I’m Not Feeling Like Myself
A diagnosis of dissociative amnesia is given when a subject is suddenly unable to recall this type of information.
What is autobiographical information?
This term describes a sensation of detachment or outside observing of one’s own thoughts, senses, body, or actions.
What is depersonalization?
Symptoms resembling oppositional defiant disorder do not count if only in relationship to this type of family member.
What is a sibling?
What is being unnecessary or of low or trivial value?
In regard to their other personality states, a person with dissociative identity disorder would likely have this specific difficulty.
What is recurrent gaps in recall of important personal information or everyday events?
This term describes treatment for DID.
Long-term Trauma-Focused Psychotherapy.
The outbursts in this disorder typically last < 30 minutes and provide a sense of relief, followed by feelings of remorse.
Intermittent Explosive Disorder
To qualify for a diagnosis of pyromania, a patient must experience emotional arousal/unrest during this stage of fire setting.
What is before fire setting (planning or preparing stages)?
In children, it is very important to rule out this normal phenomena before making a diagnosis of dissociative identity disorder.
What is imaginary friendship or fantasy play?
This specifier is added to the dissociative amnesia diagnosis when memory loss is associated with wandering or travel.
In this disorder, there is persistent anger or irritability in between severe outbursts of disproportional anger, which is observable by others.
Disruptive Mood Dysregulation Disorder
These are the four named categories of behavioral symptoms in conduct disorder (name 2).
What is serious violations of rules, deceitfulness or theft, destruction of property, and aggression to people or animals?
A 14-year-old boy is brought to the office by his parents due to concerns about his behavior. His father says, "He has been talking back and arguing with us more than he used to. A few weeks ago, he got into trouble because he went to a birthday party without telling us. I also found a cigarette lighter in his pocket, although he swears that he doesn't smoke and just likes to play with it when he's stressed." The patient maintains a B average in school and spends most of his afternoons playing video games with a new group of friends. Two months ago, he was accused of being involved in a suspicious fire at the local park. His father says, "He has always wanted to be a firefighter. At age 10, he was playing with matches in the backyard and started a fire just to see how long it would take the firefighters to arrive." The patient says, "I don't know why my parents are so upset. I do well in school, and I do all my chores. Why can't they just leave me alone?" He has no significant medical history. On mental status examination, the patient is cooperative but sullen. He has no delusions, hallucinations, or suicidal ideation. Which of the following is the most likely diagnosis?
A. Antisocial personality disorder
B. Conduct Disorder
C. Normal Adolescent behavior
D. Oppositional defiant disorder
E. Pyromania
This adolescent's fascination with fire and history suggestive of intentional fire setting are consistent with a diagnosis of pyromania, a rare impulse-control disorder more commonly found in male patients. Pyromania involves deliberate fire setting with no obvious motive (eg, financial gain, revenge, political statement, recognition) to relieve internal tension. Individuals with this condition tend to be fascinated by fire and anything related to it (eg, fire stations, firefighters, cigarette lighters). They deliberately start fires to reduce tension and afterward feel pleasure or relief. Pyromania must be differentiated from fire setting associated with a manic episode, psychosis, conduct disorder, or substance intoxication.
(Choice A) Antisocial personality disorder is diagnosed in individuals age ≥18. It involves a pattern of violation of basic societal rules and the rights of others and requires a history with some symptoms of conduct disorder before age 15.
(Choice B) Fire setting can also be a symptom of conduct disorder. However, in conduct disorder, fire setting is done to cause damage and is not accompanied by a fascination with fire or the need to relieve tension. In addition, a diagnosis of conduct disorder requires a pervasive pattern of violating rules and the rights of others that includes additional problem behaviors (eg, aggression/cruelty toward people and animals, theft), which this patient does not exhibit.
(Choice C) Although normal adolescence is characterized by a desire for privacy and independence that may manifest as sullen behavior (eg, arguing with parents) and testing limits (eg, going to a party without his parents' knowledge), it would not explain this patient's fascination with fire and involvement in fire setting.
(Choice D) Oppositional defiant disorder is characterized by a pattern of angry or irritable mood and defiant behavior toward authority figures. Although this patient is more argumentative with his parents, this is typical of adolescence, and he has no pervasive pattern of defiance. Individuals with oppositional defiant disorder do not typically engage in fire setting.
A 24-year-old man is brought to the ED by his wife after sustaining a foot injury. The two were waiting for a table at a crowded restaurant when the waiter inadvertently seated a family that was behind them in line. The patient suddenly became enraged, started pacing back and forth, shouted at the waiter that he was "stupid and incompetent," and kicked a nearby chair against the wall, causing damage to the wall and injuring his own foot. He is remorseful about his behavior, but his wife says, "He can be moody, frequently gets defensive, and loses his temper with the slightest provocation." They have had several heated arguments during which he has thrown and broken objects. The patient has no medical history. Physical examination is unremarkable except for swelling and lacerations of the foot. Which of the following is the most likely diagnosis in this patient?
A. Antisocial personality disorder
B. Bipolar disorder
C. Borderline personality disorder
D. Disruptive mood dysregulation disorder
E. Intermittent explosive disorder
F. Substance intoxication
This patient's pattern of impulsive, aggressive behavior is suggestive of intermittent explosive disorder (IED), an impulse control disorder. Patients with IED are unable to restrain their aggressive impulses, resulting in verbal or physical aggression that is out of proportion to the provocation. The violent, impulsive outburst is typically preceded by rising tension that escalates rapidly to a state of rage without thought to the consequences of the behavior. Episodes last <30 minutes and may provide an immediate sense of relief, usually followed by remorse, dysphoria, and embarrassment. Significant functional impairment due to interpersonal difficulties, job loss, school suspension, and legal problems is common.
IED tends to be chronic and is associated with high rates of psychiatric comorbidity. It should not be diagnosed if the impulsive, aggressive behavior occurs exclusively in the context of another active psychiatric disorder (eg, acute manic episode in bipolar disorder). Treatment consists of cognitive-behavioral therapy and selective serotonin reuptake inhibitors.
(Choice B) Patients with bipolar disorder may have aggressive outbursts during a manic episode. However, manic episodes usually last days to months (unlike IED episodes, which last <30 minutes). In addition, this patient does not have other key manic symptoms (eg, elevated mood, increased energy, decreased need for sleep, pressured speech).
(Choice C) Patients with borderline personality disorder may exhibit inappropriate anger and rages, but these outbursts typically occur in the context of an unstable relationship and are related to underlying fears of abandonment. This patient lacks other characteristic borderline features (eg, suicidal behavior, chronic feelings of emptiness, abandonment fears).
(Choice D) Although disruptive mood dysregulation disorder may also present with disproportionate verbal or physical outbursts, diagnosis requires onset before age 10 and persistent irritability or anger between episodes. The diagnosis is not made after age 18.
(Choice F) Although substance intoxication is associated with aggressive behavior, this patient's pattern of short-lived episodes and lack of signs of intoxication on examination is more consistent with IED.
A 26-year-old woman is brought to the ED after threatening to kill herself. She says, "I feel very depressed and can't stop crying. I feel like a piece of trash." The patient thinks frequently that she would be better off dead and has thought of overdosing on sleeping pills since her boyfriend left her a week ago. The patient has had no significant change in sleep pattern, appetite, concentration, or energy level. She has felt depressed on and off since high school and describes chronic low self-esteem. She is also frequently angry and occasionally experiences a sense of detachment from her body. When a previous relationship ended a year ago, she developed severe depression and thought that people on the street were laughing at her, which lasted for several days. Physical examination is unremarkable except for multiple superficial cuts on her right arm in various stages of healing. Which of the following features is most likely to be associated with this patient's condition?
A. Chronic delusions
B. Family history of schizophrenia
C. Flat affect
D. History of childhood trauma
E. History of hypomanic episodes
F. History of manic episodes
G. Loss of mood reactivity
This patient's pattern of recurrent suicidal behavior, mood instability, unstable relationships, inappropriate anger, impulsivity, abandonment fears, and stress-related paranoia and dissociation are characteristic of borderline personality disorder (BPD). In addition to suicidal threats, gestures, and attempts, these patients often engage in nonsuicidal self-injury (eg, cutting, burning).
A history of childhood trauma (eg, physical and sexual abuse, neglect) is common in patients with BPD. Insecure attachment to the primary caregiver may underlie the unstable relationships and fears of abandonment commonly seen in the disorder. Dissociative symptoms (eg, this patient's experience of detachment from her body [depersonalization]) are common in those who have been traumatized.
(Choice A) If present, psychotic symptoms in BPD are transient and stress related (eg, this patient's transient paranoia following the end of a relationship). Patients with chronic delusions are more likely to have a primary psychotic disorder.
(Choice B) There is no clear association between a family history of schizophrenia and the development of BPD.
(Choice C) Patients with BPD typically have an intense, labile, or angry affect. Flat affect is characteristic of schizophrenia.
(Choices E and F) Although the mood instability of BPD may resemble the mood swings of bipolar disorder, these patients do not have sustained hypomanic or manic symptoms that would meet the diagnostic threshold for bipolar disorder.
(Choice G) The mood disturbance in BPD is characterized by marked mood reactivity (ie, moment-to-moment fluctuations often triggered by psychosocial stressors). Loss of mood reactivity is associated with severe, melancholic depression (ie, mood does not improve with improved circumstances).
A woman brings her 16-year-old son to the office for evaluation of his behavior. She reports that he is failing most of his classes despite being intelligent, and she is worried he will not graduate from high school. He has skipped school regularly since the 7th grade grade and frequently lies to his mother about his whereabouts. The patient says his teachers are dumber than him, and he refuses to do any homework because it is a "waste of time." He has been suspended several times for fighting and was once caught stealing money from the teachers' lounge. The patient uses alcohol and marijuana but is unwilling to say how often. He has tried cocaine but feels it made him "too hyper." His mother reports he often stays out past curfew and has come home intoxicated a few times. The patient sits in an exaggerated slump and appears annoyed about being brought to the appointment. He argues with his mother throughout the evaluation, and his responses to the physician are short and sarcastic. Which of the following is the most likely explanation for the patient's behavior?
A. Antisocial personality disorder
B. Conduct disorder
C. Intermittent explosive disorder
D. Narcissistic personality disorder
E. Oppositional defiant disorder
F. Substance-induced mood disorder
This patient's persistent pattern of lying, truancy, stealing, and fighting is most consistent with conduct disorder (CD). CD is a childhood psychiatric disorder characterized by behaviors that violate societal norms appropriate to the patient's age (eg, excessive absenteeism, consistently staying out past curfew) or the rights of others (eg, often initiating fights). Other behaviors seen in CD include bullying, using weapons (eg, broken bottle, bat, gun, knife), torturing animals, setting fires, destroying property, and forcing others into sexual activity. These conducts impact functioning (eg, not graduating from high school).
CD generally presents in middle childhood to adolescence and is more common in boys. Adolescents with CD are at greater risk for developing antisocial personality disorder as adults. Individuals must be age ≥18 to receive a diagnosis of antisocial personality disorder and must have evidence of CD before age 15 (Choice A).
(Choice C) Individuals with intermittent explosive disorder also have episodes of aggression. However, they do not have other features seen in CD (eg, deceit, theft, truancy), and their behavior is not premeditated or intended to defy rules or gain advantage over others.
(Choice D) In narcissistic personality disorder, grandiosity is related to the need to be the center of attention and admired. Individuals with narcissistic personality disorder do not display a pattern of violating social norms or the rights of others, as seen in CD.
(Choice E) Oppositional defiant disorder is characterized by a pattern of angry/irritable mood and argumentative/defiant behavior toward authority figures. Compared to CD, the symptoms of oppositional defiant disorder are less severe and do not include stealing or aggressive violations of the rights of others. This patient's history of repeated fighting, stealing, and lying is more consistent with CD.
(Choice F) Effects of substance use should always be considered in adolescents with behavior problems and/or mood disturbances. Although substance use might be related to stealing, irritability, and poor school performance, this patient's persistent pattern of violating major societal norms and the rights of others in multiple settings makes CD the more likely explanation for his behavior.