Psychiatric Foundations Chapter 5 - Mental Disorders PDF

PSYCHIATRIC FOUNDATIONS The fifth chapter introduces you to the different mental disorders, factors that put an individual at risk of having mental disorder, and the available treatment. At the end of the chapter, the students are expected to: 1. Discuss the clinic...

PSYCHIATRIC FOUNDATIONS The fifth chapter introduces you to the different mental disorders, factors that put an individual at risk of having mental disorder, and the available treatment. At the end of the chapter, the students are expected to: 1. Discuss the clinical manifestation of mental disorders 2. Discuss the treatment methods used to treat mental disorders Activity 1: List as many mental disorders as you can and discuss manifestations that you know. MENTAL DISORDERS Mental disorders are diseases that affect cognition, emotion, and behavioral control and substantially interfere both with the ability of children to learn and with the ability of adults to function in their families, at work, and in the broader society. Mental disorders tend to begin early in life and often run a chronic recurrent course. They are common in all countries where their prevalence has been examined. Because of the combination of high prevalence, Paul Cresencio R. Liberato early onset, persistence, and impairment, mental disorders make a major contribution to total disease burden. Although most of the burden attributable to mental disorders is disability related, premature mortality, especially from suicide, is not insignificant. ETIOLOGIES Mental disorders have complex etiologies that involve interactions among multiple genetic and nongenetic risk factors. Gender is related to risk in many cases: males have higher rates of attention deficit hyperactivity disorder, autism, and substance use disorders; females have higher rates of major depressive disorder, most anxiety disorders, and eating disorders. Biochemical and morphological abnormalities of the brain associated with schizophrenia, autism, mood, and anxiety disorders are being identified using approaches such as postmortem analysis and noninvasive neuroimaging. Major worldwide efforts under way to identify risk-conferring genes for mental disorders are proving challenging, but initial results are promising. Identifying the gene or genes causing or creating vulnerability for a disorder should help us understand what goes wrong in the brain to produce mental illness and should have a clinical effect by contributing to improved diagnostics and therapeutics (Hyman 2000). Twin studies make it clear that environmental risk factors also play an important role in mental disorders; concordance for disease among identical twins, although substantially higher than among nonidentical twins, is still well below 100 percent (Kendler and others 2003). However, as is the case for genetic factors, investigation of environmental risk factors has proved difficult. For schizophrenia, where nongenetic components of risk may include obstetrical complications and season of birth (Mortensen and others 1999), perhaps as a proxy for infections early in life, research has been hampered by the modest proven effect of the nongenetic risk factors identified to date. For depression, anxiety, and substance use disorders, where environmental risk factors are more robust, adverse circumstances associated with risk, such as early childhood abuse, violence, poverty, and stress (Patel and Kleinman 2003) correlate with multiple disorders and could be affected by selection bias as well as by bias associated with self-reporting. Generalizable, prospective cross-cultural studies are needed to delineate nongenetic risk factors more clearly. Posttraumatic stress disorder (PTSD) is the mental disorder for which clear environmental triggers are best documented. Even here, though, enormous interindividual variability occurs in the threshold of stress severity associated with PTSD as well as in the evidence from twin studies of genetic influences on stress reactivity in triggering PTSD. Paul Cresencio R. Liberato  DIAGNOSTIC CRITERIA OF MENTAL DISORDERS Neurodevelopmental Disorders These disorders are usually first diagnosed in infancy, childhood, or adolescence. A. Intellectual Disability or Intellectual Developmental Disorder (previously called Mental Retardation in DSM-IV). Intellectual disability (ID) is characterized by significant, below average intelligence and impairment in adaptive functioning. Adaptive functioning refers to how effective individuals are in achieving age-appropriate common demands of life in areas such as communication, self-care, and interpersonal skills. In DSM-5, ID is classified as mild, moderate, severe, or profound based on overall functioning; in DSM-IV, it was classified according to intelligence quotient (IQ) as mild (50–55 to 70), moderate (35–40 to 50–55), severe (20–25 to 35–40), or profound (below 20–25). A variation of ID called Global Developmental Delay is for children under 5 years with severe defects exceeding those above. B. Communication Disorders. There are four types of communication disorders that are diagnosed when problems in communication cause significant impairment in functioning: (1) Language Disorder is characterized by a developmental impairment in vocabulary resulting in difficulty producing age appropriate sentences; (2) Speech Sound Disorder is marked by difficulty in articulation; (3) Childhood- Onset Fluency Disorder or Stuttering is characterized by difficulty in fluency, rate and rhythm of speech; and (4) Social or Pragmatic Communication Disorder is profound difficulty in social interaction and communication with peers. C. Autism Spectrum Disorder. The autistic spectrum includes a range of behaviors characterized by severe difficulties in multiple developmental areas, including social relatedness, communication, and range of activity and repetitive and stereotypical patterns of behavior, including speech. They are divided into three levels: Level 1 is characterized by the ability to speak with reduced social interaction (this level resembles Asperger’s disorder which is no longer part of DSM-5); Level 2 which is characterized by minimal speech and minimal social interaction (diagnosed as Rett’s disorder in DSM-IV, but not part of DSM-5); and Level 3, marked by a total lack of speech and no social interaction. D. Attention-Deficit/Hyperactivity Disorder (ADHD). Since the 1990s, ADHD has been one of the most frequently discussed psychiatric disorders in the lay media because of the sometimes-unclear line between age-appropriate normal and disordered behavior and because of the concern that children without the disorder are being misdiagnosed and treated with medication. The central features of the disorder are persistent Paul Cresencio R. Liberato  inattention, or hyperactivity and impulsivity, or both, that cause clinically significant impairment in functioning. It is found in both children and adults. E. Specific Learning Disorders. These are maturational deficits in development that are associated with difficulty in acquiring specific skills in reading (also known as dyslexia); in written expression; or in mathematics (also known as dyscalculia). F. Motor Disorders. Analogous to learning disorders, motor disorders are diagnosed when motor coordination is substantially below expectations based on age and intelligence, and when coordination problems significantly interfere with functioning. There are three major types of motor disorders: (1) Developmental Coordination Disorder is an impairment in the development of motor coordination, for example, delays in crawling or walking, dropping things, or poor sports performance; (2) Stereotypic Movement Disorder consists of repetitive motion activity, for example, head banging and body rocking; and (3) Tic Disorder is characterized by sudden involuntary, recurrent, and stereotyped movement or vocal sounds. There are two types of tic disorders: the first is Tourette’s Disorder, characterized by motor and vocal tics including coprolalia, and the second is Persistent Chronic Motor or Vocal Tic Disorders marked by a single motor or vocal tic. Schizophrenia Spectrum and Other Psychotic Disorders It includes schizophrenia and other psychotic disorders such as eight specific disorders (schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, substance/medication induced psychotic disorder, psychotic disorder due to another medical condition, and catatonia) in which psychotic symptoms are prominent features of the clinical picture. Substance/Medication-Induced Psychotic Disorder These are disorders with symptoms of psychosis caused by psychoactive or other substances, for example, hallucinogens, cocaine. Psychotic Disorder Due to Another Medical Condition This disorder is characterized by hallucinations or delusions that result from a medical illness, for example, temporal lobe epilepsy, avitaminosis, meningitis. Bipolar and Related Disorders Bipolar disorder is characterized by severe mood swings between depression and elation and by remission and recurrence. There are four variants: bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder due to substance/medication or another medical condition. A. Bipolar I Disorder. The necessary feature of bipolar I disorder is a history of a manic or mixed manic and depressive episode. Paul Cresencio R. Liberato  B. Bipolar II Disorder. Bipolar II disorder is characterized by a history of hypomanic and major depressive episodes. C. Cyclothymic Disorder. This is the bipolar equivalent of dysthymic disorder. Cyclothymic disorder is a mild, chronic mood disorder with numerous depressive and hypomanic episodes over the course of at least 2 years. D. Bipolar Disorder Due to Another Medical Condition. Bipolar disorder caused by a general medical condition is diagnosed when evidence indicates that a significant mood disturbance is the direct consequence of a general medical condition, for example, frontal lobe tumor. E. Substance/Medication-Induced Bipolar Disorder. Substance-induced mood disorder is diagnosed when the cause of the mood disturbance is substance intoxication, withdrawal, or medication, for example, amphetamine. Depressive Disorders Depressive disorders are characterized by depression, sadness, irritability, psychomotor retardation and, in severe cases, suicidal ideation. A. Major Depressive Disorder. The necessary feature of major depressive disorder is depressed mood or loss of interest or pleasure in usual activities. B. Persistent Depressive Disorder or Dysthymia. Dysthymia is a mild, chronic form of depression that lasts at least 2 years, during which, on most days, the individual experiences depressed mood for most of the day and at least two other symptoms of depression. C. Premenstrual Dysphoric Disorder. Premenstrual dysphoric disorder occurs about 1 week before the menses and is characterized by irritability, emotional lability, headache and anxiety or depression that remits after the menstrual cycle is over. D. Substance/Medication-Induced Depressive Disorder. This disorder is characterized by a depressed mood that is due to a substance, for example, alcohol or medication, for example, barbiturate. E. Depressive Disorder Due to Another Medical Condition. This condition is a state of depression secondary to a medical disorder, for example, hypothyroidism, Cushing’s syndrome. F. Other Specified Depressive Disorder. This diagnostic category includes two subtypes: (1) Recurrent Depressive Episode which is a depression that lasts between 2 and 13 days and that occurs at least once a month; and (2) Short-Duration Depressive Episode which is a depressed mood lasting from 4 to 14 days and which is nonrecurrent. G. Unspecified Depressive Disorder. This diagnostic category includes four major subtypes: (1) Melancholia which is a severe form of major depression characterized by hopelessness, anhedonia, psychomotor retardation, and which also carries with it a high risk of suicide; (2) Atypical Depression which is marked by a depressed mood that is associated with weight gain instead of weight loss and with hypersomnia instead of insomnia; (3) Peripartum Depression is a depression that occurs around parturition, or within 1 month after giving birth (called postpartum depression in DSM-IV); and (4) Seasonal Pattern which is a depressed mood that occurs at a particular time of the year, usually winter (also known as seasonal affective disorder [SAD]). Paul Cresencio R. Liberato  H. Disruptive Mood Dysregulation Disorder. This is a new diagnosis listed as a depressive disorder which is diagnosed in children over age 6 and under age 18 and is characterized by severe temper tantrums, chronic irritability, and angry mood. Anxiety Disorders Anxiety disorders includes nine specific disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder or social phobia, generalized anxiety disorder, anxiety disorder caused by a general medical condition, and substance-induced anxiety disorder) in which anxious symptoms are a prominent feature of the clinical picture. Obsessive-Compulsive and Related Disorders There are eight categories of disorders, all of which have associated obsessions (repeated thoughts) or compulsions (repeated activities). A. Obsessive Compulsive Disorder (OCD). OCD is characterized by repetitive and intrusive thoughts or images that are unwelcome (obsessions) or repetitive behaviors that the person feels compelled to do (compulsions), or both. B. Body Dysmorphic Disorder. Body dysmorphic disorder is characterized by a distressing and impairing preoccupation with an imagined or slight defect in appearance. C. Hoarding Disorder. Hoarding disorder is a behavioral pattern of accumulating items in a compulsive manner that may or may not have any utility to the person. The person is unable to get rid of those items even though they may create hazardous situations in the home such as risk of fire. D. Trichotillomania or Hair-Pulling Disorder. Trichotillomania is characterized by repeated hair pulling causing noticeable hair loss. E. Excoriation or Skin-Picking Disorder. Skin-picking disorder is marked by the compulsive need to pick at one’s skin to the point of doing physical damage. F. Substance/Medication-Induced Obsessive-Compulsive Disorder. This disorder is characterized by obsessive or compulsive behavior that is secondary to the use of a medication or a substance such as abuse of cocaine which can cause compulsive skin- picking (called formication). G. Obsessive-Compulsive Disorder Due to Another Medical Condition. The cause of either obsessive or compulsive behavior is due to a medical condition, as sometimes may occur after a streptococcal infection. H. Other Specified Obsessive-Compulsive and Related Disorder. This category includes a group of disorders such as obsessional jealousy in which one person has repeated thoughts about infidelity in the spouse or partner. Trauma or Stressor-Related Disorder This group of disorders is caused by exposure to a natural or man-made disaster or to a significant life stressor such as experiencing abuse. There are six conditions that fall under this category in DSM-5. A. Reactive Attachment Disorder. This disorder appears in infancy or early childhood and is characterized by a severe impairment in the ability to relate because of grossly pathologic caregiving. Paul Cresencio R. Liberato  B. Disinhibited Social Engagement Disorder. This is a condition in which the child or adolescent has a deep seated fear of interacting with strangers, especially adults, usually as a result of traumatic upbringing. C. Post-Traumatic Stress Disorder. Post-traumatic stress disorder (PTSD) occurs after a traumatic event in which the individual believes that he or she is in physical danger or that his or her life is in jeopardy. PTSD can also occur after witnessing a violent or life- threatening event happening to someone else. D. Acute Stress Disorder. Acute stress disorder occurs after the same type of stressors that precipitate PTSD, however acute stress disorder is not diagnosed if the symptoms last beyond 1 month. E. Adjustment Disorders. Adjustment disorders are maladaptive reactions to clearly defined life stress. They are divided into subtypes depending on symptoms—with anxiety, with depressed mood, with mixed anxiety and depressed mood, disturbance of conduct, and mixed disturbance of emotions and conduct. F. Persistent Complex Bereavement Disorder. Chronic and persistent grief that is characterized by bitterness, anger, or ambivalent feelings toward the dead accompanied by intense and prolonged withdrawal characterizes persistent complex bereavement disorder (also known as complicated grief or complicated bereavement). This must be distinguished from normal grief or bereavement. Dissociative Disorders The group of dissociative disorders includes four specific disorders (dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization/derealization disorder) characterized by a disruption in the usually integrated functions of consciousness, memory, identity, or perception. Somatic Symptom and Related Disorders (previously called Somatoform Disorders in DSM- IV) This group of disorders is characterized by marked preoccupation with the body and fears of disease or consequences of disease, for example, death. A. Somatic Symptom Disorder. Somatic symptom disorder is characterized by high levels of anxiety and persistent worry about somatic signs and symptoms that are misinterpreted as having a known medical disorder. Also known as hypochondriasis. B. Illness Anxiety Disorder. Illness anxiety disorder is the fear of being sick with few or no somatic symptoms. A new diagnosis in DSM-5. C. Functional Neurologic Symptom Disorder. Formerly known as conversion disorder in DSM-IV, this condition is characterized by unexplained voluntary or motor sensory deficits that suggest the presence of a neurologic or other general medical condition. Psychological conflict is determined to be responsible for the symptoms. D. Factitious Disorder. Factitious disorder, also called Munchausen syndrome, refers to the deliberate feigning of physical or psychological symptoms to assume the sick role. E. Factitious Disorder Imposed on Another (previously called Factitious Disorder by Proxy) is when one person presents the other person as ill, most often mother and child. Factitious disorder is distinguished from malingering in which symptoms are also falsely reported; however, the motivation in malingering is external incentives, such Paul Cresencio R. Liberato  as avoidance of responsibility, obtaining financial compensation, or obtaining substances. F. Other Specified Somatic Symptom and Related Disorder. This category is for disorders that are not classified above. One such disorder is Pseudocyesis in which a person believes falsely that she (or he in rare instances) is pregnant. Feeding and Eating Disorders Feeding and eating disorders are characterized by a marked disturbance in eating behavior. A. Anorexia Nervosa. Anorexia nervosa is an eating disorder characterized by loss of body weight and refusal to eat. Appetite is usually intact. B. Bulimia Nervosa. Bulimia Nervosa is an eating disorder characterized by recurrent and frequent binge eating with or without vomiting. C. Binge Eating Disorder. Binge eating disorder is a variant of bulimia nervosa with occasional, once a week, binge eating. D. Pica. Pica is the eating of non-nutritional substances, for example, starch. E. Rumination Disorder. The essential feature of rumination disorder is the repeated regurgitation of food, usually beginning in infancy or childhood. F. Avoidant/Restrictive Food Intake Disorder. Previously called feeding disorder of infancy or childhood in DSM-IV, the main feature of this disorder is a lack of interest in food or eating resulting in failure to thrive. Elimination Disorders These are disorders of elimination caused by physiologic or psychological factors. There are two: Encopresis, which is the inability to maintain bowel control, and Enuresis which is the inability to maintain bladder control. Sleep–Wake Disorders Sleep–wake disorders involve disruptions in sleep quality, timing, and amount that result in daytime impairment and distress. They include the followingVdisorders or disorder groups in DSM-5. A. Insomnia Disorder. Difficulty falling asleep or staying asleep is characteristic of insomnia disorder. B. Hypersomnolence Disorder. Hypersomnolence disorder, or hypersomnia, occurs when a person sleeps too much and feels excessively tired in spite of normal or because of prolonged quantity of sleep. C. Parasomnias. Parasomnias are marked by unusual behavior, experiences, or physiologic events during sleep. This category is divided into three subtypes: non-REM sleep arousal disorders involve incomplete awakening from sleep accompanied by either sleepwalking or sleep terror disorder; D. Nightmare disorder in which nightmares induce awakening repeatedly and cause distress and impairment; and REM Sleep Behavior Disorder which is characterized by vocal or motor behavior during sleep. Paul Cresencio R. Liberato  E. Narcolepsy. Narcolepsy is marked by sleep attacks, usually with loss of muscle tone (cataplexy). F. Breathing-Related Sleep Disorders. There are three subtypes of breathing-related sleep disorders. The most common of the three is Obstructive Sleep Apnea Hypopnea in which apneas (absence of airflow) and hypopneas (reduction in airflow) occur repeatedly during sleep, causing snoring and daytime sleepiness. Central Sleep Apnea is the presence of Cheyne–Stokes breathing in addition to apneas and hypopneas. Finally, Sleep-Related Hypoventilation causes elevated CO2 levels from decreased respiration. G. Restless Legs Syndrome. Restless legs syndrome is the compulsive movement of legs during sleep. H. Substance/Medication-Induced Sleep Disorder. This category includes sleep disorders that are caused by a drug or medication, for example, alcohol, caffeine. I. Circadian Rhythm Sleep–Wake Disorders. Underlying these disorders is a pattern of sleep disruption that alters or misaligns a person’s circadian system, resulting in insomnia or excessive sleepiness. There are six types: (1) Delayed sleep phase type is characterized by sleep–wake times that are several hours later than desired or conventional times, (2) Advanced sleep phase type is characterized by earlier than usual sleep-onset and wakeup times, (3) Irregular sleep–wake type is characterized by fragmented sleep throughout the 24-hour day with no major sleep period and no discernible sleep–wake circadian rhythm, (4) Non–24-hour sleep–wake type is a circadian period that is not aligned to the external 24-hour environment, most common among blind or visually impaired individuals, (5) Shift work type is from working on a nightly schedule on a regular basis, and (6) Unspecified type that does not meet any of the above criteria. Sexual Dysfunctions Sexual dysfunctions are divided into 10 disorders that are related to change in sexual desire or performance. A. Delayed Ejaculation. Delayed ejaculation is the inability or marked delay in the ability to ejaculate during coitus or masturbation. B. Erectile Disorder. Erectile disorder is the inability to achieve or maintain an erection sufficient for coital penetration. C. Female Orgasmic Disorder. Female orgasmic disorder is the absence of the ability to achieve orgasm and/or a significant reduction in intensity of orgasmic sensations during masturbation or coitus. D. Female Sexual Interest/Arousal Disorder. Female sexual interest/arousal disorder is absent or decreased interest in sexual fantasy or behavior which causes distress in the individual. E. Genito-Pelvic Pain/Penetration Disorder. Genito-pelvic pain/penetration disorder replaces the terms vaginismus and dyspareunia (vaginal spasm and pain interfering with coitus). It is the anticipation of or actual pain during sex activities, particularly related to intromission. F. Male Hypoactive Sexual Desire Disorder. Male hypoactive sexual desire disorder is absent or reduced sexual fantasy or desire in males. Paul Cresencio R. Liberato  G. Premature or Early Ejaculation. Premature ejaculation is manifested by ejaculation that occurs before or immediately after intromission during coitus. H. Substance/Medication-Induced Sexual Dysfunction. Substance/medication-induced sexual dysfunction is impaired function due to substances, for example, fluoxetine. I. Other unspecified sexual dysfunction would include sexual disorder due to a medical condition, for example, multiple sclerosis. Gender Dysphoria Gender dysphoria is characterized by a persistent discomfort with one’s biologic sex and in some cases, the desire to have sex organs of the opposite sex. It is subdivided into Gender Dysphoria in Children and Gender Dysphoria in Adolescents and Adults. Disruptive, Impulse-Control, and Conduct Disorders Included in this category are conditions involving problems in the self-control of emotions and behaviors. A. Oppositional Defiant Disorder. Oppositional defiant disorder is diagnosed in children and adolescents. Symptoms include anger, irritability, defiance, and refusal to comply with regulations. B. Explosive Disorder. Intermittent explosive disorder involves uncontrolled outbursts of aggression. C. Conduct Disorder. Conduct disorder is diagnosed in children and adolescents and is characterized by fighting and bullying. D. Pyromania. Repeated fire-setting is the distinguishing feature of pyromania. E. Kleptomania. Repeated stealing is the distinguishing feature of kleptomania. Substance-Related Disorders A. Substance-Induced Disorders. Psychoactive and other substances may cause intoxication and withdrawal syndrome and induce psychiatric disorders including bipolar and related disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunction, delirium, and neurocognitive disorders. B. Substance Use Disorders. Sometimes referred to as addiction, this is a group of disorders diagnosed by the substance abused—alcohol, cocaine, cannabis, hallucinogens, inhalants, opioids, sedative, stimulant, or tobacco. C. Alcohol-Related Disorders. Alcohol-related disorders result in impairment caused by excessive use of alcohol. They include alcohol use disorder which is recurrent alcohol use with developing tolerance and withdrawal and alcohol intoxication which is simple drunkenness, and alcohol withdrawal which can involve delirium tremens (DTs). D. Other Alcohol-Induced Disorders. This group of disorders includes psychotic, bipolar, depressive, anxiety, sleep, sexual, or neurocognitive disorders including amnestic disorder (also known as Korsakoff’s syndrome). Wernicke’s encephalopathy, a neurologic condition of ataxia, ophthalmoplegia, and confusion develops from chronic alcohol use. The two may coexist (Wernicke–Korsakoff syndrome). E. Gambling Disorder. Gambling disorder is classified as a non–substance-related disorder. It involves compulsive gambling with an inability to stop or cut down, leading to social and financial difficulties. Paul Cresencio R. Liberato Neurocognitive Disorders (previously called Dementia, Delirium, Amnestic and Other Cognitive Disorders in DSM-IV) These are disorders characterized by changes in brain structure and function that result in impaired learning, orientation judgment, memory, and intellectual functions. A. Delirium. Delirium is marked by short-term confusion and cognition caused by substance intoxication or withdrawal (cocaine, opioids, phencyclidine), medication (cortisol), general medical condition (infection), or other causes (sleep deprivation). B. Mild Neurocognitive Disorder. Mild neurocognitive disorder is a mild or modest decline in cognitive function. It must be distinguished from normal age-related cognitive change (normal age-related senescence). C. Major Neurocognitive Disorder. Major neurocognitive disorder (a term that may be used synonymously with dementia which is still preferred by most psychiatrists) is marked by severe impairment in memory, judgment, orientation, and cognition. Major Subtypes of Neurocognitive Disorder (Dementia) 1. Alzheimer’s Disease 2. Vascular dementia 3. Lewy body disease 4. Parkinson’s disease 5. Frontotemporal dementia (Pick’s disease) 6. Traumatic Brain Injury 7. HIV Infection 8. Substance/medication-induced dementia 9. Huntington’s disease 10. Prion disease 11. Other medical condition (known as Amnestic Syndrome in DSM-IV-TR) 12. Multiple etiologies 13. Unspecified dementia Personality Disorders Personality disorders are characterized by deeply engrained, generally lifelong maladaptive patterns of behavior that are usually recognizable at adolescence or earlier. A. Paranoid Personality Disorder. Paranoid personality disorder is characterized by unwarranted suspicion, hypersensitivity, jealousy, envy, rigidity, excessive self- importance, and a tendency to blame and ascribe evil motives to others. B. Schizoid Personality Disorder. Schizoid personality disorder is characterized by shyness, oversensitivity, seclusiveness, avoidance of close or competitive relationships, eccentricity, no loss of capacity to recognize reality, daydreaming, and an ability to express hostility and aggression. C. Schizotypal Personality Disorder. Schizotypal personality disorder is similar to schizoid personality, but the person also exhibits slight losses of reality testing, has odd beliefs, and is aloof and withdrawn. D. Obsessive-Compulsive Personality Disorder. OCPD is characterized by excessive concern with conformity and standards of conscience; patient may be rigid, Paul Cresencio R. Liberato  overconscientious, over dutiful, overinhibited, and unable to relax (three Ps— punctual, parsimonious, precise). E. Histrionic Personality Disorder. Histrionic personality disorder is characterized by emotional instability, excitability, over reactivity, vanity, immaturity, dependency, and self-dramatization that isattention seeking and seductive. F. Avoidant Personality Disorder. Avoidant personality disorder is characterized by low levels of energy, easy fatigability, lack of enthusiasm, inability to enjoy life, and oversensitivity to stress. G. Antisocial Personality Disorder. Antisocial personality disorder covers persons in conflict with society. They are incapable of loyalty, selfish, callous, irresponsible, impulsive, and unable to feel guilt or learn from experience; they have low level of frustration tolerance and a tendency to blame others. H. Narcissistic Personality Disorder. Narcissistic personality disorder is characterized by grandiose feelings, sense of entitlement, lack of empathy, envy, manipulativeness, and need for attention and admiration. I. Borderline Personality Disorder. Borderline personality disorder is characterized by instability, impulsiveness, chaotic sexuality, suicidal acts, self-mutilating behavior, identity problems, ambivalence, and feeling of emptiness and boredom. J. Dependent Personality Disorder. This is characterized by passive and submissive behavior; person is unsure of him-or herself and becomes entirely dependent on others. K. Personality Changes Due to Another Medical Condition. This category includes alterations to a person’s personality due to a medical condition, for example, brain tumor. L. Unspecified Personality Disorder. This category involves other personality traits that do not fit any of the patterns described above. Paraphilic Disorders and Paraphilia In paraphilia, a person’s sexual interests are directed primarily toward objects rather than toward people, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances. A paraphilic disorder is acted out sexual behavior that can cause possible harm to another person. Included are: exhibitionism (genital exposure); voyeurism (watching sexual acts); frotteurism (rubbing against another person); pedophilia (sexual attraction toward children); sexual masochism (receiving pain); sexual sadism (inflicting pain); fetishism (arousal from an inanimate object); and transvestism (crossdressing). Other Mental Disorders This is a residual category that includes four disorders that do not meet the full criteria for any of the previously described mental disorders: (1) Other specified mental disorder due to another medical condition, for example, dissociative symptoms secondary to temporal lobe epilepsy; (2) Unspecified mental disorder due to another medical condition, for example, temporal lobe epilepsy producing unspecified symptoms; (3) Other specified mental disorder in which symptoms are present but subthreshold for a specific mental illness; and (4) Paul Cresencio R. Liberato Unspecified mental disorder in which symptoms are present but subthreshold for any mental disorder. Medication-Induced Movement Disorders and Other Adverse Effects of Medication Ten disorders are included: (1) Neuroleptic or Other medication-induced parkinsonism presents as rhythmic tremor, rigidity, akinesia, or bradykinesia that is reversible when the causative drug is withdrawn or its dosage reduced; (2) Neuroleptic malignant syndrome presents as muscle rigidity, dystonia, or hyperthermia; (3) Medication-induced acute dystonia consists of slow, sustained contracture of musculature causing postural deviations; (4) Medication-induced acute akathisia presents as motor restlessness with constant movement; (5) Tardive dyskinesia is characterized by involuntary movement of the lips, jaw, tongue, and by other involuntary dyskinetic movements; (6) Tardive dystonia or akathisia is a variant of tardive dyskinesia that involves extrapyramidal syndrome; (7) Medication-induced postural tremor is a fine tremor, usually at rest, that is caused by medication; (8) Other medication- induced movement disorder describes atypical extrapyramidal syndrome from a medication; (9) Antidepressant discontinuation syndrome is a withdrawal syndrome that arises after abrupt cessation of antidepressant drugs, for example, fluoxetine; and (10) Other adverse effect of medication includes changes in blood pressure, diarrhea etc. due to medication. PSYCHOTHERAPIES Psychotherapy is a therapeutic process to treat psychological problems by way of establishing a relationship between a trained professional and an individual. This treatment modality is established through therapeutic communication, both verbal and nonverbal, attempts to alleviate the emotional disturbance, reverse or change maladaptive patterns of behavior, and encourage personality growth and development. It is distinguished from other forms of psychiatric treatment such as somatic therapies (e.g., psychopharmacology and convulsive therapies). Psychoanalysis and Psychoanalytic Psychotherapy These two forms of treatment are based on Sigmund Freud’s theories of a dynamic unconscious and psychological conflict. The major goal of these forms of therapy is to help the patient develop insight into unconscious conflicts, based on unresolved childhood wishes and manifested as symptoms, and to develop more adult patterns of interacting and behaving. A. Psychoanalysis Psychoanalysis is a theory of human mental phenomena and behavior, a method of psychic investigation and research, and a form of psychotherapy originally formulated by Freud. As a method of treatment, it is the most intensive and rigorous of this type of psychotherapy. The patient is seen three to five times a week, generally, for a minimum of several hundred hours over a number of years. The patient lies on a couch with the analyst seated behind, out of the patient’s visual range. The patient attempts to say freely Paul Cresencio R. Liberato  and without censure whatever comes to mind, to associate freely, so as to follow as deeply as possible the train of thoughts to their earliest roots. As a technique for exploring the mental processes, psychoanalysis includes the use of free association and the analysis and interpretation of dreams, resistances, and transferences. The analyst uses interpretation and clarification to help the patient work through and resolve conflicts that have been affecting the patient’s life, often unconsciously. B. Psychoanalytically psychotherapy Based on the same principles and techniques as classic psychoanalysis, but less intense. There are two types: (1) insight-oriented or expressive psychotherapy and (2) supportive or relationship psychotherapy. Expressive psychotherapy. Patients are seen one to two times a week and sit up facing the psychiatrist. The goal of resolution of unconscious psychological conflict is similar to that of psychoanalysis, but a greater emphasis is placed on day-to-day reality issues and a lesser emphasis on the development of transference issues. Supportive psychotherapy. In supportive psychotherapy, the essential element is support rather than the development of insight. This type of therapy often is the treatment of choice for patients with serious ego vulnerabilities, particularly psychotic patients. Patients in a crisis situation, such as acute grief, also are suitable. This therapy can be continued on a long-term basis and last many years, especially in the case of patients with chronic problems. Support can take the form of limit setting, increasing reality testing, reassurance, advice, and help with developing social skills. C. Brief psychodynamic psychotherapy. A short-term treatment, generally consisting of 10 to 40 sessions during a period of less than 1 year. The goal, based on psychodynamic theory, is to develop insight into underlying conflicts; such insight leads to psychological and behavioral changes. Behavior Therapy Behavior therapy focuses on overt and observable behavior and uses various conditioning techniques derived from learning theory to directly modify the patient’s behavior. This therapy is directed exclusively toward symptomatic improvement, without addressing psychodynamic causation. Behavior therapy is based on the principles of learning theory, including operant and classical conditioning. Operant conditioning is based on the premise that behavior is shaped by its consequences; if behavior is positively reinforced, it will increase; if it is punished, it will decrease; and if it elicits no response, it will be extinguished. Classical conditioning is based on the premise that behavior is shaped by being coupled with or uncoupled from anxiety-provoking stimuli. Just as Ivan Pavlov’s dogs were conditioned to salivate at the sound of a bell once the bell had become associated with meat, a person can be conditioned to feel fear in neutral situations that have come to be associated with anxiety. Uncouple the anxiety from the situation, and the avoidant and anxious behavior will decrease. There are several behavior therapy techniques. Paul Cresencio R. Liberato  Token economy. A form of positive reinforcement used with inpatients who are rewarded with various tokens for performing desired behaviors (e.g., dressing in street clothes, attending group therapy). Has been used to treat schizophrenia, especially in hospital settings. The tokens can be exchanged for a variety of positive reinforcers, such as food, television time, or a weekend pass. Aversion therapy. A form of conditioning that involves the repeated coupling of an unpleasant or painful stimulus, such as an electric shock, with an undesirable behavior. In a less controversial form of aversion therapy, the patient couples imagining something unpleasant with the undesired behavior. Has been used to treat substance abuse. Systematic desensitization. This technique is based on the behavioral principle of counterconditioning, whereby a person overcomes maladaptive anxiety elicited by a situation or object by approaching the feared situation gradually and in a psychophysiologic state that inhibits anxiety. Rather than use actual situations or objects that elicit fear, patients and therapists prepare a graded list or hierarchy of anxiety provoking scenes associated with a patient’s fears. The learned relaxation state and the anxiety-provoking scenes are systematically paired in treatment. Therapeutic-graded exposure. Similar to systematic desensitization, except that relaxation training is not involved and treatment is usually carried out in a real-life context. Exposure is graded according to a hierarchy. Patients afraid of cats, for example, might progress from looking at a picture of a cat to holding one. Flooding. A technique in which the patient is exposed immediately to the most anxiety-provoking stimulus (e.g., the top of a tall building if he or she is afraid of heights) instead of being exposed gradually or systematically to a hierarchy of feared situations. If this technique is carried out in the imagination rather than in real life, it is called implosion. Assertiveness training. A variety of techniques, including role modeling, desensitization, and positive reinforcement, are used to increase assertiveness. To be assertive requires that people have confidence in their judgment and sufficient self- esteem to express their opinions. Participant modeling. Patients learn a new behavior by imitation, primarily by observation, without having to perform the behavior until they feel ready. It is useful with phobic children and used successfully with agoraphobia by having a therapist accompany a patient into the feared situation. Exposure to stimuli presented in virtual reality. Beneficial effects have been reported with virtual reality exposure of patients with height phobia, fear of flying, spider phobia, and claustrophobia. Paul Cresencio R. Liberato  Social skills training. Most used in patients with Schizophrenia or schizophrenic like disorders, this type of therapy improves social skills. Social dysfunction is normalized by teaching the patient how to accurately read or decode social inputs. Role-playing is used to decrease social anxiety and improve social and conversational skills. It is usually done in groups. Cognitive–Behavioral Therapy This therapy is based on the theory that behavior is determined by the way in which persons think about themselves and their roles in the world. Maladaptive behavior is secondary to ingrained, stereotyped thoughts, which can lead to cognitive distortions or errors in thinking. The theory is aimed at correcting cognitive distortions and the self- defeating behaviors that result from them. Therapy is on a short-term basis, generally lasting for 15 to 20 sessions during a period of 12 weeks. The cognitive model of depression includes the cognitive triad, which is a description of the thought distortions that occur when a person is depressed. The triad includes (1) a negative view of the self, (2) a negative interpretation of present and past experience, and (3) a negative expectation of the future. Cognitive therapy has been most successfully applied to the treatment of mild to moderate nonpsychotic depressions. It also has been effective as an adjunctive treatment in substance abuse and in increasing compliance with medication. It has been used recently to treat schizophrenia. Family Therapy Family therapy is based on the theory that a family is a system that attempts to maintain homeostasis, regardless of how maladaptive the system may be. This theory has been referred to as a “family systems orientation,” and the techniques include focusing on the family rather than on the identified patient. The family therefore becomes the patient, rather than the individual family member who has been identified as sick. One of the major goals of a family therapist is to determine what homeostatic role, however pathologic, the identified patient is serving in the particular family system. A family therapist’s goal is to help a family understand that the identified patient’s symptoms in fact serve the crucial function of maintaining the family’s homeostasis. Interpersonal Therapy This is a short-term psychotherapy, lasting 12 to 16 weeks, developed specifically for the treatment of nonbipolar, nonpsychotic depression. Sessions 1 to 5 are initial phase, sessions 6 to 15 intermediate, and sessions 16 to 20 are the termination phase. Intrapsychic conflicts are not addressed. Emphasis is on current interpersonal relationships and on strategies to improve the patient’s interpersonal life. Antidepressant medication is often used as an adjunct to interpersonal therapy. The therapist is very active in helping to formulate the patient’s predominant interpersonal problem areas, which define the treatment focus. Group Therapy Group therapies are based on as many theories as are individual therapies. Groups range from those that emphasize support and an increase in social skills, to those that emphasize specific symptomatic relief, to those that work through unresolved intrapsychic conflicts. Paul Cresencio R. Liberato Compared with individual therapies, two of the main strengths of group therapy are the opportunity for immediate feedback from a patient’s peers and the chance for both patient and therapist to observe a patient’s psychological, emotional, and behavioral responses to a variety of people, who elicit a variety of transferences. Both individual and interpersonal issues can be resolved. Groups tend to meet one to two times a week, usually for 1½ hours. They may be homogeneous or heterogeneous, depending on the diagnosis. Couple and Marital Therapy As many as 50% of patients are estimated to enter psychotherapy primarily because of marital problems; another 25% experience marital problems along with their other presenting problems. Couple or marital therapy is designed to psychologically modify the interaction of two people who are in conflict with each other over one parameter or a variety of parameters— social, emotional, sexual, or economic. As in family therapy, the relationship rather than either of the individuals is viewed as the patient. A. Types of therapies 1. Individual therapy. Partners may consult different therapists, who do not necessarily communicate with each other and the goal of treatment is to strengthen each partner’s adaptive capacities. 2. Individual couples therapy. Each partner is in therapy, which is either concurrent, with the same therapist, or collaborative, with each partner seeing a different therapist. 3. Conjoint therapy. It is the most common treatment method in couples therapy and either one or two therapists treat the partners in joint sessions. 4. Four-way session. Each partner is seen by a different therapist in regular joint sessions and all four persons participate. A variation developed by William Masters and Virginia Johnson is used for the rapid treatment of sexually dysfunctional couples. 5. Group psychotherapy. Consists of three to four couples and two therapists. They explore sexual attitudes and have an opportunity to gain new information from their peer groups, and each receives specific feedback about his or her behavior, either negative or positive. 6. Combined therapy. Refers to all or any of the preceding techniques used concurrently or in combination. Dialectical Behavior Therapy This form of therapy has been used successfully in patients with borderline personality disorder and parasuicidal behavior. It is eclectic, drawing on methods from supportive, cognitive, and behavioral therapies. Some elements are derived from Franz Alexander’s view of therapy as a corrective emotional experience, and also from certain Eastern philosophical schools (e.g., Zen). Patients are seen weekly, with the goal of improving interpersonal skills and decreasing self-destructive behavior by means of techniques involving advice, use of metaphor, storytelling, and confrontation, among many others. Borderline patients especially are helped to deal with the ambivalent feelings that are characteristic of the disorder. Paul Cresencio R. Liberato Hypnosis Hypnosis is a complex mental state in which consciousness is altered in such a way that the subject is amenable to suggestion and receptive to direction by the therapist. When hypnotized, the patient is in a trance state, during which memories can be recalled and events experienced. The material can be used to gain insight into the makeup of a personality. Hypnosis is used to treat many disorders, including obesity, substance related disorders (especially nicotine dependence), sexual disorders, and dissociative states. Guided Imagery Used alone or with hypnosis. The patient is instructed to imagine scenes with associated colors, sounds, smells, and feelings. The scene may be pleasant (used to decrease anxiety) or unpleasant (used to master anxiety). Imagery has been used to treat patients with generalized anxiety disorders, posttraumatic stress disorder, and phobias, and as an adjunct therapy for medical or surgical disease. Biofeedback Biofeedback provides information to a person about his or her physiologic functions, usually related to the autonomic nervous system (e.g., blood pressure), with the goal of producing a relaxed, euthymic mental state. It is based on the idea that the autonomic nervous system can be brought under voluntary control through operant conditioning. It is used in the management of tension states associated with medical illness (e.g., to increase hand temperature in patients with Raynaud’s syndrome and to treat headaches and hypertension). Paradoxical Therapy In this approach, the therapist suggests that the patient intentionally engages in an unwanted or undesirable behavior (called paradoxical injunction)— for example, avoiding a phobic object or performing a compulsive ritual. This approach can create new insights for some patients. Sex Therapy In sex therapy, the therapist discusses the psychological and physiologic aspects of sexual functioning in great detail. Therapists adopt an educative attitude, and aids such as models of the genitalia and videotapes may be used. Treatment is on a short-term basis and behaviorally oriented. Specific exercises are prescribed, depending on the disorder being treated (e.g., graduated dilators for vaginismus). Usually, the couple is treated, but individual sex therapy is also effective. Narrative Psychotherapy Narrative psychotherapy emerges out of increased interest in clinical stories. This therapy emerges from two different sides of psychiatry: narrative medicine and narrative psychotherapy. Narrative medicine uses narrative approaches to augment scientific understandings of illness. A major task of narrative psychotherapy is to be a good listener and Paul Cresencio R. Liberato to connect empathically with the patient’s story. Narrative approaches are invaluable for psychotherapy integration because they provide a metatheoretical orientation from which to understand and practice psychotherapy. Vocational Rehabilitation Vocational rehabilitation is a centerpiece of psychiatric rehabilitation. It emphasizes independence rather than reliance on professionals, community integration rather than isolation in segregated settings for persons with disabilities, and patient preferences rather than professional goals. It includes a wide range of interventions designed to help people with disabilities caused by mental illness improve their functioning and quality of life by enabling them to acquire the skills and supports needed to be successful in usual adult roles and in the environments of their choice. Combined Therapy In this therapeutic approach, psychotherapy is augmented by the use of pharmacologic agents. The term pharmacotherapy-oriented psychotherapy is used by some practitioners to refer to the combined approach. ACTIVITY 1: Answer the following question and share your opinions to your classmates. 1. Which of the psychotherapies mentioned is the best? Elaborate your answer ACTIVITY 1: 1. Select 3 of the psychotherapies mentioned. Research on its reliability and validity. Cite articles or evidences of such. Don’t forget to send your written output using your mVLE. It should not exceed 8 MB and in PDF format. 1. A 15-item quiz will be posted for you to complete for 10 minutes, next meeting, on mVLE Paul Cresencio R. Liberato