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A: Odd and Eccentric Paranoidsuspicious, Prevalence: 0.5 1.

5% Defenses Treatment:
Weird quick to take offense, Etiology: shame- (unconscious): supportive
Accusatory, aloof, Usually socially inducing experiences/ M/C defense is psychotherapy/
awkward isolated, Avoid modeling of mistrust, projection think occasionally meds:
cold, withdrawn, intimacy, read perceived/actual paranoia, think low dose anti-
irrational unintended meanings experiences of projection psychotics these are
into benign actions, mistreatment Projection attributes used off-label when
cold, calculating, to another person the have no axis I dx (pts
guarded, Harbor thoughts/feelings of w/axis II conditions
resentment for a long ones own that are will usually have an
time, Rarely seek unacceptable its axis I condition also)
treatment not my fault, its
yours. Everyone is Approach in medical
doing this to me. setting
prejudice - Trust is primary
Splitting unable to concern
see everyone as - Explain all tests,
humans w/ bad and treatment
good qualities - Attitude of
youre either with me seriousness, respect
or against me bad
half or good half
Schizoidseclusive, Prevalence: 0.5 1% CASES: fine with life, Usually dont seek tx: TQ
egocentonic, very family seeks tx, no CASE
satisfied with lonely (vs AVOIDANT which meds, in cluster A,
existence, Very wants relationships) doesn t req quick Treatment: supportive
indifferent to society intervention, not psychotherapy (meds
and others, restricted schitzophrenia arent indicated)
emotional range and precursor
affect, Life-long Approach in medical
loners, Very cold, setting
eluded, detached, Respect emotional
Little interest in sex, distance
No close Offer reassurance
friends/confidants,
non-competitive jobs
(book keeper,
librarian, something
w/o people
interaction)
Schizotypal--odd, Present in higher Defenses: denial, Treatment:
eccentric thoughts, rates in families with distortion, projection, supportive, reality-
Telepathy, Constricted schizophrenia schizoid fantasy (note based therapy
inappropriate affect; their immaturity) - Low dose anti-
Ideal of reference Prevalence: 3% psychotic medication
see people talking, Thought to be a CASES: reads minds, 2nd generation
think they are talking partial expression of odd behavior, no
about them (thought schizophrenia (usually suicide, no Approach in medical
content); lack auditory/vis hallucinations (would setting
Magical thinking-- hallucinations) or be schitzophrenia) - Statements
precursor of should not be overly
Differs from schizoid/ schizophrenia Family history, not emotional
paranoid : cognitive criteria to force - Make allowances
distortions/oddness Some progress to admit, Prognosis not for peculiarities
schizophrenia but good, meds can help, - Allow dignity,
dont have is a precursor to privacy, support
hallucinations schitzophrenia

B: Dramatic, Borderline Most common personality Defenses: splitting, Treatment:


Emotional, Erratic impulsivity; disorder in clinical setting projective Psychotherapy:
Wild identification, acting multiple modalities
Bad to the bone Pervasive pattern of Prevalence of 2% out Borderline (1ST LINE OF TX)
attention seeking, instability in self personality think E.G.
moody, labile/shallow image, High comorbidity (w/ splitting! PSYCHODYNAMIC,
affect interpersonal major Projective ID COGNITIVE
relationships, wild depression/substance Aspect of self projecting BEHAVIORAL
affect and abuse) on someone else Psychotropics to
impulsiveness, Projector wants others treat symptoms
Dramatic, self- Etiology: history of to experience what has
destructive behavior abuse, abandonment been projected USUALLY REQUIRES
sometimes called Projector and projectee LONG TERM
peri-suicidal behavior Can have past sexual abuse feel the same feel psychoTHERAPY UP
(self-mutilation, history oneness TO ONE YEAR ON A
scratching, cutting) WEEKLY BASIS
Recurrent suicidal CASE: cuts on arms, not People around BPD Psychotropic can be
behavior not suicide but feel better, drug patient have Frustated used but off label. Can
intended to kill self use, splitting angry feeling be on axiolyitc, anti
just to release whatever response u moods, anti psychotics
tension Obtain collateral history give them they will
say yes but. They act Approach in medical
Hallmark Feature: Tx: long term individual like a child. they are setting
Impulsive using psychotherapyinteraction clingy. Maintain realistic
drugs or sexually perspective
acting out These people are Communicate clearly
thought to be trapped Clear boundaries
in the separation tell how available
Switching from adoring stage of development youll be
to hating them individuation Written agreement
splitting Avoid responding to
Difficulty with Transitional object hostility, with
separation, so tend to e.g. stuff animalTeddy hostility
carry their transitional sign pos
object (ex. Teddy bear)

Histrionic Prevalence: 2% Treatment: Long-


term psychoanalytic
HAS OVER-CONCERN Etiology: Sexualization of psychotherapy
WITH APPEARANCE, parent of opposite sex physician actively
ATTENTION SEEKING, female doesnt get engages with the
BEGINS IN EARLY enough attention from patient 1-2 x/wk (not
LIFE, INAPPRO. mom so get close to the same with
SEDUCTIVENESS, father trying to get psychoanalysis---Not
SEXUALLY moms attention and psychoanalysis- meet
PROVOCATIVE, THEY carries on to other with physician 5 days
FOCUS THEIR relationships a week - not say
ATTENTION ENTIRELY anything, just sits
ON THEMSELVES, Defense to deprivation of and listens
PHYSICAL parent of same sex
ATTRACTIVENESS IS Approach in medical
THE CORE OF THEIR More commonly setting
EXISTENCE, OVERLY diagnosed in females Support,
DRAMATIC although sex ratio reassurance,
EXPRESSION OF thought to be equal structured
EMOTION availability
Firm, limit setting
these pts also want
to cross boundary
Reality-based
education
B: Dramatic, Narcissistic RARE This is a defense Treatment:
Emotional, Erratic grandiosity against low self Psychoanalytic,
Wild Prevalence: less common esteem supportive
Bad to the bone Love of self: Etiology: disturbed psychotherapy
attention seeking, Pervasive pattern of parenting age 6 months- CASE: shows off They will seek tx for
moody, labile/shallow grandiosity, 2 years money, Panic axis I instead (e.g.
affect CONITNUED superiority, lack of - Unempathic, disorder, depression)--difficult
empathy for others overcontrol, and neglect
- Potential for successful Must only tx AXIS 1 Approach in medical
Problematic anger- development undermined presenting S/s, setting
Envious of others- cluster B, typically Do not get into
Requires admiration dont ask for help, power struggle
SSRI and anxiolytic Clarify expectations,
Feel sense of (tx presenting panic limits, your capacity
entitlement d/o), Bordeline MC in to help
These people are cluster,
involved in shame Use the non-
confrontational
approach,
Supportive
therapeutic settings,
Unlikely to seek
treatment, because,
there is nothing
wrong with me, or
my behavior
Antisocialcriminal, M/C co-morbid condition Better for grp Extremely difficult to
fights, lie, con-man, substance abuse therapy usually in treat
impulsive, irratible, confined setting like
aggressive, lose jobs, More common in men prison Treatment:
morally bankrupt, (M:F is 3:1) 75% of prison - Avoid being
lack remorse, population may have manipulated
Prevalence: 2-3% this dx - Combination of
Substance abuse, If these pts come in individual/group
Depression, Suicide CASE: temper, for treatment try to therapy
risk employment probs, target Axis I dx Can use mood
stealing, drug use, fights, Many meet criteria stabilizer in
for impulse d/o or controlling
Adolescents w/ Percorsor is conduct intermittent aggression
similar traits will be disorder, asso drug use, explosive d/o tx
diagnosed with only after 18, cluster B, w/antiepileptic rxs Approach in medical
conduct d/o (up to best tx is grp tx with trial setting
age 18) precursor of valproate, tx AXIS 1, - Avoid power
dx for antisocial commonly asso. With struggle
personality d/o impulse control disorder, - Clarify roles,
they abuse BZDs/stim, boundaries
- Agree to disagree
- Be aware of drug
issues (pt may be
drug seeking)no
stim or BZD

C: Anxious and -Avoidant Prevalence: 0.5 1% Treatment: long-term


Fearful psychotherapy;
Worried Pervasive pattern of Etiology: Adjunctive use of
Coward, compulsive, feelings of Inborn temperamental anxiolytic/
clingy inadequacy, hyper- tendency antidepressant
feel over-controlled by sensitivity to any Suboptimal parental med--SSRI
others or own ideas form of criticism, response
even if minor in Asso. with social
nature, and MC in F, feel over phobia, panic
experiences extreme controlled disorder axis I
social inhibitions Etiology temperamental, Treat these if have
shyness, social anxiety, these
Different from harm avoidant Parents
schizoid b/c these couldnt foster any more Approach in medical
pts want an intimate activities/movements in a setting
relationship (actually child - Provide empathy,
embrace them, Aka parents were over- support
greater fear of protective - Reassurance and
abandonment more They avoid relationships but encouragement
so than dependent they want them! (different - Emphasize their
personality) from schizoid) positives
Dependent More common in females Strong Tx psychotherapy
preoccupation of any w/ cognitive-behavior
Pervasive need to be abandonment vs address issues of
taken care of; borderline poor self-esteem
Behavior is often CBT for
very clingy and incompetence
are fearful of
separation like Approach in medical
borderline ; Will setting
often times be - Present as
submissive to others dependent clingers
Problems with - Offer appropriate
separation (like limited availability
borderline but no self- - reassurance,
destructive behaviors) clarification, clear
Strong desire for others expectations
to care for them
Obsessive- Prevalence: 1% CASE: Pt researches Treatment/Managem
Compulsive--- disease, offers advice ent:
Pervasive/ Etiology: on running office, More likely to seek tx
preoccupation - Temperment of documents compliance, bc realize the impact
w/details, no attentional self-regulation no indication feels bad: of their d/o
efficiency - Fixation in anal phase OCD (excessive - Provide with as
(age 3) cleanliness) vs OCPD much control as
perfectionistic, Lack - Unconscious defense possible
ability to compromise, against shame & guilt OCPD: M>F, OCDs -
Rigid and preoccupy - may be mc in M>F more likely to seek tx Psychotherapy/analy
with details, Have (not OCPD), OCPD sis
problems expressing cluster C, tx with
affection, Stubborn and individual Approach in medical
rigid psychotherapy setting
Know that they have Provide with as much
problem and might OCPD = obsessive control
show up in the clinic compulsive as possible
PERSONALITY disorder Provide appropriate
OCD = treated w/SSRIs up to date
information

Defense Mechs
Acting Out Avoiding painful feelings Mother dies, so girl starts Immature
by behaving in an having sex,
attention-getting socially
inappropriate manner
Sublimation Unselfishly assisting
others to avoid negative
feelings

Altruism
Dissociation Separation of function of Woman forgets dressing woman sexually abused
mental illnesses; up and spending money as a child has two
mentally separating part distinct personalities in
of consciousness from adulthood
reality; forgetting
"events have occurred
Projection Attributing ones own A man who has sexual Paranoid delusions Normal in childhood: the
personally unacceptable feelings for his brothers and hallucinations. imaginary playmate
feelings to others wife begins to believe
that his own wife is
Ideal of reference cheating on him.
Splitting Believing people or Pt sees night and day Borderline Personality
events are either all bad staff as good and bad; Disorder, paranoid also
or all good because of doctor is goo until very
intolerance of ambiguity bad b/c late
Intellectualization-- Using the minds higher A physician with a
immature functions to avoid diagnosis of pancreatic
experiencing cancer excessively
uncomfortable emotions discusses the statistics
of the illness with his
colleagues and family.
Somatization Turning an unacceptable
feeling or impulse into a
physical symptom

Undoing Adopting acts which woman who was an compulsive acts,


symbolically cancel or immaculate housekeeper obsessional thoughts
reverse a previous develops a hand washing
unwanted act or thought compulsion after her
or event. child develops
pneumonia.

Somatoform5 Mech and motivate


disorders unconscious
Somatization Disorder Formerly, hysteria Diagnosis: multiple
or Briquets Syndrome somatic complaints of
Women > than men- several years
20:1 consisting of:
Lifetime prevalence: - 4 pain symptoms
0.4% - 2 GI symptoms
Point prevalence: 1- - 1 sexual symptom
2% -1
Usually lower pseudoneurological
socioeconomic groups s/s
Unconscious factors
Conversion Disorder Woman goes blind after more common in Female> male If there is an acute onset
seeing child die, patients with less with a stressor, if pt has
education and low a high IQ, short interval
socioeconomic status btw onset and tx
better Px
Short term focused
therapy can be used.
Examine the stressors
they are dealing with and
they will usu respond to
that.

Pain Disorder

Hypochondriasis Stressors cause S/s, then DSM4-- >6mos; older GOOD prognosis- acute Management: tx
wont believe no organic pts., frequently onset, absence of psychiatric condition,
cause, wants second associated with some life personality d/o, schedule regular appts,
opinion, stressor increased S/E status, no only base evidence on
secondary gain; Good to clinical findings, group
EQUAL male and female maintain good physician therapy, SSRI
ratio; contact; workup based
on CLINICAL findings, not
subjective complaints;
use group tx or SSRIs
Body Dysmorphic Unconscious mechanism High prevalence of major
Disorder with unconscious depression with this d/o
motivation (7-9% of pts who get
plastic sx have BD d/o)
May benefit from SSRI
Pemizide old Rx that is
used. SSRI may help.
May do well with group
and cognitive threapy

Fictitious Mech conscious,


motivate unconscious
w/ phys s/s Munchhausen, female, Establish one Do not treat unless
nurse,??? physician for objective evidence of
management disease present
Maintain regular Shift from somatic to
appointments social stressors
Gradually reduce Involve family
frequency of Watch for doctor
appointments shopping/drug abuse
Perform regular
physical appointments
Avoid unnecessary/
invasive/ dx
procedures
w/ psyc S/s Not educated, presents
as secondary needs,

Malingering Both conscious


Drug seekers Pain disappears when
dont get drugs

Malingering or Factitious Adding blood to urine on Not sure if she is getting If shes had
disorder UA, nurse, secondary gain not sure bereavement, then
about malingering. factitious, not
malingering
Munchhausen by proxy, conscious mechanism Good prognosis after
child abuse with an unconscious confrontation
motivation