Module II: Neurodevelopmental Disorders, Schizophrenia spectrum and other psychotic

disorders

Intellectual Disability
The term intellectual disability defines intellectual disability as “significantly sub average general
intellectual functioning, existing concurrently with deficits in adaptive behavior and manifested during
the developmental period, that adversely affects a child’s educational performance. The definition of
intellectual disability requires that a person must have significantly sub average intellectual functioning
and impairments in adaptive abilities with onset during the developmental period;

Adaptive Impairments

Individuals fulfilling the diagnosis of intellectual disability not only must have limitations in their
intellectual abilities, but these deficits must also impair their ability to adapt or function in daily life,
when compared with peers of similar age or culture These impairments limit or restrict participation and
performance in one or more aspects of daily life activities, such as communication, social participation,
function at school or work. The limitations result in the need for ongoing support at school, work, or
independent life. Adaptive behavior is measured using individualized, standardized, culturally
appropriate, and psychometrically sound test.

Classification of Intellectual Disability

Per the APA (2000), an individual is classified as having mild intellectual disability if his or her IQ level is
50 to approximately 70; moderate intellectual disability if his or her IQ level is 35 to approximately 50;
severe intellectual disability if his or her IQ level is 20 to approximately 35; and profound intellectual
disability if his or her IQ level is below 20–25.

Etiology

Mild intellectual disability is more likely to be associated with racial, social, and familial factors whereas
severe intellectual disability is more typically linked to a biological/genetic origin. Postnatal
environmental influences mediate biological processes through mechanisms that may be indirect.
Postnatal environmental factors may affect the expression of the neurodevelopmental dysfunction.
Mothers who never finished high school are four times more likely to have children with mild
intellectual disability than are women who completed high school. The specific origins of mild
intellectual disability are identifiable. The most common biological causes are certain genetic/
chromosomal syndromes—for example fetal deprivation, perinatal complications exposure to drugs of
abuse, especially alcohol. In children with severe intellectual disability, a biological origin can be
identified

TREATMENT APPROACHES

The most useful treatment approach for children with intellectual disability consists of education, social,
and recreational activities; behavior problems; and associated impairments. Support for parents,
siblings, and other caregivers is also important. The most common identifiable causes are Down
syndrome, fragile X syndrome, and fetal alcohol spectrum disorders.

Educational Services
The achievement of good outcomes in an educational program is dependent on the interaction between
the student and teacher. Educational programs must be relevant to the child’s needs and address the
child’s individual strengths and challenges. The child’s developmental level and his or her requirements
for support and goals for independence provide a basis for establishing an individualized family service
plan. Education for infants and toddlers usually takes place in the home. Although home is also the
primary educational setting for 3–4 year old. At age 5, most children enter kindergarten for half- or full-
day sessions and are introduced to a more formal learning environment. Formal special education
services are provided in the school setting thereafter.

Leisure and Recreational Needs

The child’s physical, social, and recreational needs should be addressed. Children’s peer socialization in
play and recreational activities constitutes an important part of their socialemotional development and
builds resilience. In the ideal world, children with intellectual disability would participate as equals in all
recreation and leisure activities. Although young children with intellectual disability are not usually
excluded from play activities, parents still may have a difficult time finding age- and skill-appropriate
adaptive play equipment (cost can be a significant factor) or socially oriented play groups. Adolescents
with an intellectual disability are often not included by their typically developing peers in extracurricular
sports and social activities. Participation in sports or related exercise regimens should be encouraged
with all children because it offers many immediate and long-term benefits, including weight
management, development of physical coordination, maintenance of cardiovascular fitness, and
improvement of self-image. Social activities are equally important to the social and emotional
development of youth with intellectual disabilities. Such activities should include those with adolescents
of the opposite gender and with typically developing youth.

Autism spectrum disorders

Autism spectrum disorders (ASDs) are a class of neurodevelopmental disorders characterized by
impairments in social reciprocity, atypical communication, and repetitive behaviors.

CAUSES OF AUTISM SPECTRUM DISORDERS

The Genetics of Autism-

Obstetric Complications-studies have strongly associated any specific prenatal or birth complication.
with the development of ASDs. Obstetric optimality scores that reflect the overall health of the
pregnancy, delivery, and newborn period, however, are lower in children with ASDs. An increased risk
for ASD has been reported among premature infants. An increased risk has also been reported to be
present in women who become pregnant within 12 months of having a first child.

Environmental Exposures
Substances that result in an increased risk of birth defects in the developing fetus are termed
teratogens. These include maternal medications, drugs of abuse, chemicals, and radiation. In addition,
increased rates of ASDs have been reported in children who were exposed during early pregnancy to
valproic acid (an antiepileptic drug) and mesoprostol (used to induce early termination of pregnancy

Vaccinations-the initial allegation of an association of the measles, mumps, and rubella vacaccine with
developmental regression and ASD.

Infections-Prenatal infection with rubella increases the risk for cerebral palsy, intellectual disability,
visual impairments, and ASDs, depending on the timing of the infection. A mother’s own immunologic
response to infections such as influenza, however, might cause subtle differences in brain development
that hypothetically could predispose a susceptible fetus to an ASD.

Gender and Autism Spectrum Disorders-Autism affects more boys than girls, with gender ratios
generally ranging from 2:1

Attention-deficit/hyperactivity disorder
Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent neurodevelopmental/
mental health conditions in childhood. It is characterized by developmentally inappropriate levels of
inattention and distractibility and/or hyperactivity and impulsivity that cause impairment in adaptive
functioning at home, school, and in social situations.

PREVALENCE AND EPIDEMIOLOGY

ADHD has been detected in 7%–10% of children. In clinic-referred samples, the ratio of boys:girls
diagnosed with ADHD ranges from 6:1 to 12:1. It is thought that boys may be referred more often due to
a higher rate of co-occurring aggressive behavior, oppositional and conduct disorders. Girls may be more
likely to be referred because of the inattentive subtype and associated learning and internalizing
disorders.

CAUSES OF ATTENTIONDEFICIT/HYPERACTIVITY DISORDER

Genetics

The most common etiological factor in the development of ADHD is heredity. Siblings of children with
ADHD are between 5–7 times more likely to be diagnosed with ADHD than children from unaffected
families. Each child of a parent with ADHD has a 25% chance of having ADHD. Norepinephrine is another
neurotransmitter that plays an important role in orienting attention and regulating alertness in the
frontal cortex and in other areas of the cortex and lower brain.

Other Etiologic Factors

the most common etiology of ADHD is genetic, other conditions known to affect brain development may
result in ADHD symptoms or increase the risk of those genetically at risk for the disorder. These include
prenatal exposures to cigarette smoking, lead at even low levels alcohol, cocaine, antidepressants
prematurity, intrauterine growth retardation, brain infections, and inborn errors of metabolism Sex
chromosome abnormalities (including Turner syndrome, and fragile X syndrome) and other syndromes
that may be inherited or genetic. Premature infants with evidence for low cerebral blood flow were
found at 12–14 years of age to have an increased risk for ADHD. In children who do not have a family
history of ADHD, there is an increased incidence of complications during labor, delivery, and infancy.
Children who undergo surgery for congenital heart disease also may have decreased cerebral blood flow
and have a higher risk for subsequent attention problems premature children confirm the increased risk
for ADHD with low birth weight and prematurity Acquired traumatic brain injury can also result in ADHD
symptoms.

Structural and Functional Differences in the Brain

(MRI) scans have shown important differences when the shape, thickness, and volume of specific areas
are compared. Five regions have shown consistent differences—frontal lobes, including the dorsolateral
prefrontal cortex and dorsal anterior cingulate cortex, inferior parietal cortex, basal ganglia. Studies of
the amygdala and hippocampus, part of the limbic system, have also shown anomalies in shape and
volume in children with ADHD. studies indicated globally decreased glucose metabolism in children with
ADHD.

TREATMENT OF ATTENTIONDEFICIT/HYPERACTIVITY DISORDER

Most treatment plans for ADHD will include education about the disorder and one or more of the
following interventions: behavioral and family counseling, special education services, and medication.

Education About AttentionDeficit/Hyperactivity Disorder and Emotional Support for Families- Parents
and older children need to learn as much as possible about ADHD so that they can be effective decision
makers and advocates. The clinician can provide some information directly but should also guide the
family toward resources such as national support and advocacy organizations, books and online
resources, and parent support groups. Although providing emotional support alone is not likely to result
in significant improvements, without emotional support parents and children may not be able to
perform the difficult work needed to address the consequences of ADHD.

Behavioral Counseling and Social Skill Intervention- Behavior therapy changes behavior by altering the
antecedents to, or consequences of, the behavior in such a way that it increases the chances that the
child will successfully engage in the desired behaviors and reduces the chances that the child will engage
in unwanted behaviors. Behavior therapy can be done in individual or group sessions and forms the
basis for most parent training and classroom management programs for children with ADHD. A study of
a very intensive behavioral intervention that also included social skill-building and emotional support.
Factors that may interfere with successful parent training in behavior management include parental
depression or ADHD, high levels of marital discord. low maternal parental self-efficacy, and multiple
coexisting conditions in the child. Family therapy can help to mitigate the effects of parenting a child
with ADHD on the marital relationship and sibling interactions. Family therapy may be necessary when
parents cannot agree on an intervention plan or other family stressors interfere with implementation of
a treatment plan. Cognitive-behavior therapy changes behavior by helping individuals to change self-
defeating thought and behavior patterns. It is a well-documented treatment for depression and anxiety
and has recently been shown to be effective in the treatment of adult ADHD. Children and teens with
ADHD frequently hold negative or inaccurate attributions that can interfere with the use of productive
strategies to face challenges. Individual psychotherapy or play therapy may be helpful for children with
coexisting mood, anxiety, or self-esteem problems. Coaching is an emerging approach to improve the
daily functioning of teens and adults with ADHD. It involves regular meetings between the individual
with ADHD and his or her coach to identify executive function impairments leading to problems in daily
functioning and to develop systems and strategies to address them. Coaching is most likely to be
successful when the individual recognizes the problems and wishes to address them but cannot seem to
do it without help. Coaches are typically psychologists, educators, social workers, or successful adults
with ADHD. Interpersonal difficulties such as peer victimization (bullying) and/or social isolation are
common in individuals with ADHD. thus social-skill interventions may be recommended as part of a
comprehensive treatment plan. Social skill groups are often conducted in school or other group settings
and teach by modeling, practicing, and reinforcing prosocial behaviors. The social skills interventions
that seem to be the most effective are conducted in naturalistic settings .

Educational Treatment- Appropriate school programs are extremely important for children with ADHD,
many of whom have coexisting learning disabilities. Even those children without a specific learning
disability may require substantial repetition or alternate methods of instruction. A well-trained teacher
who is able to provide special help and an educational program suited to the needs of the child is
invaluable to the student with ADHD. The teacher may need to use environmental modifications and
behavior management techniques to maintain the child’s attention to tasks and decrease unwanted
behavior. The child may need the teacher’s assistance to develop organizational skills and support
comprehension. Classwork or assignments may need to be modified to emphasize the child’s strengths,
help manage the child’s learning weaknesses or disabilities, and compensate for problems with initiation
or slow work production. A child with ADHD who needs modification of curricular materials, demands,
or teaching methods should have an individualized education program.

Schizoaffective Disorder
Schizoaffective disorder has features of both schizophrenia and mood disorders.

Gender and Age Differences

Approximately equal numbers of men and women. The depressive type of schizoaffective disorder may
be more common in older persons than in younger persons, and the bipolar type may be more common
in young adults than in older adults. Men with schizoaffective disorder are likely to exhibit antisocial
behavior and to have a markedly flat or inappropriate affect.

ETIOLOGY

a group, patients with schizoaffective disorder have a better prognosis than patients with schizophrenia
and a worse prognosis than patients with mood disorders.
DIFFERENTIAL DIAGNOSIS

Preexisting medical conditions, their treatment, or both can cause psychotic and mood disorders.
Psychotic disorder caused by seizure disorder is more common than that seen in the general population.
It tends to be characterized by paranoia, hallucinations, and ideas of reference. Patients with epilepsy
with psychosis are believed to have a better level of function than patients with schizophrenic spectrum
disorders. Better control of the seizures can reduce the psychosis.

TREATMENT

Psychosocial Treatment -Patients benefit from a combination of family therapy, social skills training, and
cognitive rehabilitation. The range of symptoms can be vast because patients contend with both
ongoing psychosis and varying mood states. It can be very difficult for family members to keep up with
the changing nature and needs of these patients. Medication regimens can be complicated, with
multiple medications from all classes of drugs.

Schizophreniform Disorder
The symptoms of schizophreniform are similar to those of schizophrenia; however, with
schizophreniform disorder, the symptoms last for at least 1 month but less than 6 months.

EPIDEMIOLOGY

The disorder is most common in adolescents and young adults. A fivefold greater rate of
schizophreniform disorder has been found in men than in women.

Several studies have shown that the relatives of patients with schizophreniform disorder are at high risk
of having other psychiatric disorders, the relatives of patients with schizophreniform disorders are more
likely to have mood disorders than are the relatives of patients with schizophrenia. the relatives of
patients with schizophreniform disorder are more likely to have a diagnosis of a psychotic mood
disorder than are the relatives of patients with bipolar disorders.

ETIOLOGY

One study showed the deficit to be limited to the left hemisphere and found impaired striatal activity
suppression limited to the left hemisphere during the activation procedure. central nervous system
factors may lead to either the long-term course of schizophrenia or the foreshortened course of
schizophreniform disorder.

some data indicate that patients with schizophreniform disorder may have enlarged cerebral ventricles,
as determined by computed tomography

DIAGNOSTIC AND CLINICAL FEATURES

Schizophreniform disorder is an acute psychotic disorder that has a rapid onset. The initial symptom
profile is the same as that of schizophrenia in that two or more psychotic symptoms (hallucinations,
delusions, disorganized speech and behavior, or negative symptoms) must be present. Although
negative symptoms may be present, they are relatively uncommon in schizophreniform disorder and are
considered poor prognostic features.
DIFFERENTIAL DIAGNOSIS

The duration of psychotic symptoms is one factor that distinguishes schizophreniform disorder from
other syndromes. Additional confounds are that mood symptoms, such as loss of interest and pleasure,
may be difficult to distinguish from negative symptoms, avolition, and anhedonia. Some mood
symptoms may also be present during the early course of schizophrenia.

TREATMENT

Hospitalization, which is often necessary in treating patients with schizophreniform disorder, allows
effective assessment, treatment, and supervision of a patient’s behavior. The psychotic symptoms can
usually be treated by a 3- to 6-month course of antipsychotic drugs. In one study, about 75 percent of
patients with schizophreniform disorder responded to antipsychotic medications within 8 days.
Psychotherapy is usually necessary to help patients integrate the psychotic experience into their
understanding of their own minds and lives. ECT may be indicated for some patients, especially those
with marked catatonic or depressed features.

Delusional Disorder
Delusions are false fixed beliefs. The diagnosis of delusional disorder is made when a person exhibits
nonbizarre delusions of at least 1 month’s duration that cannot be attributed to other psychiatric
disorders. Nonbizarre means that the delusions must be about situations that can occur in real life, such
as being followed, infected, loved at a distance, and so on. Several types of delusions may be present.

EPIDEMIOLOGY

The mean age of onset is about 40 years, but the range for age of onset runs from 18 years of age to the
90s. A slight preponderance of female patients exists. Men are more likely to develop paranoid
delusions than women, who are more likely to develop delusions of erotomania

Psychotherapy- Individual therapy seems to be more effective than group therapy; insight-oriented,
supportive, cognitive, and behavioral therapies are often effective. Initially, a therapist should neither
agree with nor challenge a patient’s delusions. Physicians may stimulate the motivation to receive help
by emphasizing a willingness to help patients with their anxiety or irritability without suggesting that the
delusions be treated, but therapists should not actively support the notion that the delusions are real.
Therapists should be on time and make appointments as regularly as possible, with the goal of
developing a solid and trusting relationship with a patient. Overgratification may actually increase
patients’ hostility and suspiciousness because ultimately they must realize that not all demands can be
met. Therapists can avoid overgratification by not extending the designated appointment period, by not
giving extra appointments unless absolutely necessary, and by not being lenient about the fee.

Therapists should avoid making disparaging remarks about a patient’s delusions or ideas but can
sympathetically indicate to patients that their preoccupation with their delusions is both distressing to
themselves and interferes with a constructive life.

Without agreeing with every delusional misperception, a therapist can acknowledge that from the
patient’s perspective, such perceptions create much distress. As they become less rigid, feelings of
weakness and inferiority, associated with some depression, may surface. When a patient allows feelings
of vulnerability to enter into the therapy, a positive therapeutic alliance has been established, and
constructive therapy becomes possible.

When family members are available, clinicians may decide to involve them in the treatment plan.
Consequently, both the patient and the family need to understand that the therapist maintains
physician– patient confidentiality and that communications from relatives are discussed with the
patient. The family may benefit from the therapist’s support and thus may support the patient.

A good therapeutic outcome depends on a psychiatrist’s ability to respond to the patient’s mistrust of
others and the resulting interpersonal conflicts, frustrations, and failures. The mark of successful
treatment may be a satisfactory social adjustment rather than abatement of the patient’s delusions.

Hospitalization

Patients with delusional disorder can generally be treated as outpatients, but clinicians should consider
hospitalization for several reasons.

BRIEF PSYCHOTIC DISORDER

Brief psychotic disorder is defined as a psychotic condition that involves the sudden onset of psychotic
symptoms, which lasts 1 day or more but less than 1 month.

Epidemiology

The disorder occurs more often among younger patients (20s and 30s) than among older patients. Brief
psychotic disorder is more common in women than in men. Some clinicians indicate that the disorder
may be seen most frequently in patients from low socioeconomic classes and in those who have
experienced disasters or major cultural changes (e.g., immigrants). The age of onset in industrialized
settings may be higher than in developing countries. Persons who have gone through major psychosocial
stressors may be at greater risk for subsequent brief psychotic disorder.

Comorbidity

The disorder is often seen in patients with personality disorders (most commonly, histrionic, narcissistic,
paranoid, schizotypal, and borderline personality disorders)

Etiology

The cause of brief psychotic disorder is unknown. Patients who have a personality disorder may have a
biological or psychological vulnerability for the development of psychotic symptoms, particularly those
with borderline, schizoid, schizotypal, or paranoid qualities. Some patients with brief psychotic disorder
have a history of schizophrenia or mood disorders in their families, but this finding is nonconclusive.
Psychodynamic formulations have emphasized the presence of inadequate coping mechanisms

Clinical Features
The symptoms of brief psychotic disorder always include at least one major symptom of psychosis, such
as hallucinations, delusions, and disorganized thoughts, usually with an abrupt onset. . Some clinicians
have observed that labile mood, confusion, and impaired attention may be more common at the onset
of brief psychotic disorder than at the onset of eventually chronic psychotic disorders. Characteristic
symptoms in brief psychotic disorder include emotional volatility, strange or bizarre behavior, screaming
or muteness, and impaired memory of recent events. Some of the symptoms suggest a diagnosis of
delirium and warrant a medical workup, especially to rule out adverse reactions to drugs.

Treatment

Hospitalization. A patient who is acutely psychotic may need brief hospitalization for both evaluation
and protection. Evaluation requires close monitoring of symptoms and assessment of the patient’s level
of danger to self and others.

Psychotherapy.

Psychotherapy is of use in providing an opportunity to discuss the stressors and the psychotic episode.
Exploration and development of coping strategies are the major topics in psychotherapy. Associated
issues include helping patients deal with the loss of self-esteem and to regain selfconfidence. An
individualized treatment strategy based on increasing problem-solving skills while strengthening the ego
structure through psychotherapy appears to be the most efficacious. Family involvement in the
treatment process may be crucial to a successful outcome.

Module IV: Anxiety Disorders, Obsessive-Compulsive and Related Disorders

Panic Disorder
An acute intense attack of anxiety accompanied by feelings of impending doom is known as panic
disorder. The anxiety is characterized by discrete periods of intense fear that can vary from several
attacks during one day to only a few attacks during a year.

EPIDEMIOLOGY

Women are two to three times more likely to be affected than men. The only social factor identified as
contributing to the development of panic disorder is a recent history of divorce or separation. Panic
disorder most commonly develops in young adulthood—the mean age of presentation is about 25 years
—but both panic disorder and agoraphobia can develop at any age. Panic disorder has been reported in
children and adolescents, and it is probably underdiagnosed in these age groups.

COMORBIDITY

About one-third of persons with panic disorders have major depressive disorder

About two-thirds first experience panic disorder during or after the onset of major depression.

. Of persons with panic disorder, 15 to 30 percent also have social anxiety disorder or social phobia, 2 to
20 percent have specific phobia, 15 to 30 percent have generalized anxiety disorder, 2 to 10 percent
have PTSD, and up to 30 percent have OCD. Other common comorbid conditions are hypochondriasis or
illness anxiety disorder, personality disorders, and substance-related disorders.

CLINICAL FEATURES

The attack often begins with a 10-minute period of rapidly increasing symptoms. The major mental
symptoms are extreme fear and a sense of impending death and doom. he physical signs often include
palpitations sweating. Patients often try to leave whatever situation they are in to seek help. The attack
generally lasts 20 to 30 minutes and rarely more than an hour. Patients may experience depression or
depersonalization during an attack. The symptoms can disappear quickly or gradually. Between attacks,
patients may have anticipatory anxiety about having another attack. Somatic concerns of death from a
cardiac or respiratory problem may be the major focus of patients’ attention during panic attacks.
Patients may believe that the palpitations and chest pain indicate that they are about to die.

DIFFERENTIAL DIAGNOSIS

Panic disorder also must be differentiated from a number of psychiatric disorders, particularly other
anxiety disorders. Panic attacks occur in many anxiety disorders, including social and specific phobia,
Panic may also occur in PTSD and OCD. Differentiation from generalized anxiety disorder can also be
difficult. Classically, panic attacks are characterized by their rapid onset (within minutes) and short
duration (usually less than 10 to 15 minutes), in contrast to the anxiety associated with generalized
anxiety disorder. Sometimes it is difficult to distinguish between panic disorder, on the one hand, and
specific and social phobias, on the other hand. Some patients who experience a single panic attack in a
specific setting (e.g., an elevator) may go on to have long-lasting avoidance of the specific setting,
regardless of whether they ever have another panic attack. These patients meet the diagnostic criteria
for a specific phobia, and clinicians must use their judgment about what is the most appropriate
diagnosis. In another example, a person who experiences one or more panic attacks may then fear
speaking in public.

COURSE AND PROGNOSIS

Panic disorder usually has its onset in late adolescence or early adulthood, although onset during
childhood, early adolescence, and midlife does occur. Some data implicate increased psychosocial
stressors with the onset of panic disorder, although no psychosocial stressor can be definitely identified
in most cases. Panic disorder, in general, is a chronic disorder, although its course is variable, both
among patients and within a single patient. After the first one or two panic attacks, patients may be
relatively unconcerned about their condition; with repeated attacks, however, the symptoms may
become a major concern. Patients may attempt to keep the panic attacks secret and thereby cause their
families and friends concern about unexplained changes in behavior. Panic attacks can occur several
times in a day or less than once a month. Excessive intake of caffeine or nicotine can exacerbate the
symptoms.

TREATMENT
Cognitive and behavior therapies are effective treatments for panic disorder. Various reports have
concluded that cognitive and behavior therapies are superior to pharmacotherapy alone; Several studies
and reports have found that the combination of cognitive or behavior therapy with pharmacotherapy is
more effective than either approach alone. Several studies that included long-term follow-up of patients
who received cognitive or behavior therapy indicate that the therapies are effective in producing long-
lasting remission of symptoms.

Cognitive Therapy - The two major foci of cognitive therapy for panic disorder are instruction about a
patient’s false beliefs and information about panic attacks. The instruction about false beliefs centers on
the patient’s tendency to misinterpret mild bodily sensations as indicating impending panic attacks,
doom, or death. The information about panic attacks includes explanations that when panic attacks
occur, they are time limited and not life threatening.

Agoraphobia
Agoraphobia refers to a fear of or anxiety regarding places from which escape might be difficult. It can
be the most disabling of the phobias because it can significantly interfere with a person’s ability to
function in work and social situations outside the home.

EPIDEMIOLOGY

According to the DSM-5, persons older than age 65 years have a 0.4 percent prevalence rate of
agoraphobia. studies of agoraphobia in psychiatric settings have reported that at least three fourths of
the affected patients have panic disorder as well, studies of agoraphobia in community samples have
found that as many as half the patients have agoraphobia without panic disorder

DIAGNOSIS AND CLINICAL FEATURES

Patients with agoraphobia rigidly avoid situations in which it would be difficult to obtain help. They
prefer to be accompanied by a friend or a family member in busy streets, crowded stores, closed-in
spaces (e.g., tunnels, bridges, and elevators), and closed-in vehicles (e.g., subways, buses, and
airplanes). Patients may insist that they be accompanied every time they leave the house. Severely
affected patients may simply refuse to leave the house. Particularly before a correct diagnosis is made,
patients may be terrified that they are going crazy.

No etiology

DIFFERENTIAL DIAGNOSIS

The differential diagnosis for agoraphobia includes all the medical disorders that can cause anxiety or
depression. Differential diagnosis includes major depressive disorder, schizophrenia, paranoid
personality disorder, avoidance personality disorder, and dependent personality disorder.

TREATMENT
Supportive Psychotherapy. Supportive psychotherapy involves the use of psychodynamic concepts and a
therapeutic alliance to promote adaptive coping. Adaptive defenses are encouraged and strengthened,
and maladaptive ones are discouraged. The therapist assists in reality testing and may offer advice
regarding behavior. Insight-Oriented Psychotherapy. In insight-oriented psychotherapy, the goal is to
increase the patient’s development of insight into psychological conflicts that, if unresolved, can
manifest as symptomatic behavior.

Behavior Therapy. In behavior therapy, the basic assumption is that change can occur without the
development of psychological insight into underlying causes. Techniques include positive and negative
reinforcement, systematic desensitization, flooding, implosion, graded exposure, response prevention,
stop thought, relaxation techniques, panic control therapy, self-monitoring, and hypnosis.

Cognitive Therapy. This is based on the premise that maladaptive behavior is secondary to distortions in
how people perceive themselves and in how other perceive them. Treatment is short term and
interactive, with assigned homework and tasks to be performed between sessions that focus on
correcting distorted assumptions and cognitions.

Virtual Therapy. Computer programs have been developed that allow patients to see themselves as
avatars who are then placed in open or crowded spaces (e.g., a supermarket). As they identify with the
avatars in repeated computer sessions, they are able to master their anxiety through deconditioning.

Specific Phobia
The term phobia refers to an excessive fear of a specific object, circumstance, or situation. A specific
phobia is a strong, persisting fear of an object or situation. Persons with specific phobias may anticipate
harm, such as being bitten by a dog, or may panic at the thought of losing control; for instance, if they
fear being in an elevator, they may also worry about fainting after the door closes.

EPIDEMIOLOGY

Specific phobia is the most common mental disorder among women and the second most common
among men. The peak age of onset for the natural environment type and the blood-injection-injury type
is in the range of 5 to 9 years, although onset also occurs at older ages. The peak age of onset for the
natural environment type and the blood-injection-injury type is in the range of 5 to 9 years, although
onset also occurs at older ages. In contrast, the peak age of onset for the situational type (except fear of
heights) is higher, in the mid-20s, which is closer to the age of onset for agoraphobia

ETIOLOGY

See butcher

TREATMENT

Behavior Therapy- the most studied and most effective treatment for phobias is probably behavior
therapy. The key aspects of successful treatment are (1) the patient’s commitment to treatment; (2)
clearly identified problems and objectives; and (3) available alternative strategies for coping with the
feelings. A variety of behavioral treatment techniques have been used, the most common being
systematic desensitization

Other behavioral techniques that have been used more recently involve intensive exposure to the
phobic stimulus through either imagery or desensitization in vivo. In imaginal flooding, patients are
exposed to the phobic stimulus for as long as they can tolerate the fear until they reach a point at which
they can no longer feel it.

COMORBIDITY

Reports of comorbidity in specific phobia range from 50 to 80 percent. Common comorbid disorders
with specific phobia include anxiety, mood, and substance-related disorders

Social Anxiety Disorder (Social Phobia)

Social anxiety disorder (also referred to as social phobia) involves the fear of social situations, including
situations that involve scrutiny or contact with strangers. The term social anxiety reflects the distinct
differentiation of social anxiety disorder from specific phobia, which is the intense and persistent fear of
an object or situation. Persons with social anxiety disorder are fearful of embarrassing themselves in
social situations (i.e., social gatherings, oral presentations, meeting new people). They may have specific
fears about performing specific activities such as eating or speaking in front of others, or they may
experience a vague, nonspecific fear of “embarrassing oneself.” In either case, the fear in social anxiety
disorder is of the embarrassment that may occur in the situation, not of the situation itself.

EPIDEMIOLOGY

In epidemiological studies, females are affected more often than males. The peak age of onset for social
anxiety disorder is in the teens, although onset is common as young as 5 years of age and as old as 35
years.

COMORBIDITY

Persons with social anxiety disorder may have a history of other anxiety disorders, mood disorders,
substance-related disorders, and bulimia nervosa.

ETIOLOGY

Neurochemical Factors

Patients with performance phobias may release more norepinephrine or epinephrine, both centrally and
peripherally, than do non phobic persons, or such patients may be sensitive to a normal level of
adrenergic stimulation. Another study using SPECT demonstrated decreased striatal dopamine reuptake
site density. Thus, some evidence suggests dopaminergic dysfunction in social anxiety disorder

Genetic Factors
First-degree relatives of persons with social anxiety disorder are about three times more likely to be
affected with social anxiety disorder than are first-degree relatives of those without mental disorders.
data indicate that monozygotic twins are more often concordant than are dizygotic twins, although in
social anxiety disorder, it is particularly important to study twins reared apart to help control for
environmental factors.

DIFFERENTIAL DIAGNOSIS

Social anxiety disorder needs to be differentiated from appropriate fear and normal shyness,
respectively. Differential diagnostic considerations for social anxiety disorder are agoraphobia, panic
disorder, avoidant personality disorder, major depressive disorder, and schizoid personality disorder. a
patient with social anxiety disorder is made more anxious by the presence of other people. Whereas
breathlessness, dizziness, a sense of suffocation, and a fear of dying are common in panic disorder and
agoraphobia, the symptoms associated with social anxiety disorder usually involve blushing, muscle
twitching, and anxiety about scrutiny. Differentiation between social anxiety disorder and avoidant
personality disorder can be difficult and can require extensive interviews and psychiatric histories. The
avoidance of social situations can often be a symptom in depression,

COURSE AND PROGNOSIS

Social anxiety disorder tends to have its onset in late childhood or early adolescence.

TREATMENT

Both psychotherapy and pharmacotherapy are useful in treating social anxiety disorder. Some studies
indicate that the use of both pharmacotherapy and psychotherapy produces better results than either
therapy alone, although the finding may not be applicable to all situations and patients. Effective drugs
for the treatment of social anxiety disorder include (1) SSRIs, (2) the benzodiazepines, (3) venlafaxine
(Effexor), and (4) buspirone (BuSpar). Most clinicians consider SSRIs the first-line treatment choice for
patients with more generalized forms of social anxiety disorder. cognitive, behavioral, and exposure
techniques are also useful in performance situations. Psychotherapy for social anxiety disorder usually
involves a combination of behavioral and cognitive methods, including cognitive retraining,
desensitization, rehearsal during sessions, and a range of homework assignments.

Generalized Anxiety Disorder

Persons who seem to be anxious about almost everything, however, are likely to be classified as having
generalized anxiety disorder. Generalized anxiety disorder is defined as excessive anxiety and worry
about several events or activities for most days during at least a 6-month period. The worry is difficult to
control and is associated with somatic symptoms, such as muscle tension, irritability, difficulty sleeping,
and restlessness.

EPIDEMIOLOGY

Generalized anxiety disorder is a common condition. The ratio of women to men with the disorder is
about 2 to 1, but the ratio of women to men who are receiving inpatient treatment for the disorder is
about 1 to 1. In anxiety disorder clinics, about 25 percent of patients have generalized anxiety disorder.
The disorder usually has its onset in late adolescence or early adulthood, although cases are commonly
seen in older adults.

COMORBIDITY

Generalized anxiety disorder is probably the disorder that most often coexists with another mental
disorder, usually social phobia, specific phobia, panic disorder, or a depressive disorder. as 25 percent of
patients eventually experience panic disorder. Generalized anxiety disorder is differentiated from panic
disorder by the absence of spontaneous panic attacks. An additional high percentage of patients are
likely to have major depressive disorder.

ETIOLOGY

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DIFFERENTIAL DIAGNOSIS

with other anxiety disorders, generalized anxiety disorder must be differentiated from both medical and
psychiatric disorders. Common co-occurring anxiety disorders also must be considered, including panic
disorder, phobias, OCD, and PTSD. To meet criteria for generalized anxiety disorder, patients must both
exhibit the full syndrome, and their symptoms also cannot be explained by the presence of a comorbid
anxiety disorder. Proper diagnosis involves both definitively establishing the presence of generalized
anxiety disorder and properly diagnosing other anxiety disorders. Patients with generalized anxiety
disorder frequently develop major depressive disorder.

COURSE AND PROGNOSIS

most patients with the disorder report that they have been anxious for as long as they can remember.
Patients usually come to a clinician’s attention in their 20s, although the first contact with a clinician can
occur. Only one-third of patients who have generalized anxiety disorder seek psychiatric treatment.
Many go to general practitioners, internists, cardiologists, pulmonary specialists, or gastroenterologists,
seeking treatment for the somatic component of the disorder. The occurrence of several negative life
events greatly increases the likelihood that the disorder will develop. By definition, generalized anxiety
disorder is a chronic condition that may well be lifelong.

TREATMENT

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Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is represented by a diverse group of symptoms that include
intrusive thoughts, rituals, preoccupations, and compulsions. These recurrent obsessions or compulsions
cause severe distress to the person. The obsessions or compulsions are time-consuming and interfere
significantly with the person’s normal routine, occupational functioning, usual social activities, or
relationships. A patient with OCD may have an obsession, a compulsion, or both.
 An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. In contrast to an
obsession, which is a mental event, a compulsion is a behavior. Specifically, a compulsion is a conscious,
standardized, recurrent behavior, such as counting, checking, or avoiding. A patient with OCD realizes
the irrationality of the obsession and experiences both the obsession and the compulsion as ego-
dystonic (i.e., unwanted behavior). Although the compulsive act may be carried out in an attempt to
reduce the anxiety associated with the obsession, it does not always succeed in doing so. The
completion of the compulsive act may not affect the anxiety, and it may even increase the anxiety.

EPIDEMIOLOGY

Among adults, men and women are equally likely to be affected, but among adolescents, boys are more
commonly affected than girls. The mean age of onset is about 20 years, although men have a slightly
earlier age of onset (mean about 19 years) than women (mean about 22 years). Overall, the symptoms
of about two thirds of affected persons have an onset before age 25, and the symptoms of fewer than
15 percent have an onset after age 35. The onset of the disorder can occur in adolescence or childhood,
in some cases as early as 2 years of age. Single persons are more frequently affected with OCD than are
married persons,

COMORBIDITY

The lifetime prevalence for major depressive disorder in persons with OCD is about 67 percent and for
social phobia about 25 percent. Other common comorbid psychiatric diagnoses in patients with OCD
include alcohol use disorders, generalized anxiety disorder, specific phobia, panic disorder, eating
disorders, and personality disorders.

ETIOLOGY

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DIFFERENTIAL DIAGNOSIS

Tourette’s Disorder- OCD is closely related to Tourette’s disorder. About 90 percent of persons with
Tourette’s disorder have compulsive symptoms, and as many as two thirds meet the diagnostic criteria
for OCD. In its classic form, Tourette’s disorder is associated with a pattern of recurrent vocal and motor
tics that bears only a slight resemblance to OCD. OCD exhibits a superficial resemblance to obsessive-
compulsive personality disorder, which is associated with an obsessive concern for details,
perfectionism, and other similar personality traits. Psychotic symptoms often lead to obsessive thoughts
and compulsive behaviors that can be difficult to distinguish from OCD with poor insight, in which
obsessions border on psychosis. OCD can be difficult to differentiate from depression because the two
disorders often occur comorbidly, and major depression is often associated with obsessive thoughts
that, at times. Obsessive symptoms associated with depression are only found in the presence of a
depressive episode, whereas true OCD persists despite remission of depression.
COURSE AND PROGNOSIS

The onset of symptoms for about 50 to 70 percent of patients occurs after a stressful event, such as a
pregnancy, a sexual problem, or the death of a relative. Because many persons manage to keep their
symptoms secret, they often delay 5 to 10 years before coming to psychiatric attention. About one-third
of patients with OCD have major depressive disorder.

TREATMENT

Many patients with OCD. may refuse to take medication and may resist carrying out therapeutic
homework assignments and other activities prescribed by behavior therapists. The obsessive-compulsive
symptoms themselves, no matter how biologically based, may have important psychological meanings
that make patients reluctant to give them up. Well-controlled studies have found that
pharmacotherapy, behavior therapy, or a combination of both is effective in significantly reducing the
symptoms of patients with OCD.

Behavior Therapy- Many clinicians, therefore, consider behavior therapy the treatment of choice for
OCD. Behavior therapy can be conducted in both outpatient and inpatient settings. The principal
behavioral approaches in OCD are exposure and response prevention. Desensitization, thought stopping,
flooding, implosion therapy, and aversive conditioning have also been used in patients with OCD. In
behavior therapy, patients must be truly committed to improvement.

Psychotherapy

insight-oriented psychotherapy for OCD. Reports of successes. Individual analysts have seen striking and
lasting changes for the better in patients with obsessive-compulsive personality disorder, especially
when they are able to come to terms with the aggressive impulses underlying their character traits.
analysts and dynamically oriented psychiatrists have observed marked symptomatic improvement in
patients with OCD in the course of analysis or prolonged insight psychotherapy.

Supportive psychotherapy undoubtedly has its place, especially for those patients with OCD who,
despite symptoms of varying degrees of severity, are able to work and make social adjustments. With
continuous and regular contact with an interested, sympathetic, and encouraging professional person,
patients may be able to function by virtue of this help, without which their symptoms would
incapacitate them. Occasionally, when obsessional rituals and anxiety reach an intolerable intensity, it is
necessary to hospitalize patients until the shelter of an institution and the removal from external
environmental stresses diminish symptoms to a tolerable level.

Body Dysmorphic Disorder

Body dysmorphic disorder is characterized by a preoccupation with an imagined defect in appearance
that causes clinically significant distress or impairment in important areas of functioning. If a slight
physical anomaly is actually present, the person’s concern with the anomaly is excessive and
bothersome.

EPIDEMIOLOGY

Body dysmorphic disorder is a poorly studied condition, partly because patients are more likely to go to
dermatologists, internists, or plastic surgeons than to psychiatrists for this condition. the most common
age of onset is between 15 and 30 years and that women are affected somewhat more often than men.
Affected patients are also likely to be unmarried. Body dysmorphic disorder commonly coexists with
other mental disorders. One study found that more than 90 percent of patients with body dysmorphic
disorder had experienced a major depressive episode in their lifetimes; about 70 percent had
experienced an anxiety disorder; and about 30 percent had experienced a psychotic disorder.\

ETIOLOGY

The high comorbidity with depressive disorders, a higher-than-expected family history of mood
disorders and OCD,

CLINICAL FEATURES

The effects on a person’s life can be significant; almost all affected patients avoid social and
occupational exposure. As many as one-third of patients may be housebound because of worry about
being ridiculed for the alleged deformities; and approximately one-fifth of patients attempt suicide. As
discussed, comorbid diagnoses of depressive disorders and anxiety disorders are common, and patients
may also have traits of OCD, schizoid, and narcissistic personality disorders.

DIFFERENTIAL DIAGNOSIS

Individuals with avoidant personality disorder or social phobia may worry about being embarrassed by
imagined or real defects in appearance, but this concern is usually not prominent, persistent,
distressing, or impairing. Although individuals with body dysmorphic disorder have obsessional
preoccupations about their appearance and may have associated compulsive behaviors (e.g., mirror
checking), a separate or additional diagnosis of OCD is made only when the obsessions or compulsions
are not restricted to concerns about appearance and are ego-dystonic. An additional diagnosis of
delusional disorder, somatic type, can be made in people with body dysmorphic disorder only if their
preoccupation with the imagined defect in appearance is held with a delusional intensity.

COURSE AND PROGNOSIS

Body dysmorphic disorder usually begins during adolescence, although it may begin later. The onset can
be gradual or abrupt.
TREATMENT

Hoarding Disorder
The disorder is characterized by acquiring and not discarding things that are deemed to be of little or no
value, resulting in excessive clutter of living spaces.

EPIDEMIOLOGY

Hoarding is believed to occur in approximately 2 to 5 percent of the population. t occurs equally among
men and women, is more common in single persons, and is associated with social anxiety, withdrawal,
and dependent personality traits. Hoarding usually begins in early adolescence and persists throughout
the lifespan.

COMORBIDITY

The most significant comorbidity is found between hoarding disorder and OCD, with as many as 30
percent of OCD patients showing hoarding behavior. Deficits in attention and executive function that
occur in hoarding may resemble those seen in attention-deficit/hyperactivity disorder (ADHD). Hoarding
behaviors are relatively common among schizophrenic patients and have been noted in dementia and
other neurocognitive disorders. One study found hoarding in 20 percent of dementia patients and 14
percent of brain injury patients.

ETIOLOGY

Little is known about the etiology of hoarding disorder. Research has shown a familial aspect to hoarding
disorder, with about 80 percent of hoarders reporting at least one first-degree relative with hoarding
behavior. Biological research has shown a lower metabolism in the posterior cingulate cortex and the
occipital cortex of hoarders

CLINICAL FEATURES

Hoarding is driven by the fear of losing items that the patient believes will be needed later and a
distorted belief about or an emotional attachment to possessions. Most hoarding patients accumulate
possessions passively rather than intentionally, thus clutter accumulates gradually over time. Common
hoarded items include newspapers, mail, magazines, old clothes, bags, books, lists, and notes. Hoarding
poses risks to not only the patient, but also to those around them. Clutter accumulated from hoarding
has been attributed to deaths from fire or patients being crushed by their possessions. It can also attract
pest infestations that can pose a health risk both to the patient and residents around them. The
pathological nature of hoarding comes from the inability to organize possessions and keep them
organized. Many hoard to avoid making decisions about discarding items. For example, a hoarder will
keep old newspapers and magazines because they believe that if discarded the information will be
forgotten and will never be retrieved again.

DIFFERENTIAL DIAGNOSIS

Some case reports show the onset of this behavior in patients after suffering brain lesions. Hoarding
associated with brain lesions is more purposeless than hoarding that is motivated by emotional
attachment or high intrinsic value of possessions. It is a common symptom in moderate to severe
dementia. In cases of dementia, hoarding is often associated with a higher prevalence of hiding,
rummaging, repetitive behavior, pilfering, and hyperphagia. Onset of the behavior usually coincides with
onset of the dementia, starting in an organized manner, and becomes more disorganized as the disease
progresses. The onset of dementia in a patient who has hoarded throughout his or her lifetime can
aggravate the hoarding behavior. Hoarding behavior can be associated with schizophrenia. It is mostly
associated with severe cases and is seen as a repetitive behavior associated with delusions, self-neglect,
and squalor. Bipolar disorder is ruled out by the absence of severe mood swings.

TREATMENT

only 18 percent of patients responded to medication and CBT. The challenges posed by hoarding
patients to typical CBT treatment include poor insight to the behavior and low motivation and resistance
to treatment. The most effective treatment for the disorder is a cognitive behavioral model that includes
training in decision making and categorizing; exposure and habituation to discarding; and cognitive
restructuring. This includes both office and in-home sessions. The role of the therapist in this model is to
assist in the development of decision-making skills, to provide feedback about normal saving behavior,
and to identify and challenge the patient’s erroneous beliefs about possessions. Studies have shown a
25 to 34 percent reduction in hoarding behaviors using this method

Hair-Pulling Disorder (Trichotillomania)

Hair-pulling disorder is a chronic disorder characterized by repetitive hair pulling, leading to variable hair
loss that may be visible to others. The disorder was once deemed rare and little about it was described
beyond phenomenology. It is now regarded as more common. The disorder is similar to obsessive-
compulsive disorder and impulse control in that there is increased tension prior to the hair pulling and a
relief of tension or gratification after the hair pulling.

EPIDEMIOLOGY
general populations and with female to male ratio as high as 10 to 1. A childhood type of hair-pulling
disorder occurs approximately equally in girls and boys. An estimated 35 to 40 percent of patients with
hair-pulling disorder chew or swallow the hair that they pull out at one time or another.

COMORBIDITY

Significant comorbidity is found between hair-pulling disorder and obsessive-compulsive disorder (OCD);
anxiety disorders; Tourette’s disorder; depressive disorders; eating disorders; and various personality
disorders—particularly obsessive-compulsive, borderline, and narcissistic personality disorders.

ETIOLOGY

Disturbances in mother–child relationships, fear of being left alone, and recent object loss are often
cited as critical factors contributing to the condition. Substance abuse may encourage development of
the disorder. Depressive dynamics are often cited as predisposing factors, but no particular personality
trait or disorder characterizes patients. Some see self-stimulation as the primary goal of hair pulling.
Family members of hair-pulling disorder patients often have a history of tics, impulsecontrol disorders,
and obsessive-compulsive symptoms,. One study looked at the neurobiology of hair-pulling disorder and
found a smaller volume of the left putamen and left lenticulate areas.

DIAGNOSIS AND CLINICAL FEATURES

Hair loss is characterized by short, broken strands appearing together with long, normal hairs in the
affected areas. No abnormalities of the skin or scalp are present. Hair pulling is not reported as being
painful, although pruritus and tingling may occur in the involved area

DIFFERENTIAL DIAGNOSIS

COURSE AND PROGNOSIS

The mean age at onset of hair-pulling disorder is in the early teens, most frequently before age 17, but
onset has been reported much later in life.

TREATMENT

Treatment usually involves psychiatrist and dermatologists in a joint endeavor. Successful behavioral
treatments, such as biofeedback, self-monitoring, desensitization, and habit reversal, have been
reported, but most studies have been based on individual cases or a small series of cases with relatively
short follow-up periods. Chronic hair-pulling disorder has been treated successfully with insight-oriented
psychotherapy. Hypnotherapy has been mentioned as potentially effective in the treatment of
dermatological disorders in which psychological factors may be involved

Excoriation (Skin-Picking) Disorder

Excoriation or skin-picking disorder is characterized by the compulsive and repetitive picking of the skin.
It can lead to severe tissue damage and result in the need for various dermatological treatments.

EPIDEMIOLOGY

It is more prevalent in women than in men.

COMORBIDITY

patients with OCD may have obsessions about contamination and skin abnormalities or may be
preoccupied with having smooth skin, flawless complexion, and cleanliness. Other comorbid conditions
include hairpulling disorder (trichotillomania, 38 percent), substance dependence (38 percent), major
depressive disorder (32 to 58 percent), anxiety disorders (23 to 56 percent), and body dysmorphic
disorder (27 to 45 percent). One study reported an association of both borderline and obsessive-
compulsive personality disorder (71 percent) in patients with skin-picking disorder.

ETIOLOGY

Some theorists speculate that skin-picking behavior is a manifestation of repressed rage at authoritarian
parents. These patients pick at their skin and perform other self-destructive acts to assert themselves.
Patients may pick as a means to relieve stress. For example, skin-picking has been associated with
marital conflicts, passing of loved ones, and unwanted pregnancies. According to psychoanalytic theory,
the skin is an erotic organ, and picking at the skin or scratching the skin leading to excoriations may be a
source of erotic pleasure. Many patients begin picking at the onset of dermatological conditions such as
acne and continue to pick after the condition has cleared. Abnormalities in serotonin, dopamine, and
glutamate metabolism have been theorized to be an underlying neurochemical cause of the disorder

CLINICAL FEATURES

the face is the most common site of skin-picking. her common sites are legs, arms, torso, hands, cuticles,
fingers, and scalp. Patients may experience tension prior to picking and a relief and gratification after
picking. Many report picking as a means to relieve stress, tension, and other negative feelings. In spite of
the relief felt from picking, patients often feel guilty or embarrassed at their behavior. Many patients
use bandages, makeup, or clothing to hide their picking. Of skin-picking patients, 15 percent report
suicidal ideation due to their behavior and about 12 percent have attempted suicide.
DIFFERENTIAL DIAGNOSIS

Skin-picking disorder is similar to OCD and it is associated with high rates of comorbid OCD. Skin-picking
is commonly seen in body dysmorphic disorder. The skin-picking in body dysmorphic disorder is
primarily centered on removing or minimizing believed imperfection in the patient’s appearance.
Substance use disorders often co-occur with skin-picking disorder.

COURSE AND PROGNOSIS

The onset of skin-picking disorder is either in early adulthood or between 30 and 45 years of age. Onset
in children before age 10 years has also been seen. The mean age of onset is between 12 to 16 years of
age.

TREATMENT

Most patients do not actively seek treatment due to embarrassment or because they believe their
condition is untreatable. Effective therapy requires both psychological and somatic treatment. In some
cases mechanical prevention of skin-picking by different protective measures may be of use in an effort
to break the cycle. Psychotherapy at the same time deals with the underlying emotional factors

Module V: Trauma and Stressor-Related Disorders, Dissociative Disorders

Adjustment Disorders

adjustment disorders are characterized by an emotional response to a stressful event. It is one of the
few diagnostic entities in which an external stressful event is linked to the development of symptoms.
Typically, the stressor involves financial issues, a medical illness, or relationship problem. The symptom
complex that develops may involve anxious or depressive affect or may present with a disturbance of
conduct

EPIDEMIOLOGY

Women are diagnosed with the disorder twice as often as men, and single women are generally overly
represented as most at risk. In children and adolescents, boys and girls are equally diagnosed with
adjustment disorders. The disorders can occur at any age but are most frequently diagnosed in
adolescents. Among adolescents of either sex, common precipitating stresses are school problems,
parental rejection and divorce, and substance abuse. Among adults, common precipitating stresses are
marital problems, divorce, moving to a new environment, and financial problems.

ETIOLOGY
DIAGNOSIS AND CLINICAL FEATURES

The disorder can occur at any age, and its symptoms vary considerably, with depressive, anxious, and
mixed features most common in adults. Physical symptoms, which are most common in children and the
elderly, can occur in any age group. Manifestations may also include assaultive behavior and reckless
driving, excessive drinking, defaulting on legal responsibilities, withdrawal, vegetative signs, insomnia,
and suicidal behavior.

Manifestation may include assaultive behaviour and reck less driving, excessive drinking, withdrawals,
vegetative signs, insomnia and suicidal behaiour.

DIFFERENTIAL DIAGNOSIS

Other disorders from which adjustment disorder must be differentiated include major depressive
disorder, brief psychotic disorder, generalized anxiety disorder, somatic symptom disorder, substance-
related disorder, conduct disorder, and PTSD. Patients with an adjustment disorder are impaired in
social or occupational functioning and show symptoms beyond the normal and expectable reaction to
the stressor. Because no absolute criteria help to distinguish an adjustment disorder from another
condition, clinical judgment is necessary. Some patients may meet the criteria for both an adjustment
disorder and a personality disorder.

TREATMENT

DISSOCIATIVE AMNESIA
The main feature of dissociative amnesia is an inability to recall important personal information, usually
of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness. the
disorder does not result from the direct physiological effects of a substance or a neurological or other
general medical condition.

Epidemiology

2 to 6 percent of the general population. No known difference is seen in incidence between men and
women. Cases generally begin to be reported in late adolescence and adulthood.

Etiology

In many cases of acute dissociative amnesia, the psychosocial environment out of which the amnesia
develops is massively conflictual, with the patient experiencing intolerable emotions of shame, guilt,
despair, rage, and desperation. These usually result from conflicts over unacceptable urges or impulses,
such as intense sexual, suicidal, or violent compulsions. Traumatic experiences such as physical or sexual
abuse can induce the disorder. In some cases the trauma is caused by a betrayal by a trusted, needed
other (betrayal trauma). This betrayal is thought to influence the way in which the event is processed
and remembered.
Diagnosis and Clinical Features

Classic Presentation. The classic disorder is an overt dramatic clinical disturbance that frequently results
in the patient being brought quickly to medical attention, It is frequently found in those who have
experienced extreme acute trauma. Depression and suicidal ideation are reported in many cases. Many
of these patients have histories of prior adult or childhood abuse or trauma.

Non classic Presentation. These patients frequently come to treatment for a variety of symptoms, such
as depression or mood swings, substance abuse, sleep disturbances, somatoform symptoms, anxiety
and panic, suicidal or self-mutilating impulses and acts, violent outbursts, eating problems, and
interpersonal problems. Self-mutilation and violent behavior in these patients may also be accompanied
by amnesia.

Differential Diagnosis

Treatment

Cognitive Therapy. Cognitive therapy may have specific benefits for individuals with trauma disorders.
Identifying the specific cognitive distortions that are based in the trauma may provide an entrée for
which the patient experiences amnesia. As the patient becomes able to correct cognitive distortions,
particularly about the meaning of prior trauma, more detailed recall of traumatic events may occur.

Hypnosis. Hypnosis can be used in a number of different ways in the treatment of dissociative amnesia.
In particular, hypnotic interventions can be used to recall of dissociated memories; to provide support
and ego strengthening for the patient. In addition, the patient can be taught self-hypnosis to apply
containment and calming techniques in his or her everyday life.

Group Psychotherapy. Time-limited and longer-term group psychotherapies have been reported to be
helpful for survivors of childhood abuse. During group sessions, patients may recover memories for
which they have had amnesia.

DEPERSONALIZATION/DEREALIZATION DISORDER
Depersonalization is defined as the persistent or recurrent feeling of detachment or estrangement from
one’s self. The individual may report feeling like an automaton or watching himself or herself in a movie
(Fig. 12-1). Derealization is somewhat related and refers to feelings of unreality or of being detached
from one’s environment. The patient may describe his or her perception of the outside world as lacking
lucidity and emotional coloring, as though dreaming or dead.

Epidemiology
They are the third most commonly reported psychiatric symptoms, after depression and anxiety. It is
common in seizure patients and migraine sufferers; they can also occur with use of psychedelic drugs,
especially marijuana, lysergic acid diethylamide (LSD), and mescaline. They are also common after mild
to moderate head injury. They are also common after life-threatening experiences, with or without
serious bodily injury. Depersonalization is found two to four times more in women than in men.

Etiology

Psychodynamic. Traditional psychodynamic formulations have emphasized the disintegration of the ego
or have viewed depersonalization as an affective response in defense of the ego.

Traumatic Stress- one third to one half, of patients in clinical depersonalization case series report
histories of significant trauma. Several studies of accident victims find as many as 60 percent of those
with a lifethreatening experience report at least transient depersonalization during the event or
immediately thereafter. Military training studies find that symptoms of depersonalization and
derealization are commonly evoked by stress and fatigue and are inversely related to performance.

Neurobiological Theories.

The association of depersonalization with migraines and marijuana, its generally favorable response to
selective serotonin reuptake inhibitors

Differential Diagnosis

Depersonalization can result from a medical condition or neurological condition, intoxication or

withdrawal from illicit drugs, as a side effect of medications, or can be associated with panic attacks,
phobias, PTSD, or acute stress disorder, schizophrenia, or another dissociative disorder. A thorough
medical and neurological evaluation is essential, including standard laboratory studies, an EEG, and any
indicated drug screens. Drug-related depersonalization is typically transient, but persistent
depersonalization can follow an episode of intoxication with a variety of substances, including
marijuana, cocaine, and other psychostimulants. A range of neurological conditions, including seizure
disorders, brain tumors, metabolic abnormalities, migraine, vertigo, and Ménière’s disease, have been
reported as causes.

Course and Prognosis

Depersonalization after traumatic experiences or intoxication commonly remits spontaneously after

removal from the traumatic circumstances or ending of the episode of intoxication. Many patients with
chronic depersonalization may have a course characterized by severe impairment in occupational, social,
and personal functioning. Mean age of onset is thought to be in late adolescence or early adulthood in
most cases.

Treatment

Many different types of psychotherapy have been used to treat depersonalization disorder:
psychodynamic, cognitive, cognitive-behavioral, hypnotherapeutic, and supportive. Stress management
strategies, distraction techniques, reduction of sensory stimulation, relaxation training, and physical
exercise may be somewhat helpful in some patients.

DISSOCIATIVE IDENTITY DISORDER

Dissociative identity disorder, previously called multiple personality disorder, has been the most
extensively researched of all the dissociative disorders. It is characterized by the presence of two or
more distinct identities or personality states. differ from one another in that each presents as having its
own pattern of perceiving, relating to, and thinking about the environment and self, in short, its own
personality.

Epidemiology

Clinical studies report female to male ratios between 5 to 1 and 9 to 1 for diagnosed cases.

Etiology

Dissociative identity disorder is strongly linked to severe experiences of early childhood trauma, usually
maltreatment. The rates of reported severe childhood trauma for child and adult patients with
dissociative identity disorder range from 85 to 97 percent of cases. Physical and sexual abuse are the
most frequently reported sources of childhood trauma.

Treatment

Psychotherapy. Successful psychotherapy for the patient with dissociative identity disorder requires the
clinician to be comfortable with a range of psychotherapeutic interventions. These modalities include
psychoanalytic psychotherapy, cognitive therapy, behavioral therapy, hypnotherapy, and a familiarity
with the psychotherapy and psychopharmacological management of the traumatized patient. Comfort
with family treatment and systems theory is helpful in working with a patient who subjectively
experiences himself or herself as a complex system of selves with alliances, family-like relationships, and
intragroup conflict.

Cognitive Therapy. Many cognitive distortions associated with dissociative identity disorder are only
slowly responsive to cognitive therapy techniques, and successful cognitive interventions may lead to
additional dysphoria. A subgroup of patients with dissociative identity disorder does not progress
beyond a long-term supportive treatment entirely directed toward stabilization of their multiple
multiaxial difficulties. To the extent that they can be engaged in treatment at all, these patients require
a long-term treatment focus on symptom containment and management of their overall life dysfunction

Hypnosis. Hypnotherapeutic interventions can often alleviate self-destructive impulses or reduce

symptoms, such as flashbacks, dissociative hallucinations, and passive-influence experiences. Teaching
the patient self-hypnosis may help with crises outside of sessions. Hypnosis can be useful for accessing
specific alter personality states. . Hypnosis is also used to create relaxed mental states in which negative
life events can be examined without overwhelming anxiety. Clinicians using hypnosis should be trained
in its use in general and in trauma populations.

Psychopharmacological Interventions. Antidepressant medications are often important in the reduction

of depression and stabilization of mood. A variety of PTSD symptoms, especially intrusive and
hyperarousal symptoms, are partially medication responsive.

Adjunctive Treatments

Group Therapy- Therapy groups composed only of patients with dissociative identity disorder are
reported to be more successful, although the groups must be carefully structured, must provide firm
limits, and should generally focus only on here-and-now issues of coping and adaptation.

Family Therapy. Family or couples therapy is often important for long-term stabilization and to address
pathological family and marital processes that are common in patients with dissociative identity disorder
and their family members. Education of family and concerned others about dissociative identity disorder
and its treatment may help family members cope more effectively with dissociative identity disorder
and PTSD symptoms in their loved ones. Group interventions for education and support of family
members have also been found helpful

Expressive and Occupational Therapies. Expressive and occupational therapies, such as art and
movement therapy, have proved particularly helpful in treatment of patients with dissociative identity
disorder. Art therapy may be used to help with containment and structuring of severe dissociative
identity disorder and PTSD symptoms, as well as to permit these patients safer expression of thoughts,
feelings, mental images, and conflicts that they have difficulty verbalizing.