DSM-5 TR Helpful Mnemonics PDF

**DSM-5 TR Helpful Mnemonics** **CHAPTER 5: DEPRESSION:** The specific signs and symptoms of **depression** are captured in the mnemonic **"SIGECAPS"** **S is for Sleep**: Disturbances in sleep are a core symptom of depression and are experienced by more than 90% of people during an episode. Depr...

**DSM-5 TR Helpful Mnemonics** **CHAPTER 5: DEPRESSION:** The specific signs and symptoms of **depression** are captured in the mnemonic **"SIGECAPS"** **S is for Sleep**: Disturbances in sleep are a core symptom of depression and are experienced by more than 90% of people during an episode. Depression causes not only difficulty in falling asleep but also early morning awakenings, disrupting both the **amount** and **quality** of sleep that people are be able to get. People with depression classically complain of severe symptoms of depression in the mornings which partially lift by the afternoon. **I is for Interest or enjoyment:** A hallmark symptom of depression is an inability to feel pleasure known as **anhedonia**. Anhedonia is evidenced by decreased interest in activities that are normally pleasurable such as participating in hobbies or socializing with others. Anhedonia is what makes depression a **non-reactive** state meaning that someone's mood will remain the same no matter what is going on around them. Out of all the symptoms of depression, anhedonia is the **most sensitive marker**, and the absence of anhedonia reliably rules out major depressive disorder. **G is for Guilt or hopelessness:** People in a state of depression often find that their thoughts become narrowed and, after a while, they are only able to focus on negative thoughts. The thought content in depression often revolves around feelings of **guilt** ("I deserve this"), **worthlessness** ("All I am is a burden on people), or **hopelessness** ("There is no way out of this hole I am in"). Thought patterns of depression are often **ruminative** as certain thoughts are "chewed over" repeatedly in the mind **E is for Energy**: Levels of energy and activity are often severely decreased in depression sometimes to the point where even getting out of bed in the morning is a major challenge. The **fatigue** seen in depression exceeds what would be expected just from the sleep disturbances present in this disorder, suggesting that fatigue is a core feature of the disorder rather than merely a side effect of other symptoms **C is for Concentration:** The rumination, poor sleep, and low energy experienced during a depressive episode often makes it difficult to concentrate leading to impairments in work, school, and relationships. In contrast to syndromes like attention deficit hyperactivity disorder where concentration deficits are chronic, in depression the ability to concentrate improves when the mood episode ends. **A is for Appetite:** Most people with depression find that their appetite and food intake are significantly decreased which can result in noticeable weight loss or even malnutrition over time. People in a state of depression often describe food as unappetizing or flavorless ("It\'s like I\'m eating cardboard"). **P is for Psychomotor retardation:** While many features of depression are symptoms that can only be subjectively reported, in some cases, depression involves signs that can be objectively observed by others. Psychomotor retardation refers to a general **slowing of speech and physical movements** which together suggest an inner slowing of cognition as well. It is generally considered to be a sign of severe depression. **S is for Suicidal thoughts:** For people in the depths of depression who are unable to find any pleasure in life and are constantly haunted by feelings of guilt, worthlessness, and hopelessness, suicide can seem like the only way out. Over half of all people who die by suicide were in a depressive episode at the time of their death, making the link between depression and suicide incredibly robust. Additional signs and symptoms that are clinically seen in depression include a slouched posture, monotone speech that lacks prosody, severe anxiety, a high rate of unexplained medical symptoms like headaches and stomach pain, feelings of depersonalization, and derealization and a general lack of motivation. Per the DSM 5, patients must have **5 out of 9** symptoms for a period of **two weeks** or more to qualify for a **major depressive episode**. The time frame for depression is **"2 blue weeks."** Remembering the features of **Atypical Depression**: **"Ate-typical depression":** Mood remains reactive in atypical depression, and many people will experience a lifting of depressive symptoms during happy life events or a worsening of symptoms when things don't go their way. Patient will often also display a long-standing pattern of interpersonal rejection sensitivity. "A depressed person who had mood reactivity and became happy when they ate food would probably start to gain weight causing their limbs to feel heavy and may become sensitive to people rejecting them because of their weight." Atypical depression involves **increased appetite**, **hypersomnia**, **leaden paralysis**, and **interpersonal rejection sensitivity.** Use the mnemonic **"Reactive PLANETS"** to remember the specific high-yield factors that commonly differentiate depression from alternative diagnoses. Use reactive planets to systematically assess mood complaints and try to focus on the patient's pattern of symptoms across the lifespan. **R is for Reactivity:** The presence or absence of mood reactivity is an important diagnostic clue. Non-reactivity suggests a mood disorder such as unipolar or bipolar depression while a reactive mood may suggest atypical depression, borderline personality disorder, or even just plain old normalcy. **P is for Polarity:** A history of both depression and mania is the diagnostic hallmark of bipolar disorder. Make sure to inquire about any history of manic or hypomanic episodes as bipolar depression requires a fundamentally different treatment approach compared to unipolar depression. **L is for Lability:** Mood symptoms can either be stable or labile. Mood symptoms from major depressive disorder or bipolar disorder are often quite stable and endure for weeks, months, or years at a time. In contrast a labile affect (changing within minutes or hours) is often more characteristic of personality disorders or substance use. **A is for Attributability:** In some cases, depression can be attributable to specific causative factors including medical conditions (like hypothyroidism), substances (alcohol), external circumstances (postpartum depression), and timing (seasonal depression or premenstrual dysphoric disorder) among many others. **N is for Normality:** Normalcy should *always* be on the differential. Take some time to consider whether the patient's reported symptoms are within the realm of normal human emotion. **E is for Episodicity:** Depressive symptoms often occur in discrete episodes, which is characteristic of both unipolar major depressive disorder as well as bipolar disorder. Chronic non-episodic depression should raise your suspicion for other diagnoses including, dysthymia and personality disorders. **T is for Treatment responsivity:** How well a person has responded to treatments for depression can offer a helpful clue as well. A history of failing multiple trials of conventional antidepressants should have you searching for alternate explanations including misdiagnoses (bipolar disorder), misdiagnosis (anxiety disorders), or other attributable factors (alcohol induced depression). However, poor treatment response in and of itself is not sufficient to rule out major depressive disorder (they may just have treatment resistant depression). The best way of conceptualizing the effect of treatment response is to think that poor treatment response can *be but is not always* a marker of a misdiagnosis or missed diagnosis. **S is for Severity:** Finally, the severity of depressive symptoms can help to differentiate between "full blown" and subsyndromal symptoms of depression as well as to differentiate between normalcy and pathology. **Dysthymia** is different from major depressive disorder in two crucial ways. First it is **chronic rather than episodic**, with symptoms being present most of the time without a break for at least two years. Second, it is subsyndromal in that the patient does not quite meet full criteria for a major depressive disorder episode but still suffers from depressed mood. Mood symptoms in dysthymia tend to avoid those symptoms of depression that are generally found more often in severe cases of depression (such as psychomotor retardation or thoughts of suicide). You can remember the common symptoms and time course of dysthymia using the mnemonic **"HE'S 2 SAD."** **H is for Hopelessness:** Increased **E is for Energy**: Decreased energy **S is Self-esteem:** Decreased **2 is for all symptoms present for at least 2 years** **S is for Sleep:** Abnormal **A is for Appetite:** Changes in appetite **D is for Decision making:** Impaired **CHAPTER 6: BIPOLAR DISORDER** The Specific Signs and Symptoms of **Mania** can be remembered by the mnemonic **"DIGFAST"** **D is for Distractibility:** People in a state of mania, often describe their thoughts as "racing" and having trouble staying on any one subject. They may have difficulty finishing a conversation, or even a slight sentence, as their attention is quickly pulled in different directions. **I is for Impulsivity:** Impulsivity, indiscretion, and irresponsibility characterized most cases of mania, with people without having fully considered the possible consequences of their actions. Accordingly, people in a state of mania are known to engage in risky behaviors, including drug use, reckless driving, unprotected, sex, and spending thousands of dollars at a time on frivolous or unnecessary purchases. **G is for Grandiosity:** Thought content in mania often involves a degree of grandiosity that can border on the psychotic. People in a manic state can come to believe that they are a special or exalted figure (such as a king, president, prophet, Messiah, leader, or CEO), and make plans accordingly. Often these plans lack a clear connection to reality ("I'm going to save the world by selling micro greens right back to farmers") and aren't very durable, changing drastically from one minute to the next. **F is for Flight of ideas:** While grandiosity describes the thought *content* in mania, flight of ideas describes the thought *process* in mania. Ideas "fly" through the mine so rapidly that it is difficult for anyone to keep track of the conversation ("I have the most beautiful cat in the world, I need to pick up a dozen gallons of orange juice from the store. What is congress thinking? is this microphone even on?"). Difficulty keeping up with a patient that you are interviewing is highly suggestive of a manic episode. **A is for Activity:** More than any other sign or symptom, an increase in energy and activity, (sometimes referred to as **psychomotor agitation**) is a key hallmark of mania. Specifically, the activity in mania is **goal directed** and involves working towards some kind of reward or outcome. The increased "busyness" of people in a manic state has been noted since the early days of psychiatric diagnosis, and it appears to be a **highly sensitive marker** of mania (analogous to anhedonia and depression). In fact, the DSM five changed its diagnostic criteria so that the absence of increase goal directed activity rules out a diagnosis of mania. When this activity is blocked (such as by a well-meaning, spouse or friend, who is concerned about how erratically they are behaving), someone in a manic state is liable to become quite **irritable**, yelling, or lashing out at the person who is getting in the way of their world changing aspirations. **S is for Sleep:** Decreased sleep is another key symptom of mania. In contrast to depression, which is most often characterized by perceived *inability* to sleep, sleep disturbance in mania is experienced as a *decreased need* for sleep (generally due to the increase in goal directed activity). It's not uncommon for people in a manic state to keep going for days or even weeks and only a few hours of sleep per night. **T is for Talkativeness:** Finally, people in a manic state are often hypersocial and exceptionally talkative, which is described on mental status exams as *pressured speech*. They walk around the room, repeatedly shaking the hand of every single person present. Some studies have even found that specific aspects of speech such as fluctuating pitch, and high rate of speech, are highly sensitive markers of mania. A **manic episode** involves an **increase in psychomotor energy** **and activity**, accompanied by other signs and symptoms. Remember **elevated** or **irritable** mood + **DIG FAST.** Per the DSM-5, patients must have **three out of seven** symptoms for a period of **one week** or more to qualify for an **acute manic episode**. The timeframe for mania is "**one fun week**." Reward hypersensitivity is correlated with over activation of neural circuits in the **left lateral orbitofrontal cortex**, a region of the brain that governs the relationship between emotions and decisions. Interestingly, bipolar, depression, and unipolar depression are both associated with decreased reward sensitivity in the left lateral orbitofrontal cortex, which in turn, reduces motivation, and the ability to gain pleasure from normally enjoyable activities. It explains both the increased goal-directed activity seen in mania, as well as the anhedonia that is the most sensitive marker of depression. You can remember the association of the **l**eft **l**ateral **o**rbito**f**rontal **c**ortex by thinking of it as the part of the brain that says "**L**et's **L**ive **O**utrageously! **F**orget **C**onsequences." Asking about goal directed activity rather than a period of "feeling happier than normal" can improve your diagnostic process and help you more accurately identify when mania is, and is not, part of the clinical picture. You can remember this by thinking that **MANIA** involves **M**ore (goal-directed) **A**ctivity and is **N**ot **I**nherently **A**ffective in nature. Mania involves **increased goal-directed** **activity** more often than elevated mood. **Bipolar one disorder** is characterized by episodes of **mania**, alternating with episodes of **depression**. The presence of even a single manic episode qualifies the patient for a diagnosis of bipolar one disorder regardless of how many depressive episodes they have had. You can use the mnemonic **DIG FAST** to remember the symptoms of mania. Depressive episodes in bipolar depression are often indistinguishable from unipolar depression so the **SIGECAPS** mnemonic applies here as well. **Bipolar two disorder** is characterized by both **hypomanic and depressive episodes**, the latter of which are more frequent and severe compared to bipolar one. Think of bipolar two with "two lowercase L's" to remember **l**ower **l**ows (and lower highs as well). Compared to mania, the timeframe for diagnosing an episode of hypomania is shorter, requiring only **four days** of staying hypomanic symptoms to be present. **Cyclothymia** is bipolar disorder's version of dysthymia, as it is a more persistent, but less severe version of the prototypical disorder. The patient has both **hypomanic** episodes (that do not meet criteria for a manic episode), and periods of **dysthymia** (that do not meet criteria for a major depressive episodes). As with dysthymia, a patient must have the characteristic pattern of this disorder **for two years** prior to receiving the diagnosis. However, a diagnosis of cyclothymia is **incredibly rare.** **CHAPTER 7: SCHIZOPHRENIA** The phenomenology of **schizophrenia** includes **hallucinations**, **delusions**, **disorganized behavior**, **disorganized speech**, and **negative symptoms**. You can remember this using the mnemonic **"HD BS Network"** **H** is for Hallucinations **D** is for Delusions **B** is for Behavior: Disorganized **S** is for Speech: Disorganized **Network** is for Negative Symptoms **"2-4-6-ophrenia":** You need **2** symptoms **FOR** at least **6** months. In contrast to the **vis**ual hallucinations found in delirium (which are typically **vis**ceral in origin), the hallucinations associated with schizophrenia are primarily **auditory** or (**odd**-itory) in nature, reflecting the **odd**-ness of psychosis. **Hallucinations** related to **schizophrenia** are generally **auditory**, not visual. **Odd**-itory hallucinations are linked to **odd** behavior, speech and thoughts. In contrast to **P**ositive symptoms, (things that are **P**resent, but shouldn't be), **N**egative symptoms are things that *should* be present, but are **N**ot, including deficits in the emotional, social, and cognitive skills that most people have. You can remember the main negative symptoms of schizophrenia by thinking of them as "The **5 A's".** **A is for Affect:** People in a state of primary psychosis often have a **blunted affect** as if facial expressions are being constrained by an unseen force. Because of this, their affect is often completely incongruent to what they say they are saying. For example, you might think that someone who believed that their every thought has been transmitted to a secret society intent on destroying the world would appear quite distraught when talking about this. However, due to the blunting of affect seen in schizophrenia, they may instead talk about it passively without any change in their facial expressions. Affective deficits often begin prior to the onset of any positive symptoms of psychosis, and family members will often describe that a person looks "off" even months before an official diagnosis. Affective deficits also tend to be progressive, and older people with long-standing psychotic conditions may develop a completely flat affect with zero trace of emotional expression. **A is for Ambivalence:** Another negative symptom of schizophrenia is **ambivalence** or extreme difficulty in making decisions. A certain amount of uncertainty in decision making is completely normal. However, in schizophrenia this ambivalence is severe and extends into many areas of life, preventing most meaningful or goal directed behavior. Even when asked about things that should be relatively uncontroversial ("it's particularly cold tonight. Do you want a blanket?"), someone with schizophrenia related ambivalence may still have trouble deciding ("Hmm...I'm not sure."). **A is for Alogia:** While speech in schizophrenia can often be disorganized (which is a positive symptom), in many cases, speech can be impaired, reduced, or even entirely absent as well, which is known as **alogia**. Alogia can range from small reductions in the amount of speech to being completely mute for months or years on end. **A is for Anhedonia:** People with schizophrenia often experience **anhedonia**, which is the inability to feel pleasure or engage in activities that they previously found enjoyable. Anhedonia can lead to a state of **amotivation**, where people stop trying to pursue any form of goal directed behavior, and instead simply sit, stare or lie down for hours on end. Despite sharing their name, anhedonia in schizophrenia likely differs from anhedonia on a mechanistic level. (Recall that while anhedonia is quite *sensitive* for depression, it is not necessarily *specific*, and can be seen in other disorders as well.). **A is for Asociality:** People with schizophrenia often develop severe difficulties relating to other people, and instead are preoccupied with their own internal experiences, resulting in **asociality.** People with schizophrenia often appear completely disinterested about what is going on around them even during major life events that would normally provoke strong emotions, such as death, birth, and marriage. Many end up withdrawing socially, and "live in their own world", leading to isolation and loneliness. The social difficulties may be due, at least in part, to the presence of positive symptoms which can be disturbing or off-putting to others. However, the social deficits in schizophrenia often extend far beyond what would be expected from the effects of positive symptoms alone. **Negative symptoms** of schizophrenia include **deficits** in emotional range, decision making ability, speech, pleasure, and socialization. "The **5 A's":** **A**ffect **A**mbivalence **A**logia **A**nhedonia **A**sociality Research has shown that the **P**ositive symptoms of psychosis are highly s**P**ecific for schizophrenia. These **first-rank symptoms** include auditory hallucinations in the characteristic "critical running commentary", delusions of thought manipulation, (including thought withdrawal, insertion, interruption, and broadcasting) and delusions of control, (including a sense that one's actions are being manipulated by outside force). While the first rank symptoms are **highly specific** for schizophrenia, they are not particularly sensitive. In contrast, the **N**egative symptoms of schizophrenia are quite se**N**sitive, and a lack of negative symptoms can help to rule out the diagnosis (particularly for someone who has had the diagnosis for several years as the ratio of negative symptoms to positive symptoms tends to increase over time). However, negative symptoms are not very specific as anhedonia, ambivalence, and lack of motivation can be found in non-psychotic illnesses, like severe depression as well. **Positive symptoms** are those that are **present in schizophrenia**, while **negative symptoms** are functions that are **absent in schizophrenia.** **P**ositive symptoms = Things that are **P**resent but shouldn't be = S**p**ecific! **N**egative symptoms = Things that are **N**ot present but should be = Se**n**sitive! The diagnosis of schizoaffective disorder was created to describe people who, by all appearances, genuinely experience both psychotic and affective symptoms. The key with schizoaffective disorder is that **both processes need to have been present in the absence of the other** for at least some period of time. Someone who has only ever had psychotic symptoms *during* a mood episode, would be diagnosed with a mood disorder with psychotic features. Only when there is a clear history of psychosis *in the absence* of a normal mood state and an *additional* history of mood episodes should the diagnosis of schizoaffective disorder be applied. Mood symptoms must be in excess of what would be expected from the psychotic disorder alone (such as the anhedonia, or amotivation seen in schizophrenia.) Incorrect diagnoses often stem from **improper history taking** and knee-jerk tendencies to assume that any patient with both psychotic and mood symptoms has schizoaffective disorder (rather than more common disorders like a mood disorder with psychotic features). This is important enough that it bears repeating: **MOOD + PSYCHOSIS DOES NOT ALWAYS = SCHIZOAFFECTIVE DISORDER** Having a structured method of assessing auditory hallucinations can help to distinguish between genuine and feigned symptoms. Use the mnemonic **"Vague AWD (odd) LIARS"** when asking patients about their auditory hallucinations to get a better sense of their likely origin (this will also help you to review what we learned earlier about the phenomenology of schizophrenia!) **Vague is for Vague:** Patients who are feigning auditory hallucinations will often say that the voices are vague or fuzzy, in contrast to schizophrenia where content of the voices are quite clear. **AWD is for Associated With Delusions:** Hallucinations in schizophrenia are almost always associated with delusions. In contrast, people who are feigning psychosis will tend to report auditory hallucinations as their sole symptom. **L is for Laterality:** Voices in schizophrenia sound like they are coming from all around, whereas people feigning psychosis may say the voices are coming from one side of their head or the other. **I is for Inside:** Patients with schizophrenia genuinely perceive their voices as coming from the outside world. In contrast, people who are feigning psychosis are more likely to talk about "voices inside my head." **A is for Able to resist:** Command auditory hallucinations can occur in schizophrenia. However, the patient is generally able to resist what they tell them to do, especially if doing so would be dangerous. In contrast, people who are feigning psychosis are more likely to say that they are forced to do what the voices tell them to do. **R is for Reducing strategies:** Most patients with schizophrenia find their voices to be distressing, and will have found specific strategies to help reduce the intensity of the voices. In contrast, people who are feigning psychosis will often not be able to describe any strategies to reduce hallucinations. **S is for Secondary gain:** Finally, feigned psychosis should be high on your differential when there is a clear reward to be gained by reporting auditory hallucinations. **CHAPTER 8: ADDICTION** **Delirium tremens**, or DT's, is a *potentially deadly* state associated with severe vital signs, instability, confusion, and both visual and auditory hallucinations (the classic "seeing pink elephants") that occurs around 24 to 72 hours after the last drink. In severe cases, seizures or death can occur. There are often objective signs of stress and organ damage as well, including markers of inflammation, (such as elevated ESR, elevated white blood cell count, and liver damage.). You can remember the syndrome using the mnemonic **"DTS are HELL"** which stands for **D**elirium, **T**remor, **S**eizures, **H**allucinations, **E**SR, leukocytosis, and **L**iver function test. **Delirium tremens** is a **potentially fatal** outcome of **alcohol withdrawal** that must be differentiated from **alcoholic hallucinosis**, which is more benign: **"DTS are HELL"** **D** stands for Delerium **T** stands for Tremors **S** stands for Seizures are **H** stands for Hallucinations **E** stands for elevated ESR **L** stands for Leukocytosis **L** stands for elevated Liver markers To remember the functions of opioids, think of the 19^th^ century disputes over British trade in China known as the opium wars. This will help you connect opioids to the mental image of an **"ARMED Colonist"** which stands for **A**nalgesia, **R**espiratory depression, **M**iosis, **E**uphoria, **D**rowsiness, and **C**onstipation. Drugs that bind to **opioid receptors** are clinically useful as painkillers, but can also cause **respiratory depression**, **miosis**, **euphoria**, **drowsiness** and **constipation** as well. Remember the mnemonic: **"ARMED Colonist"** **A stands for** Analgesia **R stands for** Respiratory depression **M stands** for Miosis **E stands for** Euphoria **D stands for** Drowsiness **Colonist stands for** Constipation The particular balance between THC and CBD accounts for the different effects found in various strains of cannabis. Strains that have more THC tend to produce a greater "high" while those with more CBD tend to have a greater analgesic, anti-inflammatory and anti-anxiety effects. Because it opposes many of the effects that cannabis is known for, you can think of **CBD** as a "**C**annabis **B**ringer **D**owner." **Tetrahydrocannabinols** is the active ingredient in **cannabis** while **cannabidiol** acts as a cannabinoid receptor **antagonist**. Remember: **"THC** is **T**he **H**igh **C**hemical, **CBD** is the **C**annabis **B**ringer **D**owner." The DSM five lists 11 distinct criteria for substance use disorders and other forms of addiction, which you can remember using the phrase **"TIME 2 CUT DOWN PAL."** The 2 will remind you that **2 or more** of these criteria are required for diagnosis. The rest of the phrase will remind you that patients spend a lot of **Time** using or obtaining the substance, experience **C**ravings or urges to continue using, are **U**nable to cut down on using the substance even after repeated attempts, experience **T**olerance to the effects of the substance so they need more and more to get the same affect, can have **D**angerous results of use, affect **O**ther people through their use resulting in interpersonal or social problems, experience **W**ithdrawal when they stop using the substance, end up **N**eglecting major roles and responsibilities such as work or family, have physical or psychological **P**roblems that have been created and/or made worse by substance use, have given up **A**ctivities, like socializing or hobbies due to excessive use, and finally have used **L**arger amounts of the substance or for longer than wanted. **Addiction** presents with variety of signs and symptoms resulting in **distress** and **functional impairment.** Remember the mnemonic: **"TIME 2 CUT DOWN PAL"** **T stands for** Time spent **2 or more** of these symptoms **C stands for** Cravings **U stands for** Unable to cut down **T stands for** Tolerance **D stands for** Dangerous use **O stands for** Others affected **W stands for** Withdrawal **N stands for** Neglect of roles/responsibilities **P stands for** Problems created or made worse **A stands for** Activities given up **L stands for** Larger amounts or for longer You can recognize the overall pattern of addiction using just 3 things which we will refer to as the **"3 Reapers**: **rep**eated use of **re**inforcers (**p**ositive) despite negative **rep**ercussions. If those eight words describe the pattern of someone's behavior, then in most cases you can diagnosis addiction. **Repeated Use:** Addiction involves doing something repeatedly. This can involve use of substances, such as alcohol, or specific items or behaviors, such as gambling at slot machines. **Reinforcers (Positive):** The specific substances and behaviors in addiction must be positively reinforcing. To understand what is meant by this, we will need to discuss the concept of **operant conditioning**. Operant conditioning describes how a behavior can be modified by the response it gets. Reinforcement is any response that *increases* the frequency of the behavior while **punishment** is any response that *decreases* its frequency. As an example, picture a boy trying to sneak a cookie from the cookie jar before dinner time. If he is caught, he will get a swat on the hand (a punishment meant to decrease that particular behavior). On the other hand, if he gets away with it, the deliciousness of the cookie may act as a reinforcer of that behavior, and he is likely to try and sneak more cookies in the future. Reinforcement and punishment can be described as either **positive** or **negative**. Positive and negative refer to whether something is *introduced* or *taken away*. In the cookie example, both the reinforcer (the cookie) and the punishment (a slap on the hand), would be considered *positive*, because they both introduced something into the situation. However, if the mother had taken away something that the boy desired (such as access to the TV), this would be considered a *negative* punishment as the behavior was made less frequent by taking something away. In contrast, if the boy was incredibly hungry, and the cookies primary effect was to remove hunger, this would also be a *negative* reinforcement. A negative reinforcer can also act by *preventing* an aversive experience. For example, someone who studies hard for a test may be negatively reinforced by avoiding the upsetting experience of getting a bad grade, and will likely continue to study hard in the future. **Repercussions (Negative):** Finally negative repercussions of use such as losing a job, alienating family and friends, getting into legal trouble, or jeopardizing one's health are a key part of the equation for addiction, and addiction cannot be diagnosed in their absence. **Addiction** involves **repeated use** of **positive reinforcers** despite **negative repercussions.** Remember **"The 3 Reapers":** **Rep**eated use of **Re**inforcer (**p**ositive) despite negative **Rep**ercussions None of these components on their own or sufficient to diagnose addiction. Even *any two* of them combined is not enough. It is only one all three components combine that the specific state of addiction emerges. The precise reasons why some people are more prone to addiction than others are unclear. Some evidence has suggested that people who are prone to addiction are more likely to experience **negative emotions at baseline.** This makes use of substances both *positively and negatively reinforcing* from the very first use by not only inducing a pleasurable feeling, but also leaving the state of chronic dysphoria in which the person lives. However, some additional factors have also been found to stratify the risk of developing an addiction. In particular, **impulsivity** also appears to be a significant risk factor for addictive disorders. In a classic experiment, children were given access to a sweet treat (a marshmallow) and told that they could either eat it immediately or wait 15 minutes to be given a second marshmallow. Children who were able to delay gratification for longer (an indicator of low impulsivity) were found to have lower rates of addiction as adults, suggesting that impulse control and the ability to delay gratification are protective against developing addictive disorders. In contrast, the children who ate the marshmallow right away were noted to be at a much higher risk of addiction later in life, suggesting that their inability to refrain from activities which provided **im**mediate **pos**itive reinforcement, is related to problems with impulse control, which you can remember as **"impos** control" to connect the two concepts. **Addiction** often involves **poor impulse control** or a tendency to seek **immediate positive reinforcers** without consideration of consequences. **"Impos** control" problems are related to **im**mediate **pos**itive reinforcement (even if there are long-term negative consequences later). The combination of a tendency towards negative emotions (which makes use of drugs both positively *and* negatively reinforcing from the get-go) along with a greater focus on immediate rewards over long-term gains, appears to predispose certain individuals over others to developing addictive behaviors. Once exposure to these reinforcers has occurred, however, a different set of processes involving the protein **Delta FosB** take over. Delta FosB appears to play a critical role in all forms of addiction by acting as a **"molecular switch"** that is turned on following exposure to a reinforcer. Interestingly, Delta FosB appears to be involved in all addictions regardless of the specific reinforcers involved, including drugs like heroin and cocaine, or behaviors like gambling and shopping. You can remember the association of Delta FosB with addiction by thinking of a delta triangle with the **"3 Reapers"** in each corner. Addiction is not hard to diagnose. As long as all **"3 Reapers"** are there (**rep**eated use, **p**ositive **re**inforcers, and negative **rep**ercussions), you can diagnose addiction. You can systematically gather a complete substance history using the mnemonic **"TRAPPED"** which stands for **T**reatment history, **R**oute of administration, **A**mount used, **P**attern of use, **P**rior abstinence, **E**ffects of use (both positive and negative), and **D**uration of use. **Complete substance history** should systematically evaluate the **pattern of the patient's substance use** and the **attempt at sobriety**, if any: **"TRAPPED"** **T stands for** Treatment history **R stands for** Route of administration **A stands for** Amount used **P stands for** Pattern of us **P stands for** Prior abstinence **E stands for** Effects of use **D stands for** Duration of use. A specialized screening tool has been developed to help identify patients with an active alcohol use disorder. Anyone who answers "yes" to 2 or more of the following **CAGE** questions has a high likelihood of having an alcohol use disorder: "Have you ever felt you ought to **C**ut down on your drinking?" "Have people **A**nnoyed you by criticizing your drinking?" "Have you ever felt **G**uilty about your drinking?" and "Have you ever had an **E**ye-opener (a drink first thing in the morning)?" Screen for **alcohol use disorder** using the four **CAGE questions**: CAGE ("yes" to 2 or more is a positive screen) **C stands for** Cut down **A stands for** Annoyed **G stands for** Guilty **E stands for** Eye-opener While there are increases in both AST and ALT, a greater increase in AST compared to ALT (known as the **AST/ALT ratio**) is characteristic of chronic alcohol abuse. You can remember the greater increase in **AST** by thinking that "getting w**AST**ed raises your **AST.**" A **high AST-to-ALT** ratio is characteristic of **alcohol use disorder**: (Getting w**AST**ed raises your AST) Another liver enzyme known as gamma-glutamyl transferase (GGT) is a highly sensitive marker of chronic alcohol use. Combined with a high AST/ALT ratio it is highly suggestive of excessive alcohol intake. You can remember the association of **GGT** with alcohol by thinking that it is elevated in people who are "**G**onna **G**et **T**rashed." Elevated **gamma, glutamyl transferase** is a sensitive index of **alcohol use disorder**: ("**G**onna **G**et **T**rashed and raise my **GGT**!") Gambling is particularly addictive because it operates on a **variable reinforcement schedule**. To better understand what is meant by the term, compare a slot machine to a vending machine. A vending machine acts in the same way every time: if you put in one dollar, you will get a can of soda. Therefore, you go to a vending machine when you want a drink, but not at any other time. In contrast, a slot machine is inherently *unpredictable*: If you put in one dollar, you don't know if you will get, zero dollars, one dollar or 100 dollars back. Variable reinforcement schedules seem to intrinsically be much more addictive than predictable reinforcement schedules and make the rewards seem much more enticing and valuable. This unpredictability is incredibly **salient** to our brains and motivates us to act, and for this reason variable reinforcement schedules are often highly addictive. **Variable reinforcement schedules** can lead to **behavioral addictions**: ("**Veri-able** reinforcement schedules are **very able** to addict people!). Having a framework for the various types of addictions can be helpful when taking a complete substance history. Remember the mnemonic **"CAN HIS DOG Behave?"** **"CAN HIS DOG Behave"** **C stands for** Cannabis **A stands for** Alcohol **N stands for** Nicotine **H stands for** Hallucinogens **I stands for** Inhalants **S stands for** Stimulants **D stands for** Depressants **O stands for** Opioids **G stands for** Gambling **B stands** for Behavioral **CHAPTER 9: ANXIETY** **Acute anxiety** presents with both physiological signs, including a racing heartbeat, shortness of breath, tingling sensations and nausea, as well as psychological symptoms, including racing thoughts, fear of dying and feelings of impending doom. The complete list of core signs and symptoms for acute anxiety are encompassed in the mnemonic **"STUDENTS, Fear C's"** which stands for **S**weating, **T**rembling, **U**nsteadiness or dizziness, **D**isassociation, **E**levated heart rate, **N**ausea, **T**ingling, **S**hortness of breath, **Fear** of dying, losing control or going crazy, **C**hest pain, **C**hills, and **C**hoking sensation. **Acute anxiety** manifests in both **physical signs** and **physiologic symptoms** including vital signs, changes, feelings of fear and racing thoughts remember the mnemonic **"STUDENTS Fear C's"** **S stands for** Sweating **T stands for** Trembling **U stands for** Unsteadiness **D stands for** Dissociation **E stands for** Elevated heart rate **N stands for** Nausea **T stands for** Tingling **S stands for** Shortness of breath **Fear stands** for Fear of dying, losing control, or going crazy **C stands for** Chest pain, Chills, and Chocking sensations In contrast, the core signs and symptoms of **chronic anxiety** are less immediate, but are still highly distressing. You can remember these using the mnemonic **"MISERA**-ble", which stands for **M**uscle tension, **I**rritability, difficulty with **S**leep, low **E**nergy, **R**estlessness, and poor **A**ttention. Other psychological symptoms, including ruminating thoughts, and somatic complaints are very common as well. Indeed, depression and chronic anxiety appear to share many mechanistic features, which likely accounts for the similar symptoms, overlap in treatments, and links to adverse childhood events that are shared between the two disorders. **Chronic anxiety** is associated with both **physical** and **physiologic** symptoms, including muscle tension, restlessness, and irritability. You can remember chronic anxiety using the mnemonic **"MISERA**-ble": **M stands for** Muscle tension **I stands for** Irritability **S stands for** Sleep (decreased) **E stands for** Energy (Decreased) **R stands for** Restlessness **A stands for** Attention (decreased) **Anxiety** and **fear** are both part of our body's **stress response**, or physical and mental changes that occur when encountering a challenge in our environment. However, in anxiety, the focus is a perceived *future* threat, whereas in fear the focus is on a *current* threat. For example, a deer who is suddenly attacked by a cougar jumping at them from behind the bushes, will enter a state of *fear*, whereas the deer who walks around worrying about a cougar jumping out at any time is experiencing *anxiety*. While both are uncomfortable, fear and anxiety can each serve a purpose by motivating the organism to behave in an adaptive way, (such as encouraging the deer to run away from the cougar, or avoid places where cougars are most likely to be found). **Fear** is related to **current threats**, while **anxiety** focuses on **future threats**: "**Fear** is about what's **here**, while anxiety is about the future While activation of the sympathetic nervous system explains the signs and symptoms of anxiety in the *acute* sense, it has little to account for chronic anxiety lasting months or years. For this, we need to turn to the slower acting **hypothalamic-pituitary-adrenal axis**, (or HPA-axis). Activation of the HPA-axis induces long-term changes in physiology, cognition, and behavior via the release of the hormone **cortisol**. Cortisol has many functions including reducing inflammation, breaking down connective tissues, regulating blood pressure, and alternating the metabolism of carbohydrates, proteins, and fat. Chronic activation of the HPA axis has been linked to the specific signs and symptoms captured in the "**MISERA-ble"** mnemonic, as well as an increased risk of depression, which involves over activation of the HPA-axis as well. The **sympathetic nervous system** is involved in **acute fear and anxiety**, while the **hypothalamic-pituitary-adrenal axis** is activated in **chronic anxiety**: "The SN**S** is activated by both types of **S**tress, while the HP**A** is activated only by **A**nxiety. The **alarm-beliefs-coping** **(ABC) model** of anxiety disorders provides a helpful framework for understanding the specific symptoms and behaviors seen in each individual type of anxiety disorder. In this model, the starting point for any and all anxiety disorders is in an internal **alarm** signal. Something (either in the environment or internal sensation) is telling us that there is cause for concern. Regardless of the specific stimulus that triggers it, the alarm signal instantly activates the sympathetic nervous system leading to the immediate symptoms of anxiety. Psychologically, thoughts tend to become more focused on interpreting the alarm signal and developing a set of specific explanatory **beliefs** about the alarm. These beliefs form the basis upon which we consciously act in a response to the alarm signal. This experience then forms the basis of our **coping** strategies including taking steps to either avoid this situation in the future or plan for what we should do if we ever find ourselves in a similar situation again. viewed from this perspective, all anxiety disorders are characterized by a **defective alarm signal** including "false alarms" that go off for unknown reasons and overactive alarms that won\'t turn off. Exposure to adverse events during childhood including abuse, neglect, parental death, or a caregiver with a severe mental illness, appears to induce long lasting changes during the development of the HPA axis leading to the hypersensitivity seen in anxiety disorder. **Anxiety disorders** involve a consistent pattern of a defective **alarm signal** followed by **explanatory beliefs** and compensatory **coping strategies**: "**Anxiety** is as easy as **ABC**: **A**larm-**B**eliefs-**C**oping" In the DSM, you need both the anxious thought patterns and the specific symptoms to diagnose generalized anxiety disorder. You can remember the diagnostic criteria for this disorder using the mnemonic **"EGADS! I\'m MISERA-ble!** The first part will remind you that the disorder involves **E**xcessive and **G**eneralized **A**nxiety that is chronic occurring on most **D**ays for at least **S**ix months. The second part will remind you that the DSM requires **3 or more symptoms** from the "**MISERA**-ble" mnemonic to be present. **Generalized anxiety disorder** is diagnosed when someone has **anxiety** **about most things** as well as specific **symptoms of chronic anxiety: "EGADS" I'm MISERA-ble"** **E stands for** Excessive **G stands for** Generalized **A stands for** Anxiety **D stands for** occurring on most Days **S stands for** at least Six months Plus **3 or more** of the **MISERA**-ble symptoms Following the ABC model of anxiety disorders, panic disorder is akin to an **overactive alarm system that goes off randomly** leading to a state of perpetual anxiety about when the alarm will ring next. While these beliefs and coping strategies are in many ways a logical response to the experience of having panic attacks, the constant anxiety and avoiding of going to specific places (including work, school, or even the grocery store) can become incredibly impairing and directly impact one\'s ability to lead a normal life. You can remember the overall pattern of panic disorder by thinking of the word **"SURPrise":** **S**udden **U**nexpected **R**ecurrent **P**anic attacks that give **rise** to excessive and dysfunctional anxiety even between attacks. Just having panic attacks is not enough for the diagnosis, you need both the **SURP** and the **rise**. **Panic disorder** is when **sudden unexpected recurrent panic attacks** give rise to long lasting **negative consequences**: "**SURPrise!** **S**udden **U**nexpected **R**ecurrent **P**anic attacks that give **rise** to anxiety. To systematically evaluate any patients presenting with anxiety, use the mnemonic **"ONSTAGE"** to remind yourself to check whether their symptoms stem from **O**CD (or related disorders), are consistent with **N**ormalcy, are related to **S**omatization, can be ascribed to **T**rauma, are **A**ttributable to some external factor (such as a medical problem, substance use, or life events), are **G**eneralized (versus specific to certain situations or stimuli like in specific phobia and social anxiety disorder), or are **E**pisodic (as in panic attacks). Disorders that are commonly present with **anxiety as the chief complaint** include **obsessive compulsive, traumatic**, and **somatoform** disorders: **"ONSTAGE"** **O stands for** OCD **N stands for** Normalcy **S stands for** Somatization **T stands for** Trauma **A stands for** Attributable **G stands for** Generalized **E stands for** Episodic You can remember some of the most common medical diseases that frequently present as anxiety using the mnemonic "**Ph**ysical **Di**seases **T**hat **H**ave **C**ommonly **A**ppeared **A**nxious" which stands for **Ph**eochromocytoma, **Di**abetes mellitus (typically during hyper or hypoglycemic episodes), **T**emporal lobe epilepsy, **H**yperthyroidism, **C**arcinoid, **A**lcohol withdrawal, and **A**rrhythmias. Clues that someone may be suffering from a medically induced anxiety disorder include an atypical onset of symptoms (such as someone in their late 60s who never had problems with anxiety until months ago), the presence of objective physical findings, or vital sign abnormalities, or an episodic (rather than chronic) pattern of anxiety symptoms. Severe **medical conditions** can produce symptoms resembling **anxiety disorders**: "**Ph**ysical **Di**seases **T**hat **H**ave **C**ommonly **A**ppeared **A**nxious" **Ph stands for** Pheochromocytoma **Di stands for** Diabetes mellitus **T stands for** Temporal lobe epilepsy **H stands for** Hyperthyroidism **C stands for** Carcinoid **A stands for** Alcohol withdrawal **A stands for** Arrythmias **CHAPTER 10: OCD** Specifically, obsessive thoughts are **intrusive, mind based, unwanted, resistant, distressing, ego dystonic**, and **recurrent.** Handily, these attributes form the mnemonic **"I MURDER?"** **I stands for Intrusive:** obsessive thoughts are experienced as intrusive meaning that they enter the mind suddenly and without warning. **M stands for Mind-based:** People with obsessional thoughts recognize that they originate from their own mind. This sets them apart from the auditory hallucinations found in schizophrenia which are experienced as originating outside of one\'s head and are genuinely believed to be an accurate perception of the real world. **U stands for Unwanted:** Obsessions are unwanted and people who have these thoughts often try to ignore them or put them out of their mind. Paradoxically, any attempts to suppress obsessive thoughts often seem to make them even *stronger,* and in severe cases no amount of self-reassurance can make a dent in how frequent or intrusive the obsessions are. **R stands for Resistant:** Obsessive thoughts are remarkably resistant to efforts to ignore or suppress them. If the thought of killing your baby could be resisted easily through self-reassurance, then it would likely be regarded as an unpleasant but ultimately meaningless occurrence (a bit of "flotsam" in the stream of consciousness). However, with obsessions these thoughts aren\'t defeated so easily. **D stands for Distressing:** Obsessional thoughts are upsetting and cause distress to the person experiencing them. While most people have intrusive thoughts from time to time, it is the thoughts that are most distressing\--those that are felt to be highly **inappropriate, disgusting, or immoral**\--that are most likely to develop into obsessions (no one comes into the clinic complaining of intrusive thoughts about cute kittens). This explains why obsessional thoughts so often fit the worries and anxieties of the person who develops them, with someone growing up in a clean household being more likely to develop obsessions about orderliness, and someone from a religious home being more likely to develop obsessions about blasphemous thoughts. **E stands for Ego-dystonic:** Someone having obsessional thoughts is generally able to recognize that, despite being based in their own mind, the intrusive thoughts are not reflective of their true desires. In this example, the mother is able to say very clearly that she has no desire to act upon these thoughts and that she finds them incredibly disturbing (That\'s not the kind of person I am!") The word **ego dystonic** is used to describe these thoughts as they are discordant with someone's self concept (or their "ego" in psychiatric jargon). **R stands for Recurrent:** It is the recurrent nature of obsessive thoughts that truly defines them as a disorder. After all, even the most disturbing thoughts will be quickly forgotten unless they begin to happen repeatedly. The frequent recurrence of obsessive thoughts directly sets the stage for someone to seek out specific things they can do to help fight these thoughts when they recur, creating a fertile ground for the development of compulsions. Because obsessions tend to provoke feelings of intense anxiety or distress, people with obsessions will try to find any thoughts or actions that they can do to relieve this distress. These **neutralizing behaviors** are known as **compulsions** (although you can think of them as "**calm**-pulsions" to help you remember that their intended purpose is to **calm** distress related to obsessions!). **Compulsions** are **neutralizing behaviors** that help to **reduce stress** related to obsessions: "**Calm**-pulsions help to **calm** obsessive thoughts." Unlike the pleasurable activities that form the targets for addiction, compulsive behaviors are not inherently enjoyable (there is no "thrill" or "rush" to be found in checking a lock repeatedly). Instead, it is a compulsion's ability to *take away* distress (at least temporarily) that makes it so difficult to resist. It is the calming function that makes compulsions so difficult to resist. To remember this distinction remember, that "**calm**-pulsions" work to **calm** an internal sense of anxiety. In contrast, "**impos**'es" provide **im**mediate **pos**itive reinforcement when they are indulged. **Impulses** and **compulsions** both involve an **inability to inhibit an action** but differ in whether the behaviors are **positively reinforcing** or **negatively reinforcing**: "**Impos**'es provide **im**mediate **pos**itive reinforcement when they are indulged." The first component (the inner sense of imperfection) is related to dysfunctional **error signals** that generate a distinct sense that *something is wrong.* **Error signals** in response to situations are processed in a part of the brain known as the **anterior cingulate cortex** (ACC). The discrepancy between two situations that we know *should not go together* (such as "eating" and "toilet paper") makes the anterior cingulate cortex launch into action creating a feeling of disgust and distress. This pattern is core to the idea of **obsessions**, with the sensitivity of the anterior cingulate cortex being linked to how likely someone is to recognize error signals. You can remember the function of the **A**nterior **C**ingulate **C**ortex by thinking that it\'s the part of the brain that yells, "**ACC**! that\'s so wrong!" The distress we feel when our anterior cingulate cortex has recognized an error isn\'t there to just make us feel bad. Instead, its function is to put us into a state of **motivational arousal** that prompts us to act and fix the error. However, there is a spectrum of sensitivity to error signaling that appears which may or may not put people at a higher or lower risk for obsessive compulsive disorders. In some cases, the **sensitivity to error signaling** is so strong that people perceive errors even where none exist. The **anterior cingulate cortex** is involved in **error recognition** and is believed to be **hyperactive and obsessive-compulsive disorder**: "The **A**nterior **C**ingulate **C**ortex makes you think, **ACC**! That's so wrong!" You can remember the overall pattern of body dysmorphic disorder using the phrase **"Fix ME DOC!"** which should be easily linked to the concept of body dysmorphic disorder. This will help you to remember the **Fix**ation on a perceived flaw, the pattern of seeking **M**edical care, the **E**go-syntonic thought pattern, the **D**isabling nature of the disorder, the similarities to **O**bsessive thought patterns found in OCD, and finally the **C**ompulsive grooming and checking behaviors that result. **Body dysmorphic disorder** is an **obsessive-compulsive spectrum disorder** invovolving a **perceived flaw in physical appearance: "Fix ME DOC!"** **FIX stands for** FIXation on perceived flaw **M stands for** Medical care-seeking **E stands for** Ego-syntonic **D stands for** Disabling **O stands for** Obsessive thoughts **C stands for** Compulsive behaviors. Hypochondriasis (called "illness anxiety disorder" in the DSM-5) involves an **obsessional preoccupation that one has a medical illness**. While everyone has physical symptoms at various points throughout the day (including random pains, aches, upset stomach, blurry vision, and ringing in the ears), people with hypochondriasis are likely to interpret these sensations as error signals of the most serious kind (I've had this headache for a few hours now. This must mean that I have brain cancer!") This leads them to spend lots of time and energy in **compulsive behaviors** such as researching possible causes of their symptoms on the internet or frequently going to the doctor for evaluation. However, just like in OCD, no amount of reassurance will lead to a "feeling of knowing" that they don't have an illness, and their obsessional preoccupation with the idea of having a contrary ("I don't *care* what all the doctors and labs and imaging reports say! I *know* that I have cancer!") **Hypochondriasis** involves a **persistent belief** that one has a **physical illness** **despite reassurance** and **evidence to the contrary**: "In hypo-**conned**-riasis, the patient believes that their doctor is being **conned** by the normal signs and lab findings." **Tics** are **sudden contractions** of specific skeletal muscles or vocal muscle groups that tend to occur in **repetitive bouts**. Tics may involve simple movements (such as eye blinking, grunting, or throat clearing ), or more complex actions (such as arm jerking, foot stomping, or forming a whole word or sentence). On a cognitive level, tics are preceded by a conscious sensation of **rising inner tension** (often described as an "urge") that is relieved by performing the tic. Tics are neither entirely voluntary nor entirely involuntary. Instead, tics are best thought of as **irresistible** in the sense that they can be *delayed* with mental effort but not repressed entirely. **Tics** are **transient irresistible contractions** of specific **muscle groups** that occur **suddenly** in **repetitive bouts**: "A **TIC** is a **T**ransient **I**rresistible **C**ontraction." Tics are **relatively common**, with around 20% of school-aged children experiencing transient tics, and 5% experiencing chronic tics. However it is only a minority (around 1%) of children who develop tics that are severe enough that they interfere with functioning and would therefore be said to have **tic disorder**. A specific variant of tic disorder known as Tourette syndrome which involves a combination of multiple motor tics and at least one vocal tic. Despite popular media portrayals of **Tourette syndrome** often involving sudden shouts of profanity (known as *coprolalia)* this phenomenon occurs only in a minority of children with the disorder (around 10%). **Tourette syndrome** is characterized by **multiple motor tics** and at least **one vocal tic:** "**Two**-rette syndrome involves **two** forms of tics (both motor and vocal)." **Obsessive-compulsive spectrum disorders** include **tic disorders, trichotillomania, hypochondriasis**, and **body dysmorphic disorder**: "Think of the **icks:** **tic, trich, sick**, and dysmor**phic**." **CHAPTER 11: PTSD** The primary symptoms required for a diagnosis of PTSD can be captured in the acronym **"TRAUMA"** **T stands for Trauma:** Exposure to a traumatic event is *required* for a diagnosis of PTSD, and the characteristic signs and symptoms of PTSD must not have been present prior to this event. The event must either be **life threatening** and/or involve actual or threatened **physical and/or sexual violence**, while the response must involve significant feelings of **fear, helplessness, and terror**. This means that other events (such as harassment, nonviolent bullying, or having images of yourself posted online by an ex) do not "qualify" as trauma per the DSM 5 despite the fact that these experiences can often result in signs and symptoms indistinguishable from "textbook" PTSD. Secondary exposure to a traumatic event (such as hearing about a spouse or family member who was robbed at gunpoint) still qualifies per DSM 5 standards. The trauma can be a single event (as in a car crash) or it can be chronic (such as childhood abuse). The nature of the trauma has important considerations with the development of PTSD as less than 10% of people experiencing a **non-intentional** trauma such as a car accident develop PTSD while nearly 50% of those experiencing **intentional trauma** such as rape or assault do. **R stands for Re-experiencing:** People with PTSD often re-experience their trauma in various ways. This primarily takes the form of **flashbacks** which are sudden and unexpected re-experiencing episodes of the trauma. Flashbacks can be either cued ("triggered" by certain stimuli that are reminiscent of the trauma such as a Vietnam War veteran hearing a helicopter), or uncued (occurring seemingly at random or "out of the blue"). Flashbacks are not *thoughts* so much as *experiences*, and someone in the midst of a flashback tends to experience it in highly emotional and sensory ways (including specific images, sounds, or smells) rather than verbal or narrative memories ("I remember that one time in Vietnam\..."). This appears to be related to how stress affects the ability to encode memories with traumatic events often being encoded in a "flashbulb" manner rather than being stored in terms of a personal autobiographical narrative as most memories are. Flashbacks are experienced as occurring in the "here and now" and appear to be a form of **dissociation**. Re-experiencing can also occur in the form of **nightmares** which are common in individuals diagnosed with PTSD (as over 70% of people with this condition reporting frequent nightmares compared to only 5% of the general population). The content of the nightmares is often, though not always, related to the trauma itself. Nightmares are impairing as they can result in poor quality of sleep or even attempts to avoid sleep due to anxiety about having more nightmares. **A stands for Arousal:** People with PTSD often develop a state of increased anxiety and awareness of their surroundings known as **hyperarousal**. This is similar to the state of arousal seen in fear that is mediated by the sympathetic nervous system. However, unlike adaptive fear in PTSD this state of arousal becomes **persistent** and **generalized**, occurring most of the time and in multiple environments regardless of whether there is reason to be fearful or not. For example, someone who was robbed while travelling in another country may begin carrying forms of protection upon at all times keeping these at their side before answering the doorbell at home. People in a state of hyperarousal often engage in constant scanning of their environment for possible clues to the presence of any danger (**hypervigilance**). Due to the involvement of the HPA axis, people with PTSD often experience the same symptoms that are seen in the states of chronic anxiety as captured in the "**MISERA**-ble" mnemonic including **M**uscle tension, **I**rritability, trouble with **S**leep, low **E**nergy, **R**estlessness, and inability to pay **A**ttention to non-trauma related stimuli. **U stands for Unable to function:** The re-experiencing, hyperarousal, and avoidance patterns experienced by people with PTSD can be incredibly impairing for both social and occupational functioning. People with PTSD often find themselves unable to concentrate at work or have no interest in maintaining relationships with "normal people" who cannot understand the experiences that they have been through, leading to difficulty in maintaining a job and an adequate social support system. **M stands for Month:** By definition, PTSD is a **chronic** disorder meaning that trauma-related symptoms must be present for a certain period of time. In the DSM 5, this period of time is defined as one month. (People showing signs and symptoms related to trauma for less than one month would be diagnosed as having an acute stress disorder). To be clear, this does not mean that symptoms have to be present in the first month after the trauma occurs! In fact, a **delayed onset** is most characteristic of PTSD, with nearly 80% of those who eventually received this diagnosis not showing any symptoms within the first month after trauma. **A stands for Avoidance:** People with PTSD will often go to great lengths to **avoid people, places, or things** associated with those memories so as to not trigger a flashback. For example, someone with PTSD from a construction-related accident may try to avoid tall buildings, while someone who was kidnapped walking out of a friend\'s house at night may find it difficult to return to that part of town. Avoidance can go beyond *physical* avoidance to include a more *psychological* avoidance of emotions known as **numbing**. Emotional numbing helps to protect against strong negative emotions such as fear, helplessness, or anxiety, but it can also interfere with the ability to experience positive emotions such as joy, satisfaction, or love. This results in a **flattening of affect** which can impair one\'s ability to interact with other people and engage in meaningful relationships. **Post-traumatic stress** disorder is characterized by exposure to a **life-threatening** event that results in **re-experiencing**, **hyperarousal, avoidance**, and **dysfunction**: **"TRAUMA"** Specific treatments for PTSD have been shown to be effective at reducing the distress and dysfunction related to trauma. The primary form of treatment for PTSD is **trauma-focused** **CBT**. In particular, a form of CBT known as **exposure therapy** helps to overcome avoidance by encouraging patients to intentionally come into contact with places and things that remind them of their traumatic experiences (such as driving a car in the area where the accident previously occurred) to re-encode these memories in a way that is less "flashbulb" and more "narrative," leading to fewer re-experiencing episodes. Medications (particularly **SSRI\'s**) can be helpful as an adjunct to psychotherapy. However, they are generally not preferred as a first line treatment given that they are not only less effective but also produce effects that tend to disappear after treatment has ended. In addition to SSRI\'s, another drug known as **prazosin** (which works by blocking the sympathetic nervous system and its associated "fight or flight" response) has been shown to be helpful for preventing **PTSD-related nightmares** when taken before bed. Benzodiazepines rapidly reduced the anxiety and hyperarousal associated with PTSD but they should generally be avoided as they appear to *worsen* many outcomes (including rates of depression, aggression, and substance abuse following a trauma). **Treatment** for **PTSD** consists of **CBT** with **SSRI\'s** as an adjunctive treatment. **Prazosin** can be used to reduce **PTSD-related nightmares**: "**P**ost **T**raumatic **S**tress? Try **P**razosin, **T**herapy, and **S**erotonin." Someone with the trifecta of an overactive amygdala, an underactive medial prefrontal cortex, and an underdeveloped hippocampus is at high risk for developing PTSD as they are more likely to react to trauma with fear and less able to use sensory information from the environment and memories of happier times in their lives to lessen the sting of the traumatic event. You can remember the association of these brain structures with PTSD by thinking of a girl named "**Amy** who sees a **P**retty **F**rightening **C**amel and a **hippo**potamus" while out at a park. Knowing that these animals can be aggressive, her **fear response** is activated in response to this perceived life-threatening situation. However, the camel and the hippo tried to calm her down by reminding her that she\'s in a private park with only tame animals (they are using contextual information to bring down her fear response). Use this situation to help you remember the relationship between the **Amy**gdala (which is prone to be frightened) and both the **P**re**F**rontal **C**ortex and the **hippo**campus (which try to calm the amygdala down using contextual information and prior memories). PTSD involves an **overactive amygdala** that is inadequately regulated by an **underactive medial prefrontal cortex** and an **underdeveloped hippocampus:** "Remember Amy, the woman who encounters a **P**retty **F**rightening **C**amel and a **hippo**potamus while visiting the zoo." **CHAPTER 12: DISSOCIATION** Dissociative experiences involve a variety of signs and symptoms. These can roughly be divided into 3 categories: **subjective experiences** (depersonalization and derealization), **memory abnormalities** (retrograde amnesia and memory errors of commission), and **hypnotic phenomena** (absorption, motor automaticity, and suggestibility). To help keep these straight, use the mnemonic, **"DDREAMS"** **D stands for Depersonalization: Depersonalization** is the feeling of having become mentally detached from one\'s sense of self. People experiencing depersonalization may look at their body and think "I\'m not myself" or look in the mirror and say to themselves, "that isn\'t me." This can be experienced as a sense that one\'s body is out of their control or that one is observing their body from an outside perspective. **D stands for Derealization: Derealization** is a sudden and profound sense that one's current experience of the world is illusory or fake. People often describe derealization as a "mental fog" or "veil" that suddenly descends and makes those surroundings seem alien or dream-like (even if they are in a familiar place like their own home).People in a state of derealization also report that they often feel unsteady or uneasy ("it\'s like I am walking on shifting ground"). Notably, depersonalization and derealization are not in any way mutually exclusive states, and people will often feel both at the same time! **R stands for Retrograde amnesia:** While derealization and depersonalization are the two primary ways in which the association is subjectively experienced, there are often other signs as well. Most prominently, lapses in memory are a key clinical symptom of dissociation. Memory lost during dissociation is characterized by **retrograde amnesia** which is the loss of *previously* encoded memories (as opposed to anterograde amnesia where *new* memories cannot be encoded). For example, someone diagnosed with dissociative amnesia may be unable to remember any significant events in the month-long period after the death of their son but would be able to encode and memorize new information such as a list of items to buy from the store, that she is given. **E stands for Errors of commission:** Memory lapses in dissociation are also characterized by the presence of both omission and commission errors. **Omission errors** are things that happen that you cannot remember (you have *omitted* the information from your mind) whereas **commission errors** are false memories of things that didn\'t actually happen (you remember yourself *committing* an act that hasn\'t actually been committed). Human memory is far from perfect, and omission errors are incredibly common (can you remember what you ate for dinner exactly 1 year ago?). In contrast, commission errors appear to be related the capacity to dissociate, and evidence suggests that people who score high on measures of dissociation differ from most people primarily in the increased number of commission errors (rather than omission errors) that they make. This is not to say that normal people don\'t make commission errors of memory as well (they absolutely do!). However, people with a high degree of trait dissociation appear to remember false or suggested memories with a much higher frequency than most and with an intensity similar to their memories of actual events. **A stands for Absorption:** The last three signs and symptoms of dissociation all overlap with phenomena observed during a state of **hypnosis**. In fact, there is evidence to suggest that dissociation may be similar to or even the same thing as hypnotic states, with the main difference being that it occurs spontaneously rather than being induced by others. The first of these symptoms is **absorption** which is a state of being highly engaged in or entranced by mental imagery to the exclusion of everything else going on. Think of someone who is taking a walk in the woods while reading a gripping fantasy novel! This person is absorbed in their imagination to the point where they are not consciously aware of everything going on around them. **M stands for Motor automaticity: Automaticity** refers to behaviors that a patient does automatically without conscious awareness or effort. Consider the example of walking while reading from before: for someone who is absorbed in the story, the process of walking is done without conscious effort, including more complex tasks such as staying on the path or avoiding walking into a tree! In more extreme cases of automaticity, someone may not even be aware that they are doing the behavior, and when asked, may report no desire to do it. **S stands for Suggestibility:** Finally, **suggestibility** is a trait of being inclined to accept and act on the ideas of others. People who are highly suggestible may believe information without critically examining it or may do as someone tells them without considering whether it is the right thing to do. For example, let\'s say someone goes on a roller coaster for the first time and has a great time while on it. However, after getting off the ride their friend tells them, "you look so terrified!" If the person is highly suggestible, they may now remember being terrified on the ride rather than excited. Suggestibility can also take more subtle forms, such as a lawyer asking leading questions in an attempt to get an eyewitness to remember something differently. **Dissociative episodes** involve feelings of **depersonalization** and **derealization**, specific types of **memory errors,** and **hypnosis-like phenomena**: "**DDREAMS"** Dissociation appears to be related to a disrupted sleep-wake cycle in which the dreaming state overlaps with waking life, resulting in the highly characteristic combination of feelings of unreality, specific forms of memory errors, and hypnotic phenomena. To remember this, use the same "**DDREAMS"** mnemonic from earlier to link dream-like consciousness to dissociative experiences. (As a final note, while daydreaming and imagination are both likely related to dissociation, they are completely normal parts of life and should not be considered pathologic in any way!) **Dissociative episodes** involve sudden **intrusions of dreamlike consciousness** into waking life caused by an **unstable sleep wake cycle**. "**Dissociation** involves **DDREAMS** that happen during waking consciousness!" There are three dissociative disorders listed in the DSM: **Dissociative amnesia**, **depersonalization-derealization disorder**, and **dissociative identity disorder.** **Dissociative amnesia** refers to **episodes of retrograde amnesia** that leads to gaps in one\'s autobiographical memory. These gaps often occur around the time of traumatic events and tend to have **well-defined** **borders** (everything before and after a specific time, is remembered, just not that period itself). The amnesia can be brief (only a few minutes or hours) but it is usually becomes a disorder when it lasts for a while (months or even years for some patients). In severe cases, the amnesia can be so profound that people forget their own name and identity leading to a **fugue state** in which they will wander around with no knowledge of who they are or where they are from. Dissociative amnesia is a **diagnosis of exclusion** and other causes for memory loss must be ruled out the prognosis for dissociative amnesia is good and that most people will recover their memories even without treatment. However, the overall level of functioning for these patients is often poor, although this is more likely related to various comorbidities such as (PTSD or depression) than from the dissociative amnesia itself. **Depersonalization-derealization disorder** is characterized by depersonalization and/or derealization symptoms that are severe and persistent enough to result in significant distress and impairment. This diagnosis is broad enough to capture a **wide range** of pathology related to dissociative experiences. For most people with the disorder, depersonalization and derealization are chronic, although for a minority they occur in transient episodes. The onset of symptoms can either be **spontaneous** or linked to specific **triggers** (with common ones being stress, depression, or use of drugs cannabis or hallucinogens). Age of onset is typically in the **teenage years** although some people describe experiencing depersonalization and/or derealization as far back as they can remember. It affects **men and women** equally. In studies, patients are generally well- educated and employed, but often they feel that their life functioning is below where it should be (such as having employment that is below their training). While **dissociative identity** disorder is the rarest of the dissociative disorders (affecting only 1% of the population, in contrast to dissociative amnesia and depersonalization- derealization disorder which each affect around 5 or 10%), it is considered to be the most impairing of the three. Dissociative identity disorder is characterized by a consistent pattern of derealization, depersonalization, and memory lapses that are severe enough that someone experiences them as **completely separate identity states,** leading to a **fragmentation of identity** and a sensation that they are completely different person from one moment to the next. Dissociative identity disorder does *not* involve multiple different people, each with their own names, personalities, and back stories, all living in the same body and switching back and forth between one another in a sudden or dramatic way. Instead, dissociative identity disorder is best described as involving a *sensation* of different identities rather than their literal *presence*. This fragmentation of identity can lead to observable changes in mannerisms, behavior, and speech patterns between the different identities (sometimes called "alters "). A patient\'s identity at any given time appears to correspond most with their **emotional state,** such as feeling like one identity when angry, another one scared, another one sad, and another one elated. The sense of identity fragmentation is compounded further by the fact that patients with dissociative identity disorder often have **affective lability** or the tendency to switch quickly from one emotion to another. A tendency toward memory errors also makes it harder for patients to hold on to a consistent sense of self. Most of us will say that we know ourselves based on two things: a consistent set of **memories** and a consistent pattern of **thoughts,** **behavior,** and **emotions**. We know, based on our memories of the past, how we feel and act in various situations, and recognizing these patterns in ourselves helps to build a consistent sense of identity. However, if your memories were shaky and your thoughts, behaviors, and emotions were constantly changing in response to new emotional states, it can be difficult to feel like the same person at 5:00 (when you are calmly sitting in the chair reading a book) than you did at 4:00 (when you were angrily shouting and throwing things around the room). This is how dissociative identity disorder feels for a patient experiencing it, and this is the pattern you should look for (rather than anything involving multiple people living inside the same body). It appears most likely that people who present with "dramatic" dissociative identity disorder are using media depictions as an **idiom of distress** to demonstrate a severe level of pathology that will be validated and taken seriously by others. For example, movies and TV shows featuring characters with dissociative identity disorder in the United states tend to depict the shifts between personalities as instantaneous, while in India the transitions between different identities is shown as happening during sleep. Patients in each of these countries behaved accordingly in clinical settings. (While cultural factors do play a large role in how patients experience these disorders, the tendency to reflect media depiction and dissociative identity disorder far exceeds what is seen with other disorders like bipolar disorder and schizophrenia). **Suggestibility** appears to play a large role as well, as these patients may be inclined to act out provider expectations of what dissociative identity disorder looks like. The fact that this disorder is studied and diagnosed almost exclusively by a small number of clinics and clinicians rather than being commonly recognized among all practitioners supports this notion as well. It is possible that the "dramatic" form of dissociative identity disorder doesn\'t even *exist* but rather is an **iatrogenic diagnosis** ( a disorder that is *caused* by medical treatment rather than cured by it it). It is likely that "dramatic" dissociative identity disorder is less of a consistent psychiatric *syndrome* than it is a false diagnostic *construct* that has been perpetuated by overzealous clinicians and imposed upon patients with a high capacity for suggestibility. It is reasonable to conclude that dissociative identity disorder *does* exist but only in the form described earlier: as a sensation of different personalities allowing to affectively lability, memory errors, and fragmentation of identity. For patients who are diagnosed with this form of dissociative identity disorder, the prognosis is often poor. Research suggests that most people with this condition experience ongoing distress and disability, although (like other dissociative disorders) this may be due as much to comorbidity with other psychiatric conditions as it is to the dissociative experiences themselves. The research that does exist suggests that most patients with dissociative identity disorder do not feel that any form of treatment meets their goals and many drop out of treatment entirely. Most of this may be due to a mismatch between patient and provider goals. Some clinicians focus so much on the idea of trying to "re-integrate" the various identities back into one that they neglect to focus on other symptoms, such as depression, anxiety, somatization, and substance use which may be significantly more treatable than the dissociative pathology itself. When working with patients presenting with dissociative identity disorder, always take a supportive and validating stance, and keep in mind that *taking someone seriously does not always mean taking them literally* (especially for patients presenting with the "dramatic form"). In addition, make sure to have a discussion about the patient\'s goals of care as well as what they can expect to happen with treatment ("I can't promise that we will be fully able to re-integrate your sense of various identities, but I can work with you to improve your ability to cope with fragmentation of identity as well as the panic attacks and depressive episodes you described"). **CHAPTER 13: SOMATIZATION** Treating somatization requires a fundamentally different approach. Use the mnemonic **"I Do CARE"** to remember the necessary ingredients for successful treatment of somatoform disorders. **I stands for Interface:** Patients who somatize tend to have many health care providers, including multiple specialists in various areas of medicine. Work closely to interface with all the medical providers on the patient\'s team, and integrate your findings so that none of you are working in isolation. **Do stands for "Do no harm":** Patients who somatize are at high risk for injury, disability, or even death as a result of frequent tests and treatments. Because of this, keep the dictum "do no harm" closely held in your mind, and always weigh the potential risks of treatment against the benefits to avoid doing more harm than good. **C stands for CBT:** CBT is the best studied treatment for somatization, with a **small to moderate effect size** and benefits that are durable (lasting years after treatment has stopped). **Mindfulness-based therapies** have also been shown to be helpful, with a similar effect size. However, getting patients to buy into the idea that they need to use these treatments is difficult, leading to high drop-out rates. **A stands for Antidepressants:** Antidepressants are the best studied medication treatment for somatization, and evidence suggests that they can be effective (though with a **smaller effect size** compared to CBT). However, their potential benefits must be weighed against the possibility that the medications themselves can cause side effects which may further trigger or exacerbate somatization. **R stands for Regular visits:** For someone suffering from severe anxiety about physical symptoms, a visit to the doctor can be very comforting. However, this can have the effect of inadvertently providing *negative reinforcement* for having experienced severe symptoms in the first place as it is easy for the patient to think (even unconsciously) that "I get to go to the doctor *only when I\'m sick."* You can reduce this association by scheduling visits on a regular basis rather than only seeing the patient when they have a physical complaint. **E stands for Empathy:** Try to spend most of your time during the appointment listening to the patient, empathizing with their distress, and educating them on the overall good prognosis for symptoms that they are concerned about ("In similar cases I\'ve worked on, these symptoms went away on their own without the need for potentially harmful treatments, and I\'m hopeful that this will happen for you too!"). **Treatment of somatization** involves **therapy**, **antidepressants**, scheduling **regular appointments**, and **avoiding iatrogenic harm: "I Do CARE"** The key to understanding this process is the concept of **interoception,** or the ability to sense one's *internal* bodily state (as opposed to exteroception, which is the ability to focus on stimuli *outside* of the body). People differ in their interoceptive abilities. (For example, some people are more able to sense their own heartbeat than others). A brain region known as the **insula** appears to be the key player involved in interoception, with the activity of this region correlating to the degree of pain that is reported. People who experience persistent somatization appear to have hyperactive signaling pathways connected to the insula which manifests as a heightened awareness of, and a tendency to over focus on, signals from one\'s own body. However, this is only half of the story. On a biological level, the **anterior cingulate cortex** is believed to be involved in this process. As you\'ll recall from the chapter on obsessive-compulsive disorders, the anterior cingulate cortex is responsible for recognizing *error* signals. When the insula passes along interoceptive information to the anterior cingulate cortex, the anterior cingulate cortex interprets that signal as representing an error ("something bad is happening"), and generates alarm signals. This creates a state of motivational arousal that prompts the person to take action (such as seeing a doctor or asking a friend for reassurance). In this way, somatization is revealed to be a 2-step process between increased **IN**teroception in the **IN**sula along with a tendency for the **A**nterior **C**ingulate **C**ortex to overinterpret these signals as representing a problem and then take **ACC**-tion on them. You can remember this by thinking that these abnormalities together caused someone to generate **IN-ACC**-urate self-diagnosis. **Somatization** involves hyperactivity of the **insula** which mediates **interoception** and the **anterior cingulate cortex** which interprets the signal as an **error**: "When someones self- diagnosis is repeatedly **IN-ACC**-urate, consider abnormalities in the **IN**sula and **A**nterior **C**ingulate **C**ortex." **Somatic symptom disorder** is the prototype somatoform disorder and is characterized by **persistent** and **impairing somatization.** As with all forms of somatization, these symptoms are genuinely experienced by the patient. To remember the diagnostic criteria for somatic symptom disorder, use the mnemonic **"SOME ATTIC."** This should remind you of the somatic **S**ymptoms that are at the heart of the disorder. Most people with this disorder have multiple symptoms, but ultimately only **O**ne is required. The symptoms are often either **M**edically unexplained or so clearly in **E**xcess of what would be expected from any given disease process that it suggests a large psychological component. The symptoms must be accompanied by maladaptive thoughts, feelings, and behaviors such as **A**nxiety about what this symptom could mean, frequently **T**hinking about the symptom, and lots of **T**ime and energy being spent in activities related to the symptom such as researching things online for hours each day. The patient must be clearly **I**mpaired or distressed by the disorder. Finally, somatic symptom disorder is **C**hronic lasting months or years at a time. **Somatic symptom disorder** involves **persistent somatic symptoms** that are **excessive** and **lead to impairment: "SOME ATTIC"** **S stands for** Symptoms **O stands for** One or more **M stands for** Medically unexplained **E stands for** Excessive **A stands for** Anxiety about the symptom **T stands for** Thinking about the symptom **T stands for** Time and energy consumed by the symptom **I stands for** Impaired or distressed **C stands for** Chronic (months or years) **Conversion disorder** is when a patient presents with **neurologic abnormalities** with no evidence of observable neurologic cause. These abnormalities can be either subjectively reported *symptoms* such as blindness, blurry vision, and loss of sensation, or objectively observed *signs* such as weakness, imbalance, or shaking. Notably, conversion disorder can involve either the *absence of function* (as in motor paralysis) or the *presence of dysfunction* (as in convulsions). Historically, the DSM required that there be a **recent stressor** (the stressor being the thing that is "converted" into the neurologic abnormality) such as a patient developing leg weakness and becoming unable to walk after their parents are killed in a car crash. However, this requirement was dropped in the DSM 5 and the more neutral name "functional neurological symptom disorder" is increasingly being used. Given that the majority of neurologic deficits involve areas that people have voluntary control over, it is easy to come to the conclusion that people with conversion disorder are either "faking it" or not trying hard enough. However, clinical experience tells us that most people with conversion disorder are not manufacturing their symptoms, and recent research even suggests that conversion disorder (and in particular cases involving the presence of abnormal movements such as seizure-like fits), is a specific manifestation of the **automaticity** **seen in dissociation**. You can remember the core features of conversion disorder by thinking of it as "**CAN'T**-version" disorder which should help you remember that it involves a **C**linically unexplained **A**bnormality specifically involving the **N**ervous system that is sometimes, but not always, brought on by a stressful **T**rigger. This "CAN'T" will help you remember as well that these patients aren\'t faking it: they genuinely *can\'t* do the things they say they can\'t even in the absence of observable evidence. **Conversion disorder** involves **clinically unexplained neurologic signs or symptoms** that are often but not always brought on by a **stressful event: "CANT-**version disorder" **C stands for** Clinically unexplained **A stands for** Abnormality **N stands for** Neurologic **T stands for** Trigger (sometimes) (Can't = genuinely unable) In cases of the **fictitious disorder**, the goal is **primary gain**, a term used to refer to all of the intangible benefits associated with being sick such as sympathy and nurturance. For example, someone with factitious disorder may complain of severe abdominal pain that they aren\'t actually experiencing in order to be admitted to the hospital and receive medical attention because they desire to remain in the "sick role" over and above preserving their own bodily integrity. In extreme cases, people with factitious disorder may even intentionally harm themselves to provide evidence that they are truly sick. For example, someone in the hospital claiming symptoms of an infection may begin injecting feces into their bloodstream to *actually* give themselves an infection. This is known as **Munchausen syndrome** (or "factitious disorder imposed on self" in the DSM 5). At other times, someone may harm their children or other dependents for similar purposes as they strongly desire the sympathy and attention that accompanies having a sick child. This is known as **Munchausen syndrome by proxy** (or "factitious disorder imposed on another" in the DSM 5). This is one of the **deadliest forms of child abuse** that exists. **Malingering** involves the *intentional* production or exaggeration of medical or psychiatric symptoms. However, malingering differs from factitious disorder in the reasons for producing the symptoms. In contrast to factitious disorder (where the main draw is all the benefits *intrinsic* to being in the sick role), in malingering the goal is **secondary gain** or an *extrinsic* benefit that someone is getting from the sick role, including obtaining disability payments, an excuse from work or military service, a lighter sentence in a criminal case, financial compensation for a fake injury, or admission to a hospital with its associated food and shelter. It\'s important to note that malingering does not always involve complete fabrication of symptoms. Often, at least some of the symptoms do exist but are significantly played up or exaggerated (known as **partial malingering**). To distinguish between **MAL**ingering and **FAC**titious disorder, look at the pattern of behavior once the patients' needs has been met. Someone who is **M**alingering **A**lways **L**eaves once their need has been met (for example, if disability payments have been approved) because there is no longer a reason for them to seek medical care. In contrast, someone with **F**actitious disorder **A**lways **C**omes back for more treatment because their primary motivation is in the medical care itself. **Factitious disorder** and **malingering** both involve **intentional production** of medically unexplained symptoms but differ in regards to the **reason why:** "**M**alingering **A**lways **L**eaves once their need has been met whereas **F**actictious disorder **A**lways **C**omes back for more. **CHAPTER 14: PERSONALITY** There are five core personality traits (known as **the Big Five personality traits**, the **five factor model**, or the **OCEAN model**) that have been shown to be both **reliable and valid**. They are remarkably stable over time, staying consistent from childhood through adulthood and even into old age. In addition, someone's self-assessment of their scores on these traits generally agrees with ratings by significant others, family, and friends. These traits have each been observed in different cultures across the world, suggesting that they reflect patterns inherent to humanity and not just one particular society. These traits can be represented by the acronym **"OCEAN."** **O stands for Openness to experience:** People who rate highly on measures of openness to experience are generally **imaginative** and tend to be interested in **novelty**, whether that involves the arts, travel, or innovative ideas. Conversely, those who score low on this trait tend to be more conventional in their outlook, valuing perseverance and pragmatism than novelty. **C stands for Conscientiousness:** Conscientiousness is the tendency to act in accordance with **both personal and societal expectations**, including following rules, working to meet goals, and keeping things orderly. People who are highly conscientious tend towards **planned behaviors** (though they perhaps risk being overly rigid) while those who are less conscientious are often more spontaneous and free-spirited (though they may risk being impulsive or unreliable). **E stands for Extroversion:** Extroversion refers to a tendency to engage with one\'s external environment and, in particular, with **other people.** It exists on a continuum with introversion, or a tendency to focus on one\'s inner mental and emotional state. At its core, extroversion means that you *gain* mental energy from interacting with others, while introversion means that being with others *depletes* your mental energy. Because of this, extroverts tend to spend more time with others while introverts need some time away from others to "recharge." That doesn\'t mean that introverts don\'t like being around other people! They do, but they tend to prefer a few deep relationships over having many acquaintances. **A stands for Agreeableness:** Agreeableness refers to the priority that one places on **getting along** with other people. Those with high agreeableness tend to place others' interests ahead of their own and are seen as helpful, kind, and trustworthy, (though they may be more prone to peer pressure and groupthink as a result). In contrast, those who score low on agreeableness tend to be less willing to expand effort to help others and may view other people\'s motives with skepticism or suspiciousness. **N stands for Neuroticism:** Finally, neuroticism refers to the tendency to **experience negative emotions** such as anger, sadness, and anxiety over positive emotions such as happiness, joy, and contentment. People with high neuroticism tend to spend more time focusing on negative stimuli in the present, thinking of mistakes from the past, and worrying about bad things happening in the future. Because of this, people with high neuroticism are much more vulnerable to disorders like depression. On the other hand, those who score low on neuroticism are less emotionally reactive and tend to become upset less often. It\'s important to note that low neuroticism does *not* mean perpetually positive mood! Rather, it implies *freedom* from persistent *negative* moods. The **five factor model** is a **reliable and valid** model of **personality traits** that has been validated in multiple societies and cultures: **"OCEAN"** To remember the primary core features shared by *all* personality disorders, think of an **"OCEAN"** that has been disrupted by a violent **"TIDE."** This will remind you that a personality disorder is defined by one or more **T**raits that are **I**nflexible, **D**isabling, and **E**xtreme. Like the **"3 Reapers"** **of addiction,**