Introduction to clinical psychology 2nd year.pptx

INTRODUCTION TO CLINICAL PSYCHOLOGY The concept of clinical psychology "Clinical psychology is healing and research based on the science, knowledge and methods of psychology in order to understand, assess, prevent and treat psychological problems of various origins"...

INTRODUCTION TO CLINICAL PSYCHOLOGY The concept of clinical psychology "Clinical psychology is healing and research based on the science, knowledge and methods of psychology in order to understand, assess, prevent and treat psychological problems of various origins" (Hall, 1992) "Clinical psychology is an applied branch of psychological sciences that deals with abnormal psychological phenomena” (Szakács, 2001) The task of the clinical psychologist child, adult and elderly: assessment and diagnosis development of clinical psychological opinion based on: formulation of an adequate (evidence-based) treatment plan treatment and cure of psychological problems development of the individual's problem-solving and coping skills evaluation and research of interventions in relation to a wide range of psychological problems Legal definition of clinical psychology in Hungary The clinical psychology activity is aimed: to maintain and restore mental health to establish, investigate and investigate the causes of mental disorders to carry out psychodiagnostic tests necessary for the diagnosis of certain disorders as well as at correcting mental disorders with the help of psychological methods *Act CLIV of 1997 on Health Care  The history of clinical psychology „Psychology has a long past, but only a short history..” (Ebbinghaus) The history of clinical psychology is inextricably intertwined with the history of both medical sciences and philosophy. BUT! We also have data on the care of the mentally ill from prehistoric times. The roots of clinical psychology go back to the ancient Greek world (but, throughout human history, human psyche and behavior have always been important issues!). Thales, Hippocrates, and Aristotle had been philosophizing about human thought, perception and, of course, the nature of psychic phenomena, which „Psychology were considered pathological at the has a long past, but only a short time. history..” (Ebbinghaus) Healing mental illness in prehistoric times Treatment of mental illness was attempted as early as 6500 BC. Cave drawings tell us about the method of trepanation, which was a method that involved the puncture of the skull and the surgical removal of part of it. A hole was made in the skull with stone tools through which spirits could escape from the brain and the patient could be healed. They also treated skull fractures, migraines and mental illnesses. In ancient Mesopotamia, priest-doctors treated the mentally ill with religious rituals, where demonic possession was assumed to be the main cause. This included exorcisms, incantations, atonement, prayer, and other mystical rituals. Ancient times The Egyptians and the Chinese treated people with strange behavior as if they had spirits inside them. If such a person's behavior fitted into the valid framework of the religion, he was respected because "a good spirit entered him." If not, he was treated as if he had a "devil hiding." Middle Ages In the Middle Ages, it was primarily the pastors who were responsible for "caring" for the mentally ill. The sick were considered allies of the devil with supernatural powers. The body was tormented to torture the devil who was dwelling within it. The court of the Church (the Inquisition), in the 13th and subsequent centuries, drove countless mentally ill people to their deaths. These people were subject to different exorcism methods that ranged from innocent prayers, starvation, whipping, long bloodshed, beatings, stigmatization, and skull drilling so that the "bad spirit" could leave! In the 15th century, typical "prison-like" institutions appeared in the major cities of Europe, where patients were kept tied up in dark, dirty cells in inhumane conditions. Renaissance In the era of the Renaissance, the attitude appeared that the mentally ill were considered sick (as opposed to creatures possessed by devil)! The year 1793 is a key date in the history of psychiatric patient care. Philippe Pinel, a French doctor shocked by hospital brutality, "took off the chains of the mentally ill." This is called the first institutional revolution. The beginnings of humane treatment of the mentally ill There were also many of Pinel's contemporaries who did much to provide more humane care for patients. William Tuke founded a hospital in England that served as a model for the care of disturbed persons. Eli Todd created a sanatorium for patients in the USA: he emphasized care, respect and morality. Dorothea Dix campaigned for more humane care for the mentally ill. The beginnings of clinical diagnostics and measures (1850-1899) Bound to Galton and Cattel: they created the forerunners of intelligence studies. Binet (1903) creates the first IQ test - school readiness. Terman and Spearman improve it. Jung developed the word-association method. With the outbreak of World War I, there was a need to screen conscripts: a 5-member APA committee developed the Military Alpha Test (verbal) and beta test (non-verbal). Testing flourished in the interwar period, especially for performance tests.  Goodenough develops the technique of human drawing to measure the intellect Wechsler creates his intelligence test. The Hungarian adapted version of this (WAIS) is currently the official intelligence testing procedure in Hungary The first projective tests appear. The Rorschach test is the best known of these and is still in use today. Frank, an American psychologist, introduces the concept of projective techniques into clinical psychology (this is when the Rorschach test becomes more popular). Murray creates the Thematic Apperception Test (TAT) Hathaway introduces MMPI to clinical diagnostics in 1943. Beginnings of clinical psychological/psychiatric interventions Kraepelin set himself the goal of classifying psychoses. Separates dementia praecox from psychosis maniaco- depressiva. (Today it is schizophrenia and bipolar disorder). With this, the study of psychoses began. Others (Charcot, Janet, Breuer, Freud...) were researching new types of treatment for neurotic patients, and this was a great era of suggestions and hypnosis research. Freud and Breuer write a volume of case Studies on Hysteria. This officially gives birth to psychoanalysis. The behaviorists (USA) Theories based on behaviorist trends have also "produced" their own psychotherapeutic procedures. Wolpe describes the systematic desensitization method, which is still used in behavioral therapy for phobic patients. Skinner's chip method, based on operant conditioning principles, has been used in group therapies. Bandura's theory of model learning can be traced in assertiveness training. Humanistic psychology Rogers (1951) publishes Person-Centered Psychotherapy. Humanistic psychotherapy appears. Rogers describes the nonspecific core factors of psychotherapy: Empathy Congruence Unconditional positive regard. The independent birth of clinical psychology Lightner Withmer, also known as the "father of clinical psychology," established the first psychological clinic (treating children and adolescents) in 1896. In 1907, he proposed that the new profession be called clinical psychology He founded the first journal of clinical psychology and developed the first clinical psychology training program. The question of normality vs abnormality In parallel with the development of the profession (both clinical psychology and psychiatric), there is an increasing need to create uniform disease categories: research, educational, legal and financial aspects – This need leads to the development of nosological systems (ICD/BNO, DSM) The emergence of this need has led to controversy over the concept of "normality". There have been many definitions of normality. Criteria for normality General adaptability Ability of enjoyment and pleasure Competent social behavior Effective intellectual functions Emotional and motivational control Social attitudes Productivity Autonomy Integrity Favorable self-image Definition of mental health (according to WHO) A healthy person is who is able to lead an independent life accepts the roles arising from their life situation does work according to his abilities is able to make pleasure carries out his life together with other people in accordance with communal, social goals. Theoretical paradigms of the origin of psychic disorders Psychopathological models include: How behavior develops How it becomes problematic How to study psychological phenomena How to research and deal with psychological phenomena No single theoretical paradigm provides a perfect and problem-free system of thinking, all models must be considered equally valid! The psychoanalytic paradigm Human behavior and development are dependent on intrapsychic factors, the role of social factors is only secondary. Intrapsychic factors are the cause of behavior. Understanding psychic phenomena is assisted by knowing the underlying foundations. A fundamental factor in the development of behavior and behavioral disorders is the satisfaction or frustration of early childhood needs. Intrapsychic factors need to be explored, analyzed and made understood by the patient in order to solve his problem (intellectual and emotional insight is required!). The psychoanalytic paradigm is the basis of all psychodynamically oriented psychotherapy. The behaviorist paradigm This model examines exclusively the relationship between man and his environment, focusing on the type of relationship with the environment. According to the behaviorist paradigm, psychopathological phenomena are observable behavior themselves. Individual behavior is always a learned behavior formed under the influence of environmental factors. Learning under the influence of environmental factors is a function of the central nervous system. A person with a behavior problem is treated by the behavorist model as a erronepusly programmed person. Therefore, the study focuses on how, under what circumstances, the person's current difficulties developed, how they learned it, and how new, more adaptive behavior could be developed through learning. From this paradigm behavioral therapy emerged. Later, with the advent of cognitive psychology they merged and today we call it the cognitive-behavioral therapy school. Phenomenological/Humanistic paradigm The phenomenological perspective focuses on the subjective experience of the individual. Its basic premise is that man is nothing more than the way he perceives the world. Man is an active, thinking being who is individually responsible for what he does, has the power and opportunity to make plans, to choose, to dictate his behavior. Everyone is born with a certain developmental potential, during therapy the therapist helps the client to achieve this, but does not change it, accepts it as it is. Empathy, congruence, and unconditional positive regard of the therapist are fundamental. Organic models They assume that abnormality (i.e. abnormal behavior or psychological phenomenon) is the result of some disorder in the body. A strongly reductionist model! These theories are based on the assumption that psychic processes correspond to bodily processes, when in reality this correspondence is far from direct and far from being explored or known. There are many new and increasingly open forms of this nowadays that can be applied well! Nosological systems Stages of the creation of classification: "Great Professors Principle": They developed around great professors and were confined to a narrow circle, sometimes a city. "Expert consensus": since the 1950s, scientific systematization needs are in the focus. The need for classification comes from the necessity that clinicians speak a common language! This is the condition for scientifically organized education and research, which is later translated back into clinical practice! INTERNATIONAL CLASSIFICATION OF DISEASES (ICD) Based on broad international expert consensus. Mental illness first appeared in ICD-6, in a very short chapter(1948) Currently, ICD-11 is in effect all over the world (it is also official in America, but DSM 5 is also used /mainly in practical work/). ICD-11 Mental, behavioral or neurodevelopmental disorders (Chapter 6) 6A0 Neurodevelopmental disorders 6A2 Schizophrenia or other primary psychotic disorders 6A4 Catatonia 6A6 Mood disorders /Bipolar and related disorders, Depressive disorders/ 6B0 Anxiety or fear-related disorders 6B2 Obsessive-compulsive or related disorders 6B4 Disorders specifically associated with stress/Dissociative disorders 6B8 Feeding or eating disorders 6C0 Elimination disorders 6C2 Disorders of bodily distress or bodily experience 6C4 Disorders due to substance use or addictive behaviours 6C7 Impulse control disorderd 6C9 Disruptive behavior or dissocial disorders 6D1 Personality disorders and related traits 6D3 Paraphilic disorders 6D5 Factitious disorders 6D7 Neurocognitive disorders / Dementia 6E2 Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium 6E6 Psychological or behavioural factors affecting disorders or diseases classified elsewhere Disorders classified under other ICD-11 chapters compared to ICD-10 Chapter 7: Sleep-wake disorders (insomnia, hypersomnia, sleep-related movement disorders, circadian rhythm disorders, parasomnias, REM sleep- related parasomnias) Chapter 17: Sexual health related conditions (sexual dysfunctions, sexual pain disorders, sexual incongruences) Two main areas of clinical psychology Psychopathology It deals with the description of pathological variants of basic psychic phenomena (memory, emotions, thinking...). Pathopsychology It basically deals with the description of mental illnesses (schizophrenia, depression...) and the co-occurrence of various disorders. Psychopathology Psychopathology deals with clinical disorders of psychic functions. 3 large groups of disorders: Centripetal Central Centrifugal Centripetal disorders These include disturbances in the nervous processes that carry out the reception and processing of stimuli from the external and internal environment. That is, disturbances of perception! Perception disorders (e.g. hallucinations, illusions...) Central disorders Central disturbances are disturbances of nervous processes that mediate between centripetal and centrifugal processes. These include: Thinking Intelligence Remembering and learning Attention Orientation Emotion-affectivity disorders Centrifugal disorders Disturbances in those nervous processes that ensure the body's repercussions on its environment. Behavior from the inside out can be: reactive (response action) proactive (initiative action) All of them are movement (motor), oriented at something and time-bound. These include:: Movement disorders Speech disorders Writing Disturbances of action and reaction Psychosis vs neurosis Psychosis Neurosis Reality control is lost Reality control retained No (or little) awareness of There is awareness of illness illness Advanced pathopsychology Neurodevelopmental disorders (6A0) These include neurodevelopmental disorders occurring during the developmental period, which significantly inhibit the acquisition and functioning of specific intellectual, motor or social functions(ICD-11). This includes only those disorders (despite the fact that behavioral and cognitive deficits can be present in many categories of mental and behavioral disorders) where neurodevelopmental disorder is a basic characteristic.  Disorders of mental development Mild intellectual development disorder IQ is approximately between 50-69. (in adults, the intellectual age is 9-10 years) Moderate intellectual development disorder IQ is approximately between 35-49. (in adults, the intellectual age is 6-9 years) Severe intellectual development disorder IQ is approximately between 20-34. (in adults, the intellectual age is 3-6 years) Very serious intellectual development disorder IQ below 20 (intellectual age under 3 years) Developmental speech or language disorders This includes disorders where the normal process of language acquisition is disturbed from a very early stage. Language disorders cannot be attributed to a social or cultural factor and cannot be completely explained by anatomical or neurological disorders. These include: Developmental speech sound disorder (disorder of speech articulation) Developmental speech fluency disorder (e.g. repeating sounds, words, syllables, stuttering/stammering...) Developmental language disorder (persistent deficits in the acquisition, understanding, production or use of language) These include: Developmental language disorder with impaired receptive and expressive functions, Developmental language disorder, mainly with impairment of expressive function, Developmental language disorder, mainly with impairment of pragmatic language, Developmental language disorder with other detailed language impairment  Autism spectrum disorder Persistent deficits in reciprocal social communication (both initiate and sustain). Restricted, repetitive, and inflexible patterns of behaviour and interests. The onset of the disorder occurs typically in early childhood. Deficits are sufficiently severe to cause impairment in personal, family, social, educational, occupational or other important areas of functioning Individuals along the spectrum exhibit a full range of intellectual functioning and language abilities. Features of the clinical picture: -Social impairment -Communication problems Limited repetitive behavior and interest  Developmental learning disorder Significant and persistent difficulty in learning the school curriculum (writing, reading, arithmetic). Dyslexia: - Significant and decisive deterioration in the development of reading skills, -Difficulty in mastering the subtasks necessary for reading, -Spelling difficulty is an associated symptom, -Its development is usually preceded by speech and language development disorders, -Often associated with behavioural disorders at school. Dysgraphia: Spelling problems associated with writing that does not develop due to motor disorders (difficulty articulating words, sentences, hyphenation, or spelling regular-irregular forms correctly). Dyscalculia: Neurological disorder in numeracy skills independent of intelligence.  Developmental motor coordination disorder A significant delay in the acquisition of gross and fine motor skills and impairment in the execution of coordinated motor skills. Dyspraxia: disturbance in the performance of voluntary movements or complex actions which cannot be explained by impaired mobility and loss of muscle strength.  Attention-Deficit Hyperactivity Disorder Attention-Deficit Hyperactivity Disorder (ADHD) is characterized by exccessive inattention, impulsivity and hyperactivity. Epidemiology: One of the most common childhood mental disorders (about 3-5%). It is more common in boys (4:1). Attention deficit disorder is more common in girls, while impulsive, hyperactive forms are more common in boys. Although it is primarily known as a childhood disorder, research clearly shows that the symptoms and difficulties associated with the condition extend into adolescence and even adulthood. Children with ADHD are at higher risk of developing mental disorders later in life, especially antisocial behaviour and substance abuse in adolescence and adulthood. Symptomatology: In addition to inattention, impulsivity, and hyperactivity, significant impairment can be observed in several areas, such as school performance and social relationships with parents, teachers, and peers. Etiology: The condition is believed to stem from central nervous system damage. Family aggregation, twin studies, typical disease progression, and characteristic risk factors point to a genetic origin. However, environmental factors (e.g., intrauterine damage, early chronic diseases) may also play a role in the etiology. Therapy: Medication: Medication has long and widely been used in children with ADHD, the first-line drugs being psychostimulants (e.g., Ritalin). Psychotherapy - behavior therapy -parent training - teacher training -complex behavior therapy for children Its elements: intensive token system withdrawal of rewards, overcorrection, and removal group cognitive-behavioral therapy framed self-control training group social skills training group anger regulation training daily communication card with reinforcement at home development of school skills Combined Therapy – Medication and Behavior Therapy: Research shows that combined therapy is more effective and provides longer-term results than either medication or behavior modification techniques alone.  Stereotyped movement disorder Voluntary, repetitive, stereotyped, apparently purposeless (and often rhythmic) movements that arise during the early developmental period. Symptoms may interfere with social activities, and may induce self-harm. Schizophrenia or other primary psychotic disorders (6A2) These symptoms are characterized by significant disturbances in reality perception (reality control), as well as positive symptoms shown in behavior (delusions, hallucinations, thought disorder (most apparent in language use), grossly disordered behavior, as well as negative symptoms (passivity, dullness, emotional fatigue, psychomotor disturbances,initiation problems, weakness of will).  Schizophrenia The word schizophrenia is of Greek origin (schizo = cleavage, phren = mind). Epidemiology: Schizophrenia is a disorder that affects about 1% of the general population. The first appearance is most common in people aged 20 to 35 years. In young adulthood, both men and women experience a spike, and a second peak appears in women around the age of 50. In men and women, it appears in equal proportions, but in men the earlier onset of the disease is characteristic, while in women it has a later onset and therefore the prognosis is better. Clinical picture Bleuer divided schizophrenia into basic and accessory symptoms: Basic symptoms: The four "A”s Association Affect Autism Ambivalence Associated symptoms: Delusions Behavioral symptoms Schneider distinguished between primary (e.g., delusions) and secondary (perception disorders, emotional fatigue) symptoms. Crow According to his division, two types are distinguished: Positive symptomatic: (plus compared to normal) hallucinations, doxasmas, thinking disorders Negative symptomatic: (minus compared to normal): alogia, apathy, anergy, anhedonia, social withdrawal, attention disorder Symptomatic picture Content disorders of thinking: delusions Formal disorders of thinking: incoherence, loosened associations, unrealistic conclusions, thought flow/blockage Speech features: concretization, symbolism, incoherence, echolalia Perception disorders: hallucination in all modalities Affect disorders : anhedonia, apathy Self-perception disorders: loss of self-identity and self-boundaries Intention and will disorders : confusion of purposeful plans, inability to complete a sequence of actions Disturbance of contact with the outside world: retreats into his own thoughts, autistic Psychomotor disorders: catatonia Course of disorder: 1. Prodromal stage: previous level of operation is declining in several areas (strange behavior, decrease in grooming, unusual perceptions, experiences, affects) 2. Active stage: psychotic symptoms (delusions, hallucinations, loosened associations, incoherence, impoverishment of content, illogical thinking) 3. Residual stage: Similar to the first, already completed stage + desolation Schizophrenia takes place in subs! There is a general distortion of thinking and perception, as well as inadequate or bleak affects. Consciousness is clear, intellectual abilities are preserved, but certain cognitive deficits may develop during the course. ICD-11 considers the following symptoms necessary for a diagnosis of schizophrenia: Symptoms must have persisted for at least one month in order for a diagnosis of schizophrenia to be assigned These symptoms may include: Thought disorder Impaired perception Self-experience disorders Cognition disorders Disorders of volition Affective disorders Behavioral disorders Core symptoms include: Delusions, hallucinations, disorders of thinking, experience of influence, passivity. The symptoms are not a manifestation of another mental health condition and are not due to the effect of a substance or medication. According to our current understanding, schizophrenia can be thought of as a spectrum, where patients with different pathological course and symptomatic dominance are located within the spectrum. Etiology: Biological (genetics, neurochemical models, neurodevelopmental disorder..), psychological (regression, early childhood wounds, family pathologies...) and sociodemographic (stigma, migrant status...) factors all contribute to the development of the disorder. None of these factors alone can explain the totality of schizophrenia! Therapy: Pharmacotherapy (antipsychotics) are essential! Among psychotherapies, supportive therapy and behavioural therapies stand out. Family therapies also play a significant role, especially in preventing relapse.  Schizoaffective disorder This includes psychoses characterized by symptoms of both schizophrenia and affective disorders. (estimated prevalence between 0.5-0.8%). Its cause is currently unknown. The two most studied assumptions are whether it is a common manifestation of schizophrenia and affective disorders, or a separate type of psychosis independent of both schizophrenia and affective disorders. Clinical symptoms: You can find all the symptoms of both schizophrenia and mania and depression in different variations. Symptoms can be combined or alternating. Special mention deserves the presence of psychotic symptoms incongruous with mood. In this case, when the content of delusions and hallucinations is not in harmony with the mood state, we should think of schizoaffective disorder.  Schizotypal disorder The term schizotypal was coined by Radó to indicate that he considers this disorder to be a non-psychotic, phenotypic variant of the schizophrenic genotype. The DSM classifies it as a personality disorder. ICD-10 considers it part of the schizophrenia spectrum! According to a more recent clinical view, the schizotypialpersonality actually corresponds to the premorbid personality of schizophrenics. Schizotypic personality disorder occurs at a higher rate among relatives of schizophrenics than among members of the control group. The main characteristic of schizotypal disorder is eccentricities in behaviour and thought, accompanied by deviations in affectivity similar to schizophrenia, however, without symptoms of schizophrenic psychosis. Clinical symptoms: Inappropriate or narrowed affects, The behavior or appearance is eccentric, unrageous, bizarre, Poor ability to establish relationships and tendency to seclusion from community Strange beliefs or magical thinking, Suspicious or paranoid overvaluation Compulsive rumination without internal resistance, often with dysmorphophobic, sexual or aggressive content, Unusual sensory experiences or illusions, Depersonalization or derealization Vague, circumstantial, metaphorical, boisterous or stereotypical thinking Sometimes transient psychotic states with intense illusions, acoustic hallucinations, delusional thoughts, which usually occur without external provocation, but cannot meet the criteria of schizophrenia, delusional disorder or schizoaffective disorder. If some kind of limiting or inappropriate mood appears in the symptomatic picture, then we speak of negative schizotypy, if it is characterized by psychotic symptoms, hallucinations or delusions, then we speak of positive schizotypy.  Acute and transient psychotic disorder It is characterized by psychotic symptoms that begin acutely and without prodroma, reaching their maximum severity within two weeks. Symptoms typically change rapidly. The duration of the episode should not exceed 3 months, most often it lasts from a few days to a month.  Delusional disorder Delusional disorder is characterised by the development of a delusion or a set of related delusions, typically persisting for at least 3 months. In its pure form, these delusions are not bizarre and not fragmented, but logically structured and well systematized. The emotional response to delusions is adequate, the part of the personality not affected by delusions remains intact, or declines only to a small extent. /Former names: paranoia, delusive disorder/ The delusions may be either simple or elaborate, usually revolving around a single theme or several but interrelated themes. Minor detriments are magnified by the patient. Accompanying symptoms: resentment and anger, which can lead to violence. Grandiose thoughts or delusions of references are common. Social isolation, loneliness, and behavioral eccentricities are often typical. A common symptom is suspiciousness, which occurs either in a generalized way or in a focus on certain individuals. Prognosis: The performance of daily functions rarely declines, the patient's intellectual and job functions remain intact. Social and marital functioning, on the other hand, deteriorates sharply. Epidemiology and etiology of delusional disorder Epidemiology: Gathering reliable data on prevalence is difficult due to the rarity of the disease, changes in diagnostic criteria and the strong willingness of patients to dissimulate (approximately 4% of those treated in psychiatric wards). Women get sick at slightly higher rates than men. The onset of the disorder is mostly late, usually in the forties. Etiology: Freud described projection as the main defense mechanism of paranoia (based on Schreber's autobiography) He explains it by mechanisms of denial and projection to ward off unconscious homosexual tendencies. Since homosexuality is consciously unacceptable to most paranoid patients, they deny the feeling of "I love him" and transform it into an "I don't like him" feeling through reaction formation. This feeling is translated into a further projective deflection that says, "It's not me who hates him, it's him who hates me. In a special unraveled paranoid state, this feeling manifests itself as "he is chasing me." The patient can then rationalize his own hatred by consciously hating the person he feels hates him. Instead of becoming aware of his passive homosexual tendencies, the patient rejects the love of everyone but himself. Freud believed that the cause of jealousy delusions is also unconscious homosexuality. In an effort to block out threatening desires, the patient engages himself with thoughts of jealousy. According to Freud, the paranoid patient is jealous his wife of the man for whom he himself is actually homosexually attracted. From Freud's idea, projection as the leading defense mechanism in the development of the disease is still relevant today (his arguments about sexuality have not stood the test of time).  There are many psychological theories that the basis of the pathology is severe lack of confidence. There is speculation that paranoid patients failed to develop basic trust in childhood, which is the cornerstone of all future social relationships with the child. Clinical observations also show that paranoid patients struggled to develop warm and trusting relationships with their parents during childhood. Paranoids describe their mothers as often over-controlling, seductive, or dismissive, and their fathers as aloof, rigid, sadistic, or weak and incompetent. If children cannot trust parent figures to help them endure their disappointments, humiliations, and frustrations, they will soon adopt an attitude of treating the environment as potentially hostile, oversensitive to perceived grievances. Theory of overdetermined goals: A child whose social development fails may seek satisfaction in his performance. As a rule, they are the ones who are expected to perform impeccably, they are punished if they fail to meet the expectations of their parents. And a child who is insecure about himself can develop fantasies in which he will try to increase his self-esteem. Delusions with persecuted or critical and frightening content are very often projections of the superego’s threats. Different types of delusions can be described based on their content: Jealous (Othello syndrome) characterized by hypochondriac/somatic symptoms Erotomanic (The person thinks that someone (a famous person) is in love with them, but for external reasons he cannot openly indicate this to them. Grandiose (ide tartozik a származtatási/genealógiás téveseszmék) Persecutory Querulous Catatonia (6A4) Is characterized by the co-occurrence of several symptoms: Stupor Catalepsy Waxy flexibility Mutism Negativism postures, mannerism, stereotypes Psychomotor agitation(grimacing, echolalia, echopraxia)  Catatonia can occur in the context of another mental disorder, such as Other Psychotic Disorders, Mood Disorders, and Neurodevelopmental Disorders, can also develop due to use of certain psychoactive substances, including prescription drugs. Catatonia was described as early as the 19th century as a syndrome with motor, affective and behavioral symptoms. During the 20th century, it was considered more of a rare type of schizophrenia (catatonic schizophrenia) with primarily motor symptoms, as a result of which catatonia as an independent symptomatology was almost forgotten. There are several forms of catatonia: inhibited, agitated, periodic. Typical symptoms of the inhibited form include stupor (physical or mental immobility), mutism (muteness with retained ability to speak), negativism (passive or active resistance to prompting), repetitive movements, posing or catalepsy, or its most severe form, waxy flexibility. The characteristic symptoms of the agitated form are excessive, aimless motor activity, stereotypes, echophenomena, disorganized speech, disorientation, delirious consciousness and aggression. Periodic catatonia is characterized by alternation of stupor and agitation. In terms of diagnostics, catatonia should always be considered when motor dysregulation is detected, especially if it is accompanied by a disturbed state of consciousness or mood swings. Mood disorders (6A6) The mood is permanently shifted to an extreme, which is not or hardly influenced by the events of the environment. Changes in mood, i.e. general well-being, are accompanied by disturbances in behavior, emotional reactions, cognitive and vegetative functions. Interpersonal and social relationships, performance at work are almost always impaired. Mood disorders are characterized by a triad of psychological, subjectively experienced discomfort, somatic dysfunction and social and interpersonal difficulties. The main group of mood disorders refers to bipolar and depressive disorders. The classification is based on the specific type and temporal pattern of the mood episode.  Depression Clinical picture Basic symptoms Depressed mood. Typically, the mood is worst in the morning, it is not or hardly influenced by external events. Irritability may also occur. Anhedonia, decreased interest and pleasure, low levels of experiencing positive emotions are another basic symptom of depression. Additional symptoms Depleted energy levels. School/work performance decreases. Social activity also decreases. Negative cognitive schem. You have a negative view of yourself, your environment and your future (it also appears in negative language code). Changes in psychomotor also appear above a certain level of severity, in the form of inhibition or agitation. Social activities and interpersonal relationships are narrowed. Here, impaired emotional communication also plays a role. Vegetative symptoms are common, but not necessary: sleep disturbance, changes in appetite, decreased sexual interest Physical symptoms may also appear in depression. Somatic well-being changes. Pains and discomfort in various organs are common. The most common are gastrointestinal complaints, chest and spine pains, headaches. Typical appearance, patient looks older than his age, his posture is untoned, his movements are slowed, cumbersome, sluggish, his face is poor in mimicry, his gestures are restricted. Less varied clothing, with many dark clothes, in severe cases no attention is paid to dressing up, physical hygiene might also be neglected. Severity characteristics in case of a depressive episode: Mild: does not or hardly exceeds the mandatory number of symptoms required for diagnosis and causes only mild social impairment of working capacity, general social activity and social relationships. Moderate: Symptoms and functional impairment range from mild to severe. Pronounced non-psychotic: In addition to the mandatory minimum, there are a number of symptoms that significantly impede the ability to work, social functions and social relationships. Severe, psychotic symptoms: delusions or hallucinations, which can be both congruent and incongruent with mood. Partial remission: Symptoms of a major depressive episode are present, but not all criteria are met or the period of complete symptom relief after the end of the major episode is less than two months. Complete remission: For the past two months, there have been no signs or symptoms of the disorder.  Mania The most characteristic symptom of a manic episode is an elevated, expansive or irritated, irritable mood, accompanied by hyperactivity, increased self-esteem, impaired judgment and release of inhibitions. Physical and mental activity accelerates. Hypomania is characterized by a sense of well-being, physical and mental efficiency, increased sociability: talkative, friendly. Sexual energy increases, performance at work can even improve. In a manic state, social inhibitions are lost, the patient may become irritable and suspicious, attention and concentration disorders significantly impair performance and social activity at work.  Characteristic symptoms of mania Mood elevation: It can escalate from unduly optimistic serenity to captivating cheerfulness, cheerfulness, excitement and frenzy. For the affected person, the outside world is revalued in accordance with the elevated mood. Feeling of joy and interest in pleasure-giving activities are heightened. (Often you get yourself into activities and adventures with harmful or dangerous consequences – often to the point that hospitalization becomes justified!). Cognitive functions: Attention and perception intensifies, accelerates, nothing permanently engages them, attention is easily distracted. Accelerated and loosened associations. Individuals have a positive self-image and increased self-esteem. They report expansive, grandiose content. Their judgment is impaired, Their social inhibitions are loosened. Their disease perception is usually impaired. Psychomotility: As a rule, accelerated, the manic patient is full of energy, becomes more active, uninhibited. With mild symptoms, their work performance may increase, but due to deconcentration it becomes inaccurate Their appearance is youthful, Their attire can be lively, in a serious condition, disheveled, untidy. In their condition, aggressive outbursts, assaults may also occur. Vegetative symptoms: Patients' sleep time and need are reduced, they wake up early, full of energy. Their appetite is increased, their sexual drive is also increased, their sexual behavior is uninhibited, interpersonal conflict situations easily arise. Their pain threshold rises. Severity characteristics in case of a manic episode Mild: the minimum symptoms of a manic episode are met Moderate: Extreme increase in activity or weakened judgment Pronounced but not psychotic: They require almost constant supervision to prevent physical harm to oneself and others Severe, psychotic: Delusions, hallucinations Partial remission: Symptoms of a manic episode are present, but not all criteria are met. Or the completely asymptomatic period after the end of the manic episode does not reach two months. Complete remission: For the past two months, there have been no signs or symptoms of the disorder. Bipolar or related disorders(6A6) Bipolar and related disorders are episodic mood disorders defined by the occurrence of Manic, Mixed or Hypomanic episodes or symptoms. Depressive episodes typically alternate or mix with manic or hypomanic episodes. Based on the characteristics of each episode, bipolar type I disorder, where manic and depressive episodes are observed, and bipolar type II disorder, where hypomanic and depressive episodes are observed, can be distinguished.  Bipolar type I disorder Egy vagy több mániás és kevert epizód jelentkezése. A mániás epizód legalább egy héten át tart (eufória, ingerlékenység, felfokozott tevékenységek, fokozott belső energia…). Bipolar type II disorder Egy, vagy több hipomániás epizód és legalább egy depresszív epizód előfordulása jellemző. Cyclothymic disorder Jellemző a hangulat, tartós, ingatagsága (legalább 2 éven át). Az idő javát ezek töltik ki, a tünetmentes időszakok rövidek. Depressive disorders(6A7) It can be single: mild, moderate, severe, without psychotic symptoms and with psychotic symptoms. May be recurrent: mild, moderate, severe, without psychotic symptoms and with psychotic symptoms. Dysthymic disorder Persistent, depressive mood is typical for most days (2 years or more) Mixed depressive and anxiety disorder It is characteristic that both depression and anxiety dominate more days than not for two weeks Epidemiology of mood disorders It is one of the most common psychiatric syndromes. Life expectancy prevalence in the adult population is 8.3 -24 % According to all study sites, it is 2x-3x more common in women than in men. In childhood, the rate of illness is the same for both sexes, the difference begins at adolescence age. The onset of illness is usually in the 20s and 30s, but it is not uncommon to start in childhood either. The first episode rarely appears in old age. The lifetime prevalence of bipolar disorders is between 0.5% and 1.5%. The onset of the disease can be found in the late teens and early 20s, but it can occur in childhood and less often over the age of 50. Etiology of mood disorders Several factors are thought to play a role in their development: a variable combination of genetic, organic, psychological and social factors. Role of inheritance: Based on family research, relatives of patients with bipolar mood disorder are 8-18x more likely to develop bipolar mood disorder and 2-10x more likely to have unipolar depression than controls. The risk of first-degree relatives of patients with unipolar depression is two or three times higher for depression and 1.5-2.5x higher for bipolar mood disorder than healthy controls. However, accumulation within families is not necessarily evidence of genetic background. The same environmental factors, the pattern and impact of the family member suffering from the disorder may also play a role. The role of genetic inheritance is undeniable, however, the pattern of heredity, the relevant gene or genes are unclear. People with bipolar disorder often choose to marry each other. Neurobiochemical theories: Decreased central serotonin activity was considered specific to depression. Premorbid personality: There is no single personality type or personality trait that has a clear link to mood disorder. People with certain personality disorders (compulsive, histrionic, borderline) have an increased risk of depressive disorders. Among personality traits, compulsiveness and anxiety readiness, as well as dysthymia and cyclothymia predispose to the development of depressive episodes and bipolar mood disorder. Life events: The experience of early years of life, family climate, methods of upbringing, non-genetic influence of possible psychiatric illness of parents contribute to the formation of a personality prone to mood disorders. A depressive episode often develops after a stressful life event. The closest connection is with threatening or unwanted life events (e.g. loss). Lack of social support, self-reinforcing factors, and that of intimate relationships and social integration increase the likelihood of developing depression Psychodynamic theories Abraham (1911), Freud (1917) – problems arising in the oral phase of psychosexual development, primarily deprivation of maternal love and support, cause a blockage in emotional development. Early unprocessed loss makes it difficult to process subsequent losses. Depression in adulthood occurs when an adult faces a real, threatening, or perceived loss. In connection with the patient's current loss, he relives the unconscious early loss. Depressed individuals tend to develop ambivalent relationships. According to Freud, the symptoms of a grief reaction triggered by the loss of an important person, ability, or attribute are much like the symptoms of depression. In melancholy (depression), severe disturbances in self-esteem, guilt, self-blame, a feeling of worthlessness are at the forefront of the clinical picture, loss is often unconscious for the patient. According to Klein, there is an innate primitive self that can experience anxiety and operate coping mechanisms. Psychological development in infancy is characterized by so-called paranoid-schizoid and depressive positions, the solution of which is essential for later personality development and integration, susceptibility to interpersonal relationships and psychological disorders. Learning theory Seligman (1972) proved the behaviorist theory of the development of depression through a model experiment. In a laboratory experiment, he placed the dogs in an environment of stimuli uncontrollable for them. Regardless of their behavior, the animals were randomly electrocuted. Initially, dogs actively tried to ward off unpleasant stimuli. Later, as a result of repeated failures, they learned that they could not mitigate painful stimuli with activity, and they became passive, indifferent, and resigned to repeated electric shocks. This reaction Seligman called learned helplessness. If this reaction becomes general and occurs repeatedly in different situations, apathy and depression develop. According to Lewinson (1974), the problem lies in interpersonal interactions, which arise from a lack of social literacy in the depressed individual. This deficit prevents the disease. Discomfort in social situations is characteristic, the repertoire of social behavior is narrow, the individual is highly sensitive to the critical expressions of others. Beck (1963) – Dysfunctional attitudes and cognitive distortions are essential components of depressive syndrome. Every depressed individual is characterized by the so-called cognitive triad, which is an automatic, recurrent, hard-to-control negative view of themselves, the world and the future. Beck originally believed that this thinking pattern is persistent and characteristic of the individual, but is activated only in situations of stress. Anxiety and anxiety-related disorders (6B0) This category is characterized by symptoms generated by behavior related to anxiety and fear. They cause considerable suffering and disadvantages in personal, family, social, educational, employment or other functions. Psychodynamic model of anxiety The neurotic anxiety symptom is nothing more than the conflict between Id's sexual, aggressive instincts and Super Ego. Later (signal anxiety concept): According to this, anxiety is not only a transformed libido, but a signal generated by the ego, which can trigger repression processes. Different stages of development are characterized by different anxieties. Sullivan and Horney focused on interpersonal contexts of anxiety. The goal is to maintain a sense of security. Contemporary psychodynamic theorists of anxiety agree that most anxiety disorders can be modeled in developmental psychological frameworks. Cognitive model of anxiety Cognitive theory sees the essence of anxiety disorders in vulnerability. Vulnerability can be defined as an individual's perception of an external or internal danger over which he or she has no or insufficient control to achieve a sense of security. In clinical syndromes, feelings of vulnerability are amplified by certain dysfunctional cognitive processes: the patient underestimates the positive side of his own resources (minimization), tends to focus primarily on his weakness (selective abstraction), considers all his mistakes as a harbinger of disaster (catastrophizing). Because he tends to overgeneralize his stumbles, he feels more and more vulnerable after making mistakes. Apparently, from his past memories, he remembers negative memories rather than positive ones. Family therapy approach Anxiety disorders have many interpersonal components and Anxieties, as well as the behavioral patterns associated with it, are very easily adopted by family members. The limitations created as a result of anxieties can fundamentally change attachment and dependency relationships within the family and lead to the emergence of a new pathological balance. Later on, family efforts to maintain this balance may become one of the main obstacles to treatment. The purpose of anxiety symptoms is often to provide another member of the family with protection and symptom relief and to provide positive feedback. One of the hidden, unconscious sources of anxiety can be the fear of losing an intimate relationship, and the symptoms often take over the role of threads that gradually disappear from relationships, thus ensuring the survival of the relationship. (e.g.: Jealousy-panic).  Generalized anxiety disorder is characterised by marked symptoms of anxiety that persist continuously, are stable and generalized, with common symptoms such as nervousness, tremor, muscular tension, sweat, dizziness, palpitations, stomach upset, forgetfulness. Criteria: worry Motor tension (restlessness, tension headache, trembling…) sympathetic autonomic over-activity The disorder usually begins in early adulthood, with symptoms developing slowly and gradually. The tension is persistent and results in significant impairment in areas of functioning  Panic disorder Panic symptoms usually begin in the early twenties and are usually not closely related to sociodemographic variables. Recurrent unexpected panic attacks that are not restricted to particular stimuli or situations. Panic attacks are discrete episodes of intense fear or apprehension with more or less clear beginning and end. During an attack, at least four of the following 13 develop simultaneously and escalate to a relatively sudden maximum: Palpitation, trembling, sweating, feeling of suffocation, chest pain, shortness of breath, dizziness, paresthesia, nausea, or abdominal discomfort, derealization, depersonalization, chills or hot flushes, fear of imminent death or of going crazy. Etiology Psychodynamic view: An anxiety attack is an unsuccessful attempt to ward off the impulses that provoke anxiety. An important dynamic factor is the ambivalent dependence demand or dependence conflict. Cognitive behavioral therapy model: The cognitive model of panic disorder is based on the following basic assumptions: Increased psychophysiological susceptibility to emergency response and increased sensitivity to hyperventilation. The bodily sensations, catastrophizing as cognitive impairment. Catastrophizing thinking causes anxiety to intensify, so physical symptoms continue to intensify. Increased self-observation due to anticipated anxiety. The various avoidance behaviors that maintain negative interpretations and lead to the fixation and intensification of anxiety. Avoidant behaviors prevent patients from having experiences that contradict and challenge their negative beliefs. Agoraphobia, specific phobia, social anxiety disorder Phobias A group of disorders in which anxiety develops exclusively or predominantly in a well-defined, but not dangerous situation or when some object appears. These situations or objects are avoided by patients and overcome with fear. Phobia in general and induced anxiety is subjectively, physiologically and behaviorally indistinguishable from other anxieties. Patients usually pay attention to individual symptoms, such as palpitations, weakness, which are accompanied by a feeling of death, fear of going crazy and losing control. It is not unusual that the thought of entering a situation that causes a phobia is sufficient to provoke anxiety.  Agoraphobia Fear of open spaces, fear of crowds, fear of leaving safe areas, fear of travelling alone on means of transport. The possibility of immediate escape is an essential feature of many varieties of agoraphobia. He regularly avoids such situations are generally avoided and a partner is needed in these situations. It begins at a young age, has a higher rate in women. Very often accompanied by panic attacks. Without treatment, the majority of agoraphobic patients reach complete social isolation, their suffering is severe and their quality of life is impaired. Agoraphobia and depression can often be pronounced simultaneously.  Specific phobia A phobia arises in a very specific situation, e.g. proximity to a specific animal, height, storm, flight, confined space, blood, injury... So the presence of a specific object or situation is important. Despite the fact that the triggering situation is so circumscribed, meeting with it can provoke panic sickness, otherwise it is characteristic to avoid the situation. They develop in childhood or early adulthood and can last for decades without treatment.  Social anxiety disorder Its main symptom is: constant and repeated fear of public situations or actions where you may be exposed to the attention or possible judgment of others (eating in a public place can be particularly disturbing). The patient is afraid that in such a situation he may find himself in an embarrassing, embarrassing or humiliating situation. Social situations therefore almost always provoke immediate anxiety, sometimes in the form of situational panic attacks. Fear is always associated with avoidant behaviour. Psychodynamic model of phobias Psychodynamic model It was formulated by Freud, who originally considered it anxiety hysteria. Parenting that severely punishes sexual and aggressive endeavors can also lead to phobic anxieties. Anxiety in early childhood affects later relationships, the child may gradually become dependent and withdrawn for fear of losing a loved one if his desires are fulfilled. To avoid dangers, the person operates defense mechanisms to protect himself by suppression, displacement, symbolization and avoidant behavior. Through displacement, anxiety of unknown origin is linked to a known object, therefore its condition becomes understandable thus tolerable for him, which creates the opportunity to avoid the source of anxiety.  Separation anxiety disorder Marked and excessive fear or anxiety about separation from specific attachment figures. /In the case of children, it is usually the parent, in adults, the focus is typically a romantic partner or children/ This includes thoughts that those affected may be harmed and nightmares about separation. Selective mutism Consistent selectivity in where (at home or school...) the affected child speaks. It must persist for at least a month. Obsessive-compulsive or related disorders (6B2) Compulsive (obsessive-compulsive) disorder Compulsive symptoms may occur in the behavior of any person. Rituals, but this does not mean illness (e.g. lucky objects, clothes in an exam situation) Compulsive compulsive disorder is a syndrome consisting of obsessions and/or compulsive actions that persists for at least two weeks and that compulsive symptoms occupy at least one hour a day, significantly hindering the person's daily life. Obsessions Recurrent, unpleasant thoughts, urges or images that cause anxiety or suffering. The patient tries to suppress it or neutralize it with other thoughts or actions. Patients recognize that they are products of his own psyche and do not come from outside. Most common compulsive thoughts: They are related to contamination (which leads to hygiene acts) Infection obsessions, Pathological doubt (caused by pathological sense of responsibility, external internal security, which triggers compulsions of control and counting) Obsessions associated with somatic symptoms, death, Compulsive thoughts about order and symmetry that lead to arrangement compulsions, Thoughts with aggressive content, which lead to compulsive acts of confession. Compulsions Repetitive behaviours (e.g. hand washing, sorting, checking) or mental rituals (praying, counting, silently repeating words), the exaggeration of which the patient is aware of. The purpose of compulsions is to reduce anxiety, suffering, or to prevent some dreaded event from occurring, while these behaviors have no real relation to the thing they are created to prevent. The patient is aware of the pathopathy of the symptoms, their insight of the disease is preserved. Most common compulsions: Cleansing and cleaning Coercive control action Compulsion of hoarding Counting symptoms Compulsion to ask questions Confession Related to symmetry, order, precision Types of compulsions: Restorative – is aimed at correcting a "problem" (e.g. washing dirt/grooming) – Preventive – to prevent future disasters (e.g. checking gas to prevent the house from exploding)  Compulsive disorder The constant or permanent presence of obsessions or compulsive actions, or both. They are intrusive, involuntary and generally anxiety- inducing in nature. Compulsions are ignored or neutralized by the person by performing compulsions. This may be following rigid rules or achieving "perfection". Symptoms occupy a significant part of waking time and cause considerable suffering. Epidemiology: Men and women get sick at equal rates, there is a difference between the sexes only at the beginning of the disease. In men, it starts on average between 11-18 years, in women often between 20-24 years, often after the first childbirth. Etiology: Psychodynamic The most important elements in the development of compulsive neurosis are regression to the anal-sadistic phase of psychosexual development, and also, ambivalence towards parents and their introjective counterparts. The individual tries to protect himself against anxiety with characteristic defense mechanisms: (displacement, making it not happen, reaction formation, isolating, turning it into opposition, intellectualization, rationalization). Learning theory Compulsive symptom is an active avoidance behavior given to anxiety, a learned form of behavior that is strengthened and fixed through its anti-anxiety effect.  Body dysmorphic disorder Persistent preoccupation with one or more perceived defects or flaws in appearance that are either unnoticeable or only slightly noticeable to others. Characterised by excessive self-consciousness. Diagnostic criteria: -Increased concerns about appearance -Preoccupation with one or more perceived defects or flaws of physical appearance (these are not or barely noticeable to others) repetitive behaviours related to appearance (repeated examination of the appearance in mirrors, excessive beautification, search for reassurance) -Constant comparison of appearance with others’ The symptoms are sufficiently severe to result in significant distress significant impairment in social, occupational or other important areas of functioning. The symptoms are not a manifestation of another health condition (e.g. weight or body fat concerns in case of an eating disorder) Marker: Muscular dysmorphia: too much preoccupation with your body structure (too small or not muscular enough).  Olfactory reference disorder Persistent preoccupation with the belief that one is emitting a perceived foul or offensive body odour or breath that is either unnoticeable or only slightly noticeable to others. Excessive self-consciousness about the perceived odour, with the conviction that people are judging Symptoms can result in marked avoidance of social situations.  Hypochondriasis The patient's physical feelings are misinterpreted, the desperate deal with the disease fills almost his entire life, his living space narrows and his performance decreases. Essentially unrealistic occupation with a disease. The patient is deeply convinced that he has a serious illness, despite the fact that the test results show the opposite. They consistently reject medical opinions, the psychic possibility of their complaints. Its course fluctuates, can last for months or years, there is a connection between psychosocial factors and the appearance of symptoms. Persistent preoccupation or fear about the possibility of having serious illnesses. Normal bodily sensations are overestimated and considered symptoms of illness. These complaints are usually localized to one organ or organ system. Key symptoms: specific cognitive schema of the disease, visceral sensitivity, prominent patient role behavior. It is difficult for him to get into emotional contact, he devalues the doctor, he often bears his illness conceited, despite his anxiety, he is almost proud that he cannot be cured.  Hoarding disorder Diagnostic criteria: -Persistent difficulty in throwing away objects -The suffering resulting from discharging, regardless of their value -The need to preserve objects -Significant accumulation of objects - Living spaces becoming cluttered to the point that their use is compromised - Negatively affects social, workplace and other important areas Hoarding can not be attributed to any other health condition The symptoms are not better explained by another mental disorder  Scratching disorder Repetitive and harmful scratching behaviour directed at the patient’s own skin, accompanied by unsuccessful attempts to decrease or stop the behaviour involved. Most often scratched areas: face, arms, hands. The symptoms result in significant distress. Disorders specifically associated with stress (6B4) A necessary condition for the diagnosis of disorders in this group is an identifiable stressor (but not all individuals exposed to stress develop the disease). Stressor: Stress is the response of the whole organism to a stimulus called a stressor. It usually causes a negative reaction (distress). (But there is also good stress (eustress) that does not inhibit performance). Trauma: An emotional response that a person produces after a serious event or emotional shock and denial after the event. Later reactions may include flashbacks, alienation and physical symptoms such as headache and nausea. Traumatic stressor: The person has experienced, witnessed or faced an event in which there was a real or imminent death, serious injury, endangerment of his/her own or others' physical integrity (accident, disaster, violent crime, sexual molestation...) The person reacted to this with intense fear, helplessness or terror.  Post-traumatic stress disorder(PTSD) PTSD is a characteristic symptomatology that develops following exposure to an event related to an extremely traumatic stressor. An individual's reactions involve intense fear, helplessness, and terror (or disorganized or agitated behavior). Symptoms developed as a result of extreme trauma typically include:: re-experiencing the traumatic event Persistent avoidance persistent, enhanced alert. Epidemiology: 60-70% of the average population suffers some form of trauma, but does not develop acute or post- traumatic symptoms. (average population: 7.8%, standard deviation: 0.6-43.8%). Annual prevalence: 1.1%. Male : female = 1 : 2. Etiology: PTSD is actually a natural reaction to an abnormal event, where previous coping strategies may have been effective for milder stress, but now tend to perpetuate symptoms. The experience of trauma floods the consciousness to such an extent that unprocessed memories and fragments of memory begin to live an "independent" life, i.e. they are easily triggered by any similar stimulus, i.e. they invite the experience of trauma into consciousness. Genetic factors: max. 30% Coping depends on vulnerability and resilience.  Complex post-traumatic stress disorder A disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, from which escape is difficult or impossible (e.g. torture, genocide campaigns, repeated childhood sexual or physical abuse). All diagnostic requirements for PTSD are met: – re- experiencing, avoidance, constant feeling of threat! Additional symptoms: Self-disorganization (DSO) symptom group: severe emotion regulation disorder negative self-image: extensive feelings of shame, guilt or failure difficulties in sustaining relationships and in feeling close to others  Prolonged grief disorder persistent and pervasive grief response (sadness) to the loss or death of a close person (parent, child, partner...) characterized by constant preoccupation with the deceased person. difficulty accepting the death, an inability to experience positive mood difficulty in engaging with social or other activities Duration is critical: more than 6 months at a minimum Characteristic feelings: sadness, guilt, anger, denial, self- blame, search of responsibility  Adjustment disorder Characterized by maladaptive reaction to a identifiable psychosocial stressors (e.g. divorce, disability, unemployed status, socio-economic problems, relationship conflicts) Symptomatic criteria: A) Development of emotional or behavioral symptoms in response to identifiable stressors within 3 months of the onset of the stressor. B) Symptoms are clinically significant because – disproportionate to the severity of the stressor, – cause impairment of social, work or other important areas of functioning. C) The symptoms are not a manifestation of another health condition D) Symptoms are not manifestations of normal grief. E) After the stressor or its consequences have resolved, symptoms persist for a maximum of 6 months.  Reactive attachment disorder Grossly abnormal attachment behaviours in early childhood, occurring in the context of a history of grossly inadequate child care (e.g., severe neglect…). The disorder cannot be diagnosed before the age of less than 9 months or above 5 years of age! Diagnostic criteria: A) Inhibited, emotionally withdrawn permanent behavior pattern towards adult caregivers, manifested by the following 2 symptoms: - the child hardly ever turns to the primary caregiver for comfort; - rarely responds when comfort is offered. B) Persistent social and emotional disorder: minimal emotional responsiveness, few positive emotions, unexplained irritability and fear C) The child receives insufficient care: neglect / frequent alternation of caregivers D) Autism spectrum disorder diagnosis can be ruled out.  Disinhibited social engagement disorder Symptomatic picture: A) A pattern of behavior in which the child approaches adults indiscriminately, and interacts with strangers (min. 2 symptoms):-lacks reticence to approach, -overly familiar verbal/physical behaviour;- distancing from an adult caregiver and not paying any attention to them -tends to come into contact with strangers. B) Criterion A is not a consequence of ADHD C) A history of grossly inadequate child care (e.g., severe neglect, frequent alternation of caregivers) Dissociative disorders (6B6) Definition of dissociation: Involuntary disruption or discontinuity in the normal integration of one or more of the following: memories, awareness, identity, affective states, perceptions, bodily experience, motor control, or behaviour. The behavior becomes disorganized. Self-identity disappears entirely or partly. Psychogenic origin! Hypnosis: The weakness of self-regulation of personality stands out artificially induced dissociative state! Likelihood of trauma impact! Abrupt start and end of symptoms Dissociative neurological symptom disorder Presentation of motor, sensory, or cognitive symptoms that imply an involuntary discontinuity in the normal integration of these functions and are not consistent with a recognised disease of the nervous system, other mental or behavioural disorder, or other medical condition. The symptoms do not occur exclusively during another dissociative disorder and are not due to the effects of a substance or medication on the central nervous system, including withdrawal effects, or a Sleep- Wake disorder. Includes: Dissociative neurological symptom disorder, with visual disturbance Dissociative neurological symptom disorder, with auditory disturbance Dissociative neurological symptom disorder, with vertigo or dizziness Dissociative neurological symptom disorder, with other neurological disturbance Dissociative neurological symptom disorder, with non-epileptic seizures Dissociative neurological symptom disorder, with speech disturbance Dissociative neurological symptom disorder, with paresis or weakness Dissociative neurological symptom disorder, with gait disturbance Dissociative neurological symptom disorder, with movement disturbance Dissociative neurological symptom disorder, with chorea (involuntary bodily movement) Dissociative neurological symptom disorder, with myoclonusokkal (izom, vagy izomcsoport akaratlan rángatózása) Dissociative neurological symptom disorder, with tremors Dissociative neurological symptom disorder, with dystonia (abnormal muscle contractions) Dissociative neurological symptom disorder, with spasm of mimic muscles Dissociative neurological symptom disorder, with Parkinsonism Dissociative neurological symptom disorder, with unspecified symptoms Dissociative neurological symptom disorder, with cognitive symptoms Dissociative neurological symptom disorder, with other specified symptoms  Dissociative amnesia The cardinal symptom is that memory(memories) of an important event are lost and the disorder is not better explained by an organic condition or the effect of a psychoactive substance. Memory loss due to psychological causes (psychogenic amnesia), which cannot be explained by organic causes. The inability to periodically recall stored memories, lasting hours to days, is not uncommon. The memories are usually related to traumatic experiences in an individual's life. And the problem of recall cannot be explained by ordinary forgetfulness. In most cases, it dissolves spontaneously. The focus is on some traumatizing event. The patient's memory is retained in other respects.  Trance disorder Trance states in which there is a marked alteration in the individual’s state of consciousness or a loss of the individual’s customary sense of personal identity A narrowing of consciousness. Időszakosan megszűnik a személyi identitás érzése és a környezettel kapcsolatos tudatosság A state of consciousness induced by autohypnosis or suggestion, in which the sense of personal identity temporarily decreases or disappears, the individual comes under the power of some external force. Visual hallucinations may occur. Among the triggers, coercion is in the foreground.  Possession (trance) disorder A trance disorder in which an individual experiences that their personal identity is "possessed from the outside” the individual’s behaviours or movements are experienced as being controlled by the possessing agent. Diagnosis is based on an episode that has lasted for at least several days.  Dissociative identity disorder there are two or more distinct personalities, which, at the time of their presence, determine the behavior and attitudes of the individual. The course of the disease is chronic, and in the absence of appropriate therapeutic interventions recovery is rare. Chaotic lifestyle, promiscuity, addiction, suicidal attempts are common, boys tend to be antisocial. In other cases, reclusive, infantile behavior is in the foreground. The shift is sudden, personality variants mostly appear independently of each other, but they may also know about each other. Unexpected, stressful events can provoke a shift. Typically, each personality is integrated, with individual memories, personal attitudes and patterns of behavior. In some cases, memories remain, in other cases personalities leave amnesia.  Partial dissociative identity disorder One of the two or more personality states is dominant and normally functions in daily life, but is intruded upon by one or more non-dominant personality states (affective, cognitive or behavioural). They are experienced as interfering with the functioning of the dominant personality state and are typically aversive. These intrusion episodes are occasional, limited and excessively transient. Depersonalization-derealization disorder persistent or recurrent experiences of depersonalization, derealization (or both). Depersonalization: experiencing the self as strange or unreal, or feeling detached from, or as though one were an outside observer of, one’s thoughts, feelings, sensations, body, or actions. (e.g. perceptual changes, distorted sense of time, unreal or missing self, emotional and/or physical paralysis, near-death experiences. Derealization: experiencing the environment as strange or unreal (experiencing people or objects as dreamlike, distant, foggy, lifeless, colourless, or visually distorted) or feeling detached from one’s surroundings. During experiences of depersonalization or derealization, reality testing remains intact. Other specified dissociative disorders Ganser's syndrome A special, hysterical, foggy state. The patient seems to understand the questions, but gives incorrect but realistic answers (2+2=5) It occupies a position between psychosis and neurosis, or between illness and pretense. It is characterized by a certain change in personality, a desire- fulfilling recoloring of the world and changes in cognitive functions. Infantile behavior is typical. The condition lasts from hours to days and is followed by amnesia after clearing. It occurs mainly in total institutions (prison, military...). In these places, it often serves to get out of an unacceptable situation (prison hospital, infirmary)). Epidemiology and etiology of dissociative disorders Epidemiology Dissociation is independent of gender, marital status, nationality or education, but is only related to age, in such a way that it decreases with age. Dissociation is generally more common than Janet thought, with about 3% of the population exhibiting severe dissociative disorders and around 1% showing Dissociative Identity Disorder. Etiology Tarumatic experiences play a decisive role! Dissociation is a mechanism that protects the individual from external circumstances that burden him, spares him from internal tensions that feel unbearable, and serves the individual's unconscious need for dependence in regulating the relationship with his environment. Conflicting, unacceptable memories, urges and conflicts for the individual are disconnected from the conscious self-image. An extreme form of this is the multiplication of personality. Under the influence of a traumatic experience, dissociation is adaptive, but in the long run, due to lack of integration, it becomes maladaptive. Feeding or eating disorders (6B8) Abnormal feeding or eating behaviours that are not explained by another health condition and are not a developmental disorder and not a cultural or religious requirement. Eating disorders are linked to constant worries about weight and body image, but feeding disorders are not. Eating disorders Eating disorders are typically diseases of young girls. Anorexia nervosa usually begins at 12 to 18 years of age, and bulimia nervosa at 17 to 25 years of age. Bulimia is 2-3x more common than anorexia. In teenagers, anorexia is the third most common disease after obesity and bronchial asthma. Eating disorders are diseases of the upper and middle social classes. Groups at increased risk are students, groups with the requirement of slimness, people with diabetes mellitus, homosexuals in men. Regarding comorbidities, depression can be highlighted, and the prevalence of obsessive compulsive disorder, social phobia, alcoholism and drug use is also high. In bulimia nervosa, suicidal trials occur in 20-30% of patients. Psychoanalytic theories Eating disorders can also be interpreted as oral regression, bulimic symptoms may correspond to the oral-sadistic phase, while symptoms of anal regression may also be present, such as laxatives or compulsive, perfectionist personality. Pathological mother-child relationships may also be indicated by abnormalities in infant feeding. Cognitive-behaviorist models They emphasize the importance of cognitive deficits and body image disorders. The family dynamics model Family reporting of symptoms based on a systemic view (refusal to eat can often be a manifestation of defiance within the family. The family environment is characterized by the tension that exists between the patient and other family members.  Anorexia Nervosa It is characterized by voluntary weight loss, which is started and maintained by the patient. Most common among adolescent girls and young women. Body weight is 15% less than ideal (20% in adolescents), body mass index is 18.5 or less. Adolescent patients do not always reach the desired body weight during growth. can be characterized by: Self-induced weight loss, avoidance of fatty foods + intense exercises, self-vomiting, laxative, appetite suppressants, as well as the use of diuretics. A disorder of the body schema can be observed, which shows a definite psychopathological picture, fear of fatness, inadequate body proportions, as an overvalued thought. Many endocrine abnormalities can be detected as hypothalamic-pituitary- gonada axis, which can also manifest itself in the form of amenorrhea. The level of growth hormone, cortisol, may increase. If it is started before puberty, then puberty is delayed or may even be missed.  Bulimia nervosa Characterized by binge eating accompanied by behaviour aimed at preventing weight gain. The age and gender distribution is similar, but starts slightly later than AN. Confusion can also be seen as a continuation of AN. At first, AN seems to improve, menstruation returns, the patient's body weight increases, but later the harmful behavior pattern associated with overeating and vomiting becomes more stable. During repeated vomiting, ionic imbalance and bodily complications (tetanic spasm, occasional convulsions, cardiac rhythm disorder, muscle weakness) and later severe weight loss may develop. Persistent preoccupation with eating, and an irresistible craving for food, the patient has periods of gobbling, when he eats huge amounts of food in a short period of time. The patient wants to avoid the fattening effect of food by the following methods: self- induced vomiting, laxatives, fasting, appetite suppressant drugs, diuretics. From psychopathology should be highlighted the fear of obesity, the patient precisely determines the limit of his body weight for himself. It is often, but not always, preceded by an episode of anorexia nervosa.  Binge eating disorder Frequent, recurrent episodes of binge eating (e.g. once a week or more over a period of several months). A subjective loss of control over eating, patient is unable to stop eating or limit the type or amount of food eaten. As a result, the amount of consumed food is significantly more than necessary. Experienced as very distressing, and is often accompanied by negative emotions such as guilt or disgust. binge eating episodes are not regularly followed by compensatory behaviours (e.g. self-induced vomiting).  Avoidant-restrictive food intake disorder It is an abnormal idea that a diet that is insufficient in quantity or variety will provide it with adequate energy. It is associated with significant weight loss, but there are no weight or shape concerns. Pica Requiring and regularly consuming inedible materials (e.g. earth, paint, paper, stone, hair) or raw food ingredients (e.g. salt, cornmeal...). The affected person is able to distinguish edible from inedible. Rumination-regurgitation disorder Intentional and repeated bringing up of previously swallowed food back to the mouth (i.e., regurgitation), which may be re-chewed and re-swallowed (i.e. rumination), or may be deliberately spat out (but not as in vomiting!). behaviour is frequent (at least several times per week) and sustained over a period of at least several weeks. Elimination disorders (6C0) Includes voiding of urine into clothes or bed (enuresis) and the repeated passage of faeces in inappropriate places (encopresis). The disorder should only be diagnosed after the individual has reached 5 years of age for enuresis and 4 years for encopresis. Enuresis Types: Diurnal (enuresis diurna) Nocturnal (enuresis nocturna) Primary: before toilet independence has been achieved Secondary: after toilet independence has been achieved, and abrupt urination problems are formed. Encopresis inappropriate passage of faeces. Relatively rare (more common in boys). Disorders of bodily distress or bodily experience (6C2) Ide tartoznak a saját testtel kapcsolatos, rendkívül fájdalmas tapasztalatok, amik teljesen lekötik az érintett figyelmi kapacitását. Bodily distress disorder Mértéktelen figyelemmel kísért testi tünet jellemző, amivel ismételten felkeresi az egészségügyi ellátórendszert. A kivizsgálások, orvosi vélemények nem enyhítenek a szenvedésén a betegnek. A testi tünetek állandóak, szinte mindennap megjelennek, több hónapon át. Lehet enyhe, mérsékelt, vagy súlyos. Body integrity dysphoria Korai kamaszkortól jellemző, intenzív vágyakozás, hogy komoly mozgássérültté váljon az egyén. (pl.: végtag amputálása). Diszkomfort érzete van, mert nem sérült. Előfordulhatnak kísérletek, hogy megsérüljön. Disorders due to substance use or addictive behaviours (6C4) Mental and behavioural disorders that develop as a result of the use of predominantly psychoactive substances, including medications, or specific repetitive rewarding and reinforcing behaviours. Basic concepts of addictology Addiction: Compulsive behaviour of seeking substances or situations of excitement equivalent to substance abuse and consumption of psychoactive substances, characterized by an insurmountable desire for the drug's effects and a strong tendency to relapse after withdrawal. (psychoactive substances displace natural enhancers from the consumer's life over time). The time allotted for obtaining and consuming these substances dominates a significant part of the waking time. An important consequence of regular consumption is addiction. Tolerance: decrease in the effect of a particular drug during continuous consumption. Sensitization: Increase in the effect of the agent due to repeated administration. Dependence: It means uncomfortable discarding of substances, i.e. substance dependence, the physiological and psychological forms of which are distinguished. A well-captured clinical characteristic is the appearance of withdrawal symptoms. Some drugs have the ability to alleviate symptoms that occur during withdrawal from other drugs. Three broad groups of psychoactive substances can be distinguished: Psychostimulants: cocaine, amphetamines and nicotine Hallucinogens: LSD, mescaline, psilocybin Depressants of the central nervous system: alcohol, opioids, benzodiazepines and Subcategories in disorders caused by psychoactive substances Alcohol Cannabis Synthetic cannabinod Opioids sedatives, hypnotics, anxiolytics Cocaine Stimulants (amphetamine, methamphetamine, methcathinone) synthetic cathinon Caffeine Hallucinogens Nicotine Volatile inhalants MDMA Dissociative grugs (ketamine, PCP) Other psychoactive substances (including medications) Multiple specified psychoactive substances Unknown psychoactive substances Non-psychoactive substances Categories to register: Abuse Continued abuse Dependency with current usage Dependence, early complete remission Dependence, partial remission Dependence, complete remission Withdrawal, simple course Withdrawal with perceptual disorders Withdrawal, with seizures Withdrawal with mixed symptoms Withdrawal, with psychotic disorders, hallucinations Withdrawal, with psychotic disorders, delusions Withdrawal, psychotic disorders, mixed Withdrawal, with mood disorders Withdrawal, with anxiety disorders Withdrawal with compulsive disorders Withdrawal, with impulse control disorder Disorders due to addictive behaviours (6C5) Clinical syndromes associated with distress or interference with personal functions that develop as a result of behaviours other than the use of dependence- producing substances. The behavior is recurrent and addiction develops. May involve both online and offline behaviour.  Gambling disorder characterised by a pattern of persistent or recurrent gambling behaviour, which may be online (i.e., over the internet) or offline. Manifested by: Impaired control over gambling (frequency, intensity, duration, termination, context) Narrowed life space Continuation of gambling despite the occurrence of negative consequences. Gaming disorder A pattern of persistent or recurrent gaming behaviour performed mostly online (video-gaming Manifested by: Impaired control over gambling (frequency, intensity, duration, termination, context) Narrowed life space Continuation of gambling despite the occurrence of negative consequences. Impulse control disorders(6C7) A common characteristics is the repeated failure to resist an impulse, drive, or urge to perform an act that is rewarding to the person in the short term, but has consequences such as harm either to the individual or to others  Pyromania Deliberate and purposeful multiple acts of setting fire. There is an increasing sense of tension or affective arousal prior to instances of fire setting, fascination or preoccupation with fire and firefighting, and a sense of pleasure, excitement, relief or gratification during, and after the act of setting the fire. Preparations are made for lighting a fire. An apparent motive of monetary gain, political statement, sabotage or attracting attention/fame is an exclusion criterion. Kleptomania Characterized by theft of items worthless or unnecessary for the patient. They could usually afford the purchase. Increasing tension before stealing, gratification after. They don't plan it or involve others. Compulsive sexual behavior disorder Persistent pattern of failure to control intense, repetitive sexual impulses or urges. Repetitive sexual activities become a central focus of the person’s life to the point of neglecting health and personal care (e.g. lack of protection). Manifested over 6 months or more, and causes marked distress in areas of functioning. Intermittent explosive disorder A failure to control aggressive impulses (repeated brief episodes of verbal or physical aggression or destruction of property, e.g. objects), with the intensity of the outburst or degree of aggressiveness being grossly out of proportion to the provocative stimulus (precipitating psychosocial stressors). Disruptive behaviour or dissocial disorders (6C9) These behavior problems are characterized by markedly and persistently defiant, disobedient, provocative or spiteful (i.e., disruptive) behaviours to those that persistently violate the basic rights of others or societal norms, rules, or even laws (i.e., dissocial). Onset is commonly, though not always, during childhood.  Oppositional defiant disorder Markedly defiant, disobedient, provocative or spiteful behaviour that has been detectable for at least 6 months, directed against peers, and is not restricted to interaction within the family. May be manifest in prevailing, persistent angry or irritable mood, often accompanied by severe temper outbursts. The behaviour pattern is of sufficient severity to result in significant impairment in areas of functioning. In this section: -Oppositional defiant disorder with chronic irritability-anger -Oppositional defiant disorder with chronic irritability-anger, with limited prosocial emotions -Oppositional defiant disorder with chronic irritability-anger, with typical prosocial emotions -Oppositional defiant disorder with chronic irritability-anger, unspecified -Oppositional defiant disorder with chronic irritability, without anger -Oppositional defiant disorder with chronic irritability, without anger with limited prosocial emotions -Oppositional defiant disorder with chronic irritability, without anger and with typical prosocial emotions -Oppositional defiant disorder without chronic irritability-anger, unspecified  Conduct dissocial disorder Characterized by aggression towards people or animals; destruction of property; deceitfulness or theft; and serious violations of rules. The basic rights of others are violated. The patient is unable to conform to social norms by obeying the law, so he repeatedly commits acts for which he is punished. Tendency to cheat, lie repeatedly, deceive others for personal gain or pleasure. Impulsivity or lack of foresight. Irritability, aggressiveness resulting in repeated brawls, attacks. Disregard of one's own safety or that of others. Stubborn irresponsibility, which entails a violation of ongoing work or financial obligations. Lack of remorse. Isolated dissocial or criminal acts are not in themselves grounds for the diagnosis. In this section : -Conduct-dissocial disorder, childhood onset - Conduct-dissocial disorder, childhood onset, with limited prosocial emotions - Conduct-dissocial disorder, childhood onset, with typical prosocial emotions - Conduct-dissocial disorder, childhood onset, unspecified - Conduct-dissocial disorder, adolescent onset (No features of the disorder are present prior to 10 years of age!) - Conduct-dissocial disorder, adolescent onset, with limited prosocial emotions - Conduct-dissocial disorder, adolescent onset, with typical prosocial emotions - Other specified conduct-dissocial disorder, adolescent onset Conduct-dissocial disorder, adolescent onset, unspecified Other specified conduct-dissocial disorder Conduct-dissocial disorder, unspecified Personality disorders and related traits (6D1) problems in functioning of aspects of the self, e.g. identity, self-worth, accuracy of self-view, self-direction, and, as a result, interpersonal dysfunction. The disturbance is manifest in several areas: patterns of cognition, emotional experience, and behaviour that are maladaptive and is manifest across a range of personal and social situations. The disorder have persisted over an extended period of time, 2 years or more. The patterns of behaviour characterizing the disturbance are not developmentally appropriate and cannot be explained by social or cultural factors. The disturbance is associated with substantial distress or significant impairment in several areas of functioning. The division of personality disorders has undergone significant changes in ICD-11, so it is worth reviewing it on the basis of ICD-10 and DSM-IV and DSM-5: Degree of severity Mild personality disorder (the disorder affects only some areas of personality functioning, other areas are intact) Moderate personality disorder. Severe personality disorder Personality disorder, severity unspecified Prominent personality traits or patterns Characteristics of the individual’s personality that are most prominent and that contribute to personality disturbance. It can only be coded with the addition of severity categories! Negative affectivity in personality disorder or personality difficulty The core feature is the tendency to experience a broad range of negative emotions, associated with poor emotion regulation; negativistic attitudes; low self-esteem and self-confidence; and mistrustfulness. Detachment in personality disorder or personality difficulty It manifests in two dimensions: social and emotional distance/detachment Dissociality in personality disorder or personality difficulty Disregard for the rights and feelings of others and lack of empathy associated with self-centeredness. Prominent personality traits or patterns Disinhibition in personality disorder or personality difficulty Lényege a hajlam a hirtelen cselekvésre, a belső (gondolati, érzelmi) állapot és a külső következmények megfontolása nélkül. Ide tartozó vonások: impulzivitás, terelhetőség, felelőtlenség, vakmerőség, tervezés hiánya. Anankastia in personality disorder or personality difficulty A narrow focus on one’s rigid standards in making judgements and on controlling behaviour to follow (one’s own and others’) and inflexibility. Also, a sense of duty, an extreme hyper-scheduling of things that kills spontaneity. Orderliness is very pronounced. Borderline pattern A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity. Further characteristics: Frantic efforts to avoid real or imagined abandonment; immediate reaction to strong negative emotions, potentially adverse behaviors, self-harm, chronic feeling of inner emptiness, inadequate anger management, transient dissociative symptoms or psychotic-like features Based on ICD-10 Disorders of adult personality and behaviour (F60-F69) A persistent disorder of experience and behavior that deviates from the norms of a particular culture. This pattern manifests itself in at least two of the following areas: 1.) Cognitive 2.) Affective 3.) Interpersonal relationships 4.) Impulsivity Types Eccentrics /A-cluster/: paranoid, schizoid, schizotypic Dramatics /B-cluster/: antisocial, borderline, histrionic, narcissistic Anxious /C-cluster/: compulsive, anxious, dependent Paranoid personality disorder From early adulthood, in many different situations, general distrust and suspicion of others, so that their motives are interpreted as malicious. 4 or more of the following: suspiciousness and a tendency to distort experience by misconstruing the actions of others as hostile or contemptuous suspiciousness, without justification, regarding the fidelity and reliability of the friends or relatives distrust of others Attributing benign comments or events to hidden malice or threats. Persistent resentment, that is, unforgiveness of insults, hurt or neglect. He perceives and quickly reacts to attacks on his person or honor with anger that others do not consider obvious. recurrent suspicions, without justification, regarding the sexual fidelity of the spouse or sexual partner Schizoid personality disorder From early adulthood, a general characteristic manifested in withdrawal from social relationships and interpersonal narrowness of emotional expression in many different situations. withdrawal from affectional, social and other contacts with preference for fantasy, solitary activities, and introspection. There is a limited capacity to express feelings and to experience pleasure. 4 or more of the following: Close social relationships, including family relationships, are neither desired nor enjoyed. solitary activities little sexual interest in another person, if any. There is a limited capacity to experience pleasure. Apart from his immediate relatives, he has no close confidants or friends. Indifferent to praise or criticism of others. Emotionally, it is characterized by coldness, seclusion or bleak affects. Histrionic per