definition, adults have recognized these are excessive or unreasonable (kids may lack sufficient cognitive awareness).

• Common Compulsions: washing and cleaning, counting, checking, requesting or demanding assurances, repeating actions, and ordering.

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Diagnostic Criteria for OCD• A. Either obsessions and/or compulsions:

– Obsessions as defined by:• Recurrent and persistent thoughts, impulses, or images that are

experienced as intrusive and inappropriate (at least at some point) and that cause marked anxiety or distress

• Cannot be excessive worries about real-life problems• Person attempts to ignore or suppress obsessions or to neutralize them

with some other thought or action• Person recognizes that the obsessions are a product of his or her own mind

– Compulsions as defined by:• Repetitive behaviors or mental acts that the person feels driven to perform

in response to an obsession, or according to rules that must be applied rigidly

• Aimed at preventing or reducing distress or preventing some dreaded event or situation; however, they are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive

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Diagnostic Criteria for OCD Cont.• B. At some point during the course of

the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable– Doesn’t apply to children– This is key as it differentiates from some

type of psychosis• C. The obsessions or compulsions cause

marked distress, are time consuming (in total, take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational or academic functioning, or usual social activities or relationships.

• D/E. Obsessions or compulsions should not be a result of a different Axis I disorder, substance use, or GMC.

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Somatoform Disorders• Examples:– Hypochondriasis– Body Dysmorphic

Disorder

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Somatization Disorder

• Can be very hard to distinguish between Anxiety Disorders and GMCs.

• Panic Disorders contain multiple somatic symptoms during Panic Attacks

• GAD (Generalized) individuals may have a lot of physical complaints. Distinguishing factor is focus on anxiety/worry, not physical ailments

• Mood Disorders may also have somatic complaints

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Diagnostic Criteria for Somatization Disorder

• A. History of many physical complaints beginning before age 30. These occur over a period of several years and result in treatment being sought or significant impairment in important areas of functioning.

• B. Each of the following must be met at some time over the course of the disturbance:– Four pain symptoms (different sites)– Two gastrointestinal symptoms (non-pain symptoms) (e.g.,

nausea, vomiting, diarrhea, or intolerance of several different foods)

– One sexual symptom: Non—pain sexual/reproductive (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding)

– One pseudoneurological symptom: (e.g., conversion symptoms like impaired coordination or balance, paralysis or localized weakness, difficulty swallowing, loss or impairment of one or more of senses, urinary retention, hallucinations, amnesia)

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Diagnostic Criteria for Somatization Disorder

• C. Either:– Each of the symptoms cannot be

fully explained by a known GMC or the direct effects of a substance

– When there is a related GMC, the physical complaints or resulting impairment are in excess of what would be expected from patient

• D. Symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering)

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Other Somatoform Disorders• Conversion Disorder: Affects

voluntary motor or sensory function

• Pain Disorder: Limited to or predominantly pain-based

• Hypochondriasis: Preoccupation with the fear of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms or bodily functions

• Body Dysmorphic Disorder: Preoccupation with an imagined or exaggerated defect in physical appearance

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Somatoform vs. Factitious vs. Malingering

• Somatoform: Not under voluntary control/Not intentional

• Factitious: Intentionally produced or feigned in order to assume the sick role– May take something in order to produce

symptoms– Sympathy, social-based– Subtypes: Psychological vs. Physical Symptoms– Think “not fact”– Patient CS

• Malingering: Intentionally produced or exaggerated for personal gain– Car wreck whiplash

insurance/court/whatever– Get out of jury duty, school, avoid the draft– Think “maligning”

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Dissociative Disorders• Dissociative Amnesia: Inability to

recall important personal information, usually of a traumatic or stressful nature

• Dissociative Fugue: Sudden, unexpected travel away from home or work, accompanied by an inability to recall one’s past and confusion about personal identity or the assumption of a new identity

• Depersonalization Disorder: Persistent or recurrent feeling of being detached from one’s mental processes or body

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Sexual and Gender Identity Disorders

• Lifelong vs. Acquired• Generalized vs. Situational

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Sexual and Gender Identity Disorders

• Sexual Dysfunctions: Disturbance in sexual desire and in the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal difficulty (Sexual Desire Disorders, Sexual Arousal Disorders, Orgasmic Disorders, Sexual Pain Disorders)

• Paraphilias: Recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause distress or impairment of functioning

• Gender Identity Disorders: Strong and persistent cross-gender identification accompanied by persistent discomfort with one’s assigned sex.

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Bell Work

• Which disorder, if any, that we have talked about so far do you want to learn more about?

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Sexual and Gender Identity Disorders

• Paraphilias– Exhibitionism– Fetishism– Frotteurism– Pedophilia– Sexual Masochism– Sexual Sadism– Transvestic Dysphoria– Voyeurism– None Specified

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Bell Work

• How hard do you think it is to find pictures for paraphilia on the Internet on the school computer without having to end up gouging your eyes out?

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Paraphilias• Recurrent, intense sexually arousing fantasies,

sexual urges, or behaviors generally involving:– Nonhuman objects– The suffering or humiliation of oneself or one’s partner– Children or non-consenting persons

• Occurs over a period of at least 6 months• Obligatory vs. episodically due to stress or other

factors• For Pedophilia, Voyeurism, Exhibitionism, and

Frotteurism: person has acted on urges, or urges/sexual fantasies cause marked distress or interpersonal difficulty

• Sexual Sadism: Person has acted on these urges with a non-consenting person, or the urges/fantasies/behaviors cause marked distress or interpersonal difficulty

• Remaining Paraphilias: Behavior/urges/fantasies cause clinically significant distress or impairment in important areas of functioning

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Fetishism

• Begins by adolescence, but may have been given special significance earlier in childhood

• A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the use of nonliving objects

• B. Cause clinically significant distress or impairment in functioning

• C. Cannot be limited to articles of female clothing used in cross-dressing. Cannot be an object that is designed for the purpose of sexual arousal or orgasm

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Pedophilia• Remember, this is not the legal definition, but the clinical.

• Prepubescent child (generally 13 years or younger). • Individual with Pedophilia must be age 16 years or older and at least

5 years older than the child. – Those in late adolescence with Pedophilia, no precise age difference is

specified—use clinical judgment, taking into account sexual maturity of child as well

• Individuals with Pedophilia generally report an attraction to children of a specific age range

• Some show preference in males vs. females; preference for females is most common

• Exclusive vs. Nonexclusive

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Voyeurism• Observing unsuspecting

individuals, usually strangers, who are naked, in the process of disrobing, or engaging in sexual activity

• Generally no sexual activity with the observed person is sought

Exhibitionism• Exposure of one’s genitals

to a stranger

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Gender Identity Disorder: Keep in mind that psychology & science differentiates

between sex and gender

Sex is biological makeup of a person’s reproductive anatomy.

Gender is culturally-learned social roles.

Gender Identity Disorder: Conflict between sex and gender.

Is this a disorder?

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Gender Dysphoria: A persistent aversion toward some or all of those physical characteristics or social roles that connote one’s own biological

sex.

Gender Identity: A person’s inner conviction of being male or female.

Gender Role: Attitudes, patterns of behavior, and personality attributes defined by the culture in which the person lives as stereotypically

“masculine” or feminine” social roles.

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Gender Identity Disorder• A. Strong and persistent cross-gender identification (not

merely a desire for any perceived cultural advantages of being the other sex)– In children, is manifested by four or more:

• Repeatedly stated desire to be, or insistence that he or she is, the other sex

• “cross-dressing”• Strong and persistent preferences for cross-sex roles in make-

believe play or persistent fantasies of being the other sex• Intense desire to participate in the stereotypical games and

pastimes of the other sex• Strong preference for playmates of the other sex

– In adolescents/adults, manifested by stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he/she has the typical feelings and reactions of the other sex.

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Gender Identity Disorder• B. Persistent discomfort with his or her sex or sense of

inappropriateness in the gender role of that sex.– In children:

• Boys: assertion that his penis/testes are disgusting or will disappear or that it would be better not to have them. Aversion toward rough-and-tumble play and rejection of male stereotypical games, toys, activities

• Girls: rejection of urination in a sitting position; assertion that she has or will grow a penis; does not want to grow breasts or to menstruate; aversion toward normative feminine clothing

– In adolescents/adults: preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics) or belief that he or she was born the wrong sex

• C. Not concomitant with a physical intersex condition• D. Clinically significant distress or impairment of

functioning

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Differential Diagnosis

• Nonconformity to stereotypical sex-role behavior

• Transvestic Fetishism• Intersex condition• Schizophrenia

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What is gender?

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“[A] clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and

that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in

one or more important areas of functioning) or with a significantly increased risk of suffering death, pain,

disability, or an important loss of freedom).”Cannot be a socially or culturally acceptable

response (think about different response to the death of a loved one)

Regardless of cause, “it must currently be considered a manifestation of a behavioral,

psychological, or biological dysfunction in the individual)

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In future DSM, do you think Gender Identity Disorder will be listed as a disorder?

Limiting and Biased View“Clinically significant distress or impairment of functioning”

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Glossary/Vocab• Affect-a pattern of observable

behaviors that is the expression of a subjectively experienced feeling state (emotion).– Mood is pervasive/sustained “climate”– Affect is fluctuating “weather”– Blunted-significant reduction in

intensity – Flat-absence or near absence of any

signs of affective expression– Inappropriate-discordance between

affective expression and the content of speech or ideation

– Labile-Abnormal variability with repeated, rapid, and abrupt shifts

– Restricted or constricted-mild reduction

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Glossary/Vocab• Anxiety: The apprehensive

anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension.

• Catalepsy: Wavy flexibility-rigid maintenance of a body position over a period of time

• Cataplexy: Episodes of sudden bilateral loss of muscle tone resulting in the individual collapsing, often in association with intense emotions (fear, surprise, laughter, anger, etc.)– Narcolepsy with cataplexy

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Glossary/Vocab• Delusion: A false belief based on incorrect inference about external reality

that is firmly sustained despite what almost everyone else believes/proof to the contrary.– Bizarre: Involves a phenomenon that the person’s culture would regard as totally

implausible– Delusional Jealousy: One’s sexual partner is unfaithful– Erotomanic: Another person, usually of higher status, is in love with the individual.– Grandiose: Inflated worth, power, knowledge, identity, or special relationship to a

deity or famous person– Of being controlled– Of reference: Theme is that events, objects, or other persons in one’s immediate

environment have a particular and unusual significance (usually negative)– Persecutory: Delusion that one (or someone to whom one is close) is being

attacked, harassed, cheated, persecuted, or conspired against.– Somatic: Pertains to the appearance or functioning of one’s body– Thought Broadcasting: One’s thoughts are being broadcast out loud so they can be

perceived by others– Thought Insertion: One’s thoughts are not one’s own, but are inserted into one’s

mind

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Glossary/Vocab• Echolalia: Pathological, parrotlike, and apparently

senseless repetition of a word or phrase just spoken by another person.

• Echopraxia: Repetition by imitation of the movements of another.

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Glossary/Vocab• Mood: A pervasive and sustained emotion that colors the perception of

the world– Dysphoric: Unpleasant mood (e.g., sadness, anxiety, irritability)– Elevated: Exaggerated feeling of well-being, euphoria, or elation. Feeling

“ecstatic,” “on top of the world,” “up in the clouds”– Euthymic: Mood in the “normal range” (absence of depressed or elevated mood)– Expansive: Lack of restraint in expressing one’s feelings, frequently with an

overvaluation of one’s significance or importance– Irritable: Easily annoyed and provoked to anger

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Glossary/Vocab• Panic attacks: Discrete periods of sudden onset of intense

apprehension, fearfulness, or terror, often associated with feelings of impending doom.– Unexpected: uncued– Situationally bound– Situationally predisposed

• Phobia: A persistent, irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid it.

• Symptom: A subjective manifestation of a pathological condition.• Syndrome: A grouping of signs and symptoms, based on their

frequent co-occurrence, that may suggest a common underlying pathogenesis, course, familial pattern, or treatment selection.

• Tic: An involuntary, sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.

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Sleep Disorders• Dysomnias

– Primary Insomnia– Primary

Hypersomnia– Narcolepsy– Breathing-Related

Sleep Disorder (Sleep Apnea)

– Circadian Rhythm Sleep Disorder• Delayed Sleep Phase• Jet Lag• Shift Work

• Parasomnias– Nightmare– Sleep Terror– Sleepwalking

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Bell Work

• A common form of mental disorder afflicting 10-20% of the population is– A. schizophrenia– B. Senile Dementia– C. Depression– D. Delusional Disorder– E. Anorexia Nervosa

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Bell Work

• What is the difference between Anorexia Nervosa and Bulimia Nervosa?

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Anorexia Nervosa

• Far more prevalent in industrialized societies, in which there is an abundance of food and in which, especially for females, being considered attractive is linked to being thin.– How would Maslow

explain this?– How would social

psychologists explain this?

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Anorexia Nervosa Diagnostic Criteria• Refusal to maintain body weight at or above a minimally normal weight for

age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected)

• B. Intense fear of gaining weight or becoming fat, even though underweight• C. Disturbance in the way in which one’s body weight or shape is perceived,

or denial of seriousness of body weight• D. Amenorrhea in postmenarcheal females (i.e., the absence of at least

three consecutive menstrual cycles)

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Restricting TypeBinge-Eating/Purging Type

Differentiates from Bulimia with Criterion A (weight)

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Bulimia Nervosa Diagnostic Criteria• A. Recurrent episodes of binge eating as

characterized by both:– Eating, in a discrete period of time (e.g.,

within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

– A sense of lack of control over eating during the episode

• B. Recurrent inappropriate compensatory behavior in order to prevent weight gain (e.g., vomiting, laxatives, enemas, excessive exercise, fasting)

• C. On average, occurs at least twice a week for 3 months

• D. Self-evaluation is unduly influenced by body shape and weight

• Purging and Nonpurging (fasting/exercise)

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Dissociative Identity Disorder• Often linked to traumatic event (specifically

where the individual feels defenseless) as a coping mechanism– Reciprocal Determinism—there is a genetic

factor• Each personality state may be experienced as

if it has a distinct personal history, self-image, identity, separate name, reported age and gender, vocabulary, general knowledge, etc.

• Usually there is a primary identity that carries the individual’s given name and is passive, dependent, guilty, and depressed.

• Passive identities tend to have more constricted memories, whereas the more hostile, controlling, or “protector” identities have more complete memories.– What have learned about memory that explains

this?

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Identity Switching• Switch between identities is often

triggered by psychosocial stress• The time to switch from one identity

to another is usually a matter of seconds, gradual is far less frequent

• Accompanying “switch” behaviors often include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual’s train of thoughts

• Number of identities reported ranges from 2 to more than 100.

• Diagnosed 3-9 times more frequently in adult females than adult males

• Females tend to have more identities than do males, averaging 15 or more, whereas males average at about 8

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DID Diagnostic Criteria• A. The presence of two or more

distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self)

• B. At least two of these identities or personality states recurrently take control of the person’s behavior

• C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness

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Impulse-Control Disorders Not Elsewhere Classified

• Intermittent Explosive Disorder

• Kleptomania• Pyromania• Pathological Gambling• Trichotillomania

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Impulse-Control Disorders• Intermittent Explosive

Disorder– Very little reliable research– Very rare disorder

• Kleptomania– Very rare and occurs in fewer

than 5% of identified shoplifters

• Pyromania– Very rare– Over 40% of those arrested for

arson offense in the US are under 18, but Pyromania’s onset in childhood pretty much never happens

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Impulse-Control Disorders• Pathological Gambling

– Obviously prevalence is influenced by availability of gambling, legal or other

– 0.4-3.4% of adults sometime in their lifetime

– 2.8-8% in adolescents/college students• Frontal lobe development

• Trichotillomania– No good data on the

prevalence– One survey (reliability?) of

college students found lifetime rate of 0.6%

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Personality Disorders

• Axis II

• Paranoid• Schizoid• Schizotypal• Antisocial• Borderline• Histrionic• Narcissistic• Avoidant• Dependent• Obsessive-Compulsive

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General Diagnostic Criteria for a Personality Disorder

• A. An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture. This pattern is manifested in two (or more) of the following areas:– Cognition– Affectivity– Interpersonal functioning– Impulse control

• B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations

• C. Significant distress or impairment• D. Pattern is stable and of long duration, its onset can be traced

back at least to adolescence or early adulthood• E/F. Not a manifestation or consequence of another mental

disorder, drug, GMC

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Personality DisordersNormal Expression/Mental Disorder

• Reserved/Schizoid• Eccentric/Schizotypal• Suspicious/Paranoid• Nonconforming/Antisocial• Moody/Borderline• Sociable/Histrionic• Confident/Narcissistic• Shy/Avoidant• Cooperative/Dependent• Conscientious/Obsessive-Compulsive

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Schizoid• A. Pervasive detachment from social

relationships and a restricted range of expression of emotions. Four or more of the following:– Neither desires nor enjoys close

relationships, including family– Almost always chooses solitary

activities– Little to no interest in sexual

experiences– Takes pleasure in little to no activities– Lacks close friends other than first-

degree relatives– Indifferent to the praise/criticism of

others– Shows emotional coldness,

detachment or flattened affectivity• B. Not due to Schizophrenia, a Mood

Disorder, a Psychotic Disorder, Developmental Disorder, or GMC

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Schizotypal• A. Pervasive pattern of social and interpersonal

deficits marked by acute discomfort with and reduced capacity for close relationships, cognitive/perceptual distortions, eccentricities of behavior present in a variety of contexts. Indicated by five or more:– Ideas of reference– Odd beliefs or magical thinking that influences

behavior and is inconsistent with subcultural norms (e.g., superstitious, ESP)

– Unusual perceptual experiences– Odd thinking and speech– Suspiciousness or paranoid ideation– Inappropriate affect– Behavior or appearance that is odd, eccentric, or

peculiar– Lack of close friends other than first-degree

relatives– Excessive social anxiety that does not diminish

with familiarity• B. Not due to Schizophrenia, a Mood Disorder, a

Psychotic Disorder, Developmental Disorder, or GMC

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Avoidant• A. Pervasive pattern of social inhibition,

feelings of inadequacy, and hypersensitivity to negative evaluation and present in a variety of contexts. Indicated by four or more:– Avoids occupational activities that involve

significant interpersonal contact for fear of criticism, disapproval, rejection

– Unwilling to get involved with people unless certain of being liked

– Shows restraint within intimate relationships because of the fear of being shamed or ridiculed

– Preoccupied with being criticized or rejected in social situations

– Inhibited in new interpersonal situations because of feelings of inadequacy

– Views self as socially inept, personally unappealing, or inferior to others

– Unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

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Dependent• A. Pervasive pattern need to be taken care of that

leads to submissive and clinging behavior and fears of separation. Indicated by five or more:– Has difficulty making everyday decisions without an

excessive amount of advice and reassurance from others

– Needs others to assume responsibility for most major areas of his/her life

– Difficulty expressing disagreement with others for fear of loss of support or approval

– Difficulty initiating projects or doing things on his/her own due to fear, not due to energy/motivation

– Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

– Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for self

– Urgently seeks another relationship as a source of care and support when a close relationship ends

– Unrealistically preoccupied with fears of being left to care of self

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Histrionic• A. Pervasive pattern of excessive

emotionality and attention seeking. Indicated by five or more:– Uncomfortable in situations in which

he/she is not the center of attention– Interaction with others is often

characterized by inappropriate sexually seductive/provocative behavior

– Displays rapidly shifting and shallow expression of emotions

– Consistently uses physical appearance to draw attention to self

– Has a style of speech that is excessively impressionistic and lacking in detail

– Shows self-dramatization, theatricality, and exaggerated expression of emotion

– Suggestible– Considers relationships to be more

intimate than they actually are

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Narcissistic• A. Pervasive pattern of grandiosity (in

fantasy or behavior), need for admiration, and lack of empathy and present in a variety of contexts. Indicated by five or more:– Grandiose sense of self-importance (e.g.,

exaggerates achievements and talents)– Preoccupied with fantasies of unlimited

success, power, brilliance, beauty, or ideal love– Believes that he/she is “special” and unique

and can only be understood by, or should associate with, other special or high-status people/things

– Requires excessive admiration– Sense of entitlement– Interpersonally exploitative– Lacks empathy and is unwilling to recognize or

identify with the feelings/needs of others– Often envious of others or believes that others

are envious of him/her– Shows arrogant, haughty behaviors/attitudes

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Paranoid• A. Pervasive distrust and suspiciousness of

others such that their motives are interpreted as malevolent. Indicated by four or more:– Suspects, without sufficient basis, that

others are exploiting, harming, or deceiving him/her

– Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends/associates

– Reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him/her

– Reads hidden demeaning or threatening meanings into benign remarks or events

– Persistently bears grudges– Perceives attacks on his/her character or

reputation that are not apparent to others and is quick to react angrily or counterattack

– Recurrent suspicions, without justification, regarding fidelity of spouse/sexual partner

• B. Not due to Schizophrenia, a Mood Disorder, a Psychotic Disorder, Developmental Disorder, or GMC

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• D

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Antisocial• A. Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years. Indicated by three or more:– Failure to conform to social norms with

respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

– Deceitfulness (e.g., use of aliases, conning others for profit or pleasure)

– Impulsivity or failure to plan ahead– Irritability and aggressiveness (e.g.,

physical fights or assaults)– Reckless disregard for safety or self

others– Consistent irresponsibility (e.g., can’t

keep a job or honor financial obligations)– Lack of remorse, indifference or

rationalization of having hurt, mistreated, or stolen from another

• B. At least age 18• C. There is evidence of Conduct

Disorder before age 15

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• D

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Bell Work

• The discovery that psychologically disordered behavior could result from syphilis infections facilitated the credibility and acceptance of:– Trait theory.– Psychoanalytic theory.– The medical model– DSM IV– Humanistic perspective.

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Obsessive-Compulsive• A. Pervasive pattern of preoccupation with

orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. Indicated by four or more:– Preoccupied with details, rules, lists, order,

organization, or schedules to the extent that the major point of the activity is lost.

– Perfectionism that interferes with task completion

– Excessively devoted to work and productivity to the exclusion of leisure activities and friendships

– Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by culture or religion)

– Unable to discard worn-out or worthless objects even without sentimental value

– Reluctant to delegate tasks unless they do everything according to his/her way of doing things

– Miserly spending style– Rigidity and stubbornness

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• D

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Borderline• A. Pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity in a variety of contexts. Indicated by five or more:– Frantic efforts to avoid real or imagined

abandonment.– Pattern of unstable and intense interpersonal

relationships alternating between extremes of idealization and devaluation

– Identity disturbance– Impulsivity in at least two areas that are

potentially self-damaging, not suicidal (e.g., spending, sex, substance abuse, reckless driving, binge eating)

– Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

– Affective instability that lasts a few hours, rarely more than a few days

– Chronic feelings of emptiness– Inappropriate, intense anger or difficulty

controlling anger– Transient, stress-related paranoid ideation or

severe dissociative symptoms

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• D

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Medical Model

• R.D. Laing• Set procedures in which all doctors are

trained.– Complaint, patient history, physical examination,

ancillary tests if needed, diagnoses, treatment, and prognosis with or without treatment

• Need the full story to properly diagnose and treat

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Defensive mechanisms (or coping styles) are

automatic psychological processes that protect the individual against anxiety and from the

awareness of internal or external dangers or

stressors

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High Adaptive Level• Optimal adaptation• These defenses usually maximize

gratification and allow the conscious awareness of feelings, ideas, and their consequences.

• Anticipation: anticipates consequences, considers realistic, alternative responses or solutions

• Affiliation-turns to others for help/support

• Altruism-helps meets the needs of others and feels gratification from it

• Humor• Self-assertion-expresses thoughts or

feelings in a non-manipulative way• Self-observation-reflects on self and

responds appropriately• Sublimation• Suppression

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Mental Inhibitions (Compromise Formation) Level

• Keeps potentially threatening ideas, feelings, memories, wishes, or fears out of awareness.

• Displacement• Dissociation• Intellectualization• Isolation of Affect:

Compartmentalize feelings• Reaction Formation• Repression• Undoing

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Minor Image-Distorting Level

• Image of self, body, or others to regulate self-esteem

• Devaluation• Idealization• Omnipotence

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Disavowal Level

• Keeps unpleasant or unacceptable stressors, impulses, ideas, affects, or responsibility out of awareness with or without misattribution to external causes.

• Denial• Projection• Rationalization

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Major Image-Distorting Level• Gross distortion or misattribution of the

image of self or others

• Autistic Fantasy: Excessive daydreaming to substitute human relationships, more effective action, or problem solving

• Projective Identification: Like projection, but the individual remains aware of own affects or impulses but misattributes them as justifiable reactions to the other person. Often induces those feelings in others, making it difficult to clarify who did what to whom first

• Splitting of Self-Image or Image of Others: Compartmentalize; doesn’t view the whole, but breaks it into negative and positive and deals with one or the other or both separately

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Action Level• Action or withdrawal

• Acting Out• Apathetic Withdrawal• Help-Rejecting Complaining• Passive Aggression

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Level of Defensive Dysregulation

• Failure of defensive regulation to contain the individual’s reaction to stressors, leading to a pronounced break with objective reality

• Delusional Projection• Psychotic Denial• Psychotic Distortion

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Explain This• Studies have indicated that

children in North America and parts of Europe born during winter/early spring, specifically February/March have a slightly higher than average rate of schizophrenia.

• Those born in August and September have a slightly lower than average rate.

• There seems to be about a 10% difference in risk of schizophrenia between the high and low risk months.

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• Prenatal Factors

• Pregnant mother has less exposure to sunlight, which can lead to a vitamin D deficiency

• Action: Vitamin D supplements

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Men vs. Women

• Men more likely: Antisocial Personality, Alcohol abuse

• Women: Bipolar, Mood disorders, OCD, anorexia, Dissociative Identity