What are somatoform disorders?
bodily symptoms without any organic, physical cause
� This group of disorders is distinguished by certain key features: prominent reporting of somatic (sensory) symptoms, concern about medical illness, & frequent presentation to general medical providers
What is a primary gain?
Primary Gain example: A patient feels guilty about not being able to perform a task, but if there IS a medical condition justifying this inability, the guilt diminishes.
What is a secondary gain?
Secondary Gain example: A patient is allowed to miss work and gets financial compensation as the result of a medical condition.
� Psychologists would call secondary gains positive reinforcement.
� Reinforcement strengthens a behavior.
Rewards:Control in t
What are the types of somatoform disorders?
Types of Somatoform Disorders
� Factitious Disorder
� Conversion Disorder
� Illness Anxiety Disorder (Hypochondriasis)
�Body Dysmorphic Disorder
A disorder in which a person feigns (fakes) or induces physical symptoms, typically for the purpose of assuming the role of a sick person. (consciously aware faking/inducing s/s)--> to draw attention to self/sympathy/reassurance
Factitious disorder
AKA Munchausen Syndrome (a/w emotional difficulties)
What is Malingering?
Malingering- intentional (deliberate) falsification/ exaggeration of s/s for secondary gain (food, shelter, finances, avoid prison) --> intention to receive reward
� Financial Compensation (Insurance Claims)
� Law suits/ Deferment from military service
Re
Both factitious disorder and malingering are associated with intentionally faking signs and symptoms. What is the difference between malingering and factitious disorder?
The difference is that in malingering, the pt feigns illness for secondary gain whereas in factitious disorder the primary motive is to assume the sick role and get sympathy!
What is Munchausen Syndrome/ by proxy?
induced illness ON someone else in the person's care (ie mother exaggerates or deliberately causes illness on the child)
� Consciously create the appearance of illness
� Sometimes through the use of substances (laxatives, anticoagulants, etc.)
� Usually f
What should you look for in a pt in whom you suspect has Munchausen Syndrome/ by proxy?
� Extensive medical treatment as a child --> can be a form of child abuse; may need removal from home
A 6-year-old boy is brought to the emergency department after a sudden loss of consciousness. His medical history is relevant for attention deficit disorder, to which he currently takes methylphenidate. The mother, who is a nurse, mentions that the boy wa
b. Initiate IV glucose infusion
What is at the top of your differential? In this case the mother appears to be making her son ill and you would dx the mother with Munchausen syndrome by proxy
Major takeaway
Munchausen syndrome by proxy
is a form of child
A 6-year-old girl is brought to the emergency department because of a 48 hour history of vomiting. The patient has been seen in the same emergency department 3 times within the past 6 months for the same complaint. The patient's past medical history is si
Consult child abuse services
Major takeaway
Munchausen
disorder by proxy is a factitious disorder in which the caretaker induces or exaggerates a medical condition in someone else to gain medical attention.
Main explanation
Munchausen
disorder (now known
A 30 yo F presents to the clinic c/o of a sore throat that has not gone away. She has been to the clinic for the 12th time in 6 months. She states that her sore throat pain is mild and that gargling with salt water helps but she said she checked Dr.Google
Illness Anxiety Disorder (aka hypochondriasis)
Treatment: Most patients respond to antidepressants, Cognitive/behavioral therapy*** (most pts with mood disorders together with anti depressants)
A 12-year-old girl is brought to her pediatrician's office because of an elongated nose. She reports that her nose is too big, long, and ugly. She describes it as "disgusting" and is obsessed with getting a rhinoplasty. Her parents state that she has been
Body dysmorphic disorder
Major takeaway
Body dysmorphic disorder
is a preoccupation with an imagined or slight defect in appearance, sufficient to cause the patient significant distress or interfere with their functioning in some way.
Main explanation
Bod
The patient is preoccupied with an imagined physical defect or a minor defect that others often cannot see.
� People with Body dysmorphic disorder see themselves as "ugly" and often avoid social exposure or turn to plastic surgery to try to improve their
Psychotherapy, Group therapy (able to get rational objective opinion socially), antidepressants (SSRIs).
What are some red flags to recognize in body dysmorphic disorder?
� RED FLAGS - seeking plastic surgery for the same or multiple perceived physical defects; believing that such surgery will solve their interpersonal problems.
What are the Cluster A personality disorders?
Cluster A: Odd/eccentric (weird)
- Paranoid
- Schizoid
- Schizotypal
What is paranoid personality disorder?
Essential feature is a pattern of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
� Begins in early adulthood
� Patients assume that other people will exploit, harm or deceive them even with no evidenc
Coworkers describe Max as a person who is overly defensive and frequently gets into arguments. He recently got into an argument with Yessica another coworker, and the manager was called in to break up the argument. Max states that Yessica is always intent
Paranoid type personality disorder
Approach to treatment:
� Combination of individual AND group therapy, medication, self-education
� Psychotherapy
- Treatment of choice
- Cognitive/behavioral
- Group therapy
Medications: No FDA approved medications
� tre
There are no FDA approved medications to treat paranoid personality disorder but if there is underlying depression you can treat with SSRIs. You can use an antipsychotic, if severe like haloperidol- typical or benzodiazepine for anxiety/agitation. What is
Approach to treatment:
� Combination of individual AND group therapy, medication, self-education
� Psychotherapy
- Treatment of choice
- Cognitive/behavioral
- Group therapy
What is schizoid personality disorder (Cluster A odd/eccentric)?
Essential feature of schizoid personality disorder is a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
� Pattern begins by early adulthood and is present in a variety of
What are the RF for developing schizoid personality disorder?
� Development and course: childhood and adolescence with solitariness, poor peer relationships, underachievement in school, may be subject to bullying
� Risk: may have increased prevalence in relatives with schizophrenia
� Gender: slightly more common in
Jim is described by his sister as not wanting to be part of the family because he prefers to be alone. She also state that her brother has no interest in girls at school like his other friends. Several of his peers describe him as a quiet loner type.
What
Schizoid personality disorder
Treatment
� Psychotherapy is treatment of choice
� Low dose atypical (2nd gen) antipsychotics may be helpful
No FDA approved medications
PPP: quick way to remember Schizoid Personality disorder
Think Schizoids like to AVOID ppl
Anhedonic- little pleasure in activities, appears indifferent, lacks response to praise or criticism
Voluntary social withdrawl- prefers to be alone (unlike avoidant PD), No desire for close or sexual relationships, prefe
What is schizotypal personality disorder?
Essential feature is pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for close relationships as WELL AS cognitive or perceptual distortions or eccentricities of behavior
� Ideas of reference com
How would you treat a or with schizotypal personality disorder?
Treatment
� Psychotherapy is first line, mainstay of treatment
� No FDA approved medications
� Atypical antipsychotics may be helpful
What is the DSM-V diagnostic criteria for schizotypal personality disorder?
DSM-V Diagnosis
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well ascognitive or perceptual distortions and eccentricities of behavior, beginning by early adu
ALL Cluster A personality disorders appear to have RF that is common among them, what is it?
� Risk: may have increased prevalence in relatives with schizophrenia
After watching a particular movie 5 months ago, a young man becomes infatuated with an actress in the film and believes the movie is really about their destiny to be together. He begins to stalk her and sees a conspiracy unfolding that is keeping them apa
Major takeaway
Schizotypal personality disorder
is a cluster A personality disorder characterized by odd behavior and magical thinking. They lack delusions or hallucinations, unlike schizophrenia.
Main explanation
Schizotypal personality disorder
(PD) is
What are the cluster B personality disorders?
antisocial, borderline, histrionic, narcissistic
What is antisocial personality disorder?
Essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood
� This pattern has been referred to as psychopa
Many individuals with antisocial personality disorder end up in the prison system, psychotherapy has NOT been shown to be effective. How would you treat the aggression in a pt with antisocial personality disorder?
Treatment:
� Therapy has NOT been shown to be effective in clinical trials
� Many of these individuals end up in the prison system
� Medications: No FDA approved
- Aggression:
� atypical antipsychotics, SSRI's (careful: there is abuse potential)
� Lithium
Jake a 19 yo M with a hx of conduct disorder, has been very kind and charming with his grandmother so taht she can give him money and lend him the car. However in school he gets into fights constantly and fails to maintain employment or honor financial ob
Antisocial Personality Disorder
A 23 year-old man comes to the psychiatry clinic, accompanied by his mother, because she is concerned after seeing cut marks on his arms. His mother says that his life is chaotic and unstable. He often brings nice girls home whom he "likes a lot" to meet
Major takeaway
Borderline personality disorder
is characterized by instability of interpersonal relationships, self-image, and emotions, as well as by impulsivity across a wide range of situations, causing significant impairment or subjective distress.
Ma
A 25-year-old woman is brought to the emergency department after telling her roommate that she wants to just "go away" following an argument with her boyfriend. Her roommate states that the patient has few close friends and often believes that her relatio
Major takeaway
Histrionic personality disorder
is characterized by excessive displays of emotion, belief that relationships are more intimate than they are, tendency to be easily influenced by others, style of speech that is impressionistic and lacking de
A 25-year-old woman comes to the psychiatrist because of a referral by her family physician. She has been treated for a myriad of oral and genital sexually transmitted infections over the past five years, and she says she has had several hundred sexual pa
Major takeaway
Histrionic personality disorder
is characterized by attention-seeking behavior, excessive emotionality and excitability, attention seeking, sexual provocation, and excessive concern with appearance.
Main explanation
The patient in this ques
A 23-year-old woman is urgently reviewed by the psychiatric crisis team because of a suicide attempt an hour ago. Her mother states that she found her daughter on the floor cutting her wrists because her boyfriend broke up with her today. Medical history
Major takeaway
Borderline personality disorder
is a DSM-V diagnosis characterized by seeking approval from others for self-identity, impairments in empathy and intimacy, and pathological personality traits such as grandiosity and attention seeking.
Main e
A 17-year-old girl comes to the emergency department with her parents because she inflicted multiple cuts on her forearms once her boyfriend left her. Her primary physician is notified, he arrives to her room and she says: "I am so happy that you are here
Major takeaway
Splitting is a primitive coping mechanism and the key symptom for patients of borderline personality disorder, such as the one described in this clinical vignette. Splitting is an ego mechanism that fluctuates between idealization and deval
A 27-year-old woman and her boyfriend of 2 years are referred to couples counseling. The boyfriend is thinking of proposing, however there has been strain on their relationship because of the patient's inappropriate behavior. The boyfriend states that she
Major takeaway
Histrionic personality disorder
is characterized by a pervasive pattern of excessive emotionality and attention seeking and includes features such as inappropriate sexual behaviors, shallow or exaggerated expression of emotion, and consiste
A 25-year-old woman comes to the emergency department because of cuts she made with a razor blade to her left forearm and right hip. She says her boyfriend broke up with her recently, and she has been feeling very lonely and empty. She reports frequent cu
Major takeaway
Borderline personality disorder
is characterized by instability of interpersonal relationships, self-image, and emotions, as well as by impulsivity across a wide range of situations, causing significant impairment or subjective distress.
Ma
A 30-year-old woman is brought to the emergency department following a minor car accident. Physical examination is unremarkable except for a small laceration above her eyebrow. As the physician is talking to the woman she becomes very emotional and theatr
Major takeaway
Histrionic personality disorder
is characterized by a pervasive pattern of excessive emotionality and attention seeking and includes features such as inappropriate sexual behaviors, shallow or exaggerated expression of emotion, and consiste
An 8-year-old girl comes to the emergency department because she is a victim of physical abuse. After the case was notified to the authorities by one of their neighbors, she was removed from home and taken into the custody of child protection services. Wh
Major takeaway
Borderline personality disorder
is a pattern of abnormal behavior with extreme fear of abandonment, and unstablerelationships with other people. This pattern of behavior typically begins in early adulthood. Victims of child abuseare at risk
A 12-year-old comes to the hospital because of a repetitive pattern of aggressive behavior. He has had episodes of peer-fights, theft, and vandalization without remorse for the past year. He was caught torturing his neighbor's cat. Compared to his peers,
Major takeaway
Antisocial personality disorder
is characterized by a developmental or acquired abnormalities in the prefrontalbrain systems, with reduced autonomic activity. This may cause low arousal, poor fear conditioning, and decision-making deficits.
A 45-year-old woman comes to the office because of chronic headaches. As soon as the physician enters the room, the patient starts angrily describing how the nurse "did not care at all." She says that all nurses are cold, and just want money. Then she cal
Major takeaway
Splitting is a defense mechanism commonly seen in patients with borderline personality disorder, in which people are seen as "all good" or "all bad."
Main explanation
This patient is using the defense mechanism known as splitting. Patients
A 32-year-old female is caught by the police because of identity theft. When confronted by the police, she lies about the accusations and tries to run. She also tries to escape custody by putting the lives of the police officers in danger. Which of the fo
Major takeaway
Antisocial personality
disorder is always characterized by a history of conduct disorder before the age of 15. If left untreated, this will cause antisocial personality disorder.
Main explanation
The DSM-V defines antisocial personality dis
A 25-year-old medical student comes to the psychiatric clinic because of difficulties working in groups over the past year. While in the waiting room, he demands to be seen by the chair of psychiatry himself because he has "a reputation to uphold." During
Major takeaway
Narcissistic personality disorder
is a cluster B disorder. These patients have an inflated sense of self, sense of entitlement, and lack of regard for others.
Main explanation
Narcissistic personality disorder is a cluster B disorder. These
A 30-year-old woman comes to the emergency department because of an attempt of suicide. She took an entire bottle of acetaminophen after breaking up with her boyfriend. She is tearful and shouts that she has nothing to live for since she lost the love of
Major takeaway
Patients with borderline personality disorder have unstable moods and relationships. These patients tend to be impulsive and it is common for them to have a history of multiple suicide threats or attempts.
Main explanation
This woman has bo
What is borderline personality disorder?
unstable, unpredictable mood & affect. Unstable self-image & relationships.
� "black and white thinking": everything is either all good or all bad
� Splitting behaviors (your good, but last PA was bad)
� Significant mood swings/changes
� Impulsive behavio
What is DSM-V diagnostic criteria for Borderline Personality Disorder?
DSM-V Diagnosis
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:
1. Frantic
Per PPP, what is a quick way to remember the diagnostic criteria for Borderline personality disorder?
Think of the B's for borderline:
"Bat"- mood swings
Black and white thinking: thinks in extremes "all good" or bad:- no middle ground (splitting)
Blown up (intense) reaction disproportionate to the event.
Broken: unstable relationships.
Breaking up- fear
There are no FDA approved medication to treat Borderline personality disorder but there are psychotropic medications used:
Antipsychotics, Antidepressants and Benzodiazepines that are used was adjunct to the the 1st line treatment. What is the 1st line tr
Psychotherapy: 1st line treatment !!
� Dialectal behavioral therapy (DBT)*
- Form of CBT
- Support oriented-pt builds up self esteem
- Collaborative- learn new ways of interacting
� Cognitive behavioral therapy (CBT)
� Group therapy
� Mindfulness training
What is Histrionic Personality Disorder?
Exhibit overly emotional, attention-seeking, dramatic, seductive behaviors
- Emotions may be shallow/inconsistent
- Belief that sharing these feelings brings them closer to clinician
� Deliberate use of excessive, superficial emotionality and sexuality to
What are the DSM-V Criteria for histrionic personality disorder?
DSM-V Diagnosis
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts as indicated by 5 (or more) of the following:
1. Is uncomfortable in situations in which he or she is no
Per PPP, what is a quick way to remember the diagnostic criteria for histrionic personality disorder?
Think if the H's for histrionic
1. Hey look at me - attention seeking with the need to be the center of attention, overly emotional, dramatic, seductive.
2. Hissy Fits - temper tantrum's, self-absorbed.
3. Come Hither- often inappropriate, sexually provoc
How do you treat histrionic PD?
Treatment:
� Psychotherapy�treatment of choice
� CBT
� Group therapy
What is Narcissistic personality disorder?
� Grandiosity
� Need for attention and admiration
� Superficial interpersonal relationships
� Lack of empathy
� Cause: unknown (hypothesis- lack of clear parental appreciation of the child's accomplishments)
Highly comorbid with other psychiatric disorder
Mr. Trump is a man that has as self-inflated image and believes he is special, entitled and requires special admiration. Is preoccupied with fantasies of brilliance when all he knows how to say are the words " huge" and "great things" without any real exp
Narcissistic personality disorder
Treatment-
� Psychotherapy- Treatment of choice
What are Cluster C Personality Disorder: Anxious/ Fearful?
Avoidant, Dependent, and Obsessive-Compulsive Personality Disorder (OCPD)
What is avoidant personality disorder?
Characterized by social inhibition due to an intense fear of rejection, affecting their lives. Timid, shy, and lacks confidence.
- Desired relationships but AVOIDS them
- Fear of rejection
- "inferiority complex": feeling of inadequacy, sensitive to criti
Persistent behavioral pattern of avoidance created by anxiety
� Leads to restricted lifestyle and social interactions, Introverted, Anxious, Inhibited,Awkward, Social discomfort.
How would you treat avoidant personality disorder?
Treatment:
� Psychotherapy= treatment of choice
� Medications:
- Beta blockers for anxiety
- SSRI's for depression
What is dependent personality disorder?
� Characterized by clingy, submissive behavior
� Females > Males
� Cause unknown
- Studies suggest childhood environment where dependent behaviors were directly or indirectly rewarded, and independent activities were discouraged
� Lifelong interpersonal s
How would you treat dependent personality disorder?
Treatment:
� Psychotherapy= 1st line treatment
� Group therapy
� Marital therapy
� Medications:
- Anxiolytics
- Antidepressants- SSRI's
What is Obsessive-Compulsive Personality Disorder (OCPD)?
Characterized by Pre-occupation with orderliness, perfectionism, mental and interpersonal control at the expense of flexibility, openness, and efficiency
What is the DSM-V diagnostic criteria for OCPD?
DSM-V Diagnosis:
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as ind
How would you treat OCPD?
Treatment:
� Psychotherapy= 1st line management
� Medications:
- B-blockers for anxiety
SSRI for depression