B. PSYCHOPHYSIOLOGIC RESPONSE AND SLEEP

I. SLEEP DISORDERS – ongoing disruptions of normal waking and sleeping patterns

Sleep – is a recurrent, altered state of consciousness occurring in sustained periods > necessary for human survival

Behavioral Perspective – state of decreased awareness of environmental stimuli & unconsciousness with no memory in state

Physiologic Perspective – dopamine, serotonin, GABA, adensosine, histamine, hypocretin, melatonin and cortisol > plays role in changing sleep states 2.) reticular activating system (wakefulness) > decreases = releases neurotransmitter promoting sleep

Primary Sleep Disorder:A. DYSSOMNIAS – disorders of initiating or maintaining sleep: insomnia, primary hypersomnia, narcolepsy, breathing related

sleep disorder & circadian rhythm sleep disorders

1. PRIMARY INSOMNIA – refers to difficulty falling asleep for @ least 1 month, trouble maintaining sleep, or waking up too early > affecting interpersonal and functional condition

Assessment: daytime fatigue, difficulty concentration and poor mood, uses polysomnography (perform @ night during sleep: poor sleep continuity, increase in Stage 1 and decrease in SWS)

InterventionsBiological:

Further assessment: description, duration (when problem began), stability (every night) and intensity (how bad is it)o Medications (OTC), medical conditions, diet

Sleep diary > written account of sleep experience Activity & Exercise = earlier the day (active exercise) before retiring (quite/relaxing activity) Diet: no heavy meal before sleeping, avoid stimulants (spicy, caffeine, smoking) & alcohol, encourage warm milk

without additional snacks Environment modification: cool, less distraction: noise, less light or none, decrease external stimulus Pharmacological:

o Benzodiazepines Receptor Agonists (BzRA) - facilitates GABA effects, greatly suppressed slow-wave sleepo Non-Benzodiazepines – provides immediate relief but used in short-term treatment (margin of safety is

narrow) = high abuse and dependence potential + rebound effectso Melatonin Receptor Agonist: Ramelteon (Rozerem) – high affinity to melatonin receptors (MT1 & MT2)o Antidepressant – (Trazodone:Desyrel - SARI)) potent effect on sleep + moodo Antihistamine – (Diphenhydramine: Benadryl) antagonist of histamine = sedation and diminished alertness +

anticholinergic effects Exogenous melatonin – OTC (dietary supplement) Valerian – nutritional herbal supplement > inhibits GABA reuptake = increasing sleepiness Avoid grape-fruit juice when taking most of this medications = FURANOCOUMARINS derivatives

> interferes with  hepatic and intestinal enzyme cytochrome P450 (CYP450)  = either increasing or decreasing bioavailability of a number of drugs

Psychosocial:

Further assessment: recent changes in relationship, fatigue/stress, shift work > compromises circadian rhythm Sleep hygiene: keeping regular bedtime and rising times > even if sleep is very poor, client needs to get up and out of

bed at a regular and consistent time, avoid naps, abstain from alcohol (shorten SOL- length of time that it takes to accomplish the transition from full wakefulness to sleep), refrain caffeine & nicotine after mid-afternoon, use bedroom for sleeping, avoid frustrating/provoking activities.

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Develop bedtime ritual: behavioral interventions > 1. stimulus control by avoiding behavior incompatible to sleep = re-establishing a stimulus for sleep

Sleep restriction – less time in bed and avoid napping = regular sleep schedules Relaxation training – imagery, meditation, thought stopping or biofeedback = restore focus to sleep Psychoeducation – sleep cycle and factor influencing sleep, family support w/ changes

2. PRIMARY HYPERSOMNIA – excessive sleepiness for @ least 1 month > daytime sleep episode & extended sleep period at night

Assessment: Diagnostic Criteria: MSLT (multiple sleep latency test) thru polysomnography- Excessive sleepiness for @ least 1 month- Prolonged sleep episodes- Daytime sleep episodes: napping- Significant distress in social/occupation or functioning- Not accounted for by insufficient sleep

Intervention Further assessment: any form of anxiety the client wants to avoid = could also be a non-verbal cue of suicidal ideation Safety as a real issue Provide a consistent well-structured activities/exercise = productive for the client Sleep hygiene addressing excessive sleepiness Pharmacologic:

o Stimulants > Dextroamphetamine (Dexedrine), Methylphenidate (Ritalin/Concerta) = increasing levels of dopamine: increase ability to stay awake and perform

o Caffeine – cup of brewed coffee (150 mg), ounce of chocolate (25 mg) = peak plasma concentration reached in 30 – 60 minutes after consumption for 3-5 hours duration > improve psychomotor performance

Individual Psychotherapy: emphasize the effect of excessive sleepiness to functional level Remotivation therapy and assertiveness = if self-integrity issues

3. NARCOLEPSY – irresistible urge to sleep occurring at any time of the day, regardless of the amount of previous sleep and commonly in a inappropriate situations: driving a car/reading newspaper = ETIOLOGY: deficient hypocretin and injury to CNS: Multiple Sclorosis, Myasthenia Gravis or Huntington’s Chorea

Assessment:Irristible attack of refreshing sleep occurring daily over 3 months periodBrief episodes of sudden bilateral loss of muscle tone – CATAPLEXY > subtle drooping eyelids to buckling knees lasting only secondsDreamlike hallucinations while falling asleep – HYPNAGOGIC HALLUCINATIONS > usually visual or auditoryVoluntary muscle paralysis – SLEEP PARALYSIS > inability to move or speak when falling asleep or waking up2 to 6 sleep attack/day

Intervention Extreme safety Diversion activities – meet criteria of safety Pharmacologic:

o CNS stimulant: Dextroamphetamine (Dexedrine), Methylphenidate (Ritalin/Concerta)o Antidepressant: TCA – suppress REM sleep

Psychoeducation: factors that makes symptoms worse including alcohol, stress & sleep deprivation, developing strategies to manage symptoms taking naps in day break or lunch or before engaging activities to sustain alertness: driving or evening meal

Remotivation therapy

4. OBSTRUCTIVE SLEEP APNEA SYNDROME – a breathing-related sleep disorders characterized by excessive snoring during sleep and episode of sleep apnea = disrupt sleep & cause daytime sleepiness

Assessment: increased amount of Stage 1 and decreased amount of SWS & REM accompanied with heartburn or esophageal reflux, nocturnal enuresis, bradycardia or arrhythmias > common in middle age and old age overweight, male

Intervention: Nocturnal Polysomnography- helps in diagnosing the client

Surgical (uvolopalatopharyngoplasty) Non-surgical (CPAP), weight loss, positioning (lateral), sleep hygiene, family therapy or psychoeducation

5. CIRCADIAN RHYTHM SLEEP DISORDER – mismatch between individual’s internal sleep-wake circadian rhythm and the timing and duration of sleepSubtypes:

Delayed sleep phase type: “owls” tends to be unable to fall asleep before 2 to 6 am = whole sleep pattern shifts and having difficulty rising in the morning = cause might be intrinsic

Jet-lag type: occurs after travel across time zones in coast-to-coast and international travel > the normal endogenous circadian sleep-wake cycle does not match the desired hours of sleep and wakefulness on new time zone

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Shift work type: endogenous sleep-wake cycle is normal but is mismatched to the imposed hours of shift work > rotating shift schedules = disruptions because consistent adjustment is prevented

Intervention Chronotherapy - commonly used for delayed sleep phase type by manipulating sleep schedule thru progressively

delaying bedtime and rising time by hours until an acceptable bedtime is attained – strictly maintained

Light therapy (luminotherapy), chronopharmacotherapy (short-acting hypnotics to induce sleep), reducing on diet causing wakefulness on the night and sleepiness in the day, exercise accordingly, sleep hygiene

B. PARASOMNIAS – disorders of particular physiologic or behavioral reactions during sleep

1. NIGHTMARE DISORDER – repeated occurrence of frightening dreams that fully awaken an individual = persisting sense of anxiety and difficulty returning to sleep

Four distinct criteria: Experience repeated awakenings from frightening dreams. When the patient awakes, he or she must wake fully and be aware of his or her surroundings. The nightmares must cause the patient distress in important areas of his or her life. The nightmares cannot be directly attributed to another disorder, or be the direct effects of medications, substance abuse, or a

medical condition.

REM sleep interruptions = since it occur during the second half of sleep > it can be a symptom, a cause by levodopa, betablockers, antidepressant, barbiturates and alcohol

Intervention TOC: Psychotherapy – aimed in conflict resolution CBT, Desensitization and relaxation technique

2. SLEEP TERROR DISORDER – referred to as pavor nocturnus when it occurs in children, and incubus when it occurs in adults > repetition of episode of sleep terrors: screaming, fear and panic = rapid heart rate and breathing, flushed skin, dilated pupils - - - caused by genetic predisposition or a delay in the maturation of the child's central nervous system + factors as sleep deprivation, psychological stress   , and fever

Criteria: Do not respond to attempts to comfort or awaken them Not able to recall their dreams, and they must not remember the episode itself Episodes may not be attributed to a medical condition or drug use Usually begins in NREM slow wave sleep – occurs during first third of sleep

Intervention Rearranging furniture Avoid overemphasizing on the episode and avoiding to stressor Psychotherapy Hypnotic medication to induce sleep

3. SLEEPWALKING DISORDER – “somnambulism” – an arousal disorder > does not complete the process of sleeping-wake cycle = individual is partially awake yet particularly asleep > repeated motor behavior during sleep (sitting up in bed and mumbling incoherently – mild form or confusional arousal) or (getting out of bed, walking around in house or driving an automobile – complex form)

Causes: Genetic predisposition Interrupted slow wave sleep- occurs first third of the night Tirggering factor: alcohol use, emotional stress, fever, sleep deprivation, hormonal changes Medication: Anti-anxiety or sleep-inducing, anti-seizure, stimulants, antihistamines, and anti-arrhythmic

Intervention Precaution: ensuring adequate sleep > alert family, keep a sleep log, install noise device on door, deadbolt locks in door and

windows, alert social peers Stress management Hypnosis Psychotherapy Antianxiety drugs: benzodiazepines

C. PERSONALITY DISORDERS

PERSONALITY DISORDERS > syndrome in which the person’s inner difficulties = revealed through general behaviors and by a pattern of living that seeks immediate gratification of impulses and instinctual drives without regard to society’s laws, mores and customs and without censorship of personal conscience > behavior is inflexible & maladaptive

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1. DISRUPTIVE BEHAVIOR DISORDER – group of childhood personality disorders with overlapping and closely related difficult behaviors: CONDUCT DISORDER (CD) & OPPOSITIONAL DEFIANT DISORDER (ODD)

a. CONDUCT DISORDER - is the repetitive and persistent pattern of behaviors that violate societal norms and the rights of other people: aggressiveness & destructive behavior = seemingly antisocial personality

Causes: Neurologic dysfunction & hereditary – common in family with alcoholic and poor temperamentFamily dysfunction – dysfunctional parenting, marital discord, environmental factors: social disadvantage, Acting out – anxiety from being socially rejected

DIAGNOSTIC CRITERIA: Repetitive & persistent pattern of behaviors violating major appropriate societal norms > past 2 months

∞ Aggression to people & animals – bullies, intimidates, initiates fight, cruel, forced someone in sexual activity

∞ Destruction of property – deliberately engaged in fire setting or destroyed other property – intent for serious damage

∞ Deceitfulness or theft – stolen items, cheating, lying to obtain goods or favors “kutong”∞ Serious violations of rules – stays out @ night despite parental prohibition beginning before age 13 years,

run away from home (at least twice) or left for lengthy period w/o returning (once), truancy (cutting class or unauthorized absence)

Disturbance in behavior = impairment in social & academic functioning If the individual is age 18 yrs or older, criteria are not met for Antisocial Personality Disorder

According to Onset:∞ Childhood-onset type - is appropriate for children showing at least one of the

behaviors in criteria before the age of 10. ∞ Adolescent onset type - is defined by the absence of any conduct disorder criteria

before the age of 10

According to Severity:∞ Mild – few conduct problem causing minor harm: lying, truancy, breaking parental rules∞ Moderate – significant numbers of conduct problem causing significant unbearable & prominent

effect to people∞ Severe – multiple conduct problems causing great harm: rape, assault, mugging,

breaking/entering a house to steal

Intervention Key: Early intervention and meeting the needs of the child & family Child custody must be considered > focus instead on strengths and assets in both the child and his or her family Imparting core values consistently Parent Management Training and Family therapy   – allowing parents learn to apply parental behavioral principles

effectively, how to play with their children, and how to teach and coach the child to use new skills. CBT , Millieu Therapy + social skills training Medication: controlling aggression

OPPOSITIONAL DEFIANT DISORDER - characterized by negative, disobedient, or defiant behavior that is worse than the normal "testing" behavior most children display from time to time.

ODD has been called a problem of families, not of individuals. It occurs in families in which some or all of the following factors are present:

Limits set by parents are too harsh or too lax, or an inconsistent mix of both. Family life lacks clear structure; rules, limits, and discipline are uncertain or inconsistently applied. At least one parent models oppositional behavior in his or her own interactions with others.

o For example, mother or father may get into frequent disputes with neighbors, store clerks, other family members, etc., in front of the child.

At least one parent is emotionally or physically unavailable to the child due to emotional problems of the parent o Depression, separation or divorce, or work hours.

Criteria:A pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four (or more) of the following are present. The child:

∞ often loses his or her temper∞ frequently argues with adults∞ often disregards adults' requests or rules∞ deliberately tries to provoke people

∞ frequently blames others for his or her mistakes or misbehavior∞ is often easily irritated by others∞ is often angry and resentful∞ is often spiteful & vindictive

INTERVENTION: Focus: child & parents

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Medical check up + mental health exam (child and parents) The goals of treatment include helping the child to feel protected and safe and to teach him or her appropriate behavior.

o Parents may need to learn how to set appropriate limits with a child and how to deal with a child who acts out consistently.

o Appropriate reward & punishment techniqueso Behavioral Modification – general people around must be unified and active involvement of parents, no reward of

money or things that are bought (privileges), simple and straightforward rules, shows true consistency with limit setting, strengthen family system, limit TV or media use, promote recreational activities (sports) and diversional

o Medication: if non-medical interventions is not possible, symptoms are severe, and with other co-morbid conditions is present

PERSONALITY DISORDERS- most personality disorders begins as a problem in personal development and character which peak during

adolescence as this starts to disrupt emotional, intellectual, or perceptual functioning > suffer a life that is not positive, proactive, or fulfilling = associated with failures to reach potential

DIAGNOSTIC CRITERIA: PSYCHOLOGICAL CHARACTERISTICS

1. Self image2. Interpersonal relationships3. Range of emotion > affectivity & emotional instability4. Cognitive triad – maladaptive cognitive schema5. Impulse control

Classification:

Cluster A Personality Disorders: ECCENTRIC OR ODD PEOPLE■ Paranoid personality disorder, Schizoid personality, and Schizotypal personality disorders.> This cluster includes the distrustful, emotionally detached, eccentric personalities.

Cluster B Personality Disorders: DRAMATIC-ERRATIC OR EGOCENTRIC PEOPLE■ Antisocial personality disorder, Borderline, Histrionic, and Narcissistic personality disorders.> This cluster includes those who have disregard for others, with unstable and intense interpersonal relationships, excessive attention seeking, and entitlement issues with a lack of empathy for others.

Cluster C Personality Disorders: FEARFUL OR ANXIOUS PEOPLE■ Cluster C personality disorders include the avoidant personality, dependent personality, and the obsessive-compulsive personality disorders.> This cluster includes the avoider of social situations; the clinging, submissive personality; and the person preoccupied with details, rules, and order.

CLUSTER A

1. PARANOID PERSONALITY DISORDER (SUSCIPICIOUS PATTERN) > consistently mistrustful to others and desire to avoid relationship = chronic hostility projected to others (experienced loneliness & poor interpersonal family relationship)

DIAGNOSTIC CRITERIA:∞ Pervasive distrust and suspiciousness of others∞ Assume harm, exploitation or deception by others∞ Reluctant to confide in others∞ Interprets there is hidden meaning into remarks or events∞ Unwilling to forgive to any minor insults∞ Quick to react & counterattack to perceived insults∞ Recurrent suspicion about fidelity of spouse

INTERVENTION: Honest, concrete approach + passive friendliness Build rapport gradually, consider proxemics: 7 feet away from the client = + if client begins to disclose some of his/her more

bizarre paranoid ideation Individual Psychotherapy – new coping skills + interpersonal skills CBT – illogical suspiciousness must be corrected Do not argue, challenge or disagree with patient’s paranoid ideation Group therapy – should be small about 3-4 members only Medication: depends if hallucination + severe anxiety is present

2. SCHIZOID PERSONALITY DISORDER (ASOCIAL PATTERN) > expressively impassive & interpersonally unengaged > unable to experience the joyful and pleasurable aspects of life = referred to as a "pleasure deficiency"

DIAGNOSTIC CRITERIA

∞ Pervasive pattern of detachment from social relating∞ Restricted range for emotional expression

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∞ Lacking desire of intimacy∞ Indifference to opportunities for close relationship∞ Little satisfaction from being part of family or social group∞ Preference for alone time rather than being with others ( choosing solitary activities or hobbies)∞ Little interest in having sexual experience with others∞ Reduced pleasure from sensory, bodily or interpersonal experiences∞ No close friends or relatives∞ Indifference to approval or criticism from others∞ Emotional coldness, detachment, or flattened affectivity

INTERVENTION Individual Psychotherapy + CBT – promote socialization skill & increase ability to feel pleasure = she will withdraw from

the fantasy world Establishing rapport is gradual and long process = allowing to develop feeling of security thru stability & support, theme of

rejection must be explained in any form of relationship to decrease expectant behavior and in touch with realityo Regular time and place of meeting = be consistento Never argue and be judgmentalo Honesty and matter-of-fact approach, calmnesso Mutual expectations and promises are clearo Avoid laughing/talking when client can see youo Clarifying misinterpretation answer all questions as honestly and directly as possibleo Rationales or explanations for rules, activities or requestso Do not force to participate in activitieso Give food in sealed containers and open in front of the client, don’t mix medicine w/ client’s food or beverages

without the client knowing or seeing, do not change expected menu without informing Respect personal distance and try to set relationship expectation and be consistent in meeting expectations Family Therapy /Group Therapy / Support group – overcome fear and feelings of isolation and learn skills of interaction

3. SCHIZOTYPAL PERSONALITY DISORDER (ECCENTRIC PATTERN) > characterized with ongoing pattern in which the affected person distances him- or herself from social and interpersonal relationships + odd behaviors and thoughts that would typically be viewed by others as eccentric, erratic, and bizarre.

DIAGNOSTIC CRITERIA

∞ Pervasive pattern of social and interpersonal deficits evidenced by acute discomfort; reduced capacity for close relationship∞ Ideas of reference∞ Odd beliefs or magical thinking influencing behavior (superstitions and preoccupation/ paranormal phenomena and special

powers - CLAIRVOYANCE∞ Perceptual alterations∞ Odd thinking and speech∞ Odd or eccentric behavior or appearance∞ Suspiciousness or paranoid ideation∞ Stiff, inappropriate or constricted interactions∞ Few close friends or confidants∞ Anxiety in social situations especially unfamiliar ones (no decrease in anxiety even w/ increasing familiarity)

INTERVENTION Establish trusting relationship > long process Reinforcing reality for distorted thoughts and behavior + antipsychotic medication

o Assess delusion/hallucinations > theme of violence to self or others, powerlessness, guilt, hatred loneliness Comment about the behavior: “It seems like you are listening to something”? What are these voices telling you? If content is known do not focus on it: I know you hear these voices or these visions are important to you but

let’s talk about your feelings when you hear these voices? Discourage situations in which client talk about distorted perceptions – use distraction or review medication Point out that client have control over to distorted thoughts and allow to engage in activities that needs

concentrationo If command hallucination is noted > make a contract w/ client not to act on these commando Monitor television selectiono Help pt identify stressor precipitating distorted thoughtso Learn to negotiate with clients hallucinationso Assist to test reality – never agree or disagree = resistance/tension

CBT + Psychotherapy + Social skills training thru Group Therapy

CLUSTER B

1. ANTISOCIAL PERSONALITY DISORDER (AGGRANDIZING PATTERN) > referred as psychopathy, sociopathy or dyssocial personality disorder applied to persons who routinely behave with little or no regard for the rights, safety or feelings of others – chronic with onset before the age of 15 > have not developed enough superego “no guilt or remorse” = tendency to violence and poor self-control

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DIAGNOSTIC CRITERIA∞ Pervasive pattern of disregard for and violation of the rights of others

o Failure to conform to social norms w/ respect to lawful behaviorso Deceitfulness (repeated lying, use of aliases or conning others for personal profit)o Impulsivity of failure to plan aheado Irritability & aggressiveness (repeated fights)o Reckless disregard for safety of self or otherso Consistent irresponsibility (repeated failure to sustain consistent work or obligationso Lack of remorse

∞ Occur since 15 years of age∞ At least 18 years of age∞ Evidence of conduct disorder w/ onset before 15 years of age

INTERVENTION: Individual Psychotherapy + REBT = awareness of interrelatedness of feelings and behaviors (self-insights) , provide model

of mature &appropriate behavior, point out effect of behavior on others Strict limit setting: united staff, no gifts or favors, confront manipulative behavior, consistent + firm & honest + non-

judgmental and matter of fact approach Group therapy / Self-help group

2. BORDERLINE PERSONALITY DISORDER (UNSTABLE PATTERN) > characterized by disturbed interpersonal relationships and self-image, along with impulsive, reckless, and often self-destructive behavior.

DIAGNOSTIC CRITERIA∞ Pervasive pattern of unstable interpersonal relationships, self-image, and affects

o Frantic efforts to avoid real or imagined abandonment o Pattern of unstable and intense interpersonal relationships (alternating between extremes of idealization and

devaluation)o Identity disturbance (markedly and persistently unstable self-image)o Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless

driving or binge eating) o Affective instability o Chronic feelings of emptinesso Recurrent suicidal behavior, gesture o r threats: self-mutilation o Inappropriate, intense anger or difficulty controlling angero Transient, stress-related paranoid ideation

∞ Beginning by early adulthood and presenting in a variety of contexts

INTERVENTION: Individual Psychotherapy + Behavior Modification – help gain insight with clients behaviors (daily journals, encourage

verbalization or expressing angry feelings, showing empathy) Address manipulative behavior – consistent boundaries, confront behavior & enforce consequence for behavior Protect from self-destructive tendencies Assertiveness therapy/Group Therapy / Self-help DBT (Dialectical Behavior Therapy)

o Combines cognitive and behavior therapy focusing in many interconnected behaviors = understand their disorders by actively participating in establishing treatment goals > emotion regulating, interpersonal effectiveness skills, mindfulness skills, distress tolerance skills, self-management skills

Medications: antipsychotic , antidepressant and mood stabilizers

3. HISTRIONIC PERSONALITY DISORDER ( GREGARIOUS PATTERN) > characterized by displays of enduring pattern of attention-seeking and excessively dramatic behaviors > explicitly connected to a patient's physical appearance

DIAGNOSTIC CRITERIA∞ Center of attention∞ Sexually seductive∞ Shifting emotions∞ Physical appearance∞ Speech style∞ Dramatic behaviors∞ Suggestibility∞ Overestimation of intimacy

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Causes:o highly responsive noradrenergic systems = norepinephrine elevationo socioculturalo disapproval in the early mother-child relationship.

INTERVENTION: Address emotionally dependent nature > encourage independence & consistent limit setting (manipulative

behavior), avoid counterference Individual Psychotherapy/Psychoanalytic + REBT + Assertiveness Training – imparting problem solving

skills Deal with clients exaggeration:

o Guide discussion to a logical flow > client will realized unrealistic expectations & fears then allow to self-examine and clarify feelings = correcting dysfunctional thinking

o Offering alternative points of view – encouraging to explore realistically Protect from self-destructive tendencies No group therapy indicated – because of manipulative behavior, dramatic & shallow interaction

4. NARCISSISTIC PERSONALITY DISORDERS (EGOTISTIC PATTERN) > as a pattern of grandiosity (exaggerated claims to talents, importance, or specialness) in the patient's private fantasies or outward behavior = a need for constant admiration from others

DIAGNOSTIC CRITERIA:∞ He or she has a grandiose sense of self-importance (exaggerates accomplishments and demands to be

considered superior without real evidence of achievement).∞ He or she lives in a dream world of exceptional success, power, beauty, genius, or "perfect" love.∞ He or she thinks of him- or herself as "special" or privileged, and that he or she can only be understood by

other special or high-status people.∞ He or she demands excessive amounts of praise or admiration from others.∞ He or she feels entitled to automatic deference, compliance , or favorable treatment from others.∞ He or she is exploitative towards others and takes advantage of them.∞ He or she lacks empathy and does not recognize or identify with others' feelings.∞ He or she is frequently envious of others or thinks that they are envious of him or her.∞ He or she "has an attitude" or frequently acts in haughty or arrogant ways.

INTERVENTION: Individual Psychotherapy/Psychoanalytical + CBT Limit setting and boundaries

PERSONALITY SUBTYPES

Craving narcissists. These are people who feel emotionally needy and undernourished, and may well appear clingy or demanding to those around them.

Paranoid narcissists. This type of narcissist feels intense contempt for him- or herself, but projects it outward onto others. Paranoid narcissists frequently drive other people away from them by hypercritical and jealous comments and behaviors.

Manipulative narcissists. These people enjoy "putting something over" on others, obtaining their feelings of superiority by lying to and manipulating them.

Phallic narcissists. Almost all narcissists in this subgroup are male. They tend to be aggressive, athletic, and exhibitionistic; they enjoy showing off their bodies, clothes, and overall "manliness."

Cluster C

1. AVOIDANT PERSONALITY (WITHDRAWN PATTERN) > characterized by soc2. distrustfulness, and emotional distance - desire to be in relationships with others but lack the skills and

confidence that are necessary in social interactions > in order to protect themselves from anticipated criticism or ridicule = they withdraw from other people

DIAGNOSTIC CRITERIA∞ Pervasive pattern of social inhibition w/ feelings of inadequacy and hypersensitivity to negative

evaluationo Avoidance of activities involving significant personal contact because of fear of criticism,

disapproval, or rejectiono Lack of willingness for involvement unless certainty of being liked

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o Restraint within intimate relationship for fear of shame or ridiculeo Preoccupation with criticism or rejection in social situationso Inhibition in new interpersonal situationso Viewing self as socially inept, personally unappealing or inferioro Unusual reluctance to take personal risks or engage in new activities

INTERVENTION: Individual Psychotherapy + group therapy Provide activity increasing self-esteem and increasing social skills Deal with perception of “too unimportant to bother” consistently = assertiveness

therapy/CBT/Desensitization

3. DEPENDENT PERSONALITY (SUBMISSIVE PATTERN) > characterized by an excessive need to be taken care of or depend upon others = have a low level of confidence in their own intelligence and abilities.

DIAGNOSTIC CRITERIA∞ Pervasive and excessive need for being taken care of resulting in submission and clinging with

fears of separationo Advice and reassurance needed from others for decision-makingo Responsibility for major areas of life assumed by others o Difficulty expressing disagreement with others for fear of loss of support or approvalo Difficulty initiating things by selfo Excessive methods used to obtain support and nurturance from otherso Uncomfortable and helpless when aloneo Urgent seeking of another relationship if previous one endso Unrealistic preoccupation with fears of having to take care of self

INTERVENTION: ASSESSMENT: self-worth, interpersonal relationship and social behavior Psychotherapy – short term > avoiding reinforcement of client dependent relationship w/ therapist

o Pt telephones nurse frequentlyo Request to see nurse frequentlyo Ask the nurse to make decision for himo Request for more frequent & longer therapy sessions

Emphasize expectations of the therapy and stress limit setting, set an objective evaluative tool for treatment (assessing behavior toward independence), deal with separation anxiety therapeutically at the end of therapeutic relationship

Home management skills and assertiveness therapies + interpersonal skills enhancement

4. OBSESSIVE-COMPULSIVE PERSONALITY DISORDERS (CONFORMING PATTTERN) > marked by rigidity, control, perfectionism, and an overconcern with work at the expense of close interpersonal relationships - often have trouble relaxing because they are preoccupied with details, rules, and productivity

DIAGNOSTIC CRITERIA∞ Pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal

control at the expense of flexibility, openness, and efficiencyo Major points of activity lost because of preoccupationo Task completion interfered with because of perfectionismo Excessive devotion to work and productivity, excluding friends and leisureo Overly conscientious, scrupulous and inflexible about morality, ethics, or valueso Difficulty discarding worn-out or worthless objectso Reluctance to delegate tasks or work with otherso Miserly spending attitudeo Rigidity and stubbornness

INTERVENTION: Psychotherapy – client is usually resistant to changes + have high expectations (he rejects anything that do

not fit his cognitive schema) REBT + Write a journal of his/her feeling > to gain awareness of their emotions

OTHERS:

PASSIVE-AGGRESSIVE PERSONALITY DISORDER > characterized by passively expressing covert aggression rather than dealing with it directly that can interfere with social and work activities – “chip on the

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shoulder attitude” = reflects hostility which he dare not to express openly due to fear of rejection & retaliation > they express it passively

Causes: dominant-rigid father, oral character, fear of rejection when exhibiting aggressive behavior (sociocultural/interpersonal)

DIAGNOSTIC CRITERIA: Pessimistic, procrastination, stubbornness, intentional insufficiency, forgetfulness and dependency

CYCLOTHYMIC PERSONALITY DISORDER > characterized by a symptomatically mild form of bipolar disorder - involves mood swings ranging from mild depression to mild mania = w/o apparent reason or identifiable cause > last for a week or longer

DIAGNOSTIC CRITERIA:∞ Numerous episodes of hypomania and depression that is not severe enough to be considered major

depression. These episodes must have lasted for at least two years.• During the same two-year period (one year for children and adolescents), the individual has not

been free from either hypomania or mild depression for more than two months at a time.• No major depression, mania, or mixed (both depression and mania together) condition has been

present during the first two years of the disorder.• The symptoms cause significant impairment in the patient's social, occupational, family, or other

important areas of life functioning.

INTERVENTION: Antimanic + Psychotherapy > directed toward increasing the patient's awareness of his or her condition and helping to develop effective coping strategies for mood swings + Family Therapy and Social Skills Enhancement

IMPULSE –CONTROL DISORDERS > irresistible impulsivity or temptation to complete an activity that is considered harmful to self or others > an increase tension before committing the act = excitement or gratification at the time the act is committed

Release of tension is perceived pleasurable but remorse and regret usually follows the act

a. INTERMITTENT EXPLOSIVE DISORDER – episodes of aggressiveness resulting to assault or destruction of property = severity of aggressiveness is out of proportion to the provocation

∞ Intervention: Psychotherapy (behavior modification) + psychopharmacologic > anxiolytic, GABA-ergic mood stabilizer, serotonergic antidepressant

b. KLEPTOMANIA – cannot resist the urge to steal and independently steal items that they could easily afford (items is not useful or wanted) = tension at first then pleasure and relief at the time of the theft

c. PYROMANIA – irresistible impulse to start fire > fascinated with fires = arsonist (intentionally set fires or make an effort at fire setting) = have low self-esteem and difficulty managing anger

∞ Interventions: Psychoeducation +CBT

d. PATHOLOGICAL GAMBLING – starts w/ social gambling > recurrent and disrupt personal, family, or vocational pursuits = preoccupied with Gambling & experiences euphoria/aroused state during actual betting

Seeking an aroused state is often more important to the pathologic gambler than the desire for money itself Bigger & bigger bets to relentlessly chase their loses in an attempt to win them back > lose control Repeating = escape from depressive mood + OMNIPOTENCE (self-deceptions) -> denial Stages: WINNING - -> LOSING - DESPERATION -- HOPELESSNESS

∞ Intervention: psychotherapy + CBT + family/group therapy + SSRI

e. TRICHOTILLOMANIA – chronic, self-destructive hair pulling = result in noticeable hair loss (including eyebrow/eyelashes)

Increase in tension before pulling out the hair or resisting behavior Relief = after hair is pulled > reflects self-mutilation = pt does it alone and denies it Hair ingestion = development of hair ball > anorexia, stomach pain, anemia, obstruction and

peritonitis, infection

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