BM test 2
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Questions and Answers

Which symptom cluster of PTSD involves experiencing flashbacks, nightmares, and intrusive memories?

  • Hyperarousal
  • Avoidance
  • Intrusion (correct)
  • Negative affect

    • What does the 'R' in the PTSD acronym (TRAUMA) stand for?

  • Recovery
  • Repression
  • Resilience
  • Re-experience (correct)

    • Which of the following factors is NOT typically associated with an increased risk of developing PTSD?

  • Male gender (correct)
  • Genetic predisposition
  • History of trauma
  • Female gender

    • How long must symptoms persist for a PTSD diagnosis according to the DSM-5 criteria?

    <p>At least 1 month</p> Signup and view all the answers

    What purpose does the PTSD Checklist for DSM-5 (PCL-5) serve?

    <p>For screening and monitoring symptom change</p> Signup and view all the answers

    What is a key difference between PTSD and Acute Stress Disorder in terms of symptom classification?

    <p>PTSD includes non-fear-based symptoms</p> Signup and view all the answers

    What is the minimum duration for symptoms of Acute Stress Disorder to be present after a traumatic event for a diagnosis to be made?

    <p>3 days to 1 month</p> Signup and view all the answers

    Which type of symptoms does PTSD include that are not addressed in Acute Stress Disorder?

    <p>Risky or destructive behavior</p> Signup and view all the answers

    Which of the following is NOT included in the diagnostic criteria for Acute Stress Disorder?

    <p>Duration of symptoms exceeding 1 month</p> Signup and view all the answers

    What are the primary methods of treatment for Acute Stress Disorder?

    <p>Psychotherapy and medications</p> Signup and view all the answers

    What characterizes Bipolar I disorder?

    <p>At least one manic episode</p> Signup and view all the answers

    What is a common symptom of manic episodes in Bipolar Disorder?

    <p>Loss of reality</p> Signup and view all the answers

    Which risk factor is most significantly associated with the development of bipolar disorder?

    <p>Family history of mood disorders</p> Signup and view all the answers

    What is one of the main treatment goals for managing bipolar disorder?

    <p>To achieve symptomatic remission</p> Signup and view all the answers

    Which statement about cyclothymia is correct?

    <p>Symptoms create significant functional problems.</p> Signup and view all the answers

    What is the maximum total score for the self-report rating scale used in PTSD assessments?

    <p>80</p> Signup and view all the answers

    What is a primary symptom of Post-traumatic Stress Disorder (PTSD)?

    <p>Persistent insomnia</p> Signup and view all the answers

    Which of the following medications is approved by the FDA for the treatment of PTSD?

    <p>Sertraline</p> Signup and view all the answers

    What age group is typically associated with the onset of bipolar disorder?

    <p>Late teens to 20s</p> Signup and view all the answers

    Which symptom is NOT a requirement for the diagnosis of PTSD?

    <p>Significant weight gain</p> Signup and view all the answers

    Which factor can delay the onset of PTSD symptoms after a traumatic event?

    <p>Symptoms can manifest up to years later</p> Signup and view all the answers

    Which of the following is an effective non-pharmacological treatment for PTSD-related nightmares?

    <p>Imagery Rehearsal Therapy</p> Signup and view all the answers

    Which type of treatment is emphasized for managing cyclothymia?

    <p>Mood stabilizers and psychotherapy</p> Signup and view all the answers

    Which condition is characterized by symptoms resolving within a month after a traumatic event?

    <p>Acute Stress Disorder</p> Signup and view all the answers

    Why should caution be exercised when prescribing certain medications to women of reproductive age?

    <p>Because they may negatively impact fetal health</p> Signup and view all the answers

    What differentiates Adjustment Disorder from PTSD?

    <p>Symptoms arise within 3 months of a stressor</p> Signup and view all the answers

    What is considered a risk factor for developing Adjustment Disorder?

    <p>Frequent family relocations</p> Signup and view all the answers

    Which of the following is NOT a typical symptom of Adjustment Disorder?

    <p>Hypervigilance</p> Signup and view all the answers

    Individuals with which conditions are likely to have poorer prognoses when recovering from PTSD?

    <p>Complex PTSD and personality type disorders</p> Signup and view all the answers

    Which psychological testing observation suggests a higher likelihood of Adjustment Disorder?

    <p>Enhanced perception of others' expectations</p> Signup and view all the answers

    In the diagnosis of PTSD, which of the following is required regarding the re-experiencing symptoms?

    <p>Experience of at least one must be present</p> Signup and view all the answers

    Which factor does NOT influence the prognosis of PTSD?

    <p>Ability to forget the traumatic event</p> Signup and view all the answers

    Which personality disorder is characterized by a pervasive pattern of distrust and suspiciousness of others?

    <p>Paranoid PD</p> Signup and view all the answers

    What distinguishes Borderline Personality Disorder from other personality disorders?

    <p>Instability in relationships and self-image</p> Signup and view all the answers

    Which of the following personality disorders is typically more common in males?

    <p>Antisocial PD</p> Signup and view all the answers

    What is a common environmental factor associated with the development of Borderline and Antisocial Personality Disorders?

    <p>Early childhood trauma</p> Signup and view all the answers

    According to the DSM-5, what is a key characteristic of personality disorders?

    <p>Behavior deviates from cultural expectations</p> Signup and view all the answers

    Which cluster of personality disorders includes Paranoid, Schizoid, and Schizotypal disorders?

    <p>Cluster A</p> Signup and view all the answers

    What aspect of personality disorders typically complicates patient-provider relationships?

    <p>Recurrent and maladaptive behaviors</p> Signup and view all the answers

    Which of the following is NOT considered a cluster of personality disorders according to DSM-5?

    <p>Cluster D - Complex disorders</p> Signup and view all the answers

    What characterizes the emotional expression of individuals with schizoid personality disorder?

    <p>Restricted range of emotional expression</p> Signup and view all the answers

    Which behavior is typically associated with people who have paranoid personality disorder?

    <p>Long-standing distrust and suspiciousness</p> Signup and view all the answers

    What is a common management approach for individuals with borderline personality disorder?

    <p>Regularly schedule check-ups</p> Signup and view all the answers

    How should clinicians approach patients with narcissistic personality disorder?

    <p>Provide generous validation and factual responses</p> Signup and view all the answers

    What is a defining feature of the emotional state of individuals with avoidant personality disorder?

    <p>Fear of humiliation and embarrassment</p> Signup and view all the answers

    What characteristic behavior is notable in antisocial personality disorder?

    <p>Lack of remorse for harmful actions</p> Signup and view all the answers

    In the management of histrionic personality disorder, clinicians should focus on which approach?

    <p>Maintaining professional objectivity</p> Signup and view all the answers

    Which cognitive distortion is commonly experienced by individuals with schizotypal personality disorder?

    <p>Magical thinking</p> Signup and view all the answers

    What is a potential underlying fear for individuals with obsessive-compulsive personality disorder?

    <p>Fear of losing control</p> Signup and view all the answers

    Which of the following is a characteristic symptom of dependent personality disorder?

    <p>Intense fear of abandonment</p> Signup and view all the answers

    What is a common characteristic of individuals with antisocial personality disorder in relation to social norms?

    <p>Lack of conformity to social norms</p> Signup and view all the answers

    In the management strategy for paranoid personality disorder, what should clinicians prioritize?

    <p>Attention to patient fears, even when irrational</p> Signup and view all the answers

    How should cognitive distortions be handled in patients with schizotypal personality disorder?

    <p>Avoiding emotional engagement with the patient</p> Signup and view all the answers

    Which of the following symptoms is commonly associated with multiple somatic complaints in victims of intimate partner violence?

    <p>Chronic fatigue</p> Signup and view all the answers

    What psychological barrier may prevent intimate partner violence victims from leaving their relationship?

    <p>Psychological dependence</p> Signup and view all the answers

    What should be documented during the management of a patient experiencing intimate partner violence?

    <p>All interactions and observations</p> Signup and view all the answers

    Which of the following statements accurately reflects the complexity of a survivor's desire regarding their intimate partner relationship?

    <p>Survivors may want to eliminate the violence but not the relationship.</p> Signup and view all the answers

    What common response might friends and family give to victims of intimate partner violence when they seek help?

    <p>Advising them to work things out for the children’s sake</p> Signup and view all the answers

    What is the most common form of child abuse reported?

    <p>Neglect</p> Signup and view all the answers

    Which of the following is NOT considered a risk factor for child abuse?

    <p>Parental divorce</p> Signup and view all the answers

    Which warning sign is commonly associated with neglect in children?

    <p>Unexplained absences from school</p> Signup and view all the answers

    What is the primary characteristic of elder abuse?

    <p>Intentional acts causing harm or risk of harm</p> Signup and view all the answers

    Which term describes the most common form of elder abuse?

    <p>Emotional abuse</p> Signup and view all the answers

    Which demographic is most commonly affected by intimate partner violence (IPV)?

    <p>Younger women</p> Signup and view all the answers

    Which characteristic is often related to psychological symptoms of IPV in women visiting healthcare settings?

    <p>Underreporting of traumatic experiences</p> Signup and view all the answers

    Which condition is likely to underlie the cognitive impairment risk factor in elder abuse?

    <p>Dementia</p> Signup and view all the answers

    How should an adult approach a child who may have experienced abuse?

    <p>Reassure the child it is not their fault</p> Signup and view all the answers

    Which characteristic indicates a higher likelihood of experiencing elder abuse?

    <p>Cognitive impairments</p> Signup and view all the answers

    What is the approximate frequency of suicides occurring in the US?

    <p>Every 12 minutes</p> Signup and view all the answers

    Which mental health condition is most commonly linked to suicidal ideation?

    <p>Depression</p> Signup and view all the answers

    In cases where suicidal ideation is present but there is no intent to act, what is the recommended management approach?

    <p>Outpatient management with underlying condition assessment</p> Signup and view all the answers

    What type of information should a provider gather when assessing a patient with suicidal ideation?

    <p>Collateral information from a 3rd party in person or via phone</p> Signup and view all the answers

    Which statement best describes a summary statement used in managing suicidal ideation?

    <p>It should articulate the patient's current mental state and future plans.</p> Signup and view all the answers

    Which of the following is considered a key risk factor for suicide?

    <p>Chronic medical conditions</p> Signup and view all the answers

    What symptom is NOT typically associated with suicidal behavior?

    <p>Talking about enjoyable life experiences</p> Signup and view all the answers

    Which tool is recommended for routine screening of depression in primary care?

    <p>PHQ-9 Depression Screening Tool</p> Signup and view all the answers

    Which age group has the highest prevalence of depression-related suicides?

    <p>Persons aged 18-25 years</p> Signup and view all the answers

    Which of the following describes a common clinical characteristic of individuals exhibiting homicidal ideation?

    <p>History of physical or sexual abuse</p> Signup and view all the answers

    Which factor significantly increases the risk for suicide among transgender persons?

    <p>High prevalence of major depression</p> Signup and view all the answers

    Which of the following may indicate a prolonged bereavement that justifies antidepressant treatment?

    <p>Prolonged functional impairment</p> Signup and view all the answers

    What is a prevalent misconception regarding bereavement?

    <p>Bereavement can trigger major depression in some individuals.</p> Signup and view all the answers

    Which behavior is commonly exhibited by someone who is experiencing extreme emotional pain?

    <p>Driving extremely fast without concern for safety</p> Signup and view all the answers

    Which of the following best describes command hallucinations?

    <p>Voices instructing the individual to take action</p> Signup and view all the answers

    Which demographic is considered at the highest risk for suicide according to family history factors?

    <p>People with a family history of suicide</p> Signup and view all the answers

    What is a common emotional response clinicians may experience after losing a patient?

    <p>Feelings of guilt and remorse</p> Signup and view all the answers

    What is an essential component of bereavement care provided by clinicians?

    <p>Following up with the bereaved family members</p> Signup and view all the answers

    What is the primary consequence of sleep-wake disorders on a person’s functioning?

    <p>Daytime distress and impairment</p> Signup and view all the answers

    Which of the following is considered the most common sleep disorder?

    <p>Insomnia disorder</p> Signup and view all the answers

    For a diagnosis of insomnia disorder, how often must sleep difficulties occur?

    <p>At least 3 times a week for 3 months</p> Signup and view all the answers

    Which disorder involves excessive daytime sleepiness and can negatively impact functioning?

    <p>Hypersomnolence disorder</p> Signup and view all the answers

    Which phase of sleep is primarily associated with dreaming?

    <p>Rapid eye movement (REM) sleep</p> Signup and view all the answers

    Which demographic is most associated with problems getting to sleep?

    <p>Young adults</p> Signup and view all the answers

    What is NOT a typical method for diagnosing insomnia disorder?

    <p>Continuous glucose monitoring</p> Signup and view all the answers

    Which effect can poor sleep quality have on a person's cognitive abilities?

    <p>Decreased decision-making ability</p> Signup and view all the answers

    Which age group is most commonly affected by narcolepsy?

    <p>Childhood and adolescence</p> Signup and view all the answers

    What is the primary method for diagnosing narcolepsy?

    <p>Multiple Sleep Latency Test (MSLT)</p> Signup and view all the answers

    Which of the following is NOT a symptom associated with chronic insomnia?

    <p>Episodic symptoms lasting less than 3 months</p> Signup and view all the answers

    What is a common trigger for cataplexy in individuals with narcolepsy?

    <p>Laughter or joking</p> Signup and view all the answers

    Which treatment is specifically approved by the FDA for managing cataplexy in narcolepsy?

    <p>Sodium oxybate (GHB)</p> Signup and view all the answers

    In sleep hygiene practices, which factor is recommended to help improve sleep quality?

    <p>Maintaining a consistent sleep schedule</p> Signup and view all the answers

    Which of the following conditions is least likely to be associated with insomnia disorder?

    <p>Diabetes</p> Signup and view all the answers

    What types of medications are typically used for chronic insomnia treatment?

    <p>Combination of behavioral techniques and sleep medications</p> Signup and view all the answers

    Which statement regarding REM parasomnias is true?

    <p>They may include nightmare disorder.</p> Signup and view all the answers

    What percentage of adults in the US report symptoms of insomnia annually?

    <p>~30% to 40%</p> Signup and view all the answers

    What is a common characteristic of episodes in Non-Rapid Eye Movement Sleep Arousal Disorder?

    <p>Episodes typically cause significant distress or impairment.</p> Signup and view all the answers

    Which of the following age groups is most commonly affected by sleepwalking?

    <p>Children, particularly under 12</p> Signup and view all the answers

    What is a recommended management strategy for individuals with Nightmare Disorder?

    <p>Imagery rehearsal therapy focused on changing dream endings.</p> Signup and view all the answers

    In what way does Restless Leg Syndrome primarily affect a person's sleep?

    <p>It leads to difficulty getting to sleep and frequent awakenings.</p> Signup and view all the answers

    What is a potential underlying cause attributed to Restless Leg Syndrome?

    <p>Genetic components present in families</p> Signup and view all the answers

    Which feature distinguishes sleep terrors from other sleep disturbances?

    <p>They begin with a panicky scream and involve intense fear.</p> Signup and view all the answers

    Which of the following is NOT part of the diagnostic criteria for Non-Rapid Eye Movement Sleep Arousal Disorder?

    <p>Influence from an exogenous substance.</p> Signup and view all the answers

    What is considered a first-line pharmacological treatment for Restless Leg Syndrome?

    <p>Dopaminergic agents like ropinirole</p> Signup and view all the answers

    What is a common characteristic of the dreams experienced in Nightmare Disorder?

    <p>They feature threats or dangers with well-remembered details.</p> Signup and view all the answers

    What characteristic of sleepwalking is typically observed during episodes?

    <p>A blank, staring face and difficulty waking.</p> Signup and view all the answers

    What behavioral approach is recommended for enuretic children?

    <p>Behavioral measures without shaming or punishing.</p> Signup and view all the answers

    After which age do sleep terrors typically decrease in prevalence?

    <p>Adolescence</p> Signup and view all the answers

    What might be a key focus in managing and treating RLS based on its presentation?

    <p>Addressing any underlying conditions present.</p> Signup and view all the answers

    What is NOT a type of hallucination associated with psychosis?

    <p>Persecutory</p> Signup and view all the answers

    Which type of delusion involves the belief that ordinary events have hidden meanings related to oneself?

    <p>Referential</p> Signup and view all the answers

    Which of the following statements about hallucinations is true?

    <p>They can be vivid and clear, resembling actual perceptions.</p> Signup and view all the answers

    Which of the following types of delusions is classified as non-bizarre?

    <p>Persecutory</p> Signup and view all the answers

    What is the most common type of hallucination experienced in schizophrenia?

    <p>Auditory</p> Signup and view all the answers

    What is a common feature of deficit schizophrenia compared to non-deficit schizophrenia?

    <p>Primary enduring negative symptoms</p> Signup and view all the answers

    Which age range is most commonly associated with the onset of schizophrenia in men?

    <p>18-25 years</p> Signup and view all the answers

    Which of the following situations has been suggested as a risk factor for developing schizophrenia?

    <p>Advanced paternal age at child conception</p> Signup and view all the answers

    How is schizophrenia currently classified according to the modern understanding?

    <p>As a spectrum disorder</p> Signup and view all the answers

    Individuals with schizophrenia often experience a prodromal period characterized by what?

    <p>Increase in social isolation</p> Signup and view all the answers

    What is a potential consequence of heavy marijuana use during early adolescence in relation to schizophrenia?

    <p>It increases the later risk of schizophrenia</p> Signup and view all the answers

    Which group has a higher reported incidence of schizophrenia based on familial ties?

    <p>Siblings of individuals with schizophrenia</p> Signup and view all the answers

    What is a characteristic symptom associated with the disorganized thinking in individuals with schizophrenia?

    <p>Incoherence or 'word salad'</p> Signup and view all the answers

    Which category of schizophrenia symptoms includes hallucinations and delusions?

    <p>Positive symptoms</p> Signup and view all the answers

    What is a defining criterion for diagnosing schizophreniform disorder?

    <p>Symptoms lasting 1-6 months</p> Signup and view all the answers

    Which treatment is most commonly used for managing schizoaffective disorder?

    <p>Combination of antipsychotics and psychotherapy</p> Signup and view all the answers

    In the context of antipsychotic medications, which side effect is more commonly associated with first-generation antipsychotics?

    <p>Extrapyramidal symptoms</p> Signup and view all the answers

    What is a significant distinguishing feature of delusional disorder compared to schizophrenia?

    <p>Absence of psychotic symptoms</p> Signup and view all the answers

    Which antipsychotic medication can take up to 6 months to achieve a full therapeutic response?

    <p>Clozapine</p> Signup and view all the answers

    What is the main characteristic of brief psychotic disorder?

    <p>Sudden onset of psychotic symptoms with rapid resolution</p> Signup and view all the answers

    Which symptom must be present for at least 6 months to diagnose schizophrenia?

    <p>Any two or more symptoms</p> Signup and view all the answers

    What defines treatment-resistant schizophrenia?

    <p>Failure to respond to two adequate trials of antipsychotic medications</p> Signup and view all the answers

    Which disorder is characterized by symptoms of schizophrenia lasting less than one month?

    <p>Brief psychotic disorder</p> Signup and view all the answers

    In which age group is schizophreniform disorder most commonly diagnosed?

    <p>18 - 24 years</p> Signup and view all the answers

    Which of the following therapies is generally considered a last resort for refractory cases of schizoaffective disorder?

    <p>Electroconvulsive Therapy</p> Signup and view all the answers

    What aspect of cognitive functioning is commonly impaired in schizophrenia?

    <p>Concentration and problem-solving</p> Signup and view all the answers

    Study Notes

    Bipolar Disorder

    • Severe mood swings with emotional highs and lows
    • Characterized by manic and depressive episodes
    • Risk factor: family history (80-85% probability with parent or sibling)
    • Mean onset age: late teens to 20s
    • Equal prevalence in males and females
    • 18th leading cause of disability in the US
    • Bipolar I: at least one manic episode
    • Bipolar II: at least one hypomanic episode, no mania (more common than Bipolar I)
    • Manic episodes can last weeks to months and involve:
      • High energy
      • Reduced need for sleep
      • Loss of reality
    • Depressive episodes involve:
      • Low energy and motivation
      • Loss of interest
      • Suicidal ideations
    • Diagnosis includes:
      • Psychiatric and medical history
      • Mental status and physical exam
      • Basic labs to rule out medical concerns
    • Treatment:
      • Medications (mood stabilizers, antipsychotics, antidepressants)
      • Psychotherapy (CBT)
      • Mood stabilizers (lithium, carbamazepine, lamotrigine, valproate)
      • Antipsychotics (haloperidol, olanzapine, quetiapine, risperidone)
      • Antidepressants (fluoxetine, symbyax)
    • Management tips:
      • Acute treatment should align with maintenance goals
      • Psychiatric consultation recommended before therapy initiation
      • Caution with lithium, lamotrigine, divalproex, or carbamazepine in pregnant women

    Cyclothymia

    • Similar to bipolar disorder but without major depression or mania
    • Recurring periods of depression and elevated mood symptoms
    • Symptoms must last over 2 years for adults, and over 1 year for children
    • Equal prevalence in males and females
    • Risk factor: family history of bipolar disorder
    • Treatment:
      • Mood stabilizers and psychotherapy/counseling
    • Diagnosis:
      • Classified as a subtype of bipolar disorder
      • Criterion:
        • Periods of elevated mood and depressive symptoms for at least 50% of the time over 2 years (adults) or 1 year (children)
        • Periods of stable mood last only 2 months at most*

    Post-traumatic Stress Disorder (PTSD)

    • Mental health condition triggered by a traumatic event (experienced or witnessed)
    • Classified under stress and trauma-related disorders
    • Costliest diagnosis for the VA
    • Onset can occur from early childhood to late adulthood
    • Symptoms: insomnia, nightmares, hypervigilance, avoidance of emotional arousal, flashbacks
    • Diagnosis:
      • Exposure to a traumatic event
      • 4 criteria:
        • Intrusion (re-experiencing)
        • Avoidance
        • Negative affect
        • Hyperarousal
    • PTSD Acronym:
      • T: Traumatic event
      • R: Re-experience
      • A: Avoidance
      • U: Unable to function
      • M: Month (at least)
      • A: Arousal
    • Risk factors:
      • Female gender
      • History of trauma
    • Diagnosis tools:
      • PCL-5: self-administered 20-item assessment
      • CAPS-5: clinician-administered 30-item structured clinical interview
    • Treatment and Management:
      • SSRIs considered first-line medication
      • Prazosin and topiramate: improve sleep and reduce nightmares
      • Non-pharmacological management:
        • Imagery Rehearsal Therapy (IRT)
        • Cognitive Behavioral Therapy (CBT)
    • Increased risk for PTSD:
      • Female gender
      • History of trauma

    Adjustment Disorder

    • Exaggerated and abnormal reaction to a life stressor
    • Reaction is more severe than expected
    • Causes significant social, occupational, or academic impairment
    • Symptoms:
      • Sadness, hopelessness, anhedonia
      • Frequent crying
      • Worry/anxiety
      • Sleep difficulties
      • Lack of appetite
      • Difficulty concentrating
      • Feeling overwhelmed
      • Social withdrawal
      • Suicidal thoughts or behavior
    • Etiology and Risk Factors:
      • Prior stress exposure
      • Stressful early childhood experiences
      • History of mood or eating disorders
      • Family unity disruptions or frequent relocations (children)
      • Death of a parent
      • Prior exposure to war
    • Labs and work-up:
      • Labs not helpful
      • Treatment-refractory cases may indicate imaging
      • Psychological testing: individuals with a tendency toward exaggerated perception
    • Diagnosis:
      • Development of emotional or behavioral symptoms in response to an identifiable stressor
      • Symptoms occur within 3 months of the onset of stressor(s)
      • Marked distress out of proportion to stressor severity
      • Significant impairment in social, occupational, or other areas of functioning
      • Symptoms do not persist for more than 6 months after the stressor has terminated
    • Treatment and Management:
      • Psychotherapy (individual, group, family)
      • Medications (antidepressants, anti-anxiety drugs)

    Acute Stress Disorder (ASD)

    • Mental health problems that can occur in the first month after a traumatic event
    • Symptoms similar to PTSD but resolve within a month
    • Common traumas: combat, assault/rape, torture, natural disasters, accidents
    • "Precursor" diagnosis for PTSD
    • Diagnosis Criteria:
      • Exposure to a traumatic event
      • Presence of at least 9 symptoms from 5 categories:
        • Intrusion (recurrent, involuntary, intrusive memories or dreams, etc.)
        • Negative mood (inability to experience positive emotions)
        • Dissociation (dissociative amnesia, derealization, etc.)
        • Avoidance (reminders, people, places, things, thoughts, etc.)
        • Arousal (hypervigilance, sleep disturbance, concentration issues, etc.)
      • Symptoms beginning or worsening after the traumatic event(s)
      • Duration of 3 days to 1 month after trauma exposure
    • Treatment and Management:
      • Psychotherapy
      • Medications (can help with signs and symptoms)

    Personality Disorders

    • Affects around 9% of adults in the United States.
    • More common in individuals who have substance abuse and smoke.
    • Antisocial personality disorder is more prevalent in males.
    • Borderline, histrionic, and dependent personality disorders are more often diagnosed in females.
    • Usually manifest by adolescence or early adulthood.

    Etiology of Personality Disorders

    • Psychoanalysts attribute their origin to early traumatic experiences and failure to progress through normal stages of sexual development.
    • Research suggests early childhood trauma and abuse are associated with borderline and antisocial personality disorders.
    • Schizotypal personality disorder has a genetic component and is likely related to a variant of schizophrenia.
    • Borderline and antisocial personality disorders are the most severe and demonstrate a clear genetic component.

    Personality Disorders: General Features

    • Common in medical settings.
    • Characterized by recurrent, maladaptive behavior, typically dating back to childhood.
    • Can interfere with the patient-provider relationship, resulting in suboptimal care and worse medical outcomes.
    • Cause dysfunctional beliefs about oneself and others, impairing personal, social, and professional relationships.

    DSM-5 Classification of Personality Disorders

    • Defined as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.
    • Lists 10 personality disorders grouped into 3 clusters based on descriptive similarities.

    Cluster A: Odd or Eccentric Personality Disorders

    • Paranoid Personality Disorder: Characterized by long-standing distrust and suspiciousness, perceiving others' behaviors and motives as malevolent.
    • Schizoid Personality Disorder: Individuals appear cold or indifferent with a restricted range of emotional expression. They are detached from social relationships, isolate themselves, and avoid close relationships.
    • Schizotypal Personality Disorder: Individuals behave in an odd and eccentric manner, are socially inept and isolated, and often dress in odd and peculiar fashion. They experience cognitive and perceptual distortions such as magical thinking, odd beliefs, ideas of reference, bodily illusions, and telepathic or clairvoyant experiences.

    Cluster B: Dramatic, Emotional, or Erratic Personality Disorders

    • Antisocial Personality Disorder: Individuals disregard others, violate their rights, and show a tendency towards aggressive behavior. They lack conformity to social norms and laws, are impulsive and irresponsible, and prone to lying and deceit for personal gain.
    • Borderline Personality Disorder: Individuals experience instability in self-image, affect, and relationships with others. They engage in self-destructive behaviors, such as self-mutilation, substance abuse, and suicide attempts. They have an intense fear of abandonment, a deep sense of emptiness, and contradictory emotions and feelings due to rapid mood shifts.
    • Histrionic Personality Disorder: Individuals exhibit excessive attention-seeking behavior, emotionalism, dramatic and theatrical displays of feelings, and sexually provocative dressing.
    • Narcissistic Personality Disorder: Individuals have a pattern of long-standing grandiosity, need for praise and admiration, lack of sensitivity to others' feelings, an exaggerated sense of self-importance, and a drive to attain idealized social, personal, romantic, or career achievements.

    Cluster C: Anxious or Fearful Personality Disorders

    • Avoidant Personality Disorder: Individuals experience long-standing, excessive anxiety in social situations and intimate relationships. They avoid social interactions, are hypersensitive to others' opinions, and desire relationships but avoid them due to fear of rejection.
    • Dependent Personality Disorder: Individuals have a pervasive and excessive need to be taken care of, intense fear of separation and abandonment, and are submissive and clinging in relationships.
    • Obsessive-Compulsive Personality Disorder: Individuals are preoccupied with orderliness, perfectionism, and control, are excessively concerned with details and rules, and have difficulty adapting to others.

    Management of Personality Disorders

    • Paranoid Personality Disorder: Be attentive and empathic towards patient fears, even when irrational in thinking. Avoid being overly friendly and maintain an objective stance.
    • Schizoid Personality Disorder: Respect the patient's need for privacy and maintain a low-key approach. Focus on technical elements of treatment and encourage the patient to maintain daily routines.
    • Schizotypal Personality Disorder: Refrain from being bothered by the patient's appearance when odd and avoid being overly involved in trying to provide social support.
    • Antisocial Personality Disorder: Communicate directly, avoid punitive reactions, and set clear limits in the context of medically indicated interventions.
    • Borderline Personality Disorder: Don't get too close to the patient, schedule frequent periodic check-ups, provide clear, nontechnical answers to questions, tolerate periodic angry outbursts but set limits, be aware of the patient's potential for self-destructive behavior, and have a multidisciplinary team approach.
    • Histrionic Personality Disorder: Show respectful and professional concern for feelings, with an emphasis on objective issues. Avoid excessive familiarity.
    • Narcissistic Personality Disorder: Generously validate the patient's concerns with attentive but factual responses. Allow patients to maintain a sense of competence by rechanneling their "skills" to deal with illness. Present treatment recommendations in the context of their right to the best care.
    • Avoidant Personality Disorder: Provide reassurance and validate the patient's concerns. Encourage reporting of symptoms and concerns.
    • Dependent Personality Disorder: Provide reassurance, schedule frequent periodic check-ups, be consistently available but provide firm, realistic limits to availability, enlist other members of the health care team in providing support, help the patient obtain outside support, and avoid hostile rejection.
    • Obsessive-Compulsive Personality Disorder: Conduct thorough history-taking and diagnostic workups, give a clear and thorough explanation of the diagnosis and treatment options, avoid overemphasizing uncertainties about treatments, avoid vague and impressionistic explanations, treat the patient as an equal partner, and allow patient participation in treatment.

    General Considerations for Personality Disorders

    • Personality disorders may present with depression and/or anxiety as concomitant conditions when coping mechanisms fail.
    • More severe cases may decompensate with psychosis.
    • Hospitalization is required in severe cases of suicidal or homicidal dangers.
    • Social, behavioral, psychological, and pharmacologic management are all options in certain settings.
    • SSRIs/SNRIs, antipsychotics, benzodiazepines (BZDs), and mood stabilizers/anticonvulsants are sometimes used for accompanying symptoms when needed and evident but not in general.

    Child Abuse and Neglect

    • Legal definitions of child maltreatment vary by state.
    • Neglect is generally defined as failure to provide adequate care and protection.
    • Approximately 3.4 million alleged incidents of child maltreatment are reported each year.

    Risk Factors for Child Abuse and Neglect

    • Parents with mental health issues.
    • Parents with substance abuse issues.
    • Poor parenting skills.
    • Children with special needs.
    • Children under 4 years of age.
    • Parents with low socioeconomic status.
    • Parents with domestic violence issues.

    Types of Child Abuse

    • Physical abuse.
    • Sexual abuse.
    • Emotional abuse (e.g., name-calling, shaming, rejection).
    • Medical abuse (e.g., Munchausen syndrome).
    • Neglect (e.g., failure to provide for the child's basic needs, including education, medical, physical, and emotional care). Neglect is the most common form of child maltreatment.

    Warning Signs of Child Abuse and Neglect

    • Child is withdrawn, fearful, or anxious.
    • Child has extreme behavior (e.g., aggressive, demanding).
    • Child does not seem emotionally attached to the caregiver.
    • Frequent, unexplained injuries or bruises.
    • Child may wear clothing inappropriate for their age (sexual abuse).
    • Child flinches suddenly or is afraid to go home.
    • Difficulty walking or sitting (sexual abuse).
    • Knowledge of sex inappropriate for their age (sexual abuse).
    • Child shows strong efforts to avoid certain persons.
    • Concerns regarding STDs or pregnancy (sexual abuse).
    • Unkept or inappropriate clothing, especially for the season (neglect).
    • Untreated illness or physical injury (neglect).
    • Frequent lateness or absence from school (neglect).
    • Consistent bad hygiene (neglect).
    • Frequent unsupervised time for their age (neglect).

    Effects of Child Abuse and Neglect

    • PTSD and other mental health disorders.
    • Low self-esteem.
    • Trust and relationship issues.
    • Learning and cognitive problems.
    • Substance abuse behaviors.
    • Suicidal ideation, attempts, and behavior.
    • Problems in school.
    • Delayed brain development.

    How to Help a Child

    • Avoid denial. Remain calm and refrain from appearing shocked or disgusted.
    • Do not interrogate the child. Let the child explain in their own words.
    • Reassure the child. Advise them it is not their fault and that you take their situation seriously.
    • Prioritize safety. Contact appropriate professionals, agencies, and authorities.
    • Provide post-support (e.g., counseling, therapy, support groups).

    Elder Abuse and Neglect

    • Intentional act or failure that causes or creates a risk of harm to an older adult (age 65 or older).
    • Occurs at the hands of a caregiver or someone the elder trusts.
    • Most victims are women, with adult male children being the most common perpetrators.
    • Abuse occurs more commonly in the home than in facilities.
    • Estimated 1-2 million Americans age 65 or older are abused or neglected by people they trust.
    • Emotional/psychological abuse is the most common form of elder abuse.

    Risk Factors for Elder Abuse and Neglect

    • Functional dependence or disability.
    • Poor physical or mental health.
    • Lack of close or involved family or friends.
    • Low socioeconomic status.
    • Cognitive impairment (e.g., dementia).

    Types of Elder Abuse

    • Physical abuse (e.g., hitting, kicking, pushing, slapping, burning, or force causing injury).
    • Sexual abuse (e.g., engaging in sexual acts without consent).
    • Emotional abuse (e.g., harming self worth, name calling, scaring).
    • Neglect (e.g., abandonment).
    • Financial abuse.

    Signs of Elder Abuse and Neglect

    • Physical indicators: Injuries, bruises, welts, burns, broken bones, unexplained weight loss, poor hygiene, dehydration.
    • Behavioral indicators: Changes in personality, withdrawal, fear, anxiety, agitation, depression, confusion, suspiciousness, reluctance to be alone with caregiver.
    • Financial indicators: Missing financial documents, unexplained bank withdrawals, unusual purchases, missing valuables.
    • Environmental indicators: Unsafe living conditions, lack of food or medication, caregiver refusing access to elder.

    Intimate Partner Violence (IPV)

    • Any "intentional, controlling behavior" consisting of physical, sexual, or psychological assault, or stalking by a current or former intimate partner.
    • Women visiting outpatient medical and OB/GYN clinics, and emergency departments are often there for complaints directly attributable to IPV.
    • IPV victims are frequently misdiagnosed and may return multiple times with increasingly severe trauma.
    • LGBTQ members are less likely to disclose abusive relationships due to social and legal reasons and commonly held bias.
    • Approximately 37% of women have experienced sexual or physical violence or stalking by an intimate partner in their lifetime.
    • About 1 in 3 women and 1 in 4 men report experiencing severe physical violence from an intimate partner.

    Warning Signs of IPV

    • Multiple somatic complaints: Fatigue, sleep disturbance, headache, gastrointestinal complaints, abdominal and pelvic pain, genitourinary problems, chest pain, palpitations, dizziness.
    • Psychiatric disorders: Depression, eating disorders, anxiety and panic disorders, PTSD.
    • Pregnancy complications: Delay in seeking prenatal care, depressed or anxious mood, injuries to breasts or abdomen, frequent spontaneous abortions, preterm labor.
    • Substance abuse: Victim engaged in substance abuse to cope or partner struggling with substance abuse themselves.
    • HIV/STIs: Increased risk of contracting or transmitting these infections.

    Barriers to Seeking Help for IPV

    • Fear: Fear for their own safety or the safety of their children.
    • Economic dependence: Difficulty supporting themselves and/or children outside of the relationship.
    • Psychological dependence: Years of abuse can lead to feeling "worthless" and incapable of surviving on their own.
    • Lack of social support: Encouragement from friends and family to "work things out" or stay "for the children's sake."
    • Limited options: Full shelters, unavailable friends and family, inaccessible legal counsel.

    Management and Intervention for IPV

    • Validate the problem: Let the patient know that violence is unacceptable and illegal.
    • Be empathetic: Don't judge the patient.
    • Assess safety: Review an emergency escape plan.
    • Document clearly and completely any evidence of abuse.
    • Provide appropriate referrals: Shelters, counseling, legal aid.
    • Know social and legal services in the area.
    • Be aware of reporting requirements.
    • National Domestic Violence Hotline: 1-800-799-7233.
    • Remember: Not all survivors want the relationship to end, just the violence.

    Suicide and Suicidal Ideation

    • Suicide is a major public health concern in the US, occurring every 12 minutes.
    • It's among the top 10 leading causes of death across all age groups.
    • Approximately 90% of suicides are linked to mental illness, primarily depression.
    • The PHQ-9 depression screening tool is crucial for identifying individuals at risk.
    • If active suicidal ideation is present, psychiatric evaluation and potential hospitalization are necessary.
    • If there's no intent to act on suicidal thoughts, outpatient management can be considered, but with a thorough assessment for underlying conditions.
    • A "summary statement" is helpful for documenting the patient's current status in both inpatient and outpatient settings. This statement provides information about the patient's current thoughts, feelings, and plans, along with support from family or others.
    • The summary statement also outlines the patient's current safety measures and any interventions that are being put in place.

    Risk Factors for Suicide

    • Depression, other mental health disorders, and substance abuse disorders are significant risk factors.
    • Chronic medical conditions and chronic pain can also increase the risk.
    • A previous suicide attempt greatly raises the risk of future attempts.
    • Older white males are considered a high-risk group.
    • Members of the LGBTQ community are at an elevated risk of suicide.
    • Family history of mental illness, substance abuse, or suicide contributes to the risk.
    • Family violence, including physical or sexual abuse, can increase suicide risk.
    • Access to firearms in the home is a significant risk factor.
    • Individuals recently released from prison or jail are at higher risk.
    • Exposure to others' suicidal behavior, such as family members, peers, or celebrities, can also be a factor.

    Screening Tools for Suicide

    • The PHQ-9 is a widely used depression screening tool that should be administered at the start of treatment and periodically during management.
    • The USPSTF (United States Preventive Services Task Force) recommends universal depression screening in primary care for adolescents aged 12 and older.
    • Evidence suggests that depression screening and treatment can help prevent suicide.
    • The C-SSRS (Columbia-Suicide Severity Rating Scale) is a more comprehensive tool intended for use by trained clinicians.
    • The C-SSRS takes into account the intensity, frequency, and duration of suicidal thoughts and behaviors.

    Homicidal Ideation and Behavior

    • While mental health disorders are often associated with homicidal ideation, individuals with mental health disorders are more frequently victims of violence than perpetrators.
    • Certain psychotic symptoms, such as paranoid delusions and hallucinations, might increase the likelihood of acting on homicidal thoughts.
    • Thorough, objective, and accurate assessment and documentation are essential when evaluating individuals with potential homicidal ideation.

    Clinical and Epidemiological Factors Associated with Homicidal Behavior

    • Younger individuals are more likely to engage in violence.
    • Males are disproportionately represented in violent acts.
    • A history of criminal behavior is a risk factor.
    • A history of physical or sexual abuse in childhood, fire setting, or cruelty to animals can contribute to violent tendencies.
    • If the proposed victim is a family member or close associate, there is a heightened risk.
    • Exposure to violent subcultures can contribute to violence.
    • Certain diagnoses, such as manic states, schizophrenia, alcoholism or other substance dependence, conduct disorder, antisocial personality disorder, and intermittent explosive disorder are associated with an increased risk of violence.
    • Specific symptoms indicative of potential violence include command hallucinations, agitation, and hostile suspiciousness.

    Bereavement and Bereavement Care

    • Bereavement refers to the grief experienced after the loss of a loved one.

    • It's not considered a mental disorder, but some of its symptoms can resemble those of major depression, such as insomnia, loss of appetite, hopelessness, guilt, and others.

    • Studies indicate that approximately 25% of bereaved individuals meet the criteria for major depression at two months following the loss, and these symptoms can persist for up to 13 months.

    • Antidepressant treatment might be warranted if behavioral symptoms are prolonged or continue to impair functioning.

    • Clinicians should follow up with family members after the loss of a loved one to offer support and guidance.

    • This includes acknowledging the loss, educating family members about the normal grieving process, and offering support groups, counseling services.

    • Clinicians may also experience grief after the death of a patient, including sadness, guilt, or remorse. It's important for clinicians to prioritize their own emotional well-being and seek support when needed.

    • Attending a deceased patient's funeral service can be a meaningful way to demonstrate respect for the deceased and offer comfort to the family.

    ### Sleep-Wake Disorders

    • Problems with sleep quality, timing, or quantity leading to daytime distress and impaired functioning
    • Often occur alongside medical conditions or mental health issues like depression, anxiety, and cognitive disorders
    • Insomnia is the most common sleep-wake disorder

    ### Classification of Sleep-Wake Disorders

    • Ten Sleep-Wake Disorders are classified in the DSM-5
      • Insomnia Disorder
      • Hypersomnolence Disorder
      • Narcolepsy
      • Breathing-Related Sleep Disorders
      • Circadian Rhythm Sleep Disorders
      • Non-REM (NREM) Sleep Arousal Disorders
      • Nightmare Disorder
      • REM Sleep Behavior Disorder
      • Restless Legs Syndrome
      • Substance/Medication-Induced Sleep Disorder

    ### How Sleep Works

    • Two types of sleep occur in cycles throughout the night:
      • Rapid Eye Movement (REM) - when dreaming occurs
      • Non-REM (NREM) - three phases, including the deepest sleep
    • The body naturally operates on a 24-hour circadian rhythm cycle
    • Sleep needs vary based on age
    • Adults require 7-9 hours of quality sleep nightly (National Sleep Foundation)

    ### Epidemiology of Sleep Disorders

    • Young adults often experience difficulty falling asleep
    • Middle-aged and older adults face challenges staying asleep

    ### Consequences of Insufficient or Poor Sleep

    • Diminished physical and mental well-being
    • Reduced brain function and performance
    • Fatigue, low energy, and irritability
    • Impaired decision-making and focus
    • Sleep problems frequently coexist with depression or anxiety, exacerbating symptoms
    • Depression or anxiety can contribute to sleep problems

    Insomnia Disorder

    • The most prevalent sleep disorder
    • Difficulty falling and/or staying asleep
    • Transient insomnia is more common than chronic insomnia (lasting over a month)
    • Transient insomnia usually resolves without intervention
    • Diagnosis requires difficulty sleeping at least 3 nights a week for at least 3 months, causing significant distress or impairment in daily functioning
    • Other sleep disorders, medication side effects, substance use, depression, and physical or mental illnesses should be ruled out

    ### Epidemiology of Insomnia

    • Women are more likely to experience insomnia than men
    • Risk increases with age
    • 30-40% of US adults report insomnia symptoms annually
    • Frequently associated with medical, psychiatric, or substance use disorders

    Management of Insomnia Disorder

    • Insomnia symptoms can be episodic (1-3 months), persistent (3+ months), or recurrent (2+ episodes per year).
    • Good sleep habits and hygiene can often resolve insomnia
    • Chronic insomnia is typically treated with a combination of sleep medications and behavioral techniques, such as cognitive behavioral therapy (CBT)
    • Over-the-counter (OTC) medications include antihistamines, melatonin, etc.
    • Non-controlled prescription medications include trazodone, ramelteon, hydroxyzine, etc.
    • Controlled prescription medications include benzodiazepines (BZDs), Ambien, Lunesta, etc.

    Complementary Health Approaches for Insomnia

    • Relaxation techniques before bedtime may be beneficial
    • Mind and body approaches (mindfulness, meditation, yoga, massage therapy, acupuncture) are generally considered safe but lack conclusive evidence for effectiveness
    • Herbs and dietary supplements have not been proven effective for insomnia and some may pose safety concerns, including L-tryptophan and kava

    ### Sleep Hygiene Tips

    • Maintain a consistent sleep schedule, including weekends
    • Engage in calming activities, such as reading, before bed, avoiding bright lights and electronic devices
    • Avoid naps, especially in the afternoon
    • Exercise daily
    • Create a quiet, cool, and dark sleep environment
    • Use a comfortable and supportive mattress and pillow
    • Avoid alcohol, caffeine, and heavy meals in the evening

    Narcolepsy

    • Characterized by overwhelming daytime sleepiness and sudden sleep attacks
    • Sleep attacks typically last 15-20 minutes but can be longer and occur while driving, making driving dangerous
    • Sleepiness occurs daily and must happen at least 3 times a week for 3 months to diagnose narcolepsy
    • Individuals experience cataplexy, brief sudden loss of muscle tone triggered by laughter or joking, resulting in head bobbing, jaw-dropping, or falls
    • Awareness is maintained during cataplexy

    Epidemiology and Etiology of Narcolepsy

    • Rare, affecting an estimated 0.02-0.04% of the population
    • Typically begins in childhood, adolescence, or young adulthood
    • Caused by the loss of hypothalamic hypocretin (orexin)-producing cells
    • Hypocretin deficiency is thought to result from the immune system attacking hypocretin-producing cells or receptors
    • Hypocretin deficiency can be tested through cerebrospinal fluid (CSF) via a lumbar puncture

    Diagnosis of Narcolepsy

    • Confirmed by a positive Multiple Sleep Latency Test (MSLT) following a night of polysomnography (PSG) to rule out other causes for abnormal MSLT
    • If narcolepsy worsens in a previously controlled patient, investigate other potential causes for hypersomnia (medications, sleep apnea, periodic limb movement, etc.)
    • Some patients fabricate narcolepsy to obtain stimulants; PSG confirmation or previous medical records are recommended

    Treatment and Management of Narcolepsy

    • No cure exists, but reasonable control can be achieved with scheduled naps
    • Medications are often required
      • Modafinil is the primary treatment for excessive daytime sleepiness (EDS)
      • Stimulants like methylphenidate and amphetamines are also used occasionally
      • Sodium oxybate (gamma-hydroxybutyrate [GHB]) is the only FDA-approved medication for cataplexy

    Parasomnias

    • Unusual events or behavior occurring during sleep or sleep-wake transitions
    • Non-REM sleep events are often associated with difficulty awakening, confusion, and memory loss for the event
    • Behavioral manifestations include sleepwalking, sleep terrors, sleep-talking, and sex-somnia
    • REM parasomnias involve clear and rapid awakening with event recall (nightmare disorder, sleep-related painful erection, sleep paralysis)

    REM Parasomnia Diagnostic Criteria

    • Repeated episodes of arousal during sleep with vocalization and/or complex motor behaviors
    • Arise during REM sleep, generally over 90 minutes into sleep and more frequent later in the sleep cycle
    • Uncommon during daytime naps
    • Complete awakening, alertness, and lack of confusion or disorientation
    • Overnight sleep study shows REM sleep without atonia (muscular paralysis)
    • Significant distress or impairment, potential for injury to patient or bed partner
    • Not attributable to substances, medical conditions, other psychiatric/medical disorders

    Treatment and Management of Parasomnia

    • Depends on the specific disorder
    • Reassure families of children
    • Maintain a safe environment for sleepwalking and REM behavior disorders (lock balconies, special precautions in hotels, separate sleeping arrangements)
    • Thorough sleep hygiene instruction is important for all parasomnias
    • Dental devices can treat bruxism (tooth grinding)
    • Non-shaming behavioral measures are key for enuretic children (bed-wetting parasomnia)

    ### Non-Rapid Eye Movement Sleep Arousal Disorder (NREM Parasomnia)

    • Episodes of incomplete awakening, usually during the first third of the sleep cycle
    • Accompanied by sleepwalking or sleep terrors
    • Significant distress or impairment in functioning
    • Most common in children, decreasing with age

    Sleepwalking

    • Repeated episodes of rising from bed and walking while asleep
    • Blank, staring face
    • Unresponsiveness to others
    • Difficulty waking up
    • 30% of individuals have experienced sleepwalking

    Sleep Terrors

    • Also known as night terrors
    • Abrupt waking from sleep, often with a panicky scream
    • Intense fear, rapid breathing, accelerated heart rate, sweating
    • Limited memory of the dream upon waking
    • Unresponsiveness to reassurance
    • Common in young children, decreasing with age
    • Only about 2% of adults experience night terrors

    Diagnostic Criteria for Non-Rapid Eye Movement Sleep Arousal Disorder (NREM Parasomnia)

    • Repeated episodes of arising from bed while asleep and walking, with a blank staring face, unresponsiveness to others, and difficult awakening
    • Limited or no recall of dream imagery or behavioral episodes
    • Significant distress or impairment
    • No influence of substances
    • No underlying psychiatric or medical disorders

    Nightmare Disorder (REM Parasomnia)

    • Repeated occurrences of lengthy, elaborate dreams, often featuring attempts to avoid threats or danger
    • Causes intense fear, anxiety, and distress
    • Occur during the latter half of the sleep cycle
    • Quick awakening with vivid dream recall
    • Commonly begins between ages 3 and 6
    • Prevalence and severity peak in late adolescence or early adulthood
    • Considered a disorder when dreams lead to distress or insufficient sleep

    Treatment and Management of Nightmare Disorder

    • Investigate and treat underlying causes
    • Imagery rehearsal therapy (CBT variant) - changing the ending of the nightmare while awake, then rehearsing the new ending mentally
    • Medication is uncommon unless severe (ie., nightmares associated with PTSD)
    • Prazosin (3-15 mg po qhs) is used for severe or PTSD-related nightmares

    Restless Legs Syndrome (RLS)

    • Urge to move legs accompanied by uncomfortable sensations, often described as creeping, crawling, tingling, burning, or itching
    • Urges begin or worsen during rest or inactivity, alleviated by movement
    • Worsen in the evening or night
    • Symptoms occur 3 times a week for 3 months, causing significant distress or impairment
    • Affects sleep and leads to daytime sleepiness
    • Typically begins in adolescence or young adulthood, affecting 2-7.2% of the population

    Etiology of Restless Legs Syndrome

    • Many cases have unknown causes
    • Genetic component with onset before age 40
    • Low brain iron levels may contribute
    • Link between RLS and ADHD due to dopamine levels
    • Alcohol and opioid withdrawal
    • Medications linked to RLS include antidepressants, antihistamines, antiemetics, and antipsychotics

    Treatment and Management of Restless Legs Syndrome

    • Address any underlying conditions
    • Medication treatment typically involves one of three categories:
      • Dopaminergic agents (ropinirole, pramipexole)
      • GABAergic agents (baclofen, gabapentin, BZDs)
      • Opioid preparations (propoxyphene, codeine preparations)
    • Dopaminergic agents are considered the treatment of choice (ropinirole is FDA-approved), with pramipexole having fewer side effects than older agents

    Psychosis

    • A distorted perception of reality marked by hallucinations and delusions.
    • Hallucinations are perception-like experiences with no external stimulus.
      • Auditory hallucinations are most common in Schizophrenia
    • Delusions are fixed beliefs not easily changed, even with conflicting evidence.
      • Persecutory, referential, and grandiose delusions are common types

    Schizophrenia

    • Affects 1% of the world's population, with onset usually in adolescence or early adulthood.
    • Men are more likely to develop Schizophrenia, and may have worse prognosis.
    • Risk factors include genetics, urban living, immigration, obstetrical complications, and heavy marijuana use during adolescence.
    • Schizophrenia is a chronic and life-long disease affecting thinking, feeling, and behavior.
    • Symptoms include positive, negative, cognitive and disorganized symptoms.
    • Treatment focuses on antipsychotic medication to manage positive symptoms.

    Schizophreniform Disorder

    • Similar to Schizophrenia but symptoms persist for 1-6 months.
    • Men are more likely to experience this disorder at a younger age than women.
    • Treatment involves antipsychotics and psychotherapy for 12 months after resolution of symptoms.

    Schizoaffective Disorder

    • This disorder is characterized by the coexistence of psychotic and mood symptoms.
    • Psychotic symptoms are predominant and may persist even after mood symptoms resolve.
    • Treatment involves a combination of antipsychotics and psychotherapy.

    Brief Psychotic Disorder

    • Marked by the sudden onset of psychosis lasting less than a month, with a complete return to premorbid functioning.
    • Treatment involves short-term antipsychotic medication and supervision.

    Delusional Disorder

    • Characterized by the presence of persistent, false beliefs (delusions) with minimal impairment in daily functioning.
    • Typically, only delusions are present, with no hallucinations or disorganized speech.
    • Treatment may involve antipsychotics and psychotherapy, emphasizing the importance of establishing a strong therapeutic relationship.

    Diagnosis and Assessment

    • A comprehensive work-up includes a physical exam, thorough medical and psychiatric history, and laboratory testing.
    • Imaging studies may be considered if there are concerns about underlying medical conditions.
    • For newly diagnosed psychosis in individuals under 50 with no significant history or exam findings, head imaging is not recommended.
    • Diagnosis of schizophrenia requires at least two symptoms present for at least one month, with at least one symptom being delusions, hallucinations, or disorganized speech.

    Antipsychotics

    • First-line treatment for psychotic disorders.
    • First-generation antipsychotics (FGAs) have a higher risk of extrapyramidal side effects, including dystonia, akathisia, parkinsonism, and tardive dyskinesia.
    • Second-generation antipsychotics (SGAs) are more commonly associated with weight gain, dyslipidemia, and increased risk for diabetes.
    • Clozapine is effective in "treatment-resistant" cases but has a delayed therapeutic response (up to 6 months).
    • Long-acting Injectable (LAI) formulations are available for patients who have responded well to oral antipsychotics but are at high risk for relapse due to medication nonadherence.

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