AKRITI MAURYA

SEM 5 NOTES

PRT- SP
Personality traits: Perceiving to,relating to and thinking about the env and self that are exhibited in a wide
range of Social and personal contexts

Personality disorder is an enduring pattern of inner experiences and behavior that deviates markedly from
expectations of an individual's culture: pervasive and inflexible.

DSM-5 CRITERIA

• Cognition, affective, impulse control, interpersonal functioning

• Inflexible and pervasive, enduring pattern
• Significant distress
• Long duration and stable
• Mental disorder
• Substance and medication

A - ODD AND ECCENTRIC BEHAVIOUR: Paranoid, schizoid, schizotypal

B - DRAMATIC AND EMOTIONAL - Antisocial, Borderline, histrionic, narcissistic
C - FARFUL AND WORRISOME - Avoidant, dependent, OC personality disorder

Descriptive similarities
Categorical approach

Issues: diagnostic, culture, gender

Antisocial Personality Disorder

Personality disorder category

Personality disorder is an enduring pattern of inner experiences and behavior that deviates markedly from
expectations of an individual's culture: pervasive and inflexible.
Psychopathy, sociopathy or dissocial personality disorder

Cluster B: dramatic, emotional, erratic behaviors

• Diagnostic Criteria

A pervasive pattern of disregard for or violation of rights of others, beginning since age 15 years marked by
3 or more of the following 7 symptoms:
1. Failure to conform to social norms with respect to lawful behavior
2. Deceitfulness
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness
5. Reckless disregard for safety of self and others
6. Inconsistent responsibility
7. Lack of remorse

18 years
Evidence of conduct disorder with onset before 15 years
Not exclusively during course of schizophrenia or bipolar

• Clinical features
Destroy property, harassing others, stealing, pursuing illegal occupations
Personal profit or pleasure
Lie, alias, conning others
Decision made at the spur of the moment that leads to sudden changes in jobs, residences and
relationships
Physical fights and assault
Driving behavior: disregard for safety
May engage in sexual behavior or substance use that has a high risk for harmful consequences
Significant periods of unemployment and financial irresponsibility
May blame the victims for being foolish, helpless or deserving their fate
Lack empathy, inflated and arrogant self appraisal - technical terms and jargons
Heightened self reality testing
Verbal intelligence is high
Excessively self assured, opinionated and cocky
Glib superficial charm
Irresponsible and exploitative in sexual relationships
More likely to die prematurely by violent means
May experience dysphoria including complaints of tension and depressed mood

• Epidemiology

Prevalence rates: 2-3 percent (Glenn et al, 2013)

Men to women: 5 to 1
Very common in prison samples
Highest prevalence (greater than 70%): men with alcohol use disorder
High in adverse socioeconomic or sociocultural contexts
May be underdiagnosed in females

• Course: chronic, but less evident or remit by the 4th decade of life.
• DD: substance use disorders, schizophrenia, other personality disorders like narcissistic personality
disorder, criminal behavior not associated with a personality disorder
• Comorbidity: associated anxiety disorders, depressive disorders, substance use disorders, somatic
symptom disorder, gambling disorder, and other disorders of impulse control, borderline, histrionic
and narcissistic personality disorders. The likelihood of developing antisocial personality disorder in
adult life is increased if the individual experienced childhood onset of conduct disorder (before age
10 years) and accompanying attention-deficit/hyperactivity disorder. Child abuse or neglect,
unstable or erratic parenting, or inconsistent parental discipline may increase the likelihood that
conduct disorder will evolve into antisocial personality disorder.

Mark, a 22-year-old, was awaiting trial for car theft and armed robbery. His case records included a long
history of arrests beginning at age 9, when he had been picked up for vandalism. He had been expelled
from high school for truancy and disruptive behavior. On a number of occasions he had run away from
home for days or weeks at a time—always returning in a disheveled and “rundown” condition. To date he
had not held a job for more than a few days at a time even though his generally charming manner enabled
him to obtain work readily. He was described as a loner with few friends. Although initially charming, Mark
usually soon antagonized those he met with his aggressive, self-oriented behavior. Shortly after his first
therapy session, he skipped bail and presumably left town to avoid his trial. His therapist never saw him
again.
Borderline Personality Disorder

Personality disorders category

Enduring pattern of experiences and behavior that do not match with the expectation of one’s culture:
pervasive and inflexible
Border of psychosis and neurosis
ICD-10: Emotionally unstable disorder

Cluster B: dramatic, erratic and emotional

• Diagnostic Criteria

A pervasive pattern of instability in interpersonal relationships. Self image, affect and marked impulsivity
beginning from early adulthood and present in a variety of contexts. Any 5 or more out of the following 9
symptoms
1. Frantic efforts to avoid real or imagined abandonment
2. Instability in interpersonal relationships (altering btw extremes of idealization and devaluation)
3. Identity disturbance: unstable self image
4. Marked impulsivity in two or more areas that are potentially self damaging: spending, sex,
substance abuse, reckless driving, binge eating
5. Recurrent suicidal behaviour or self mutilating behaviour
6. Affective instability due to marked reactivity of mood
7. Feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant
anger, recurrent physical fights)
9. Transient stress related paranoid ideation or severe dissociative symptoms

• Clinical Features

Very sensitive to environmental circumstances

Experience fears and inapt anger even when faced with a realistic time limited separation or when there
exist unavoidable changes in plans
Abandonment implies they are bad
Intolerance of being alone and need to have other people around
Share most intimate details early in a relationship; may switch quickly
Expectation that the other person will be there to give them in return
Beneficent supports or cruelly punitive; test their close relationships
Shifting goals, values and vocational aspirations
Projective identification
Self image based on being bad; may have feelings that they don't exist at all
Threats of rejection or separation: suicides (completed suicides occur in 8-10% of individuals)
Extreme sarcasm
May have a pattern of undermining just before the goal is about to be realized
Feel more secure with transitional objects (pets)
Premature death
Cognitive symptoms: psychotic like symptoms

• Epidemiology
1-2%
Median 1.6 to 5.9
Very common in clinical settings
10 percent outpatients
15-20% psychiatric inpatients
75% women, gender imbalance in treatment seeking, equal gender ratio

• Course: considerable variability, chronic instability early adulthood, gradually wane with advancing
years, high use of mental health resources

• Onset: early adulthood

• Comorbidity: depressive and bipolar disorders, substance use disorders, eating disorders (notably
bulimia nervosa), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder.
Borderline personality disorder also frequently co-occurs with the other personality disorders like
schizotypal, narcissistic, dependence

• DD: Depressive and bipolar (bpd early onset and long standing course), other personality disorders
(self destructiveness), personality change due to another medical condition, substance use
disorders, identity problems

Ms. R. is 19 years old. Although she has no formal history of psychiatric treatment, she reports a long
history of mood instability, suicidal gestures, and skin cutting. She also has had many stormy relationships,
including a history of physical abuse, as well as three abortions. She was admitted to the hospital for the
first time after she threatened to kill herself following a physical fight with her boyfriend and crashing the
family car. The patient says that she recently moved out of her family home and went to live with her
boyfriend. After a fight with her boyfriend that left her with a bloody lip, she was feeling “depressed.” She
returned home and began to fight with her mother. She then stole the family car and crashed into a pole.
When a neighbor found her, she stated she was going to kill herself. Her mother subsequently brought her
to the hospital. On admission, Ms. R said she was “depressed” and suicidal. She was described as angry,
entitled, manipulative, and “regressed.” She was diagnosed with borderline personality. The presence of
narcissistic traits was also noted. (From Avery et al., 2012.)
Gender Dysphoria

Affective or cognitive discontent with one's assigned gender

Discomfort with one’s sex relevant physical characteristics or with one’s assigned gender
New term used in place of gender identity disorder - descriptive and theoretically neutral
Dimensional approach and may fluctuate over time within the same individual
Gender vs sex
Diagnosed at two different stages

• Diagnostic Criteria for children

Marked incongruence btw one expressed gender and assigned gender of at least 6 months duration as
manifested by at least 6 of the following:

1. Strong desire to be of the other gender or insistence that one is of other gender
2. In boys, cross dressing or simulating female attire or in girls, strong preference for wearing only
typical masculine clothing and strong resistance to wearing typical feminine clothing
3. Strong preference for cross gender roles in make believe play or fantasy play
4. Strong preference for toys typically engaged in by other gender
5. Strong preference for playmates of other gender
6. In boys, strong rejection of typical masculine toys, games and activities and rough and tumble play
and vice versa
7. A strong dislike of one's sexual anatomy
8. Strong desire for primary or secondary sexual characteristics that match ones expressed gender
Specify if: with a disorder of sex development

Associated with clinically significant distress or impairment

• Diagnostic Criteria for adolescents or adults

Marked incongruence between one’s expressed gender and assigned gender of at least 6 months duration
manifested by at least 2 of the following:

1. Marked incongruence between one’s expressed gender and primary and secondary sexual
characteristics
2. A strong desire to get rid of one’s primary or secondary sexual characters
3. A strong desire for primary or secondary sexual characteristics of the other gender
4. A strong desire to be of the other gender
5. A strong desire to be treated as the other gender
6. A strong conviction that one has typical feelings and reactions of the other gender

The condition is associated with clinically significant distress or impairment in social, occupational or other
important areas of functioning
Specify if: with a disorder of sex development

• Clinical features

Display intense negative reactions to parental attempts to have them wear dresses or other feminine attire.
may refuse to attend school or social events where such clothes are required.
Occasionally, they refuse to urinate in a sitting position
Some natal girls may express a desire to have a penis or claim to have a penis or that they will grow one
when older. They may also state that they do not want to develop breasts or menstruate
When visible signs of puberty develop, natal boys may shave their legs at the first signs of hair growth.
Girls may bind their breasts, walk with a stoop, or use loose sweaters to make breasts less visible
Clinically referred adolescents often want hormone treatment and many also wish for gender reassignment
surgery
hairstyle
Older adolescents, when sexually active, usually do not show or allow partners to touch their sexual
organs.
Adults: may find other ways to resolve the incongruence between expressed and assigned gender by
partially living in the desired role or by adopting a gender role neither conventionally male nor
conventionally female
For adults with an aversion toward their genitals, sexual activity is constrained by the preference that their
genitals not be seen or touched by their partners.
Adolescents and adults with gender dysphoria before gender reassignment are at increased risk for suicidal
ideation, suicide attempts, and suicide

Girls treated well because cross gender behavior in girls is better tolerated

Should it be considered a mental disorder?

• Epidemiology

For natal adult males, prevalence ranges from 0.005% to 0.014%, and for natal females, from 0.002% to
0.003%
Likely underestimates
In children, sex ratios of natal boys to girls range from 2:1 to 4.5:1.
In adolescents, the sex ratio is close to parity; in adults, the sex ratio favors natal males, with ratios ranging
from 1:1 to 6.1:1. In two countries, the sex ratio appears to favor natal females (Japan: 2.2:1; Poland: 3.4:1)
Most common outcome for boys have been homosexuality rather than transexualism

Richard greene (1987): 44 very feminine boys: 1 sought to sex change surgery by age 18
3 quarters became gay or bi who were evidently satisfied with biological sex

Drummond et al (2008): 25 girls from 3-12 years till young adulthood, found lower rates of persistent
gender dysphoria and homosexuality
3 classified dissatisfied; 2 wanted surgery
32% had homo or bi fantasies
24% engaged in homo or bi behavior

• Course: Onset: 2-4 years

puberty

In natal males, persistence has ranged from 2.2% to 30%. In natal females, persistence has ranged from
12% to 50%.

For natal male children whose gender dysphoria does not persist, the majority are androphilic (sexually
attracted to males) and often self-identify as gay or homosexual. In natal female children whose gender
dysphoria does not persist, the percentage who are gynephilic (sexually attracted to females) and self-
identify as lesbian is lower
Among adult natal males with gender dysphoria, the early-onset group seeks out clinical care for hormone
treatment and reassignment surgery at an earlier age than does the late-onset group. The late-onset group
may have more fluctuations in the degree of gender dysphoria and be more ambivalent about and less
likely satisfied after gender reassignment surgery

In both adolescent and adult natal females, the most common course is the early-onset form of gender
dysphoria. The late-onset form is much less common in natal females compared with natal males.

Natal females with the late-onset form do not have co-occurring transvestic behavior with sexual
excitement.

• DD: Nonconformity to gender roles, Transvestic disorder, Body dysmorphic disorder, Schizophrenia
and other psychotic disorders, Other clinical presentations

• Comorbidity: Anxiety, depression, Autism

Ms. T, a 24-year-old, an assigned female at birth, presented with a history of strong desire to be a male right
from her childhood. She would prefer to dress like a boy, playing often the stereotyped “boyish” games along
with other boys. Her behaviour was encouraged by her father as he did not have any male children. As she
grew up, she started to get attracted toward women and used to consider her orientation as heterosexual
with them. She used to constantly feel that she was trapped in the wrong body. She strongly believed that
she had feelings and reactions just like the other men and was feeling helpless as she was not able to lead
a normal life like them. In her early twenties, she fell in love with a woman and started to have a live-in
relationship with her. She considers it as a heterosexual relationship and reportedly identified herself as the
male partner of the couple. However, of late, the other lady started to get attracted toward men which the
patient could not tolerate. She started to develop symptoms such as irritability, worthlessness, hopelessness,
suicidal ideas, and suicidal attempts for the past 4–6 months. She expresses the desire to get operated so
as to become a man. She feels that her life is not worth living as she is not a female but has to be trapped in
a female body.
Intellectual Disability/ Intellectual Developmental Disorder

Category: Neurodevelopmental Disorders (group of conditions with onset in the developmental period)
Characterized by deficits in general mental abilities such as problem solving, abstract thinking, learning
from experience, planning etc. Results in impairments in adaptive functioning
After 17: dementia

• Diagnostic Criteria

It is a disorder with onset during the developmental period that includes both intellectual and adaptive
functioning deficits in conceptual, practical and social domains. The following three criteria must be present:

A. Deficits in intellectual functions such as …. confirmed by both clinical assessment and individualized
and standardized intelligence testing
B. Deficits in adaptive functioning that results in failure to meet developmental and sociocultural
standards of personal independence and social responsibility. In case of lack of support, the adaptive
deficits limit functioning in one or more activities of daily life such as communication, social participation,
and independent living across multiple environments
C. Onset of intellectual and adaptive deficits during the developmental period

Specify if
• Mild 50-55 to 70
• Moderate 35-40 to 50-55
• Severe 20-25 to 35-40
• Profound below 25

- Clinical Features

Explain all 4 specifiers (refer to notes)

Diagnosis based on clinical assessment and individualized and standardized intelligence testing
Age, gender and socio-culturally matched peers
Intellectual deficits: problem solving, planning, abstract thought, verbal comprehension, working memory,
perceptual reasoning
Adaptive deficits: conceptual domain (competence in memory, language, reading, writing, math, reasoning,
problem solving, judgment in novel situations etc), social domain (awareness of others thoughts and
feelings, empathy, interpersonal communication, friendship abilities etc), and practical domains (learning
and self-management across life settings)

IQ tests and factors influencing them - Flynn effect, practice, improper screening, co-occurring disorders
Standardized measures used by knowledgeable informants and individual for adaptive functioning, others
include educational, developmental, medical and mental health evaluations

When standard testing impossible, unspecified intellectual disability

Social judgment, risk, self-management, motivation, gullibility (possible exploitation by others)

ID with co-occurring mental disorders at risk of suicide

• Epidemiology

1% overall general population prevalence

Severe: 6 per 1000
Males more likely (both mild and severe) 1.6: 1 and 1.2: 1
Male vulnerability to brain insult

• Development and course

Onset is developmental period

May be identifiable within first 2 years among those with severe and profound
Mild may not be identifiable until school age difficulty with academic learning becomes apparent

5-6, peak at 15 and then drop off

When with genetic syndrome: physical appearance like down syndrome

Acquired: onset abrupt after illness like meningitis or encephalitis or head trauma

Non progressive, lifelong, may be influenced by co occurring conditions

Rett syndrome: periods of worsening followed by stabilization

San phillipo syndrome: progressive worsening of intellectual function

• DD: major and mild neurocognitive disorders (loss of cog functioning), SLD, ASD
• Comorbidity: Co-occurring mental, neurodevelopmental, medical, and physical conditions are
frequent in intellectual disability, ADHD, ASD, SLD, Depressive and bipolar

Kevin is a 37-year-old man with Down’s syndrome and moderate intellectual disability. He is socially isolated
and spends most of his day at home with his elderly mother. His mother would like him to develop some of
his basic daily living skills and socialize more with other people. His social worker explores some daytime
activities that Kevin could get involved with, such as a day centre, or a voluntary work scheme. Kevin has
difficulty understanding the different options. His mother informs the social worker that Kevin has not had a
health check-up for many years. Physical examination reveals that Kevin has bilateral conductive hearing
loss due to a build-up of ear wax, which is treated with ear syringing. An improvement in his hearing, in
combination with visual aids, makes it easier for Kevin to consider the different options available to him. He
still has difficulty deciding so his social worker arranges for Kevin to visit the placements with his mother and,
after several visits, Kevin decides that he would like to attend the day centre. (Barron and Hall, 2009)
Autism Spectrum Disorder

Autism spectrum disorder, previously known as the pervasive developmental disorders, is a

phenotypically heterogeneous group of neurodevelopmental syndromes characterized by a wide range of
impairments in social communication and restricted and repetitive behaviors

1943: KANNER

Manifestation depends on severity, developmental level and chronological age - SPECTRUM

Previously 5 discrete disorders

continuum model in which heterogeneity of symptoms is recognized as inherent in the disorder

• Diagnostic Criteria

A pattern of persistent deficits in social communication and social interactions across multiple contexts as
manifested by the following, currently or by history:

1. Deficits in socio emotional reciprocity - abnormal social approach, failure to make back and forth
comm to failure to initiate or respond to convos
2. Deficits in nonverbal communicative behavior used in interactions - poorly integrated verbal and
nonverbal communication, abnormalities in eye contact and body language, lack of facial
expressions and nonverbal communication
3. Deficits in developing, maintaining and understanding relationships - difficulties sharing imaginative
play or making friends to absence of interest in peers

Restricted, repetitive patterns of behavior, interacted or activities as indicated by any 2 or more of the
following:

1. Stereotyped and repetitive motor movements, use of objects and speech - simple motor
stereotypes, lining up toys, echolalia, flipping objects
2. Insistence on sameness, inflexible adherence to routines, ritualized verbal or nonverbal behavior -
extreme distress in small changes, rigid thinking patterns, greeting rituals, neet to take same route
very and eat same food
3. Highly restricted and fixated interests in objects which is abnormal in intensity and focus - strong
attachment to unusual objects, extremely perseverative interests
4. Hypo or hyperreactivity to sensory aspects of the environment - apparent indifference to
pain/temperature, excessive smelling or touching of objects, visual fascination with lights or
movement

Specify if severity is based on A or B

Symptoms must be present in early developmental period

Cause clinically significant distress
Not better explained by ID, GDD.

Specify:
• With or without intellectual impairment
• Language impairment
 •Associated with known medical or genetic condition
•Other neurodevelopmental mental or behavioral disorder
•With catatonia
SEVERITY LEVELS: L1, L2, L3 Support, substantial support, very substantial support

• Clinical Features

Intervention, compensations and current support may mask difficulties in at least some contexts
Language is one sided used to request or label rather than comment, share or converse
absent , reduced or atypical use of eye contact, gestures, facial expression, body orientation or speech
intonation
Lack of social smile
Atypical not absent attachment behavior
More skilled in video spatial tasks than verbal
Lack of Theory of mind
May not strongly react to being left with strangers
impaired joint attention as manifested by a lack of pointing, showing, or bringing objects to share interest
with others, or failure to follow someone’s pointing or eye gaze.
odd, wooden, or exaggerated “body language” during interactions
Rejection of others, passivity or inapt approaches that seem aggressive or disruptive
Insistence on play with verified rules
Preference for solitary activities
Desire to establish friendship without complete idea of what it entails

Hand flapping, finger licking, spinning coins, lining up toys, echolalia, use of you when referring to self,
stereotyped use of words,
Distress in small changes like change in packaging, repetitive questioning, pacing a perimeter

Attachment to pan, preoccupation with vacuum cleaners, adult spending hours writing time tables

Not emotionally flat; deficit in ability to attend to social cues

extreme responses to specific sounds or textures, excessive smelling or touching of objects, fascination
with lights or spinning objects, and sometimes apparent indifference to pain, heat, or cold. Extreme reaction
to or rituals involving taste, smell, texture, or appearance of food

Intellectual impairment or language impairment, motor deficits like odd gait, clumsiness and walking on
tiptoes
Self injury (head banding, biting wrist)

Remain ambidextrous, ear malformations, high rate of abnormal fingerprints

Prone to anxiety and depression
Significant decline in focus on eyes and face of others (jones and klin, 2014)

Social Deficit
Absence of speech
Self stimulation
Maintaining sameness: obsessed with the maintenance of sameness

• Epidemiology

1%
Seemingly on the increase
Centre for disease control and prevention (baio, 2014): rate is 1 in 68
Autism spectrum disorder is diagnosed four times more often in males than in females
females tend to be more likely to show accompanying intellectual disability

• Course and onset

Symptoms are typically recognized during the second year of life (12–24 months of age) but may be seen
earlier than 12 months if developmental delays are severe, or noted later than 24 months if symptoms are
more subtle

Not a degenerative disorder

Gains at least in some areas later in childhood
Improve during adolescence
Only a minority of individuals with autism spectrum disorder live and work independently in adulthood;
those who do tend to have superior language and intellectual abilities and are able to find a niche that
matches their special interests and skills.
Socially naive and vulnerable

• DD: Rett syndrome (only during some time), selective mutism (apt comm in some
contexts), language disorders (restricted movies no), ID, Stereotypic movement disorder, ADHD,
schizophrenia
• Comorbidity: ID, Language disorder, adhd, anxiety, depression, sld, epilepsy, sleep problems, and
constipation

Matthew is 5 years old. He rarely speaks to others and almost never makes direct and sustained eye
contact. Matthew’s parents began to notice 3 years ago that while other children were starting to put words
together into sentences and have back-and-forth conversations with their parents, he never seemed to
develop these abilities. Matthew spends much of his time alone, often playing with his toys in his room.
While doing so, he frequently engages in repetitive movements over and over again, such as wheeling his
toy train back and forth hundreds of times in a row. Matthew doesn’t like to leave his home, which his
parents think has to do with him being overly sensitive to all of the sights and sounds outside. He also
struggles when things deviate from his normal daily routine, which leads him to repeatedly scream at the
top of his lungs several dozen times in a row.
Attention Deficit Hyperactivity Disorder

neuropsychiatric condition affecting preschoolers, children, adolescents, and adults around the world,
characterized by a pattern of diminished sustained attention, and increased impulsivity or hyperactivity.

Neurodevelopmental disorders category

• Diagnostic Criteria

A persistent pattern of inattention and/or impulsivity-hyperactivity that interferes with the functioning or
development outcome of the child as characterized by (1) and/or (2)

1. Inattention: 6 or more of the following symptoms persisting for at least 6 months to a degree that is
inconsistent with developmental level and that negatively impacts directly the social, academic and
occupational activities:

In case of adolescents and adults, 5

a. Often fails to pay close attention to things or makes silly mistakes - overlooks or misses details
b. Often faces difficulty in sustaining attention in a task or play activity - lengthy reading, remaining
focused during lectures
c. Often does not seem to listen to when spoken to directly - mind seems elsewhere
d. Often fails to abide by instructions or is not able to finish tasks or activities - starts task but quickly
loses focus
e. Often faces difficulting in planning or organizing activities - poor time management, messy
disorganized work
f. Often dislikes or avoid those tasks that required sustained mental effort
g. Often loses out on thing required for daily activities - school materials
h. Often gets distracted by extraneous stimuli
i. Often forgetful of daily life activities - doing chores, running errands, returning to calls, paying bills
etc

2. Hyperactivity-Impulsivity: 6 or more of the following symptoms persist for at least 6 months to a degree
that is not consistent with the developmental level and which negatively impacts directly the social and
academic/occupational activities

In case of adolescents, 5 or more

a. Often fidgets around, taps on hand and feet or squirms in seat

b. Often fails to remain seated when it is required
c. Often runs about or climbs in situations when it is inappropriate
d. Often fails to engage in leisure activities quietly
e. Often on the go or as if driven by a motor
f. Talks excessively
g. Often speaks out answers even when the question is not completed
h. Often finds it difficult to wait for their chance
i. Often interrupts or intrudes in others activities

Several symptoms were present prior to 12 years

Present in two or more settings
Clinical significant duress
Not especially during schizophrenia or cognitive episodes

• Specify if
Combined presentation
Predominantly inattentive presentation
Predominantly hyperactive/impulsive presentation

• Specify if
Mild, moderate, severe

• Specify if
In partial remission

• Clinical Features

Inattention: wandering off tasks, having difficulty sustaining focus, being disorganized not due to defiance
Hyperactivity: excessive motor activity; adults: extreme restlessness
Impulsivity: hasty decisions; desire for immediate rewards or an inability to delay gratification
making important decisions without consideration of long-term consequences

Due to behavioral problems, Score 7-15 points lower on iq

Mild delays in language, motor, or social development are not specific to ADHD but often co occur

low frustration tolerance, irritability, or mood lability.

academic or work performance is often impaired
exhibit cognitive problems on tests of attention, executive function, or memory
Increased risk of suicide by early adulthood when comorbid with mood, substance use, conduct
Slow EEG waves
Peer relationships are often disrupted by peer rejection, neglect, or teasing of the individual with ADHD.

• Epidemiology

5% children
2.5 % adults

2:1
1.6:1
Females are more likely than males to present primarily with inattentive features.
13 percent men, 4 women
Male, divorced, unemployed (Kesler, 2006)
PEOPLE WITH ADHD MISS SIGNIFICANTLY MORE DAYS OF WORK (DE GRAAF, 2008)

• Development and course

Toddlerhood, Before 4 years

During elementary school years
Symptoms persist in 60% of cases

Relatively stable through early adolescence but some may have worsened course with dev of antisocial
behaviors
Symptoms of motoric hyperactivity become less obvious in adolescent and adulthood but other difficulties
persist

Preschool: main manifestation is hyperactivity

Inattention: elementary
During adolescence, signs of hyperactivity (e.g., running and climbing) are less common and may be
confined to fidgetiness or an inner feeling of jitteriness, restlessness, or impatience.
In adulthood, along with inattention and restlessness, impulsivity may remain problematic even when
hyperactivity has diminished

• DD: Oppositional defiant disorder, other neurodevelopmental disorders, intermittent explosive

disorder, sld, id, asd, anxiety disorders, depressive, bipolar, substance use, personality disorders,
psychotic disorders, neurocognitive disorders (late onset)

• Comorbidity: other externalizing disorders, oppositional defiant disorder, conduct, aspd, sld, anxiety
and depressive, ocd, tic, asd

Paul was referred to a community clinic because of overactive, inattentive, and disruptive behavior. His
hyperactivity and uninhibited behavior caused problems for his teachers and for other students. He would
impulsively hit other children, knock things off their desks, erase material on the blackboard, and damage
books and other school property. He seemed to be in perpetual motion, constantly talking and out of his
seat. Although Paul was determined to be above average intelligence, he was receiving failing grades due
in large part to his behavioral problems. Nevertheless, he often reported that he “felt stupid” and it was
clear that he had a seriously devaluated self-image
Specific Learning Disorder

Specific learning disorder is a neurodevelopmental disorder with a biological origin that is the basis for
abnormalities at a cognitive level that are associated with the behavioral signs of the disorder.

Delays in cog dev in areas of lang, speech, maths, or motor skills not due to demonstrable physical and
neurological defects.

The biological origin includes an interaction of genetic, epigenetic, and environmental factors, which affect
the brain’s ability to perceive or process verbal or nonverbal information efficiently and accurately

Unexpected academic underachievent

• Diagnostic Criteria

Difficulties in learning and using academic skills as indicated by presence of at least one of the following
persisted for 6 months at least despite provision of interventions that target those difficulties:

1. Inaccurate or slow and effortful word reading - read single words aloud incorrectly or slowly and
hesitantly, frequently guesses words
2. Difficulty understanding the meaning of words - may not understand sequence, deeper meanings,
inferences
3. Difficulty with spelling - may add, omit, substitute vowel or consonants
4. Difficulty with written expression - grammatical and punctuation mistakes, lacks clarity
5. Difficulty mastering numbers sense, number facts or calculations - gets lost in middle, count on
fingers, difficulty understanding relationships
6. Difficulties with mathematical reasoning - has severe difficulty applying mathematical concepts to
solve problems

Affected academic skills are substantially an quantifiably low below those expected for individuals
chronological age and cause significant interference as confirmed by individually administered standardized
achievement measures and clinical assessment

Begin during school age years but may not fully manifest until demands for affected skills exceed limited
capacities

Not better accounted by intellectual disabilities, uncorrected visual or auditory acuity or other mental or
neurological disorders

• Specify with
With impairment in reading (dyslexia)
Writing
Mathematics (dyscalculia)

• Mild, moderate, severe

 • Clinical features

Disrupts the normal pattern of learning academic skills

Is not simply a lack of opportunity of learning or inadequate instruction
May impede learning in other academic subjects
Problems in word recognition and reading comprehension: dyslexia

Persistent not transitory - restricted progress in learning despite provision of extra help
Avoidance of activities that require academic skills in adults
Interference in occupational performance

delays in attention, language, or motor skills that may persist and co-occur with specific learning disorders.

Uneven profile of abilities, like above avg drawing or design

Exhibit poor performance on psychological tests of cognitive processing

Clear impairment in school performance

Disparity between actual academic performance and expected academic achievement

No obvious crippling emotional problems

Disastrous to self esteem

Winston churchill, woodrow wilson

No lack in motivation, cooperativeness or eagerness to please parents or teachers

lack of interest in playing games with language sounds

frequently use baby talk, mispronounce words, and have trouble remembering names of letters, numbers,
or days of the week. They may fail to recognize letters in their own names and have trouble learning to
count.

They may have trouble breaking down spoken words into syllables (e.g., “cowboy” into “cow” and “boy”)
and trouble recognizing words that rhyme (e.g., cat, bat, hat). Kindergarten-age children also may have
trouble connecting letters with their sounds (e.g., letter b makes the sound /b/) and may be unable to
recognize phonemes (e.g., do not know which in a set of words [e.g., dog, man, car] starts with the same
sound as “cat”).

marked difficulty learning letter-sound correspondence for elementary age

Children in grades 1-3 also may have difficulty remembering number facts or arithmetic procedures for
adding, subtracting, and so forth, and may complain that reading or arithmetic is hard and avoid doing it.

Children with specific learning disorder in the middle grades (grades 4–6) may mispronounce or skip parts
of long, multisyllable words (e.g., say “conible” for “convertible,” “aminal” for “animal”) and confuse words
that sound alike (e.g., “tornado” for “volcano”)

Adolescents: reading comprehension and written expression

Avoidance of or reluctance to engage in activities requiring academic skills is common in children,
adolescents, and adults.
Episodes of severe anxiety or anxiety disorders, including somatic complaints or panic attacks, are
common across the lifespan and accompany both the circumscribed and the broader expression of learning
difficulties.

Specific
• not attributable to intellectual disabilities, global developmental delay; hearing or vision
disorders, or neurological or motor disorders; affects learning in individuals who otherwise
demonstrate normal levels of intellectual functioning; specific learning disabilities are not part of a
more general learning difficulty as manifested in intellectual disability or global developmental delay,
Specific learning disorders may also occur in individuals identified as intellectually “gifted.”
• the learning difficulty cannot be attributed to more general external factors, such as economic
or environmental disadvantage, chronic absenteeism, or lack of education as typically provided in
the individual community context
• the learning difficulty cannot be attributed to a neurological (e.g., pediatric stroke) or motor
disorders or to vision or hearing disorders, which are often associated with problems learning
academic skills but are distinguishable
• the learning difficulty may be restricted to one academic skill or domain

Comprehensive assessment required

specific learning disorder is a clinical diagnosis based on a synthesis of the individual’s medical,
developmental, educational, and family history; the history of the learning difficulty, including its previous
and current manifestation; the impact of the difficulty on academic, occupational, or social functioning;
previous or current school reports; portfolios of work requiring academic skills; curriculum-based
assessments; and previous or current scores from individual standardized tests of academic achievement.

• Epidemiology
5-15% among school children
Adults is 4%
2:1 to 3:1 male to female

• Course and onset

During elementary school years, however precursors like language delays or deficits can be seen in early
childhood

Lifelong, course and clinical expression variable; depending on the interactions among the task demands of
the environment, the range and severity of the individual’s learning difficulties, the individual’s learning
abilities, comorbidity, and the available support systems and intervention. Nonetheless, problems with
reading fluency and comprehension, spelling, written expression, and numeracy skills in everyday life
typically persist into adulthood.

Changes in manifestation of symptoms occur with age

• DD: ID, Learning difficulties due to neurological disorders, Neurocognitive disorders, adhd,
psychotic
• Comorbidity: adhd, communication, developmental coordination disorder, asd, other mental
disorders like anxiety, depression, bipolar
Jackson, a 10-year-old boy, was referred for evaluation of failing to complete in-class assignments and
homework, and failing tests in reading, spelling, and arithmetic. For the past 2 years (grades 5 and 6), he
had been attending a special education class every morning in the local community school, based on an
assessment from the second grade. A subsequent psychoeducational assessment by a clinical
psychologist confirmed reading problems. Jackson was eligible for a full-day special education class,
whereupon he started attending a program with eight other students ranging from 6 to 12 years of age. In
preschool and kindergarten, Jackson was reported to have had difficulty with rhyming games and showed a
lack of interest in books and preferred to play with construction toys. In the Orst grade, Jackson had more
difficulty learning to read than other boys in his class and continued to have problems pronouncing
multisyllabic words (e.g., he said “aminals” for “animals” and “sblanation” for “explanation”).

In the clinical interview with Jackson, he rarely made eye contact, mumbled a lot, and struggled to and the
right words (e.g., manifested many false starts, hesitations, and nonspecific terms, such as “the thing that
you draw . . . um . . . pencil—no . . . um . . . lines with”). He admitted to disliking school, adding “Reading is
boring and stupid—I’d rather be skateboarding.” Jackson complained about how much reading he was
given—even in math—and commented, “Reading takes so much time. By the time I figure out a word, I
can’t remember what I just read and so have to read the stuff again.”

Jackson met DSM-5 criteria for specific learning disorder, with deficits in reading and written expression.
Recommendations included continuation in special education plus attendance at a summer camp
specializing in children with reading disorder, as well as ongoing monitoring of self-esteem and depressive
traits. At 1-year follow-up, Jackson and his parents reported striking improvements in his reading, overall
school performance, mood, and self-esteem.
Alcohol Related Disorders
Category: Substance Related and Addictive Disorders

• Alcohol Use Disorder

• Alcohol Intoxication
• Alcohol Withdrawal
• Other Alcohol-Induced Disorders
• Unspecified Alcohol-Related Disorders

Alcohol is a psychoactive substance that affects the mental functioning in the CNS.

WHO: Harmful use of alcohol: drinking that causes detrimental health and social consequences for the
drinker, the people around the drinker and the society at large as well as patterns of drinking that are
associated with increased risk of adverse health outcomes.

Alcohol use disorder is defined by a cluster of behavioural and physical symptoms, which can include
withdrawal, tolerance, and craving.

Substance abuse: excessive use resulting in hazardous behaviour and continued use

- Diagnostic Criteria

A problematic pattern of alcohol use which leads to clinically significant impairment and distress manifested
by at least 2 of the following across a 12-month period:

1. Alcohol is used in large amounts or over a large period of time than intended
2. There is a persistent desire or unsuccessful effort to control or cut down alcohol use
3. A great deal of time is spent on activities to obtain or use alcohol
4. Craving, strong desire or urge to consume alcohol
5. Recurrent use of alcohol is causing a failure in major role obligations at work, school etc
6. Continued use of alcohol despite persistent problems in social and interpersonal relationships
7. Important social, occupational or recreational activities given up or reduced
8. Used in situations where it is physically hazardous
9. Continued use despite knowledge that causing physical and psychological problems
10. Tolerance as defined by any of the following
- Need to have more amount to achieve desired affect
- Marked diminished effect with the same amount used
11. Withdrawal as manifested by either of the following
- A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after the
cessation of (or reduction in) alcohol use described in Criterion A:
1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
2. Increased hand tremor.
3. Insomnia.
4. Nausea or vomiting.
5. Transient visual, tactile, or auditory hallucinations or illusions.
6. Psychomotor agitation.
7. Anxiety.
8. Generalized tonic-clonic seizures.
- Alcohol is used to relive or avoid withdrawal symptoms
SPECIFY

- Early remission vs sustained remission

- In a controlled environment
- Severity: mild moderate severe

- Clinical Features

Withdrawal happens after 4-12 hours of reduction of intake following a prolonged heavy alcohol ingestion

Some withdrawal symptoms can persist at lower intensities for months and can contribute to relapse

Makes it difficult to think about anything else

School, job performance, child care, house responsibilities

May be used to alleviate the unwanted effect of other substances or to substitute for them when they are
not available

Important contributor to suicide risk during severe intoxication.

Intoxication – a state of being affected by a psychoactive drug

- Activates brains pleasure areas at lower levels releasing endogenous opioids

- Depresses brain functioning, inhibits excitatory neurotransmitter glutamate which slows
down activity of brain at higher levels – impairs judgement and other rational processes and
lowers self-control – satisfaction of impulses ordinarily held in check – lack of motor
coordination and perception of cold pain etc are dulled – WARMTH, EXPANSIVENESS,
WELLBEING
- Alcohol content in blood stream reached 0.08: intoxicated; 0.5: individual passes out
- Effects vary depending on physical condition, food in stomach, duration of drinking
- Women metabolise less effectively than men and become intoxicated ta low amounts

Alcohol hangover

- Experience of symptoms of headache, nausea, fatigue, cog impairment for 8-24 hours after
consumption
- Dehydration, triggering of body’s immune system
- Buildup of alcohol metabolites

Alcohol’s effect on the brain

- PHYSICAL: work of metabolism is done by liver, when large amounts consumed, liver may
be severely overworked and eventually suffer irreversible damage – 30% heavy drinkers:
Cirrhosis of the liver. Alcohol being a high calorie drug, 1 pint of whiskey provides half of
daily requirement thus consumption reduces appetite for food. Because it has no nutritional
value, the drinker may suffer from malnutrition. Heavy drinking impairs body to utilise
nutrients, so nutritional deficiency. gastrointestinal tract, cardiovascular system, and
the central and peripheral nervous systems , organic impairment

Fetal Alcohol Syndrome

- PSYCHOSOCIAL: chronic fatigue, oversensitivity, depression. Impaired reasoning, poor

judgement, personality deterioration, behavioural inhibition, learning and memory, less
 responsibility, loses pride in appearance, neglects family, irritable, unwilling to discuss
problem, problem solving skills

May be unable to hold a job, marital breakup, unemployment, intimate partner violence

- PSYCHOSES ASSOCIATED WITH SEVERE ALCOHOL ABUSE: alcohol induced psychotic

disorders because they are marked by a temporary loss of contact with reality.

Alcohol withdrawal delirium: during state of withdrawal, disorientation for time and place,
vivid hallucinations of animals, acute fear of animals, extreme suggestibility, marked tremors,
perspiration, fever, rapid and weak heartbeat, coated tongue, foul breath - 3-6 days followed
by deep sleep, 5-25 percent die

Alcohol Amnestic Disorder: KORSAKOFF’S SYNDROME: memory defects and

confabulations, individuals delirious, delusion, disoriented

- Development and course

During mid-teens onset, late teens to mid-20s

Large majority: late 30s

Preexisting conduct problems: earlier onset

Variable course characterised by periods of remission and relapse

Promising prognosis

- Epidemiology

Common disorder, most destructive psychiatric disorders

4.6% among adolescents and 8.5% in adults in USA

Lifespan of average person with alcohol dependence is 12 years shorter

Associated with 40% deaths suffered in automobile accidents and with 40-50 % murders and over 50%
rapes

INDIA: in comparison, are mong lowest consumers of alcohol but around 14 million need help

18% psychiatric emergencies and 20% brain injuries

Debt problems, caste, class, religion, gender, globalisation, economic liberalisation (prabhu et al, 2010)

Under 21: increased from 2 to over 14 in past 15 years (prasad, 2009)

Indian women yes

Nadkarni et al: men with alcohol abuse and dependence have:

1. Marital problems
2. Report tobacco
3. Workplace and social probs
4. Accident injuries
5. Hypertension and common mental disorders
 6. High in urban areas

Rates more in adult men than women

Twelve-month prevalence varies markedly.

For 12- to 17-year-olds, Hispanics, Native Americans and Alaska Natives more than whites, African
Americans and Asian Americans and Pacific Islanders.

In contrast, among adults, the 12-month prevalence of alcohol use disorder is clearly greater among Native
Americans and Alaska Natives than among whites, Hispanics, African Americans, and Asian Americans and
Pacific Islanders.

- DD: nonpathological use of alcohol, conduct disorder and antisocial personality disorder,
sedative use disorder
- Comorbidity: Bipolar disorders, schizophrenia, and antisocial personality disorder, several
anxiety and depressive disorders, eating disorder

A 45-year-old married man presents to his primary care physician with a chief complaint of fatigue lasting
for the past 9 months. He states that he goes to sleep easily enough but then wakes up repeatedly
throughout the night. He has had this problem since he was injured on the job 9 months ago. On further
questioning, he reports low mood, especially regarding not being able to do his job. He states that his
alcohol consumption is 6 to 12 beers a day, as well as several ounces of hard liquor to “take the edge off
the pain.” He discloses that it takes more alcohol than it used to in order to “get me relaxed.” The patient
states he has experienced several blackouts caused by drinking during the past 2 months and admits that
he often has a drink of alcohol first thing in the morning to keep him from feeling shaky. Despite receiving
several reprimands at work for tardiness and poor performance and his wife threatening to leave him, he
has been unable to stop drinking. On his mental status examination, the patient is alert and oriented to
person, place, and time. He appears rather haggard, but his hygiene is good. His speech is of normal rate
and tone, and he is cooperative with the physician. His mood is noted to be depressed, and his affect is
congruent, although full range. Otherwise, no abnormalities are noted
ALCOHOL INTOXICATION

Recent ingestion of alcohol.

Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or

aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol
ingestion.

One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use:

o Slurred speech.
o Incoordination.
o Unsteady gait.
o Nystagmus.
o Impairment in attention or memory.
o Stupor or coma.

The signs or symptoms are not attributable to another medical condition and are not better explained by
another mental disorder, including intoxication with another substance

ALCOHOL WITHDRAWAL

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or
reduction in) alcohol use described in Criterion A:

o Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
o Increased hand tremor.
o Insomnia.
o Nausea or vomiting.
o Transient visual, tactile, or auditory hallucinations or illusions.
o Psychomotor agitation.
o Anxiety.
o Generalized tonic-clonic seizures.

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

Prevalence: 50% middle class, highly functional individuals

Withdrawal is relatively rare in individuals younger than 30 years, and the risk and severity increase with
increasing age.