От автора: Удачи всем ! Course support Clinical psychology, ULIM 2010-2011 COURSE SUPPORT CLINICAL PSYCHOLOGYFor third year students from the Faculty of Psychology Contents MENTAL DISORDERS ACCORDING TO DSM IV.. 4 Theme 1. ANXIETY DISORDERS.. 51.1. General presentation. 51.2. Epidemiology. 61.3. Automatic thoughts characteristic of different forms of anxiety. 181.4. Treatment 19 Module II. ADAPTATION DISORDERS ACCORDING TO DSM-IV.. 19 Theme 2. ADAPTATION DISORDERS.. 192.1. General presentation. 192.2. Epidemiology. 202.3. Etiology. 202.4. DSM IV diagnosis.. 202.5. Differential diagnosis 212.6. Treatment 21 Theme 3. FACTUAL DISORDERS.. 213.1. General presentation. 213.2. Epidemiology. 223.3. Etiology. 233.5. Differential diagnosis 233.6. Evolution and prognosis of the disease 243.7 Treatment 24 Theme 4. DISSOCIATIVE DISORDERS.. 244.1. General presentation. 244.2. Predisposing factors 264.3. Epidemiology. 264.4. Treatment 30 Theme 5. PERSONALITY DISORDERS.. 315.1. General presentation. 315.2. Epidemiology. 315.3. Differential diagnosis 375.4. Etiology. 385.5. Approaches to personality disorders. 385.6. Evolution and prognosis of the disease 415.7. Treatment 41 Module III. PSYCHOTIC DISORDERS ACCORDING TO DSM-IV.. 41 Theme 6. PSYCHOTIC DISORDERS.. 416.1. General presentation. 416.2. Epidemiology. 436.4. Etiopathogenetic models. 486.5. Risk factors. 496.6. Treatment 49 Theme 7. IMPULSE DISORDERS. 507.1. General presentation. 507.2. Epidemiology. 507.3. Etiology. 557.4. Treatment 55 Theme 8. relationship problems.. 558.1. General presentation. 558.2. Types of relationship problems. 558.3. Treatment 568a. SLEEP DISORDERS.. 568a.1. Classification of sleep disorders. 568b. Clinical disorders of children and adolescents 59Bibliography.. 60 TASKS FOR INDIVIDUAL WORK.. 61 MENTAL DISORDERS ACCORDING TO DSM IVPrinciples of using DSM IV - Multiaxial diagnostic system Axis I – on this axis the main diagnosis (mental disorders) is passed, except for situations when after the registration on axis II shows the specification "Reason for consultation" or "Main diagnosis"; - several diagnoses may appear, the first being the main one; - on this axis all disorders are recorded, except for "Personality disorders", "Mental retardation" , "Unspecified impulse disorders". Axis II - personality disorders, mental retardation, maladaptive personality traits, maladaptive and frequently used coping mechanisms are registered on this axis; - sometimes, the diagnosis on this axis can constitute the "Reason for consultation" or "Main diagnosis"; Axis III- general medical conditions are recorded on axis III;- refers to conditions such as: infectious disorders, neoplasm, endocrine, metabolic, immunological disorders, disorders of the constitutive components of the blood, diseases of the nervous system and sense organs , disorders of the circulatory system, disorders of the respiratory system, disorders of the digestive system, disorders of the genitourinary system, dermatological conditions, problems related to pregnancy, diseases of the muscular and bone system, congenital anomalies, injuries or poisoning with toxic substances. OBSERVATION: If the mental disorder is considered to be the direct consequence of a general medical condition, it is registered on axis I ("Mental disorders due to general medical conditions"), the somatic condition also passing on axis III. Axis IV - on this axis negative and positive stressors pass (if it is appreciated that they constitute or lead to a problem; - in general, conditions are recorded that appeared no more than a year before the onset of symptoms, but problems from the more distant past can also be noted, if these are relevant. OBSERVATION: Psycho-social and environmental problems are usually noted on the axisIV, but also on axis I if they are direct causes of the mental disorder ("Other conditions that can be the target of therapeutic intervention") Axis V - the global evaluation index is a measure of the general level of functioning; - it is useful for planning therapy, evaluating the effects of the therapy, the anticipation of the results; - the rating is only done vis-à-vis the functioning/psychological, social and occupational adaptation; difficulties due to physical or environmental limitations are not included. Note: For all disorders, it is necessary to: Assess the impact of co-occurring physical conditions and substance use; The clinical diagnosis assumes that the individual's functioning and ability to adapt in family, social and/or professional life are severely affected. !![b] !![/b]!![b]Topic 1. ANXIETY DISORDERS!![/b]!![b]1.1 Overview!![/b]Often the terms anxiety and stress are use as synonyms due to the similarities between them. We further emphasize some important aspects in this regard, as follows: - both stress and anxiety involve the mechanism of the discrepancy at the cognitive level; - while in the case of stress the predictions about reality differ from what really happens, in the case of anxiety the discrepancy is between the requirements of the situation and what the person thinks he can do, resulting in the feeling of helplessness. Anxiety is a term that signifies specific changes at four levels: subjective, cognitive, behavioral and biological/physiological. At the subjective level - the person describes his experiences as feelings of fear, immediate catastrophe, helplessness, horror; At the cognitive level – (1) maladaptive processing and informational contents lead to the preferential processing of anxiogenic stimuli in the environment, ignoring neutral or positive stimuli from an affective point of view; (2) the existence of a discrepancy between what the person wants or must do and what he thinks he can do; At the behavioral level - the behavior of avoiding anxious situations appears; At the biological level - the changes induced by the imbalance of the vegetative nervous system dominate, with the predominance of the sympathetic. It is not necessary that the changes specific to anxiety appear simultaneously at the four levels, in a way that is conscious of the person. Consequently, there are the following types of anxiety, as a result of combining the changes from the four levels: Levels1234567Subjective-cognitiveBehavioralBiological+++++-+---++--+-+-+-++ shows the presence of changes at the respective level- indicates the lack of a changes of conscious and significant intensity (clinical) - Patterns 1, 2, 3, 7 are specific to patients who turn to a psychologist or psychiatrist, due to the negative subjective experience; - Patterns 4, 5, 6 are specific to patients who will deny that they suffer from anxiety , these patients being found only in internal departments (cardiology, gynecology, urology, not psychiatry) due to the changes that occur at the biological level; - Pattern 6 is represented by hysterical motor conversion, in which paralysis maintained by anxiety occurs; - Patterns 1 ,4,5,7 are the ones that, in the long term, in the conditions of unresolved anxiety disorders, will generate psychosomatic disorders; - In the case of patterns 1 and 7, unresolved and chronic, anxiety disorders will be doubled by psychosomatic disorders. frequently encountered pattern in clinical practice is 1. Depending on the way the manifestations interact, the disorders included in the "anxiety disorders" category will appear: (1) panic attack - is defined as a distinct state, in which the sudden appearance of feelings of fear, terror and impending disaster. These are associated with somatic symptoms (palpitations, chest pain, feeling of suffocation) and the fear of going crazy or losing control; (2) agoraphobia -it is characterized by avoiding or enduring with extreme anxiety some situations or places from which the exit may be difficult (or embarrassing), or in which it is difficult to obtain help in case the person has a panic attack, or symptoms specific to a panic attack; (3) panic disorder without agoraphobia – is characterized by the presence of recurrent, unexpected panic attacks and persistent worries about them; (4) panic disorder with agoraphobia – is characterized by unexpected, recurrent panic attacks and agoraphobia; (5) agoraphobia without panic attack - is characterized by the presence of agoraphobia and panic attack-specific symptoms, without the presence of unexpected panic attacks; (6) specific phobias - are characterized by the presence of clinical level anxiety, due to the confrontation with a situation or object that cause fear; frequently leads to the behavioral avoidance of the anxiogenic stimulus; (7) social phobia - is characterized by the presence of clinical level anxiety, due to the confrontation with a certain social or performance situation; frequently leads to the behavioral avoidance of the anxious situation; (8) obsessive-compulsive disorder - is characterized by the presence of obsessions (which produce heightened anxiety or distress) and/or compulsions (with the role of neutralizing anxiety); (9) stress disorder post-traumatic - is characterized by the re-experiencing of an extremely traumatic event, accompanied by high arousal and the avoidance of stimuli associated with the trauma; (10) acute stress disorder - is characterized by the presence of symptoms similar to those of post-traumatic stress, which occur immediately after a extremely traumatic event; (11) generalized anxiety – characterized by a period of at least six months of persistent anxiety and worry; (12) anxiety due to a general medical condition – characterized by anxiety symptoms that are the direct consequence of the presence a general medical condition; among the medical conditions associated with anxiety we mention: endocrine disorders (hyper and hypothyroidism, hypoglycemia, hyperadrenocorticism, etc.); cardiovascular disorders (pulmonary embolism, arrhythmia, etc.); respiratory disorders (pneumonia, hyperventilation, etc.); metabolic disorders (vitamin deficiency B12, porphyria, etc.); neurological disorders (neoplasm, vestibular disorders, encephalitis, etc.); (13) anxiety induced by the consumption of substances - it is characterized by anxiety symptoms that are the direct consequence of the ingestion of alcohol, drugs, medicines or exposure to toxic substances; (14) previously unspecified anxiety - it is characterized by the presence of anxiety symptoms, which, however, do not justify granting one of the previous diagnoses. OBSERVATIONS: separation anxiety and phobic avoidance limited to genital sexual contact are included in the categories "Clinical disorders of the child and adolescent", respectively "Sexual and sexual identity disorders".!![b]1.2 Epidemiology !![/b]!![b]1.2.1. PANIC ATTACK (with and without agoraphobia)!![/b] DisorderEpidemiologyPanic attack (with and without agoraphobia)- In the general population, the prevalence is 1.5%-3.5%;- About one-third to one-half of individuals with panic attacks also have agoraphobia; in clinical groups, agoraphobia occurs even more frequently; - Panic attack without agoraphobia occurs twice as frequently and panic attack with agoraphobia three times more frequently in women compared to men. Agoraphobia without panic attack - In the clinical population, over 95% of patients with agoraphobia have or have also had a panic attack;- In the general population, the frequency of agoraphobia without panic attack is higher than the frequency of panic attack with agoraphobia (although there are criticisms related to the evaluation methods).- It occursmuch more common in women, compared to men. The disorder Explanatory theories Panic attack without agoraphobia Cognitive-behavioral theory The sequence of etiopathogenetic mechanisms in a panic attack is as follows: - The appearance of a state of arousal (coffee consumption, physical effort, etc.); - Interpretation in terms of disease of this state, associated with the feeling of lack of control and the imminence of a crisis;- This interpretation amplifies the changes induced by SNV at point 1, entering a vicious circle (cause and effect change places). Psychoanalytic theory There are four types of anxiety : Id anxiety - appears for the first time in ontogenesis due to the fear that the surrounding world will lead to the loss of the id's autonomy; Separation anxiety - the child feels that he is breaking away from the significant person; Castration anxiety - problems related to the Oedipus and Electra complex; Superego anxiety - of the ego - occurs after the development of the superego Panic attack is related to the anxiety of the id - the impulses are very strong and the ego fails to block them, resulting in the feeling of lack of control over the surrounding world. Panic attack with agoraphobia Cognitive-behavioral theory Agoraphobic avoidance occurs due to the association of different situations with panic attacks, so the person learns to avoid them to minimize the possibility of triggering a new panic attack. Type of disorder DSM IV diagnosis - Diagnostic criteria Panic attack A distinct episode of intense fear and discomfort, in which four or more of the following symptoms begin suddenly and peak within a 10-minute period: Palpitations, rapid heart rate; Sweating; Trembling; Sensation of suffocation; Chest pain; Nausea and abdominal pain; Feeling dizzy and fainting; Derealization (detachment from reality) or depersonalization (detachment from self); Fear of losing control or going crazy; Fear of dying; Paresthesias (sensation of numbness or tingling); Chills or flashes of heat. Agoraphobia - experiencing states of anxiety in situations or places from which it may be difficult (or embarrassing) to get out or where it is difficult to get help in case the person has an attack of panic or symptoms specific to a panic attack (Ex. crowded places, alone at home, on a bridge, in a means of transport, in an isolated place); B – situations are avoided or endured with difficulty. Panic attack (with and without agoraphobia) A1 – recurrent, unexpected panic attacks; A2 – at least one of the attacks was followed by at least one month of: Persistent worry about the likelihood of another panic attack or; Worry about the implications or consequences of the attack or; Significant behavioral changes related to the presence of panic attacks; B – presence or absence of agoraphobia (with or without agoraphobia). Agoraphobia without panic attack presence of agoraphobia associated with fear of developing panic attack-like symptoms; never satisfied the criteria for a panic attack; if associated with a general medical condition, the fear is disproportionate. Differential diagnosis Panic attack disorder (with and without agoraphobia) The disorder with which the differential diagnosis is made Differentiating indices Other disorders in which the panic attack may occur (social phobia, obsessive-compulsive disorder, PTSD, separation anxiety, delusional disorder) panic in panic attack disorder occurs recurrently and unexpectedly ("out of the blue"), either initially or during the course of the disorder. In the other disorders, panic is associated with specific situations or objects; agoraphobic avoidance is distinguished by the theme object - the fear of having another panic attack. Agoraphobia without a history of panic attack The disorder with which the differential diagnosis is made Differentiation indices Panic attack disorder with agoraphobia- in agoraphobia, there is no panic attack in the personal history; avoidance results from fear ofhumiliation or helplessness due to panic-like symptoms Social phobia - fear of acting in a humiliating or embarrassing manner (social phobia) versus fear of putting oneself in a humiliating position due to the development of panic symptoms (agoraphobia). Specific phobias - fear of situations where it would be difficult to leave or where help could not be obtained in case of panic symptoms (agoraphobia) versus fear of specific situations (simple phobia). Major depressive episode - refusal to leave the house due to lack of energy, ahedonia, apathy (major depressive episode) versus refusing to leave the house for fear of not being able to get help in the event of panic symptoms (agoraphobia) Delusional disorder - avoiding situations for fear of not being able to get help or that he will put himself in an embarrassing position in the event of panic symptoms (agoraphobia) versus the fear of persecution Separation anxiety - the refusal to leave the house and close people for fear of losing them (separation anxiety) versus the refusal to leave the house for fear of not being able to get help in the event of panic symptoms (agoraphobia). !![b]1.2.2 SPECIFIC PHOBIAS!![/b]DisorderEpidemiologySpecific phobias- In the general population, the prevalence is 10%-11.3%;- Approximately 75%-90% of people with phobias of animals, natural phenomena or situational forms of phobias are women; - About 55%-70% of people with a fear of heights are women; - About 55%-70% of people with a phobia of blood / injections / injury are women. The disorder Explanatory theories Simple / specific phobias Cognitive theory -behavioral There are two types of phobias, with and without maladaptive cognitions: The phobic stimulus plays the role of the conditioned stimulus and the anxious reaction represents the unconditioned response; Maladaptive cognitions (exaggerated negatively towards the phobic stimulus; e.g., "dogs are dangerous, rabid animals") amplify the symptomatology anxious and generates avoidant behavior. When maladaptive cognitions do not appear, the person considers his reaction to be irrational and unjustified, however avoidant behavior is generated. Avoidance leads to the disappearance of anxiety, thus being negatively reinforced. Psychoanalytic theory Simple phobias are mainly related to anxiety castration (see Oedipus and Electra complex). The sexual impulses directed towards the mother are unsuccessfully repressed and then sublimated, resulting in simple phobias. Type of disorderDiagnosis DSM IV - Diagnostic criteria Simple/specific phobias illogical, accentuated and persistent fear triggered by the presence or anticipation of the presence of a specific object or situation; contact with the phobogenic stimulus almost invariably causes an immediate anxious response, which may take the form of a triggered panic attack or favored by a situation (situational); the person recognizes that his fear is exaggerated and illogical; the phobic situation is avoided or endured with difficulty. Differential diagnosis Simple / specific phobias The disorder with which a differential diagnosis is made Indices of differentiation Panic disorder with agoraphobia- Avoidance of situations for fear of a panic attack (panic attack disorder with agoraphobia) versus avoidance of specific situations. Social phobia- The object of fear is social evaluation (social phobia) versus a specific situation or object (simple phobias). Posttraumatic stress- Avoidance of specific situations (specific phobias) versus avoidance of situations previously associated with trauma (PTSD). Obsessive-compulsive disorder- Avoidance is associated with the content of the obsession (OCD) versus avoiding specific situations. Separation anxiety- Refusing to leave home and close people for fear of losing them (separation anxiety) versus refusing to expose yourself to specific situations. Hypochondria- Preoccupation with the thought of having a serious illness (hypochondria) versus preoccupation with the thought that one might contact a disease (phobiaspecific).Eating disorders (bulimia, anorexia)- Avoidance of foods and aspects related to food (eating disorders) versus avoidance of specific objects (simple phobia).Schizophrenia and other psychotic disorders- Avoidance of activities in response to delirium, but fear is not perceived as unjustified and exaggerated (psychotic disorders) versus avoiding specific situations, and the fear is perceived as exaggerated (simple phobias). !![b] !![/b]!![b]1.2.3 SOCIAL PHOBIA!![/b]DisorderEpidemiologySocial phobia- In the general population, the prevalence is 3%-13%; the majority of affected people are afraid to speak in public (less than half are afraid to talk to strangers or meet new people; the fear of eating or drinking in public, or of using public toilets occurs less often);- In the population clinic, most patients are afraid of several public situations; - People with social phobia are rarely hospitalized; the treatment is often done on an outpatient basis;- In the general population, it is more common in women, but in the clinical population it occurs as often in women as in men (sometimes even more often in men). The disorder Explanatory theories Social phobia Cognitive-behavioral theory There are two types of social phobia, with and without maladaptive cognitions. The sequence of etiopathogenetic mechanisms is as follows: - Helplessness (the person does not know how to respond to social demands, this generates a state of anxiety); - Anxiety, which can be amplified by maladaptive cognitions about social situations ("I have to look perfect"); - The person does not know how to respond to the anxiety generated, which amplifies the anxiety more and triggers the avoidance behavior; - Avoidance leads to the disappearance of the anxiety, thus being negatively reinforced. Theory psychoanalytic Social phobia, like agoraphobia, is mainly related to castration anxiety (see Oedipus and Electra complex). Type of disorderDiagnosis DSM IV - Diagnostic criteriaSocial phobia is an accentuated and persistent fear of one or more social or performance situations, in which the patient makes contact with unknown persons or is exposed to the evaluation of others. The patient fears that he will act (or show anxiety) in a humiliating or embarrassing manner; contact with the phobogenic stimulus almost invariably causes an immediate anxious response, which may take the form of a panic attack triggered or favored by a (situational) situation; the person recognizes that his fear is exaggerated and illogical; social or performance situations that cause fear are avoided or endured with difficulty. Differential diagnosis Social phobia The disorder with which the differential diagnosis is made Indices of differentiation Panic attack disorder with agoraphobia- the fear of not acting in a humiliating or embarrassing manner (social phobia) versus the fear of not putting oneself in a humiliating position due to the development of panic attacks (panic attack with agoraphobia). Agoraphobia without panic attack - fear of acting in a humiliating or embarrassing manner (social phobia) versus fear of putting oneself in a humiliating position due to the development of symptoms of panic (agoraphobia). Separation anxiety - refusal to leave the house and close people for fear of losing them (separation anxiety) versus the refusal to leave the house to avoid social situations; discomfort also occurs when the social situation occurs at home (social phobia). Generalized anxiety and simple phobias - fear of humiliation, being in an embarrassing position or concerns about one's own performance also occurs when there is no evaluation situation (generalized anxiety, phobias simple) versus the fear of humiliation following the evaluation of others (social phobia).schizoid personality disorder) versus avoiding social situations that involve contact with unknown people, in the presence of interest in social relations with known people. Avoidant personality disorder - the distinction is given by the period of onset of the disorder and its severity and general character. Performance anxiety, stage fright, shyness - the diagnosis of social phobia is made only if the symptoms strongly interfere with the person's family, professional and social life.!![b]1.2.4 OBSESSIVE-COMPULSIVE DISORDER (OCD)!![/ b]DisorderEpidemiology Obsessive-compulsive disorder- In the general population, the prevalence is 2.5%;- It occurs equally frequently in men and women. The disorder Explanatory theories Obsessive-compulsive disorder Cognitive-behavioral theory The sequence of etiopathogenetic mechanisms is as follows:- The presence of normal intrusive thoughts; - The negative interpretation of these thoughts and their association with emotional experiences (anxiety); the association determines the increase in the frequency of their appearance; - The person's anticipations, the fear of these thoughts is another premise that increases the frequency of appearance. To eliminate the anxiety generated by obsessive thoughts, the person resorts to a series of negatively reinforced behaviors, which are compulsively repeated, being uncontrollable because they reduce the anxiety felt. Psychoanalytic theory Obsessive-compulsive disorder is the consequence of fixation and regression at the anal stage; this fixation generates ambivalence. As a defense mechanism, an attempt is made to separate the informational content from the affective charge; if the separation does not work, the behavioral expression of the thought is blocked - it results in a behavior opposite to that determined by the obsession, which can be automatic (compulsion) or voluntary (the reverse reaction). Type of disorder DSM IV diagnosis - Diagnostic criteria Obsessive-compulsive disorder has either obsessions or compulsions. Obsessions: thoughts, impulses, persistent images felt at a given moment as intrusive, inappropriate, causing anxiety and distress; thoughts, impulses or images are not just worries excessive for everyday problems; the person tries to neutralize these thoughts, impulses or images with other thoughts or actions; the person recognizes that the impulses, thoughts or images are products of his own mind and are not imposed from outside. Compulsions: behaviors or mental acts repetitive; behaviors or mental acts have the role of reducing distress or preventing unpleasant events or situations; they are either not logically related to the aspects they are supposed to neutralize or are excessive.B. At some point in the course of the disorder, the person recognized the excessive and illogical nature of the obsessions or compulsions Differential diagnosis Obsessive-compulsive disorder (OCD) The disorder with which the differential diagnosis is made Differentiating indices Dysmorphic disorder, social phobia, specific phobia, impulse disorders the content of the thoughts is related to specific aspects – the shape of the body, an object or a situation, an action (dysmorphic disorder, social phobia, specific phobia, impulse disorders) versus other concerns – contamination, ordering, insecurity, aggressiveness (OCD). Depressive episode major- obsessive preoccupations related to futility, congruent with the affective state (depression) non-egodystonic versus egodystonic obsessions (OCD). Generalized anxiety- excessive concerns related to aspects of everyday life (generalized anxiety) versus concerns considered irrational and meaningless by the person (OCD) .Hypochondria and specific phobia- concerns associated with the fear of having a severe disease (hypochondria), fear of contacting a disease (specific phobia), fear of having a disease and transmitting it to others, doubled by compulsive behaviors oriented to prevent this aspect (OCD). Delusional disorder and other psychotic disorders-related deliriumof less likely situations and strange non-egodystonic behaviors (psychotic disorders) versus obsessions related to more likely events - contamination with microbes and egodystonic compulsive behaviors (OCD). Stereotypic tics and movements - stereotypic tics and movements are less complex motor acts and have no the role of neutralizing anxiety caused by obsessions. Eating disorders and substance abuse - compulsive behaviors in this case are egosyntonic, pleasant and the desire to block them is only related to their negative consequences. Obsessive-compulsive personality disorder - generalized concerns with the idea of ​​order, perfection and control, which begins at a young age (OC personality disorder) versus the presence of obsessions and compulsions (OCD). Repetitive, ritualistic behaviors - appear normally in everyday life; the diagnosis of OCD is made only if the symptoms negatively affect the person's life. !![b]1.2.6. ACUTE TRAUMATIC STRESS DISORDER AND POST-TRAUMATIC STRESS DISORDER (PTSD)!![/b] DisorderEpidemiology Acute post-traumatic stress- The prevalence of stress in a population exposed to severe traumatic stress depends on the severity and duration of the intervention of the traumatic agent and the degree of exposure to it. Posttraumatic stress (PTSD)- In the general population, the prevalence is 1%-14%;- In risk groups (war veterans, victims of abuse and violence, victims of natural disasters), the prevalence is 3%-58%. The disorder Explanatory theories Posttraumatic stress Cognitive-behavioral theory The etiopathogenetic mechanisms are: - classical conditioning - a neutral stimulus becomes emotionally charged due to association with one that produces an automatic reaction of the body); - neurophysiology of memory - strong stress affects the hippocampus, so only part of the information is encoded in the explicit mnemonic system; the coded information at the level of the amygdala leads to involuntary updates, expressed behaviorally. The result is a lacunar rendering of the traumatic event, which can be completed under hypnosis, realizing the feeling of coherence of the personal history, controllability and predictability. Type of disorder DSM IV diagnosis - Diagnostic criteria Posttraumatic stress (PTSD) the person was exposed to a traumatic event in which: experienced, witnessed or experienced an event that involved threats of death or serious injury, death or serious injury or threatening the physical integrity of himself or others; the person's reaction included intense fear, feelings of helplessness, or horror. the traumatic event is frequently re-experienced in one or more of the following ways: intrusive memories of the traumatic event (images, thoughts, perceptions) ;recurrent nightmares related to the traumatic event;reliving the event at the level of behaviors, affects (including hallucinations, illusions, flashbacks);intense distress upon contact with internal and external stimuli similar to an aspect of the traumatic event;physiological reactivity upon contact with internal stimuli and externals similar to an aspect of the traumatic event. avoidance of stimuli associated with the trauma and general reduced responsiveness manifested in the following ways: trying to avoid thoughts, feelings, conversations that remind of the trauma; avoiding places, activities, people that remind of the trauma; impossibility to- and remember important aspects of the traumatic event; interest or participation in important activities is greatly diminished; feeling of detachment and alienation from others; the range of affects is very limited; pessimistic expectations about the future. high arousal manifested by: difficulty sleeping and insomnia ; irritability or outbursts of anger; difficulty concentrating; hypervigilance.E. symptoms last for more than a month Acute posttraumatic stress A. the person was exposedto a traumatic event in which: experienced, witnessed, or experienced an event that involved threats of death or serious injury, death or serious injury, or threats to the physical integrity of themselves or others; the person's reaction included intense fear , feelings of helplessness or horror.B. during or after experiencing the traumatic event, three or more of the following dissociative symptoms are manifested: the feeling of detachment and the absence of affective responses; reduced awareness of the environment; derealization; depersonalization; dissociative amnesia (cannot remember important aspects of the traumatic event) .C. the traumatic event is re-experienced repeatedly.D. stimuli that remind the traumatic event are avoided. the presence of symptoms of anxiety and high arousalF. symptoms last between 2 days and 4 weeks and appear in the first 4 weeks after the trauma. Differential diagnosis Posttraumatic stress (PTSD) The disorder with which the differential diagnosis is made Differentiation indices Adjustment disorder - the stressor is an extreme life situation (PTSD) versus the stressor can be of any severity (adjustment disorder). Acute posttraumatic stress - symptoms appear in the first four weeks after the traumatic event and disappear within a month (acute post-traumatic stress) versus symptoms that persist for more than a month (PTSD). Obsessive-compulsive disorder - intrusive thoughts are experienced as inappropriate (OCD) versus intrusive thoughts associated with a trauma and felt as natural, normal given the situation (PTSD). Simulation - situations in which there is an external benefit (financial or other). !![b]1.2.7. GENERALIZED ANXIETY!![/b] DisorderEpidemiology Generalized anxiety- In the general population, the prevalence is 5%;- In the clinical population with anxiety disorders, approximately 12% have generalized anxiety. The disorderExplanatory theoriesGeneralized anxietyCognitive-behavioral theoryThe sequences of etiopathogenetic mechanisms are as follows:- the existence of a state of chronic physiological arousal. The role of the maladaptive and catastrophic cognitive style, which maintains this state of arousal through a vicious circle, was demonstrated. SNV reactivity is also incriminated; - the occurrence of situations that generate an emotional state within normal limits; - the chronic arousal is superimposed on the one generated by the target situation, amplifying the negative emotional experience (panic attack can be reached) and gradually the avoidance behavior more and more social situations. Type of disorder DSM IV diagnosis - Diagnostic criteria Generalized anxiety excessive worry and anxiety, vivid dreams of various events and activities, present almost daily over a period of 6 months; the person feels unable to control the worries; the worries are associated with three or more of the following manifestations: restlessness and tension; fatigue; concentration difficulties; irritability; muscle tension; sleep disorders; anxiety and worry are not limited to a particular aspect (a situation, object, etc.). Differential Diagnosis Generalized Anxiety Disorder (GA)Differentially Diagnosed DisorderIndices of DifferentiationPanic Attack- Worries about the possibility of another panic attack (panic attack) vs. Worries about many aspects of life (GA).Social Phobia- worries about the possibility of being in an embarrassing position in public (social phobia) versus worries about many aspects of daily life, regardless of whether social appraisal (GA) occurs or not. OCD- fear of contamination and egodystonic intrusive thoughts (OCD) versus fears related to current problems (GA); in GA, worries in verbal form predominate, while in OCD images and impulses often appear that attract compulsive behaviors. Anorexia nervosa - worries related toweight gain (anorexia) versus concerns related to multiple aspects of current life (GA). Somatization- concerns related to multiple somatic complaints (somatization) versus concerns related to multiple aspects of current life (GA). Separation anxiety- concerns related to the fact that loved ones might suffer or be away from them or from home (separation anxiety) versus concerns related to several aspects of current life (GA). Hypochondria- concerns related to the possibility of being serious sick (hypochondria) versus concerns related to several aspects of current life (GA). Posttraumatic stress- anxiety occurs as a consequence of a severe trauma (PTSD), anxiety occurs in response to current stressors (GA). Adjustment disorder- is a residual category used only if the symptoms do not meet the criteria of another anxiety disorder. Non-pathological anxiety - worries are more controllable, less intense, related to fewer aspects of life, less often accompanied by somatic manifestations and interfere less with adaptive capacities and of the person's functioning (non-pathological anxiety). !![b] !![/b]!![b] !![/b]!![b]1.3. Automatic thoughts characteristic of various forms of anxiety!! friend with me if everyone knows I'm anxious; Because of my emotionality, everyone will think I'm a weak person; I have no chance of being a successful person if I can't control my emotions; I'm a laughing stock if others see that I am stressed and anxious. Avoids social situations, performance situations, places where there are many people; He does better in a familiar setting and with close friends. claustrophobia If I go in there I won't be able to get out; Narrow places are dangerous because you can suffocate; From a closed space I might not get out and die of suffocation. Avoid closed, tight spaces. post-traumatic stress The world is a dangerous place; The situation may remind me of my trauma; Memories of my trauma may invade me at any time. He avoids situations or things that remind him of the trauma he suffered. obsessive-compulsive disorder Thoughts or behaviors from which it is difficult for me to refrain will lead to illness or injury to myself or someone else; The thoughts that invade me are absurd and unrealistic. Engage in compulsive behaviors (from which they cannot refrain ) that reduces their anxiety. separation anxiety If those close to me are not close, something very bad can happen to them. They refuse to be alone. panic attack with agoraphobiaI get laughed at if I have a panic attack in public;If I have a panic attack in that place I can't ask for help;If I have a panic attack in that place, I won't be able to get out in time;I could have a panic attack at any time;Exaggerated anxiety I feel will lead to the onset of a serious illness;If I am left alone something bad could happen to me.Avoid social situations;Avoid social situations, performance situations, places where I am many people;Avoid closed, tight spaces;Avoid situations or things that remind them of panic attacks;Engage in behaviors that reduce their anxiety;Refuse to be alone. !![b]1.4. Treatment!![/b]Cognitive-behavioral techniques for modifying maladaptive behaviors and cognitions, inducing relaxation in all anxiety disorders; In post-traumatic stress (PTSD) and obsessive-compulsive disorder, intrusive thought control techniques are used; In post-traumatic stress , techniques for modifying knowledge from the implicit memory system are useful; drug therapy has a rapid effect, but is not recommended in combination with psychotherapy (the person will attribute the remissionthe symptomatology of the drugs and not the acquisition of control over it).!! !!Module II. ADJUSTMENT DISORDERS ACCORDING TO DSM-IV !![b]Topic 2. ADJUSTMENT DISORDERS!![/b]!![b]2.1 Overview!![/b]- the characteristic feature of adjustment disorders is the installation of symptoms emotional and behavioral (maladaptive reactions), of clinical intensity, in response to the intervention of identifiable psycho-social stressors; - symptoms appear within 3 months of the intervention of the stressors and disappear on their own after no more than 6 months from the cessation of their action ; symptoms can only persist if it is a chronic stressor or with long-lasting effects; - stressors can appear in the form of a single event (e.g., the end of a romantic relationship) or in the form of multiple problems (e.g., financial difficulties, couple problems etc.);- adjustment disorders appear in different forms, depending on the symptoms that dominate the clinical picture:- with depressive mood;- with anxiety;- mixed, with depressive mood and anxiety;- with behavioral disorders;- with disorders emotional (anxiety, depression) and behavioral disorders; - unspecified (physical charges, social isolation, school difficulties, etc.).!![b]2.2. Epidemiology!![/b]- very common among patients hospitalized for surgical interventions;- occurs twice as often in women;- prevalence in the clinical population is between 5%-20%;- people from disadvantaged socio-economic backgrounds and are exposed to the influence of many stressors constitute a risk group.!![b]2.3. Etiology!![/b]Stress can be defined as a discrepancy between the demands of the situation and the self-perceived abilities to respond to those stressors (R. Lazarus); According to Lazarus, three types of evaluations are involved in the assessment of each situation: Primary evaluation - includes automatic processing aimed at the interaction between the stressor and the person, resulting in cognitive, behavioral and biological changes. As a consequence of these changes, a primary subjective experience appears (the situation is labeled as dangerous or not) Secondary evaluation – aims at the coping mechanisms that can be mobilized to change the primary subjective experience cognitivebehavioralbiologicalConfrontativeEvitativeX (defensive mechanisms) 3. Tertiary evaluation – aims at the effectiveness of the coping mechanisms mobilized to modify the emotional experience. Therefore, the coping mechanisms intervene before or after the appearance of the subjective experience, in a cascade (successive processing), leading to the gradual approximation of the emotional experience. Although this model was proposed by Lazarus for stress and emotions, it is also applicable to adjustment disorders. In the case of adjustment disorders, the person's reaction is more intense than normal, because at the individual level there are vulnerability factors such as: Biological - genetic ( reactive SNV) or acquired (chronic arousal transferable in different situations); Psycho-social – irrational beliefs and attributional style, self-efficacy, optimism, pattern of maladaptive cognitions, social support, self-esteem, maladaptive coping mechanisms acquired in childhood. !![b]2.4. DSM IV diagnosis!![/b]Type of disorderDiagnostic criteriaAdaptation disordersappearance of emotional and behavioral symptoms in response to the intervention of identifiable stressors and which settle in at most three months after their appearance; the symptoms are of clinical intensity, expressed as: 1) the intensity of the distress experienced exceeds the normal reaction to the respective stressor; (2) it has a significant negative impact on the person's life, affecting their ability to function socially or academically); the disorder does not meet the criteria for another condition on axis I and does not represents an exacerbation of a previous I-axis disorderor II; the symptoms do not represent a mourning reaction; once the action of the stressors has ended, the symptoms persist for a maximum of 6 months.!! [b] 2.5. Differential diagnosis!! [/b]Adjustment disorders represent a residual category, which includes responses of clinical intensity to the intervention of an identifiable stressor, which do not meet the criteria for another disorder on axis I. The disorder with which the differential diagnosis is made Differentiation indices Stress post-traumatic and acute post-traumatic stress The intervention of extreme stressors and a specific symptomatic constellation (PTSD, acute stress) versus the intervention of stressors of any intensity, involving a wide variety of symptoms. The bereavement reaction The normal reaction to the loss of a close person (the bereavement reaction) versus disproportionate or prolonged reaction to the loss of a close person (adjustment disorder). Unspecified disorders (anxiety, depression, etc.) Atypical or reduced-intensity reactions to the intervention of an identifiable stressor (adjustment disorders) versus atypical or reduced-intensity reactions (other unspecified disorders).Psychological factors exacerbating a general medical condition Different psychological factors exacerbate a general medical condition, complicate its treatment or increase the risk of the disease (psychological factors exacerbating a general medical condition) versus the appearance of psychological symptoms in response to the stress involved in the diagnosis of a general medical conditions (adjustment disorders). Non-pathological reactions to stress They do not lead to excessive distress and do not cause major social or occupational dysfunctions.!! [b] 2.6. Treatment!![/b]Cognitive-behavioral techniques to control stress and its consequences.!![b]Theme 3. FACTUAL DISORDERS!![/b]!![b]3.1. General presentation!![/b]- Factitious disorders refer to those somatic or psychological symptoms produced or invented intentionally, with the aim of assuming the role of a sick person; - The artificial production of symptoms constitutes a compulsive act; symptoms are produced consciously and intentionally, but escape voluntary control; - The difference between factitious disorders and simulation consists in the goal pursued by the person (an identifiable external benefit in the case of simulation, while the motivation of people with factitious disorders is the psychological need to assume the role of the sick, in the absence of external determinants of this behavior);- In certain conditions (e.g., war camps) simulation constitutes adaptive behavior, while the diagnosis of "factual disorders" always implies a psychopathology. There are several subtypes, in according to symptomatology: (1) Factitious disorders with predominantly somatic symptoms and signs - the clinical picture is dominated by signs and symptoms that suggest the presence of a somatic disease; - the symptoms can be produced (e.g., self-infection) or invented; - the entire life of the individual is dedicated to the attempt to be admitted to a hospital (Munchausen Syndrome):- the clinical picture includes: severe pain, nausea, vomiting, dizziness, fever of undetermined origin, fainting, abscesses and irritations, bleeding due to the ingestion of anticoagulant substances;- all body organs are possible targets in the generation of symptoms, depending on the patient's medical knowledge and imagination.- patients present their disease history in a coherent manner, with affective involvement, but when asked for details they become very vague. They create chaos on the wards where they are hospitalized, demanding attention from the medical staff, in whose presence the symptoms are amplified. After communicating the fact that they do not have any disease, they will turn to other doctors for assistance; - as associated elements, they present problems related to substance consumption; - frequently present complications due to repeated surgical interventions andthe side effects of the prescribed medication. (2) Factual disorders with predominantly psychological symptoms and signs - the clinical picture mainly includes signs and symptoms that suggest the presence of a mental disorder; - as indicators of the disorder are: the varied and atypical symptomatological pattern, which does not correspond known syndromes, the course of the disease and the response to treatment are extremely unusual, an exacerbation of symptoms in the presence of medical personnel and increased susceptibility to the doctor's suggestions (the patient easily incorporates the data provided by him); - the clinical picture presented is more suitable to the conception that the patient has about the disease and not the specific symptomatology; - the most frequent accusations are: depression and suicidal ideation after the death of the life partner (his death not being confirmed by other sources), amnesias, hallucinations, delirium, dissociative symptoms; - as associated elements present disorders associated with substance use and personality disorders. (3) Factual disorders with mixed, somatic and psychological symptoms - the clinical picture includes somatic and psychological signs and symptoms, produced intentionally.!![b]3.2. Epidemiology!![/b]- the prevalence in the general population is relatively low; however, it is possible that many cases remain undiagnosed; - the prevalence of the disorder (with and without associated medical disorders) in the case of patients admitted to different departments is 9%; approximately 3% of patients presenting with fever in various clinics and hospitals suffer from this disorder; - it seems that the disorder occurs more frequently in men than in women.!![b]3.3. Etiology!![/b]The etiopathogenetic mechanisms involved are not clearly known. As risk factors we mention: repeated admissions during childhood due to real illnesses, sexual abuse by medical personnel, resentment towards the medical profession due to inadequate treatments. Often the affected people have mid-level paramedical professions. Psychoanalytical perspective - the causal mechanism is based on poor childhood relationships; the consequence is the compulsive expression of the need for attention (the childhood conflict). The feelings towards the significant people are transferred to the medical staff due to the similarities (people who offer help and support and hold the monopoly of knowledge in that situation). Cognitive-behavioral perspective The central mechanism is operant learning and stimulus generalization; patients learn this behavior because the benefits outweigh the costs. Gradually, generalization appears - the same behavior is manifested towards different stimuli. 3.4. DSM IV diagnosis Type of disorderDiagnostic criteria Factitious disordersIntentional production or invention of some somatic or psychological symptoms; The motivation of the behavior is assuming the role of the patient; There are no external benefits for the behavior (economic gains, avoidance of legal responsibility, etc.). !![b]3.5. Differential diagnosis!![/b]The disorder with which the differential diagnosis is made Differentiating indices Real somatic or mental disorders (psychotic, cognitive, short-term reactive disorders) - the possibility that a somatic or mental disorder is, in fact, a factual disorder exists if the presence of some of the following aspects is noted: - the present clinical picture is atypical, inconsistent with the symptomatology of the respective condition; - the symptoms or behaviors are manifested only when the patient is observed by others; - there is non-compliance with treatment and aggressive behavior in the salon; - the patient possesses knowledge extensive information about medical terminology and hospital routines; - non-prescription use of various substances and medicines; - the presence of traces of repeated medical interventions; - few visitors during hospitalization; - the course of the diseaseit is fluctuating, with the rapid appearance of some complications if the initial examinations do not indicate the presence of a disease. Somatoform disorders - the existence of somatic complaints that cannot be entirely attributed to a general medical condition produced intentionally (factual disorder) versus unintentionally produced (somatoform disorders). Simulation - the motivation behind the production of symptoms is an external benefit, the symptoms being suspended when they are no longer useful to the person (simulation) versus the production of symptoms from the need to assume the role of the sick, this being a compulsive, uncontrollable act (factual disorders). !![b]3.6. Evolution and prognosis of the disease!![/b]- Although sometimes the disorder can be limited to one or more short episodes, the course is usually chronic;- The onset of the condition is in the first part of adult life, often occurring after a hospitalization for a somatic or mental problem;- Chronic forms are characterized by repeated hospitalizations throughout life.!![b]3.7 Treatment!![/b]- There are still no effective psychotherapeutic intervention techniques; psychological assistance mainly targets the medical staff and the patient's primary group who are included in educational programs with reference to the disease for a more effective relationship with the patient; - The medical staff is educated to adopt a neutral attitude towards these patients; - They have a positive impact the therapeutic relationship (characterized by empathy, unconditional acceptance, congruence) and the conceptualization offered (accusations of simulation are avoided). !![b]Theme 4. DISSOCIATIVE DISORDERS!![/b] !![b]4.1. Overview!![/b]The central feature is the destructuring of integrated functions: consciousness, memory, identity, perception of the environment. Destructuring can occur suddenly or insidiously and can be temporary or chronic. Dissociation versus repression Repression - refers to the process of blocking some informational contents, which do not enter the field of consciousness and are linked through catesis to a sexual or aggressive drive. Dissociation - is a coping mechanism that consists in the fragmentation of self-related knowledge and changes in the way of self-perception; certain informational contents are separated and kept apart from the others; the removal of an informational content from consciousness occurs when it is linked to a negative affective content. While repression makes a vertical separation, dissociation leads to a horizontal separation (see figure no. 1). Five disorders belong to this category: 1 . Dissociative amnesia - has as its main characteristic the inability to remember information with personal relevance, usually of a traumatic or stressful nature and which is not due to an organic disorder or natural forgetfulness; there are several types of dissociative amnesias: - localized amnesia - the inability to remember well-circumscribed information contents in time, usually in the first hours after an extremely traumatic event; - selective amnesia - the inability to remember fragments of information from - a circumscribed period in time; occurs after traumatic or stressful events; - generalized amnesia - the lack of memories refers to the entire life of the individual (occurs less often); - continuous amnesia - inability to remember information / events from the time of a trauma to the present; - amnesia systematized - refers to the loss of memory for certain categories of information (eg, information related to a specific person). 2. Dissociative flight - manifests itself by moving from home or work, with the assumption of a new identity and confusion vis a vis the previous identity; 3. Dissociative identity disorder (previously known as MPD) - is characterized by the presence of one or more different identities or personalities (stable response patterns that appear indifferent contexts) that control the individual's behavior, doubled by the inability to remember information with personal relevance; sometimes the personalities are totally distinct, they dominate the behavior and are amnesic towards the presence of the others, other times a personality dominates but is aware of the presence of the others and communicates with them. The transition from one personality to another is accompanied by amnesia (the classic meaning) and occurs suddenly, in a matter of seconds. Personalities can be extremely different, differing by psychological characteristics, brain pattern, answer to personality and intelligence tests and even neurophysiological aspects. 4. Depersonalization disorder - has as a basic feature the feeling of detachment from one's own body or mind, while maintaining contact with reality; the feeling of observing one's own person and mental processes from the outside appears. 5. Unspecified dissociative disorder – is a category that includes disorders characterized by dissociative symptoms, which do not meet the criteria necessary for the diagnosis of one of the previous disorders; is a category used to include: elements related to derealization, in the absence of depersonalization, comatose states not associated with a general medical condition, dissociative states that appear in subjects subjected to persuasion procedures, Ganser's syndrome (has the response next to it as a characteristic) when there is no association with fugue or dissociative amnesia, dissociative trance (specific to different cultures and religions).!!! the manifestations that appear within religious practices or cultural activities, which are part of the customs of certain communities, are not considered pathological, except for situations involving distress and disability. Aspects related to the evaluation: - in almost all cases, the transition from a personality in another it is done against the backdrop of a stressful event;- The Dissociative Experiences Scale evaluates the degree of dissociation;- applying this scale it was found that, of the patients diagnosed with dissociative identity disorder: 90%- declare that there is another person inside them87%- declare that they hear voices that speak to them 82% - declare that they hear voices that come from inside them 81% - they feel that another person is controlling them 81% - they have amnesia for events that happened in their childhood 73% - when they talk about themselves they also say "we"70 %- declare that there is another person inside them who bears a different name62%- do not remember things that those around them say they did56%- experience feelings of derealization44%- do not recognize people who behave familiarly with them42%- notice that certain objects around them disappear31%- notice that various objects around them appear, unjustifiably27%- at different times, they have different writings!![b]4.2. Predisposing factors!![/b]- Extremely stressful situations, traumatic events, physical and sexual abuse, alcohol consumption.!![b]4.3. Epidemiology !![/b]!![b]4.3.1. DISSOCIATIVE AMNESIA!![/b]Epidemiology- of all dissociative disorders it has the highest prevalence;- occurs more frequently in women than in men;- occurs more frequently in periods of crisis and social problems (wars, natural disasters). Evolution and prognosis - onset and termination can be sudden or gradual; - recovery is complete and recurrence is rare; - as a rule, several episodes of dissociative amnesia are recorded in the same individual. Etiological mechanisms They are of a psychological nature, the person tries to remove strongly charged information from consciousness negative affective. Type of disorder DSM IV diagnosis - Diagnostic criteria Dissociative amnesia, the occurrence of one or more episodes in which the person cannot remember information of personal relevance, usually of a stressful or traumatic nature, and which is not due to natural forgetting; the disorder is not due to a neurological disordersor substance use; symptoms cause distress and/or disability. Differential diagnosis Dissociative amnesiaDisorder with which differential diagnosis is madeIndicia of differentiationDelirium and dementia- In delirium and dementia, memory disorders appear in a wider context of cognitive, language, affective, attentional, perceptual and behavioral deficits. Epileptic seizures- In seizures epileptics, the memory disorder has a sudden onset and is accompanied by motor symptoms and an atypical EEG pattern. Amnestic disorder due to substance use, brain damage or a general medical condition - the differentiating element consists in the direct etiological link between amnesia symptoms and drug use substances or somatic problems; - amnesia is mainly anterograde, with preservation of the ability to acquire new information (amnesic disorder) versus mainly retrograde amnesia (brain injuries) and disorders of acquiring new information (substance intoxication ).Dissociative fugue or dissociative identity disorder - if dissociative amnesia occurs exclusively during these disorders, an additional diagnosis of amnesic disorder is no longer made. Depersonalization disorder - if depersonalization symptoms appear exclusively during the period of dissociative amnesia, the diagnosis is no longer made of depersonalization disorder. Acute posttraumatic stress, somatization disorder or PTSD - if amnesia symptoms appear exclusively during PTSD, somatization disorder or acute traumatic stress, the diagnosis of amnesic disorder is no longer made. Simulation - as a rule, people with amnesia dissociative have high scores in the tests of hypnotizability and dissociative capacity; the simulating individuals present a florid symptomatology and seek an external benefit. Cognitive decline due to advanced age or non-pathological forms of amnesia - the main element of differentiation consists in the level of distress and disability involved; - there are also non-pathological forms of infantile, posthypnotic amnesia for dream events or natural forgetfulness.!![b] !![/b]!![b]4.3.2. DISSOCIATIVE ESCAPE!![/b]Epidemiology- in the general population, the prevalence is 0.2%, with a tendency to increase during crises or extreme events (wars, natural disasters). Evolution and prognosis- recovery is fast and recurrence is rare - lasts from days to weeks or months - the onset of symptoms is usually related to the presence of traumatic or stressful events; - during the period of flight, people lead a "grey" existence, without attracting the attention of those around them. Etiological mechanisms - refers to the motivation to escape from painful events from an emotional point of view. Type of disorder DSM IV diagnosis - Diagnostic criteria Dissociative escape moving away from home or work, associated with the inability to remember the past; assuming a new identity (partially or totally ) and confusion vis a vis the true identity; the disorder is not due to substance use or a general medical condition (eg, temporal lobe epilepsy); the symptoms cause distress and/or disability. Differential diagnosis Dissociative fugueThe disorder with which the differential diagnosis is madeIndicia of differentiation Epilepsy seizures- moving from home with memory loss (dissociative fugue) versus aimless movement or behaviors accompanied by motor disturbances, stereotypies, perceptual disturbances, atypical EEG path (epileptic fugue) .Manic episodes - moving away from home with a well-defined purpose, manifestations of grandeur that attract the attention of those around, without assuming a new identity (manic episodes) versus moving away from home apparently without purpose, with the assumption of a new identity (dissociative fugue). Schizophrenia- in dissociative fugue they do not appearnegative symptoms or delirium; - in schizophrenia, the difficulties in reproducing the events during the journey may be due not to amnesia but to disorganized speech. Simulation - as a rule, people with dissociative fugue have high scores on tests of hypnotizability and dissociative capacity; simulant individuals present dissociative symptoms even during interviews under hypnosis and seek an external benefit. Psychogenic amnesia - in this case, the person does not assume a new identity.!! [b] 4.3.3. DISSOCIATIVE IDENTITY DISORDER!![/b]Epidemiology- in the population admitted to psychiatric wards the prevalence is 0.5%-2%;- in the population with a psychiatric diagnosis, the prevalence is 3%-5%;- the disorder occurs more frequent in women (90% of diagnosed people are women); women have, on average, 15 personalities compared to men who have approximately 8;- it manifests itself starting from adolescence and the first part of adult life;- the disorder occurs more frequently in first-degree relatives of patients who present this condition, than in the general population general. Evolution and prognosis - the course of the condition is chronic and recurrent, with frequent fluctuations; - the period of time from the appearance of the first symptoms and the diagnosis of the condition is 6-7 years; - the disorder is less obvious after the age of 40, but they may appear recurrences during stressful, traumatic periods or characterized by substance abuse. Etiological mechanisms As etiological factors we can mention: traumatic events that happened especially in childhood, lack of adequate support from others, vicarious learning. Type of disorder DSM IV diagnosis - Diagnostic criteria Dissociative identity disorder, the presence of two or more personalities (each with its stable pattern of perception, way of relating, reporting to the environment and to oneself); at least two of these personalities repeatedly take control of the individual's behavior ;inability to recall information of personal relevance, too extensive to be explained by natural forgetting;disorder not due to substance use or a general medical condition. Differential diagnosis Dissociative identity disorderThe disorder with which the differential diagnosis is madeIndices of differentiationSubstance abuse and dissociative symptoms due to a somatic condition- the differentiation is made, mainly, depending on the etiological association between the specific symptoms and the use of substances, respectively the presence of a somatic condition. Dissociative symptoms due to crisis episodes (epileptics) - these two disorders can appear in comorbidity; the epileptic episodes are short (30 sec. - 5 min.) and do not involve the stable identity structures and behavior specific to dissociative identity disorder. Dissociative amnesia, dissociative fugue, depersonalization disorder, unspecified dissociative disorder - dissociative identity disorder involves symptoms specific to these conditions (e.g., moving from home, depersonalization, amnesia, possession trance) and constitutes a primary diagnosis in relation to these. Schizophrenia and other psychotic disorders - auditory hallucinations, delirium (psychotic disorders) versus communication between different personalities (dissociative identity disorder ) Bipolar disorder with psychotic elements - cyclic mood fluctuations, with sudden changes between states (bipolar disorder) versus personality change (dissociative identity disorder) Simulation and factitious disorders - the differentiation is made according to the objective pursued - external benefit (simulation) and assuming the role of the sick (factual disorders). !![b]4.3.4. DEPERSONALIZATION DISORDER!![/b] Epidemiology - the prevalence of this disorder in the general and clinical population is not known; - approximately 1/3 of people who havepassed through life-threatening events and 40% of hospitalized patients with mental disorders experience transient depersonalization experiences; - certain elements of depersonalization appear in over 70% of the population (without reaching clinical level symptoms). Evolution and prognosis - the duration of depersonalization episodes can last from seconds to years (in such situations, associated disorders such as anxiety, panic and depression appear); - the evolution can be chronic, marked by remissions and exacerbations; - usually begins in adolescence (rarely after 40 years); - when it appears in connection with situations that endanger the individual's life, the symptomatology sets in immediately after exposure to the traumatic event; - the setting is fast, with gradual disappearance. Type of disorderDiagnosis DSM IV - Criteria diagnoses Depersonalization disorder episodes in which the feeling of detachment from one's own person appears, as if the subject were an external observer of his body and his mental processes; during the experience of depersonalization contact with external reality is maintained; depersonalization produces distress of clinical intensity or/and disability; depersonalization is not due to substance use or a general medical condition (eg, temporal lobe epilepsy). Differential diagnosis Depersonalization disorderDisorder with which a differential diagnosis is madeIndices of differentiationSubstance abuse and depersonalization symptoms due to a general medical condition - differentiation is made on the basis of the etiological association between depersonalization symptoms and substance use, respectively the presence of a somatic condition; sometimes, the use of substances can intensify previously present dissociative manifestations; in this case, the longitudinal history of depersonalization symptoms and substance abuse is taken into account. Panic attack, social phobia, specific phobias, acute stress and PTSD - when depersonalization symptoms occur exclusively during the manifestation of one of these disorders, it is not makes an additional diagnosis of depersonalization disorder. Schizophrenia- contact with reality remains unaltered (depersonalization disorder) versus contact with reality is impaired (schizophrenia). Depression- the presence of affective flattening (depression) versus affective flattening - which also occurs when the person is not depressed - associated with detachment from one's own person (depersonalization disorder).!![b]4.4. The treatment!![/b]- It is primarily psychotherapeutic, with the use of medication as an adjuvant element. They are used: dynamic-psychoanalytical techniques aiming at the integration of conscious and unconscious aspects; hypnotherapy - considered the treatment of choice - aims at using suggestions to reduce dissociations. !![b]Theme 5. PERSONALITY DISORDERS!![/b]!![b]5.1. General presentation!![/b]Personality disorder is defined as a stable pattern of affective experiences and behaviors, which deviates significantly from the standard of the culture of belonging of the respective individual, is generalized and inflexible, has its onset in adolescence or the first part of adult life , is stable over time and generates distress or disability.- Personality disorders are approached from the perspective of the trait model, seen as relatively stable trans-situationally;- Personality disorders appear when personality traits become very inflexible, maladaptive and generate disability and distress; - These disorders can be egodystonic (the person experiences a state of distress) or egosyntonic (the distress related to the disease does not appear); it should be noted that, in the first case, the negative affective experience appears related to the presence of the disease and the reactions of others to it, while in the second case, the individual does not accept that he has a personality disorder, but may experience states of distress due to the fact that those around him do notaccepts as it is; Personality disorders are grouped based on descriptive similarities: Group A – includes paranoid, schizoid and schizotypal personality disorders. Their common feature is eccentricity. Group B – includes antisocial, borderline, histrionic and narcissistic personality disorders. Their common features are theatricality, emotionality, extravagance. Group C – includes avoidant, dependent, obsessive-compulsive personality disorders. Their common features are anxiety, fear. Personality disorders not previously specified - represents a category used in two situations: (a) the symptoms indicate a personality disorder, with features belonging to several disorders in this diagnostic group, but the criteria for to diagnose a specific personality disorder; (b) the symptoms indicate a personality disorder, but the features suggest a disorder not included in the DSM IV categorization (eg, passive-aggressive personality).!![b] !![/b]! 5.2. Epidemiology !![/b] !![b]5.2.1. PARANOID PERSONALITY DISORDER!![/b]Epidemiology- In the general population, the prevalence is 0.5%-2.5%;- In the clinical population (patients admitted to psychiatric wards), the prevalence is 10% - 30%;- An increased prevalence is observed in the case of relatives of people with chronic schizophrenia and persecutory delusional disorder. Characteristic featureDiagnosis DSM IV - Diagnostic criteria Distrust and suspicion towards others and their reasons; begins in early adulthood and manifests itself in a variety of contexts.A – mistrust and suspicion of others and their reasons manifests itself in four or more of the following ways: (a) unfounded suspicions that others are exploiting, hurting or deceiving him ; (b) distrust in the loyalty of friends and associates; (c) hesitates to reveal himself to others for (unjustified) fear that they will not use the information against him; (d) believes that behind some neutral remarks or events there are threats to the sa;(e) spiteful; he does not forget insults, insults; (f) he feels, for no good reason, that his reputation and character are being questioned and reacts aggressively; (g) he always has unfounded suspicions about the fidelity of his life partner.!! [b] 5.2.2 . SCHIZOID PERSONALITY DISORDER!![/b]Epidemiology- It occurs very rarely in the hospitalized clinical population;- It occurs more frequently in relatives of patients with schizophrenia or schizotypal personality disorder. Characteristic feature DSM IV diagnosis - Diagnostic criteria Detachment from social relationships and reduced emotional expressiveness in interpersonal situations; begins at the beginning of the adult period and manifests itself in a variety of contexts. A- detachment and reduced emotional expressiveness manifests itself in four or more of the following ways: (a) does not want or approve of close relationships, including those of family; (b) almost always prefers solitary activities; (c) is not interested in sexual relations with another person; (d) does not have many favorite activities; (e) has no close friends outside of first-degree relatives; (f ) seems indifferent to the praise and criticism of others; (g) is detached, cold, emotionless.!![b]5.2.3. SCHIZOTYPAL PERSONALITY DISORDER!![/b]Epidemiology- In the general population, the prevalence is about 3%;- It occurs more frequently in first-degree relatives of patients with schizophrenia;- First-degree relatives of patients with personality disorder schizotypal type are more prone to schizophrenia and other psychotic disorders. The characteristic feature DSM IV diagnosis - diagnostic criteria Social and interpersonal deficits, discomfort andreduced ability to establish close relationships, cognitive and perceptual distortions, behavioral eccentricities; begins at the beginning of the adult period and is manifested in a variety of contexts. Cognitive, perceptual and behavioral deficits and peculiarities are manifested in five or more of the following ways: (a) ideas of reference (different events have a special meaning for him );(b) strange beliefs and magical thinking (exceeding the norms of the culture of belonging);(c) unusual perceptual experiences, bodily illusions;(d) strange thinking and speech;(e) paranoid ideas, suspicion;(f) limited affectivity, inappropriate; (g) strange, eccentric, peculiar behavior and presentation; (h) lack of friends outside of close relatives; (i) excessive social anxiety, which does not decrease with familiarization, associated with paranoid fears rather than negative self-evaluations.! 5.2.4. ANTISOCIAL PERSONALITY DISORDER!![/b]Epidemiology- In the general population, the prevalence is 3% for men and 1% for women;- In the hospitalized clinical population, the prevalence varies between 3%-30%, depending on the characteristics population, even reaching higher values ​​in groups treated for substance abuse or groups of criminals. Characteristic trait DSM IV Diagnosis - Diagnostic criteria Disregard and violation of the rights of others; begins in adolescence (15 years) and manifests itself in a variety of contexts. The disregard and violation of the rights of others manifests itself in three or more of the following ways: (a) non-compliance with social norms, disinterest in obeying the laws (b) the tendency to aI deceive, lie and deceive others for personal gain or pleasure (c) impulsivity or inability to plan (d) irritability and aggressiveness, indicated by aggression and frequent physical confrontations (e) carelessness and indifference to one's own safety and that of others ( f) irresponsibility manifested by failure to engage in work and honor financial obligations (g) lack of remorse for the injury, abruptness or dispossession of the other manifested by indifference or rationalizations!! [b] 5.2.5. BORDERLINE PERSONALITY DISORDER!![/b] Epidemiology- In the general population, the prevalence is 2% (twice as common in women);- In the hospitalized clinical population, the prevalence rates go up to 20%;- In in the case of the clinical population with personality disorders, the prevalence is 30%-60%; - Borderline personality disorder is 5 times more common in relatives of patients with this condition; - Borderline personality is a fertile ground for the emergence of schizophrenia; - There is also an increased family risk for antisocial personality disorder, affective disorders and disorders related to substance abuse. Characteristic feature DSM IV diagnosis - Diagnostic criteria Instability in interpersonal relationships, self-image, heightened affectivity and impulsivity; begins in early adulthood and manifests in a variety of contexts. Instability and impulsivity manifest in five or more of the following ways: (a) desperate efforts to avoid real or imagined abandonment; (b) unstable and intense interpersonal relationships , alternating between idealization and depreciation; (c) identity disorders; unstable self-image and sense of self; (d) impulsivity in at least two domains with self-destructive potential (e.g., sexual behavior, substance use, compulsive eating, etc.); (e) recurrent suicidal behavior, gestures, threats, self-mutilation (f) affective instability due to heightened reactivity (frequent mood swings); (g) chronic feeling of "soul emptiness"; (h) intense outbursts of anger andinadequate or difficult to control anger; (i) transient paranoid ideation, associated with stress or severe dissociative symptoms!![b]5.2.6. HISTRIONIC PERSONALITY DISORDER!![/b]Epidemiology- In the general population, the prevalence is 2%-3%;- In the hospitalized clinical population, the prevalence is 10%-15%. Characteristic feature DSM IV diagnosis - Diagnostic criteria Affectivity excessive and attention-grabbing behaviors; begins in early adulthood and manifests in a variety of contexts. Excessive affectivity and need for attention manifests in five or more of the following ways: (a) feels uncomfortable in situations where he is not the center of attention; (b) interaction with others is characterized by inappropriate, provocative behavior with strong sexual overtones; (c) emotional expressiveness is shallow and fluctuates rapidly; (d) frequently uses physical image to attract the attention of others; (e) speech has dramatic overtones and is poor in details; (f) manifestations of theatricality and exaggerated emotional expressiveness; (g) accentuated suggestibility; (h) perceives relationships as more intimate than they are in reality.!![b] !![/b]!![b] 5.2.7. NARCISSISTIC PERSONALITY DISORDER!![/b]Epidemiology- In the general population, the prevalence is 1%;- In the clinical population, the prevalence is 2%-16%;- Among the people diagnosed with this disorder, 50%-75 % are men;- It is sometimes associated with histrionic personality disorder;- The prevalence has registered an increasing trend in recent years. The characteristic feature DSM IV diagnosis - Diagnostic criteria The need to be admired and the lack of empathy; begins in early adulthood and manifests in a variety of contexts. The need to be admired and lack of empathy manifests in five or more of the following ways: (a) an exaggerated sense of self-importance; (b) entertains fantasies of unlimited success, power, genius, beauty, or ideal love; (c) believes he is unique and special and should interact only with other powerful and special people or institutions; (d) claims excessive admiration; (e) believes he is entitled to everything; l(f) in interpersonal relationships exploits others to achieve their goals; (g) lacks empathy; does not perceive and recognize the feelings and needs of those around him; (h) is envious of others and thinks that others also envy him; (i) adopts an arrogant and condescending attitude and behavior.!![b]5.2.8. AVOIDANT PERSONALITY DISORDER!![/b]Epidemiology- In the general population, the prevalence is 0.5%-1%;- Occurs in 10% of patients with mental disorders treated on an outpatient basis;- Occurs with the same frequency in men and women. Characteristic trait DSM IV diagnosis - Diagnostic criteria Social inhibition, feeling of inadequacy, hypersensitivity to negative evaluations; begins at the beginning of adulthood and manifests itself in a variety of contexts. Social inhibition, feelings of inadequacy and hypersensitivity to negative evaluations manifest themselves in four or more of the following ways: (a) avoids professions that involve frequent interpersonal contacts, for fear of criticism, disapproval or rejection; (b) does not get involved in relationships if he is not sure that the other person likes him; (c) is restrained in intimate relationships for fear of being ridiculed; (d) is worried about the idea of ​​being criticized or rejected in social situations; (e) is inhibited in new interpersonal situations, due to feelings of inadequacy; (f) sees himself as unable to cope in social relationships, unattractive and inferior to others; (g) is extremely cautious when having to take personal risks or get involved in new activities for fear of notlaughable.!![b] !![/b]!![b]5.2.9. DEPENDENT PERSONALITY DISORDER!![/b]Epidemiology- In the general population, the prevalence is 2.5%;- It occurs more frequently in women;- It is one of the most frequent personality disorders found in the hospitalized clinical population;- It is frequently associated with avoidant personality disorder. Characteristic feature DSM IV Diagnosis - Diagnostic criteria Excessive need for protection leading to submissive, dependent behaviors and fear of abandonment; begins in early adulthood and manifests in a variety of contexts. The need for protection, submissive behavior, and fear of abandonment manifests in five or more of the following ways: (a) has difficulty making day-to-day decisions in the absence of advice and support to others; (b) needs others to take responsibility for important aspects of his life; (c) finds it difficult to express disagreement with others for fear of losing support; (d) finds it difficult to initiate projects or doing things alone (low self-efficacy); (e) would do almost anything to ensure the support and protection of others, even volunteering to do unpleasant things; (f) feels uncomfortable and helpless when he is alone for fear that he will not be able to cope; (g) when a close relationship breaks down, he immediately looks for another in which he can find protection and support; (h) he is excessively worried about the possibility of to be left to fend for himself.!![b]5.2.10. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER!![/b]Epidemiology- In the general population, the prevalence is 1%;- In the clinical population, the prevalence is 3%-10%;- It occurs twice as often in men; - It is a different disorder from the obsessive-compulsive disorder within the anxiety disorders. Characteristic feature DSM IV Diagnosis - Diagnostic criteria Preoccupation with order, perfectionism, mental and interpersonal control, to the detriment of flexibility, openness, efficiency; begins in early adulthood and manifests in a variety of contexts. Preoccupation with order, perfectionism, mental and interpersonal control manifests in four or more of the following ways: (a) preoccupation with details, rules, lists, order, organization, so that the main purpose of the activity is lost; (b) manifests a perfectionism that interferes with the accomplishment of a task; (c) is excessively dedicated to work and productivity, to the point of eliminating recreational activities and friendships (d) is rigid and excessively conscientious about matters of morality, ethics or values; (e) cannot throw away old objects, even if they have no sentimental value; (f) hesitates to delegate responsibilities or work with other people, if they do not strictly respect his standards; (g) is stingy with himself and others; money is collected for dark days; (h) is rigid and stubborn.!![b]5.2.11. UNSPECIFIED PERSONALITY DISORDER!![/b]- It is a category used for personality disorders that do not meet the criteria of the previously presented disorders; either the clinical picture presents mixed features (from different personality disorders), or it corresponds to a personality disorder not included in this classification: depressive or passive-aggressive personality disorder.- Passive-aggressive – the background is aggressive (aggressive attitude towards social demands and professional), but the manifestation is passive resistance.- Depressive - characterized by pessimism, low self-esteem, unhappiness, dissatisfaction, depression, feelings of uselessness, high self-criticism, tendency to self-blame and remorse.!![b]5.3. Differential diagnosis!![/b]The disorder with which it is donedifferential diagnosis Indices of differentiation Psychotic disorders - Paranoid, schizoid and schizotypal personality disorders have many features in common with schizophrenia, affective disorders with psychotic features and other psychotic disorders. - The diagnosis of personality disorder is made only if the symptoms do not appear exclusively on during an axis I disorder. Anxiety disorders - Personality changes that occur and persist after exposure to a traumatic event justify a diagnosis of posttraumatic stress. - Avoidant tendencies in social situations also appear in social phobia and in personality disorder of the type avoidant; the difference is given by the moment of onset, the severity of the disability, the variety of situations in which it manifests itself. Disorders related to the consumption of substances - A diagnosis of personality disorder is not made only on the basis of the behaviors that are the direct consequence of the consumption of substances, the renunciation of the consumption of substances substances, activities that facilitate addiction (e.g., antisocial behavior). Personality changes due to a general medical condition - A diagnosis of personality disorder is not made if the changes occur as a result of the presence of a general medical condition (e.g., a brain tumor ).Personality traits that do not reach the level that would justify a diagnosis of personality disorder- Personality traits define a personality disorder only if they are inflexible, maladaptive, persistent and cause major difficulties in the person's life.!![b]5.4. Etiology!![/b]Usually, in the case of a single patient with personality disorders, the presence of several types of such disorders is found.!![b]5.5. Approaches to Personality Disorders!![/b]A. Biological approaches - personality disorders are explained by appealing to the genetic factor; - the starting data in the case of these theories come from correlational studies, which indicate that the prevalence of these disorders (especially those in group A) is higher in first-degree relatives of the patients studied; - on the basis of correlational studies it was shown that in the case of: - group A - the genetic factor is very important; - group B - the genetic factor is important; - group C - the genetic factor is less influential.!!! it is not known exactly if it is only the genetic substrate, or also a learned behavior. Several factors were incriminated: temperamental factors - e.g., choleric would correspond to the antisocial type personality, while melancholic to the avoidant and dependent type hormones - e.g., excess testosterone would be the basis of aggressive behavior MAO (monoamine oxide) - excess of MAO would be characteristic of withdrawn people (schizotypals, schizoids), while the deficit of MAO would characterize the tendency to be involved in interpersonal relationships (histrionics) Neurotransmitters – the excess of endorphins would be associated with passive traits, while the deficit of serotonin would be associated with impulsivity and aggressiveness.B. Psychological approaches Psychoanalytic theory - there is a latent, behind-the-scenes personality and a manifest personality; - the dynamics of the manifest personality depends on the dynamics of the behind-the-scenes one; - the adult personality is formed according to the internal struggle to resolve conflicts and fixation at different stages of development:- if the fixation appears in stage I (oral, 0-1 years), the people will be characterized by verbal or physical aggression; - if the fixation appears in stage II (anal, 1-3 years), the people will be calm, introverted; corresponds to the obsessive-compulsive personality; - if the fixation occurs in stage III (phallic, 3-5 years), unresolved Oedipus and Electra complexes give rise to neurotic disorders. Personality traits are defensive mechanisms by which the child defends itself: projection in the case of paranoid personality, SEPARATIONin the case of the borderline. Cognitive-behavioral theory According to this theory, personality traits are names given to relatively stable responses These responses are: Answers Dimensions of personality Explanatory theories and models Psychotherapeutic approach Biological - mainly aimed at temperaments - more biological theories - the patient is taught to adapt to world with its problem (problem-solving training) Cognitive Behavioral Subjective - mainly aims at character and skills (value evaluation and from the perspective of performance) - more psychological theories of learning; character traits constitute modifiable cognitive-behavioral patterns - intervention and cognitive restructuring to modify particular and general schemes Assumptions, laws, beliefs Cognitive schemes (conditioned and unconditional) Stimuli from the environment that interact with the schemes, and based on the schemes their selection is made (interaction with double sense) Automatic thoughts) Beck & Freeman's cognitive theory Cognitive, behavioral, biological, subjective responses (symptoms on the basis of which the diagnosis is made) Cognitive schemes - to influence symptoms, automatic thoughts, beliefs, cognitive schemes must be changed; - cognitive schemes they can be unconditional (e.g., "I'm incompetent") and conditioned (e.g., "If I don't do things perfectly, then it's not worth doing them at all"); - changing automatic thoughts without changing the cognitive scheme makes that, in another context, other automatic thoughts are generated. Personality disorderStrategy usedSchemas usedUnderdeveloped strategiesCompensatory strategiesSchizoidIsolation"if I let others get too close my life will be unbearable", "I'm not like others", "I need to be left alone" IntimacyReciprocityAutonomyIsolationSchizotypalDistrustEccentricity“things and the world are not what they seem”ConformityLogical thinkingSocial avoidanceMagical thinkingParanoidInterpretationProjection“I can't trust others”, “the nice ones cheat me”, “everyone wants me bad”, “I don't have to believe anyone”SpontaneityInterpretationAntisocialAttack“ "I'm the most important", "people exist to be cheated" EmpathyReciprocityAssertivenessAggressivenessExploitation HistrionicTheatricalism"I need to impress, attract attention, be considered important"ControlOrganizingPlanningImpulsivityExpressivenessBorderline Ambivalence"I'm incompetent", "I'm unfulfilled and unimportant", "everyone will abandon me" Social Skills Problem Solving Communication Alcohol Use Unstable Relationships Self-Mutilation Narcissistic Overestimation “I'm awesome”, “I'm the best”, “I need to be appreciated by others” Separation Identifying a belonging group Overvaluation Competitiveness Avoidant Avoidance “something bad could happen to me”, “those around me -could hurt" Assertiveness Avoidance Inhibition Social withdrawal Dependent Attachment "I can't do anything alone", "I can't succeed on my own" Autonomy Need for support Attachment Obsessive-compulsive Perfectionism "errors are catastrophic", "I have to do everything perfectly" Spontaneity Superficiality Excessive control Assumed responsibility Conceptualization - existing schemas lead to the emergence of strategies (behaviors, knowledge) underdeveloped, doubled by compensatory strategies (overdeveloped) Therapy- aims to modify cognitive schemes and intervention to promote underdeveloped strategies and reduce overdeveloped strategies.- !![b]5.6. The evolution and prognosis of the disease!![/b]- The features of a personality disorder can be recognized starting from adolescence or the beginning of adult life.- By definition, a personality disorder represents a pattern of thinking, affectivity, relatively stable behavior over time.- Some personality disorders (especially typeantisocial and borderline) tend to remit with age; this is less true for others (eg, obsessive-compulsive or schizotypal).!![b]5.7. Treatment!![/b]Cognitive-behavioral techniques for changing behaviors and cognitions that support maladaptive and relatively stable manifestations, adaptation to problematic situations; Dynamic-psychoanalytic techniques for eliminating conflicts that support maladaptive manifestations; Humanistic-experiential techniques for promoting free expression and personal development. Module III. PSYCHOTIC DISORDERS ACCORDING TO DSM-IV !![b]Topic 6. PSYCHOTIC DISORDERS!![/b]!![b]6.1. Overview!![/b]- This category includes disorders whose main characteristic is the presence of psychotic symptoms;- The term "psychotic" received, over time, several definitions:- in a narrow sense - indicates the presence of delirium and unperceived hallucinations as such; - in a broad sense - indicates the presence of hallucinations perceived as such by the person (the patient realizes that he is experiencing a hallucination); - in a very broad sense - indicates the presence of other positive signs of schizophrenia (disorganized speech, catatonic behavior or disorganized), in addition to delirium and hallucinations.- The following disorders are included in this category: (1) Schizophrenia- It is a disorder that lasts at least 6 months, of which at least one month of active manifestation of symptoms (e.g., delirium, hallucinations, disorganized speech, catatonic or disorganized behavior, negative symptoms);- This disorder was described by Kraepelin as "dementia precocious" (having its onset around the age of 20 for men and 30 for women); he considered that there are biological causes (at the level of the brain) for the three described types: catatonic, hebephrenic and paranoid type schizophrenia; - E. Bleuler is interested in the psychic experiences of schizophrenia, identifying as basic symptoms: lack of affective integration, ambivalence and autism; he is the one who will call this disorder "schizophrenia", being convinced of the organic origin of the condition to which he had given a new name; - K Schneider insists on other diagnostic criteria; will propose a division of them into: - first-order criteria - hallucinations (especially auditory, which are also sufficient for the diagnosis of schizophrenia; they appear in the form of voices commenting on the person's behavior or discussing with each other) and delirium (bizarre or referential) - second-order criteria - disorganized speech, negative symptoms (affective flattening, alogia, abulia, ahedonia), disorganized thinking.- Five types of schizophrenia are presented in DSM IV: paranoid type - is the least severe; the characteristic feature consists in the presence of delirium and hallucinations, with the preservation of cognitive and affective functions; symptoms such as: disorganized speech, catatonic or disorganized behavior, affective flattening and other negative symptoms are less present; disorganized type - is the most severe; it is characterized by: disorganized speech, disorganized behavior, affective flattening and inadequate emotional expressiveness; catatonic type - it is mainly characterized by severe psychomotor disorders: catatonic excitement (motor agitation without meaning and unrelated to external stimuli), catatonic negativism (resistance to any instruction), catatonic rigidity (stiff limbs), catatonic stupor (lack of reaction to stimuli in the environment), catatonic posture (adopting strange postures), mutism, immobility, bizarre voluntary movements, echolalia, echopraxia), manifested motor immobility through catalepsy (waxy flexibility). of undifferentiated type - it is characterized by the presence of symptoms specific to schizophrenia, but they do not meet the criteria for the other typespresented; of residual type - it is used in situations where there has been at least one episode of schizophrenia, but the present clinical picture includes negative symptoms, the positive ones being greatly attenuated. (2) Schizoaffective disorder - It is characterized by the presence of an episode of affective disorder (depression or mania) simultaneously with the active phase of schizophrenia, these being preceded or followed by at least two weeks of hallucinations and delirium, without mood disorders. (3) Schizophrenic disorder- The clinical picture resembles that of schizophrenia, but the duration of the presence of symptoms is under 6 months, the functional decline not being so pronounced. (4) Delusional disorder - The main feature consists in the presence, for at least one month, of various forms of delirium, in the absence of other symptoms specific to schizophrenia; hallucinations do not constitute a dominant symptom, and the olfactory and gustatory ones that are present are related to the content of the delirium. (5) Short psychotic disorder - Symptoms last more than a day and less than a month. (6) Shared psychotic disorder - It is characterized by the fact that the symptomatology (the content of the delirium) is taken from a person who has a psychotic disorder. (7) Psychotic disorder due to a somatic condition- It is characterized by the fact that the psychotic symptoms are determined by the presence of a somatic condition. (8) Psychotic disorder due to substance use - It is characterized by the fact that psychotic symptoms are determined by the use of substances, drugs or exposure to toxic substances. (9) Unclassified psychotic disorder - Includes psychotic symptoms that do not meet the criteria for the disorders presented previously.!![b] 6.2. Epidemiology !![/b]!![b]6.2.1. SCHIZOPHRENIA! I of patients with schizophrenia;- There are gender differences; thus, in the case of women, a late onset of the disease, more pronounced mood disorders and a more favorable prognosis are recorded more frequently. Evolution and prognosis of the disorder - The onset of the disease is around the age of 20 for men and 30 for women; - The onset can be sudden or insidious; in most cases there is also a prodromal phase, manifested by the gradual appearance of various signs and symptoms; - The course of the disease can be chronic or variable, with remissions and periods of recurrence. DSM IV diagnosis - Diagnostic criteria characteristic symptoms: - two or more of the following manifestations must be present most of the time over a period of one month (in the absence of treatment): delirium, hallucinations, disorganized speech, catatonic or disorganized behavior, negative symptoms;- In the case of bizarre delirium or auditory hallucinations, only one criterion is sufficient .pronounced social / occupational disability; the duration of signs of the condition is greater than 6 months, with at least one month of symptoms specific to the active phase; exclusion of affective and schizoaffective disorders; exclusion of substance use and general medical conditions; relationship with pervasive developmental disorders (e.g., autism) - in order to make the additional diagnosis of schizophrenia, the presence of delirium and hallucinations is necessary. Differential diagnosis. The disorder with which the differential diagnosis is made. Indices of differentiation. Psychotic disorders due to a somatic condition, delirium, dementia, psychotic disorders due to substance use. Affective disorders with psychotic elements andschizoaffective disorder - psychotic symptoms appear exclusively during the mood disorder (affective disorders with psychotic elements); - affective disorders appear during the manifestation of psychotic disorders (active phase), are present most of the time throughout the duration of the disorder and must exist at least two weeks in which there are psychotic manifestations, in the absence of affective mood disorder (schizoaffective disorder); - affective mood disorders have a short duration in relation to the duration of the disorder and appear only in the prodromal or residual phases (schizophrenia). Schizophreniform disorder and psychotic disorder short - the main differentiation criterion concerns the duration of symptoms and their severity (with impact on functional decline). Delusional disorder - non-bizarre delirium and lack of active phase symptoms (delusional disorder) versus bizarre delirium and active phase symptoms (schizophrenia); paranoid-type schizophrenia is more difficult to differentiate, because the criteria of the second order do not appear. Pervasive developmental disorders - onset before the age of 3, and delirium and hallucinations are not basic symptoms (pervasive developmental disorders). Personality disorders schizoid, schizotypal, paranoid type.- These disorders can precede the onset of schizophrenia; when the symptoms are severe enough to satisfy criterion A., the additional diagnosis of "schizophrenia" is made. Dissociative identity disorder - auditory hallucinations and delusions, especially of persecution, with maintenance of cognitive and affective functions (paranoid type schizophrenia) versus multiple personalities talking to each other and sudden transition from one to another, with changes in cognitive and affective functions (dissociative identity disorder).!![b]6.2.2. SCHIZOAFFECTIVE DISORDER!![/b]Epidemiology- although there is no precise information about the prevalence of this disorder, it seems to be less common than schizophrenia;- it seems to occur more often in women and in the elderly. Evolution and prognosis of the disorder- the typical onset of the disorder is in the first period of adult life, although it can start at any time, from adolescence to old age; - the prognosis of the condition is more favorable compared to that of schizophrenia and less favorable compared to affective disorders; - severe disability professional and occupational is registered quite rarely. DSM IV diagnosis – Diagnostic criteria interposition of a major depressive, manic or mixed episode during the illness, which overlaps with the symptoms corresponding to criterion A from schizophrenia; during the illness, there were at least two weeks in which delirium and hallucinations have been recorded, in the absence of significant affective disorders; the symptomatology satisfying the criteria of an affective disorder is present for almost the entire duration of the active and residual phases of the condition; the symptoms are not due to the consumption of substances or a general medical condition; (in depending on the specifics of the affective episode, there is schizoaffective disorder of the bipolar and depressive type).Differential diagnosisThe disorder with which the differential diagnosis is madeDifferentiation indices Psychotic disorders due to a somatic condition, delirium, dementia, psychotic disorders due to substance use.- The main criterion for differentiation consists in the etiological association of the presence of symptoms with substance abuse and/or a somatic condition. Affective disorders with psychotic elements and schizophrenia - psychotic symptoms appear exclusively during the mood disorder (affective disorders with psychotic elements) - affective disorders appear during the manifestation of psychotic disorders ( active phase), are present most of the time throughout the durationmanifestation of the disorder and there must be at least two weeks in which there are psychotic manifestations, in the absence of the affective mood disorder (schizoaffective disorder) - the affective mood disorders have a short duration in relation to the duration of the disorder and appear only in the prodromal or residual phases (schizophrenia ).Delirious disorder- nonbizarre delirium and lack of active phase symptoms (delusional disorder) versus bizarre delirium and active phase symptoms (schizoaffective disorder). !![b]6.2.3. SCHIZOPHRENIFORM DISORDER! schizophreniform disorder compared to schizophrenia. Evolution and prognosis of the disorder Approximately 1/3 of the people diagnosed with this disorder will be recovered after a period of 6 months; in the case of the other 2/3, the condition will progress to schizophrenia or schizoaffective disorder. DSM IV diagnosis – Diagnostic criteria criteria A., D. and E. from schizophrenia are satisfied, the duration of an episode is a minimum of one month and a maximum of 6 months Differential diagnosis The disorder with which a differential diagnosis is made. Indices of differentiation* see the discussion from schizophrenia Short psychotic disorder - lasting less than one month (brief psychotic disorder) versus lasting more than one month (schizophreniform disorder).!! [b] 6.2.4. DELUSIONAL DISORDER!![/b] Types of delusions, depending on which subtypes of the disorder are described: erotomaniac delusion - the person thinks he is loved by a person with a higher socio-cultural status; delusions of aggrandizement and wealth (ideas of grandiosity) - the person is convinced that he has special talents, that he has made major discoveries or that he has a close relationship with an extremely important person; delusion of jealousy - the person thinks he is being deceived by his life partner; delusion of persecution - the person is convinced that he is being followed, poisoned, spied on or is the object of a conspiracy; delirium of somatic type - the theme of the delirium, in this case, is bodily functions and sensations (the presence of smells, parasites, infections, etc.); delirium of mixed type - delirium in which there is no dominant theme; delusion of unspecified type – delusion in which the theme is not clearly specified or does not correspond to the other subtypes. Epidemiology - in clinical groups, hospitalized in psychiatric wards, the prevalence is 1%-2%; - in the general population, it is estimated that the prevalence is 0.03%. Evolution and prognosis of the disorder - the onset of the disorder is in the second half of adult life; - the most frequently recorded is the delusion of persecution; - the course of the disease can be chronic, with periods of remission and recurrence of the disease; - it is estimated that the delusion of jealousy has a better prognosis than that of persecution. DSM IV diagnosis – Diagnostic criteria for non-bizarre delirium (situations that can occur in everyday life) lasting at least one month; criterion A. from schizophrenia has never been met; apart from the consequences of delirium, no disabilities or bizarre behavior appear; the disorders affects that can occur simultaneously with delirium are short-lived; the symptoms are not due to substance consumption or a general medical condition. *specify the type of delirium Differential diagnosis The disorder with which the differential diagnosis is made Differentiating indices *see previously the differential diagnosis with the other psychotic disorders Hypochondria- fear that he has a serious illness is less intense, the person admitting that there is a possibility that he does not have the said illness (hypochondria) versus the unshakable belief that he is ill (delusional disorder) Dysmorphic disorder- the belief that certain parts of the body are disproportionate and unsightly, the patient admitting that his perception can be distorted (disorderdysmorphic) versus the belief that certain parts or organs in the body are distorted, dysfunctional or parasitized (delusional disorder) Obsessive-compulsive disorder - the person recognizes the intrusive and exaggerated character of his obsessions (OCD) versus the belief that they are justified (delusional disorder) paranoid personality type - delusional ideas are not as clear and persistent as in the case of delusional disorder (personality disorder). !![b]6.3.4 BRIEF PSYCHOTIC DISORDER!![/b] Epidemiology- existing data suggest that it is a rare disorder;- must be distinguished from the specific manifestations of certain religious or cultural ceremonies. Evolution and prognosis of the disorder- average age of onset is 30 years old; - the symptomatology remits at most one month after the onset (sometimes it lasts only a few days). DSM IV diagnosis - Diagnostic criteria the presence of one or more of the following symptoms: delirium, hallucinations, disorganized speech, catatonic or disorganized behavior ; the duration of the disorder is at least one day and at most one month, with complete remission of the symptoms after this period; the symptoms are not due to the consumption of substances or a general medical condition. Differential diagnosis The disorder with which the differential diagnosis is made Indices of differentiation* see previously the differential diagnosis with the other psychotic disorders Factitious disorders and simulation - symptoms are produced intentionally for an external benefit (simulation) or in order to assume the role of the patient (factitious disorders) versus the symptoms appear unintentionally ( brief psychotic disorder) Personality disorders - against the background of a personality disorder, stress can cause the appearance of psychotic manifestations; if their duration exceeds one day, an additional diagnosis of brief psychotic disorder is made. !![b]6.3.5 SHARED PSYCHOTIC DISORDER (Folie à Deux)!![/b]Epidemiology- it is estimated that the disorder occurs more frequently in women than in men;- there are no clear epidemiological data. The evolution and prognosis of the disorder- in lack of intervention, the course of the disease is chronic; - after the separation of the individual from the sick person, the disorder sometimes remits quickly, sometimes gradually. DSM IV diagnosis - Diagnostic criteria delirium occurs in an individual in a close relationship with a person who has already been diagnosed with the presence delusional ideas; the theme of delirium is similar in both; the symptomatology is not due to substance use or a general medical condition. Differential diagnosis. The disorder with which the differential diagnosis is made. Indices of differentiation. !![b]6.4. Etiopathogenetic models!![/b] (1) The psychoanalytical model There are two psychoanalytical explanations: a) Regression - conflicts in adult life lead to regression to a previous stage of development, to which there is a fixation. In the case of psychotic disorders, the fixation is on the oral stage, while for neuroses, the fixation on the phallic stage is specific. b) The theory of the relationship with the object - there is a conflict between the self and reality; the self is not well differentiated from the surrounding world, the perception of people and reality being fragmented (black-white, good-bad perception). Normally, the normal self is autonomous, well differentiated from the surrounding world, having a nuanced perspective on others and the surrounding reality. The normal non-development of the ego leads to difficulties interacting with the world, life becoming a permanent stressor. (2) The stress-vulnerability model The basic assumption is that people who have psychotic disorders present a vulnerability (primarily biological, but also psychological) to the disease. In interaction withstressful events, vulnerability factors cause the appearance of psychotic disorder. a) Biological aspects of vulnerability: - atrophy or decrease in the number of cells at the level of the limbic system and the basal ganglia; hypofrontality; - excess of dopamine in general and deficit of dopamine in the frontal lobes; antipsychotics act at the level of D1 receptors (control of positive symptoms), while negative symptoms seem to be related to the number of D2 receptors.b) Psychological aspects of vulnerability:- the same predispositions appear in the case of schizophrenia, schizoid and schizotypal personality disorder; - vulnerability factors are considered: inadequate family environment (contradictory verbal and non-verbal messages, transmitted by the two parents; separation between parents and closeness between the child and the parent of the opposite sex; competition between parents for the child's favors; blocking of emotional expressiveness; hyperprotective parental behavior, critical or hostile); learning through modeling (taking over some behaviors from parents with psychotic disorders); socio-economic factors (the prevalence of psychotic disorders is higher in people with low socio-economic status, in people from large urban agglomerations, in people born fall, spring or winter, due to nutritional factors).Experimental studies indicate the following hierarchy in terms of vulnerability to psychotic disorders: - first place - children born and raised by mothers with mental problems - second place - children born to mothers with mental problems and raised in normal families - third place - children born and raised in normal families.!![b]6.5. Risk factors!![/b]In general, in the case of psychotic disorders, there is an increased risk for this category of conditions in the biological relatives of sick people.!![b]6.6. Treatment!![/b]- The treatment is primarily medicinal, aimed at reducing symptoms and stabilizing the individual. In the active phase of the disease, drug therapy is essential, and in the symptomatology remission phase, psychotherapy offers the chance to form adaptive reactions. Psychotherapy and psychological counseling are useful in the primary prevention of the disease (intervention at the level of the primary group) and in the prodromal phase (education to recognize the onset of symptoms). The symptomatology related to the prodromal phase: - accentuated social isolation; - deterioration of the ability to cope with professional requirements - atypical or new behavior for the individual; - decreased concern for personal hygiene; - affective flattening and affectivity inappropriate to the situation; - strange beliefs and magical thinking; - strange perceptual experiences; - changes in language; - pronounced lack of initiative and decreased interests; - psychotherapy is used as a complementary method in the active phase of the disease: Cognitive-behavioral techniques for reducing delirium and hallucinations that do not yield to medication, increasing treatment compliance, reducing negative symptoms; Hypnotherapy for strengthening the ego; Cognitive-behavioral techniques with an educational role (inclusion in the social group) and for the prevention of relapses. !![b]Theme 7. IMPULSE DISORDERS!![/b]!![b]7.1. Overview!![/b]Although there are other disorders that involve problems in self-control of impulses (paraphilias, antisocial personality disorder, schizophrenia, affective disorders, etc.), this section includes six specific disorders characterized by:(1) the impulse to do a behavior that has negative consequences for the person in question or for those around them; (2) refraining from these behaviors leads to increased tension and physiological activation; (3) relaxation and states of pleasure, satisfaction after committing the respectivebehaviors (functioning as negative reinforcement for them); (4) behaviors can be planned or spontaneous; (5) the execution of behaviors may or may not be followed by feelings of guilt, shame, regret. Because these behaviors are supported by a motivation internal and are negatively reinforced by the fact that their execution leads to relaxation, they are very difficult to change. Impulsive acts constitute egosyntonic behavior (produces pleasure); after committing the behaviors, the person can experience egosyntonic states (relaxation, pleasure) or egodystonic states (feelings of guilt, shame). This category includes: (1) Intermittent explosive disorder - characterized by the presence of episodes of uncontrollable aggression, which with attacking people or destroying their property; (2) Kleptomania – has as a basic feature the inability to control the impulse to steal objects that the individual does not need for personal use or their monetary value; (3) Pyromania – is characterized by the tendency to intentionally set fire to various objects, in order to relieve tension or obtain pleasure; (4) Pathological gambling - is characterized by pathological engagement in various games of chance; (5) Trichotillomania - consists in the uncontrollable tendency to- and pulls hair, in order to relax or obtain pleasure, which leads to massive loss of hair on the head and body; (6) Unspecified impulse disorder - characterized by the presence of symptoms specific to impulse disorders, which do not meet the criteria the diseases presented previously.!![b]7.2. Epidemiology !![/b]!![b]7.2.1. INTERMITTENT EXPLOSIVE DISORDER!![/b]Epidemiology- there are no clear epidemiological data, but it is estimated that it is a rather rare disorder;- episodes of violent behavior are more frequent in men than in women. The evolution and prognosis of the disorder- the disorder can begin from late adolescence to 30 years; - the onset can be abrupt, without a prodromal phase. DSM IV diagnosis - Diagnostic criteria the presence of several distinct episodes of uncontrollable aggression, which result in attacking people or destroying their property; the aggression expressed during the episodes it is far disproportionate in relation to the psycho-social stressors that could have triggered it; the symptoms are not due to substance use or a general medical condition. Differential diagnosis The disorder with which a differential diagnosis is made Differentiation indices Delirium, dementia, substance abuse, personality change due to a general medical condition.- The main differentiation criterion refers to the etiological association of the symptomatology with the presence of a general medical condition, neurological conditions or substance abuse substances. Intentional behavior and simulation - It is distinguished by the presence of motivation and the benefit obtained by committing aggressive acts. !![b]7.2.2. KLEPTOMANIA! of the disorder: (1) Sporadic course, with short episodes of symptoms and long periods of remission; (2) Episodic course, with long periods of symptoms and periods of remission; (3) Chronic course, with some fluctuations. Diagnosis DSM IV – Diagnostic criteria recurrent failures to control the impulse to steal objects that the individual does not need for personal use or their monetary value; exacerbation of tension immediately before committing the theft; committing the act is followed by relaxation, a feeling of pleasure, gratification; the theft is not committed for the purpose of revenge, out of anger or as a consequence of deliriumor hallucinations. Differential diagnosis The disorder with which the differential diagnosis is made Differentiation indices Intentional, planned or spontaneous theft - Deliberate acts and extrinsic motivation (intentional theft) versus theft motivated by the need to relieve tension and obtain gratification (kleptomania). Simulation - The differentiation criterion consists in the pursuit of an external benefit or avoiding a punishment (simulation) Antisocial personality disorder, conduct disorder - General pattern of antisocial behavior (personality and conduct disorder) versus the criminal acts are reduced to the theft of objects without personal or monetary value (kleptomania). Manic episodes, schizophrenia, dementia.- Thefts that occur exclusively within manic episodes, as a consequence of delirium and hallucinations or on the background of dementia are not diagnosed as kleptomania.!![b] !![/b]!![b]7.2 .3. PYROMANIA!![/b] Epidemiology- For this disorder, epidemiological data are insufficient; however, the disorder is considered to be relatively rare; - It occurs more frequently in men than in women, especially in those with poor social skills and learning disabilities. Evolution and prognosis of the disorder - The longitudinal course of the disorder is unknown; - Arson incidents intentional acts are periodic and may fluctuate in frequency. DSM IV diagnosis – Diagnostic criteria intentional arson actions, manifested on several occasions; the act of arson is preceded by an escalation of tension and arousal; fascination, interest and curiosity towards fire and the situational context of it (consequences, use, etc.); the act of arson or being a witness or participant in its consequences generates pleasure or relaxation; the act of arson is not motivated by monetary gain, masking a crime, expression of anger, revenge, expression of socio-political ideology , improvement of living conditions, delirium, hallucinations or other severe mental disorders). Differential diagnosisDisorder with which a differential diagnosis is madeIndicia of differentiationMoney gain, masking a crime, expression of anger, revenge, expression of socio-political ideology, improvement of living conditions, delirium, hallucinations or other severe mental disorders, experimental attempts by children or attempts by people with mental disorders to communicate desires or needs.- The differentiation criterion consists in the goal pursued: the pleasure of the act itself, without any external benefit (pyromania). !![b]7.2.4. PATHOLOGICAL GAMING!![/b]Epidemiology- In the general population, the prevalence is 1%-3%;- About 1/3 of the people who suffer from this disorder are women, but only a small part of them are included in therapy programs due to the more negative social reactions in their case, compared to men; - Approximately 20% of people included in treatment for pathological gambling had at least one suicide attempt. The evolution and prognosis of the disorder - The disorder usually begins in early adolescence in the case of men and a little later in the case of women; - The onset is, in most cases, insidious, the disorder being precipitated by the appearance of a stressor; - The symptoms can manifest regularly or episodically, the course of the disease being chronic; - The tendency to gamble is accentuated during periods of strong stress or depression. DSM IV diagnosis – Diagnostic criteria persistent and recurrent engagement in gambling, indicated by five or more of the following manifestations: (1) heightened preoccupation with gambling; (2) the need to gamble ever larger sums of money to obtain the desired sensation; (3) repeated unsuccessful attempts to control, reduce or stop gambling behavior; (4)irritability and agitation as a result of attempts to reduce or stop gambling behavior; (5) gambling is a way to escape problems or a dysphoric mood (eg, feelings of helplessness, guilt, anxiety, depression); (6) after losing an amount of money in a game, returns to get revenge; (7) misrepresents the situation to family, therapist or other people, in order to hide the magnitude of his gambling involvement; 8) committed illegal acts such as fraud, forgery, theft or embezzlement in order to obtain the money necessary for gambling; (9) lost or endangered an interpersonal relationship, career opportunity or job due to gambling; (10) relies on other people to provide him with the necessary money to pay off gambling debts. The person's behavior cannot be explained by the presence of a manic episode. Differential diagnosis The disorder with which the differential diagnosis is made Differentiation indices Professional gambling - limited risks and strict discipline (professional gambling) versus unlimited risks and lack of discipline (pathological gambling). Social gambling - limited duration of the game and the amount of losses accepted by default (social gambling) versus unlimited duration of the game and the amount of losses (pathological gambling). Manic episodes - compulsive gambling behavior occurs only during the manic episode (manic episodes) versus compulsive gambling behavior also occurs in the absence of other symptoms specific to manic episodes (pathological gambling). !![b]7.2.5. TRICHOTILOMANIA!![/b]Epidemiology - there are no systematic epidemiological data for this disorder; - recent studies show that approximately 1%-2% of students have episodes of trichotillomania in their personal history; - it occurs more frequently in women than in men (the proportion is approximately the same in children of both sexes). The evolution and prognosis of the disorder - the onset is frequently located in childhood, with symptomatology accentuated between 5-8 years and around the age of 13; - at a young age, hair pulling may occur as " bad habit", non-pathological; - some people show continuous symptoms for decades; other times, the course of the disease is marked by remissions and recurrences; - the areas of the body from which the hair is pulled may vary over time. DSM IV diagnosis - Diagnostic criteria uncontrollable, recurrent hair pulling, which leads to massive loss of hair on the head and body ; the accentuation of the tension immediately before committing the compulsive act or when it is blocked, committing the impulsive act leads to pleasure, relaxation; the symptomatology is not due to another mental illness or a general medical condition, the disturbance causes distress and disability in social, occupational or other areas of life. Differential diagnosis The disorder with which a differential diagnosis is made. Indices of differentiation Biological causes of alopecia or alopecia as a consequence of delirium and hallucinations - the main criterion for differentiation consists in the absence of hair-pulling behavior (biological causes of alopecia), respectively the presence of a mental illness and the manifestation of the behavior compulsive as a consequence of delirium or hallucinations. Obsessive-compulsive disorder - repetitive behavior manifests itself as a response to an obsession or according to strictly applied rules (OCD) versus compulsive behavior manifests itself for the purpose of de-tensioning, without following pre-established rules (trichotillomania). Stereotypes - compulsive behavior is limited to pulling hair (trichotillomania) versus compulsive behavior manifests itself in other ways (stereotypes). Factitious disorders - the differentiation criterion is aimed at the purpose of the behavior: assuming the role of the sick(factual disorders) versus deterrence and pleasure-seeking (trichotillomania). !![b]7.3. Etiology!![/b] (1) Biological explanation Certain biological factors related to the limbic system are blamed. (2) Psychoanalytic explanation Some psychoanalysts consider impulsive acts as coping mechanisms for anxiety and depression, while others believe they are defense mechanisms towards the awareness of certain impulses specific to the four stages of development (especially the oral one). (3) Cognitive-behavioral explanation At the level of the cognitive system there are certain patterns of low tolerance to frustration and absolutist thinking. The interaction of this cognitive pattern with external stimuli results in a state of tension (later an association between external stimuli and the state of tension appears). Impulsive acts are the result of de-tensioning, these behaviors being therefore negatively reinforced.!![b]7.4. Treatment!![/b]Cognitive-behavioral techniques for reducing the tension associated with the disorder, controlling maladaptive behaviors. !![b]Theme 8. relationship problems!![/b]!![b]8.1. Overview!![/b]Relationship problems mainly concern couple and family. From a cognitive-behavioral (integrative) perspective, the couple and the family are seen as networks, in which problems can appear at several levels, these being:- at the level of the network components - the mental or medical problems of the individual affect the functioning of the entire network;- at the level of interaction between network components - there are communication problems between network members. The problems can lead to the exacerbation or complication of the treatment of mental or somatic ailments in the case of one or more network members, they can be a consequence of these disorders, they can appear independently of other disorders present or in the absence of any other disorders. Depending on the segment in which there are deficiencies, several variants may appear: (1) deficiencies only at the level of the mode of interaction between network members; (2) deficiencies at the level of network members and at the level the interaction between them; (3) deficiencies at the level of network members and not at the level of interaction between them; (4) there are no deficiencies either at the level of network members or at the level of interaction between them.!![b]8.2. Types of relationship problems! Relationship problems associated with a mental disorder or general medical condition – the target problem is the relationship difficulties that arise as a consequence of the fact that one of the network members suffers from a mental or somatic illness .(2) Relational problems between parents and children – the target of the intervention is represented by the parent-child interaction pattern (difficult communication, overprotection, inadequate discipline). These problems cause major difficulties within the family or the emergence of some disorders of clinical intensity in the child or parent. (3) Relational problems in the couple - in this case, the target of the intervention is the interaction pattern between partners/spouses. It is characterized by dysfunctional communication (eg, exaggerated criticism), distorted communication (eg, unrealistic expectations) or lack of communication; those problems cause major difficulties within the family or the appearance of disorders of clinical intensity in one or both partners. It is considered that, in a couple, there are four major sources of problems: Conflict; contempt for the other (highly predictive factor for divorce); irrational beliefs; the belief that "I must be right because I say so". (4) Relational problems between siblings - the main problem is the dysfunctional pattern of interaction between siblings, which causes major difficulties within the family or the appearance of disorders of clinical intensity in one or more of the siblings. (5)Unspecified relational problems – this category refers to relational problems, which cannot be included in any of the previously specified categories (eg, difficulties relating to colleagues).!![b]8.3. Treatment!![/b]Intervention models at the level of communication: (a) transactional analysis; (b) cognitive-behavioral techniques - modification of maladaptive behaviors and cognitions, educational role.!![b]8a. SLEEP DISORDERS!![/b]!![b]8a.1. Classification of sleep disorders!![/b]Sleep disorders are classified into: primary sleep disorders (dyssomnias and parasomnias); sleep disorder related to another mental disorder; sleep disorder due to a general medical condition; induced sleep disorder of a substance. !![b]8a.1.1. Primary sleep disorders!![/b]1. Dyssomnias are characterized by abnormalities in the quantity, quality or regulation of sleep. They are primary disorders of sleep initiation and maintenance or excessive sleepiness and are characterized by a disturbance in the quantity, quality or opportunity of sleep. They include primary insomnia, hypersomnia, narcolepsy, sleep disordered breathing, circadian rhythm sleep disorder, and dyssomnia not otherwise specified. non-comforting, lasting at least one month (criterion A) and causing clinically significant distress or impairment in occupational, social, or other important areas of functioning. The sleep disturbance does not occur exclusively in the course of another sleep disturbance (C) or mental disorder (D) and is not due to the direct physiological effects of a substance or a general medical condition (E). Primary hypersomnia has as its essential element excessive sleepiness for the at least one month and which is manifested either by prolonged sleep episodes or by sleep episodes during the day, occurring almost daily (criterion A). Narcolepsy is characterized by repeated irresistible attacks of comforting sleep, cataplexy and recurrent intrusions of elements of sleep with rapid eye movements during the transition period between sleep and wakefulness. these attacks occur daily during at least three months. The disturbance is not due to the direct physiological effects of a substance. Sleep disordered breathing is characterized by the interruption of sleep, leading to excessive sleepiness or insomnia, considered to be due to ventilation abnormalities during sleep (sleep apnea or central alveolar hypoventilation ). The disturbance cannot be better explained by another mental disorder and is not due to the direct physiological effects of a substance. Sleep-wake rhythm disorder is characterized by a persistent or recurrent pattern of sleep interruption, which results from an inadequacy between the endogenous circadian sleep-vigilance system of the individual, on the one hand, and the external demands referred to the schedule and duration of sleep, on the other hand (criterion A). Individuals may complain of insomnia at certain times of the day and excessive sleepiness at others. Dyssomnias without any other specification refer to insomnia, hypersomnias, or circadian rhythm disorders that do not meet the criteria for any specific dyssomnia. 2. Parasomnias are characterized by abnormal behavioral or physiological events occurring in association with sleep, with specific sleep stages or sleep-wake transitions. The nightmare consists of the repeated occurrence of terrifying dreams that lead to awakening from sleep (criterion A). The individual is fully alert and oriented to wakefulness (B). Terrifying dreams or sleep interruptions resulting from awakenings cause the individual distress or lead to social or professional dysfunction. This disorder is not diagnosed if the nightmares occur exclusively duringthe evolution of another mental disorder or is due to the physiological effects of another substance. Sleep terror has as its essential element the repeated occurrence of sleep terrors, i.e., sudden awakenings from sleep, usually starting with a scream or cry of panic (criterion A). Sleep terrors usually start during the first third of the major sleep episode and last 1-10 minutes. Episodes accompanied by vegetative excitement and behavioral manifestations of intense fear (B). During the episode, the individual is difficult to wake up or sleepy (C). Upon awakening, the next morning, the individual has amnesia for the event (D). Somnambulism is characterized by repeated episodes of complex motor behavior initiated during sleep, involving getting out of bed and walking around. Episodes begin during slow-wave sleep in the first third of the night (criterion A). During the episodes, the individual shows reduced alertness and reactivity, blank gaze, and a relative lack of reactivity to communication with others or to others' efforts to wake them from sleep (B). If he wakes up during the episode, the individual remembers very little of the events (C). After the episode, there may initially be a brief period of confusion or difficulty in orientation, followed by full recovery of cognitive function and appropriate behavior (D). Parasomnias without other specification refer to disturbances characterized by abnormal behavioral or physiological events during sleep or sleep-wake transitions, but which do not meet the criteria for any specific parasomnia. 8a.1.2. Insomnia related to another mental disorder Hypersomnia related to another mental disorder The essential element of insomnia related to another mental disorder and hypersomnia related to another mental disorder is the presence of either insomnia or hypersomnia, which is considered to be related temporal and causal with another mental disorder. Insomnia or hypersomnia, which is the direct physiological consequence of a substance, is not included here. Individuals with this type of insomnia or hypersomnia usually focus on their sleep disturbance, going so far as to exclude the characteristic symptoms of the mental illness in which they occur and whose presence can become evident only after a specific and persistent interrogation. They often attribute the symptoms of the mental disorder to the fact that they did not sleep well. Mental disorders involving insomnia or hypersomnia: - major depressive disorder; - bipolar affective disorder; - generalized anxiety; - psychotic disorders; - somatiform disorders; - personality disorders; - in the case of nocturnal panic attacks. 8a.2.3. Sleep disturbance due to a general medical condition The essential element of sleep disturbance due to a general medical condition is a noticeable sleep disturbance that is severe enough to warrant separate clinical attention (criterion A), and is due to a general medical condition. Symptoms may include insomnia, hypersomnia, a parasomnia or a combination thereof. The somatic examination must show that the sleep disturbance is the direct physiological consequence of a general medical condition (criterion B). The disturbance is not better explained by another mental disorder , such as an adjustment disorder, in which the stressor is a severe medical condition (criterion C). The diagnosis is not made if the sleep disturbance occurs only during a delirium (criterion D). By convention, sleep disturbances that are due to a sleep disorders related to breathing or narcolepsy are not included in this category (criterion E). The symptoms of the sleep disorder must cause clinically significant distress or impairment in the social, occupational, or other domainsimportant fields of operation (criterion F). 8a.2.4. Sleep disturbance induced by a substance The essential element is the notable disturbance of sleep and which is considered to be due to the direct physiological effects of a substance. Sleep disturbance induced by a substance occur most frequently in the case of intoxication with the following classes of substances:- Alcohol; - amphetamine and similar stimulants; - caffeine; - cocaine; - opiates; - sedatives; - hypnotics and anxiolytics; other substances.!![b]8b. Clinical disorders of children and adolescents!![/b]Refers to disorders usually diagnosed for the first time during infancy, childhood or adolescence. Clinical disorders of children and adolescents include:1. Mental retardation It is characterized by a significantly below average intellectual functioning (QI of approx. 70 or below) with onset before the age of 18 and by concomitant deficits or impairments in adaptive functioning. Separate codes are provided for mild, moderate, severe and profound mental retardation. As well as for mental retardation of unspecified severity. 2. Learning disorders This disorder is characterized by school functioning substantially below that expected, given the person's chronological age, measured intelligence and age-appropriate education. The specific disorders included in this section are dyslexia (reading disorder), dyscalculia (calculation disorder), dysgraphia (graphic expression disorder) and learning disorder without any other specification. 3. Disturbance of motor skills This includes developmental disorder of coordination, which is characterized by a motor coordination substantially below that expected, given the person's chronological age and measured intelligence. 4. Communication disorders are characterized by difficulties in speech or language, and include expressive language disorder, mixed receptive and expressive language disorder, phonological disorder, stuttering and communication disorder without any other specification5. Pervasive developmental disorders are characterized by severe deficits and pervasive deterioration in multiple areas of development. These include impairment in reciprocal social interaction, impairment in communication, and the presence of stereotyped behaviors, preoccupations, and activities. Specific disorders included in this section are autistic disorder, Rett disorder, childhood disintegrative disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified. 6. Attention deficit and disruptive behavior disorders. This section includes attention deficit/hyperactivity disorder, which is characterized by symptoms of inattention and/or hyperactivity-impulsivity. Subtypes are provided to specify the presence of the predominant syndrome: predominantly inattentive, hyperactive-impulsive and combined type. Disruptive behavior disorders are also included: conduct disorder, characterized by a pattern of behavior that violates the fundamental rights of others or major age-appropriate social norms or rules; oppositional defiant disorder, characterized by a pattern of negative, hostile and defiant behavior. This section also includes two categories not otherwise specified: attention deficit/hyperactivity disorder not otherwise specified and disruptive behavior disorder not otherwise specified.7. Eating and eating behavior disorders of infancy or early childhood. These disorders are characterized by persistent disturbances in eating and eating behavior. The specific disorders included are pica, rumination and eating disorder of infancy or early childhood.8. Tics are characterized by motor and/or vocal tics. The disordersspecific includes Tourette's disorder, chronic motor or vocal tic, transient tic and unspecified tic.9. Elimination disorders This category includes encopresis, the elimination of feces in inappropriate places and lack of control, and enuresis, the repeated elimination of urine in inappropriate places and lack of control. 10. Other disorders of infancy, childhood or adolescence. Separation anxiety is characterized by excessive and developmentally inappropriate anxiety about being separated from home or from those to whom the child is attached. Selective mutism refers to the persistent inability to speak in specific social situations, despite speaking in other situations. Reactive attachment disorder of infancy or early childhood is characterized by a developmentally inappropriate and markedly disrupted social relationship that occurs in most contexts and is associated with grossly pathogenic caregiving. Stereotypic movement disorder is characterized by a nonfunctional, apparently impulsive and repetitive motor behavior that interferes considerably with normal activities and can sometimes lead to bodily injuries. Disorder of infancy, childhood, or adolescence unspecified refers to disorders with onset in infancy, childhood, or adolescence that do not meet the criteria for any specific disorder in the classification.!! !!!!TASKS FOR INDIVIDUAL WORK!!1. Perform the functional analysis of symptoms for two disorders within each module. Describe them in terms of duration, frequency and intensity. 2. Create a decision tree containing key questions to guide you in establishing a mental disorder of your choice from each module. 3. Create the description of an ideal case that meets the diagnostic criteria for one of the disorders, for each module. Then make predictions about how the subject thinks, behaves and feels in each of the following situations: ü When he has a loss in the family; ü When he is rejected by his partner; ü When he meets new people. Note: each description should be approximately half a page. Psychological report / Research report Psychological report Research report¨ Name, surname and affiliation of the author¨ Destination / purpose of the report Case history (approx. 750 words) Identification data Main charges History of the present disorder (emotional, behavioral, cognitive, physiological symptoms, mechanisms coping, current stressors) Psychiatric history Personal and social history Medical history Mental status DSM IV diagnosis Formulation of the case (approx. 500 words) Precipitating factors Examination of current cognitions and behaviors Longitudinal examination (evolution over time) of cognitions and behaviors Positive aspects of the subject Working hypothesis Therapeutic plan (approx. 250 words) List of problems Therapeutic goals¨ Name, surname and affiliation of the author¨ Destination / purpose of the report Objectives of the study Theoretical foundation Methodology Design Procedure Subjects Results obtained Implications – the theoretical and practical impact of the study; future directions in research. EVALUATION: The evaluation of the declarative and procedural knowledge acquired in this course will be done through an oral or written exam covering the course and seminar topics (7 points) and a report (3 points) that can cover: (1) a psychological report- case analysis (diagnosis and clinical evaluation of a real case) or a clinical research report. The presentation of the report conditions the passing of the oral/written exam. The maximum grade in the oral/written exam (7) requires, in addition to the mandatory materials (the text of the course support - 5 points) and the study of the internet sites suggested in the text of the course support and part of.