Dependent Personality Disorder

Disease class: Personality Disorders

Personality disorder cluster: C (anxious) 

 

See also

Other cluster C personality disorders

• Avoidant Personality Disorder
• Obsessive-Compulsive Personality Disorder

Histrionic Personality Disorder

Disease class: Personality Disorders

Personality disorder cluster: B (dramatic) 

Commonly known as:

• HPD

 

Aetiology / Risk factors

• Severe psychological trauma in childhood, particularly:
• Sexual abuse
• Physical abuse
• Emotional abuse
  
• Neglect
• Loss of a close friend or relative
• Severe physical illness
  
• Inheritance of high-risk genes from parents
  

 

Symptoms and signs

• Anxiety 
• Depression
• Self-harm
• Suicidal ideation
• Attempted suicide 
• Recreational drug use
• Hypersexuality  
• Psychosis
• Medically unexplained physical symptoms  
• Alexithymia (lack of insight into their own emotions) 
• Impulsivity
• Hypersensitivity to criticism
• Irritability
• Attention seeking behaviour 
• Co-dependence
• Fear of abandonment
• Lack of self identity (to quote many patients: "I feel like a blank piece of paper, which nobody ever wrote on.")
  
• Abnormally flirtatious or charismatic behaviour
• Reckless, high-risk behaviour
  
• Criminal activity
• Lack of concern for the feelings and rights of others
  

 

Age of onset

• Signs and symptoms of emerging PDs can be observed throughout childhood and adolescence, with a marked increase in severity between 14-18. 
• Personality disorders are never officially diagnosed in children, as the personality usually changes dramatically during the course of normal development.
• In some children, a diagnosis of Conduct Disorder may be made. CD is often called a precursor to Antisocial Personality Disorder, because of the similarities in the conditions. Most children with CD become less antisocial with normal development, but 25-40% of CD cases later meet the diagnostic criteria for ASPD in adulthood.
  

 

Common co-morbidities

• Eating disorder 
• Substance misuse disorder
• Anxiety disorder
• Depressive disorder 

 

Stigmatising factors

Patients with personality disorders (particularly "psychopaths" and "narcissists") are frequently vilified in the media. Stigma has increased as public awareness of "borderline PD" has increased. Many healthcare workers, including mental health specialists, describe strong feelings of fear or frustration when engaging with most PD patients. For these reasons, a diagnostic label of "personality disorder" may have a negative impact on a patient's self-esteem.

The following stigmatising features can be demonstrated in a significant proportion of the PD population:

• A widespread belief that PDs are 'incurable' or that 'every personality is fixed': Severe dysfunction often persists until the patient reaches their 40s. Significant progress is only seen once the patient develops a sincere and strong commitment to change themselves.
  
• An adversarial affect: PD patients often display aggression, hostility, unpredictability, irrationality, impulsivity, hypersensitivity, and similar traits.
  
• Intentional use of deceptive psychological manipulation techniques. For example: crying loudly, threatening, lying.
  
• Symptoms and signs which are self-inflicted (self-harm; suicide attempts; substance misuse; factitious disorder; malingering) or medically unexplainable (somatic symptom disorder).
  
• Self-destructive behaviours: Gambling, unsafe sexual practices, criminal activities.
• Non-compliance with medication, therapies and other interventions.
• A subconscious resistance to change and fears of 'getting better', becoming 'normalised', or losing support from healthcare providers.
  

 

Management 

PD patients often seek help for physical complaints (e.g. self-harm; suicide attempts; substance misuse; malingering; factitious disorder; somatic symptom disorder). 

Medical doctors have a legal and ethical obligation to investigate them each time they present to healthcare settings (within reason). After excluding any harmful 'organic' diseases, competent doctors should consider possible mental health disorders and document their objective findings thoroughly.

Diagnosis and stigmatisation

Patients with likely PDs often lack an official diagnosis, even if their healthcare providers strongly suspect it. PDs must be diagnosed by specialists after weeks or even months of regular assessment. They can be notoriously to diagnose, for reasons including:

• The huge variety of clinical presentations: 
• Many PD patients demonstrate a 'classic' set of signs, symptoms and risk factors. Experienced clinicians can recognise likely PD in some patients in a matter of minutes. However, many PD patients lack these common features or mimic other conditions. 
• They often lack insight into their condition.
• They often complain of physical problems rather than psychological ones. 
• Substance misuse is common within this group, and it is impossible to make a fair and accurate diagnosis until they are clean and sober.
  
• At first presentation, some patients with EUPD can be indistinguishable from patients with bipolar disorder. This has been demonstrated in studies with experienced psychiatrists.
  
• Frequently poor engagement with healthcare services: frequent incidents of hostility towards healthcare staff, premature self-discharge from hospital or missed appointments (DNA: Did Not Attend).
• Concealment of essential information: signs, symptoms, risk factors, etc. May be intentional or involuntary (e.g. fluctuating emotional states; dissociation; repression of traumatic memories).
  
• Difficulties in defining 'disordered' personalities: There is a broad spectrum of healthy personalities in the population and there is a risk of 'over-medicalising' uncommon, but healthy variations.

Diagnostic labels can be difficult to remove, once mentioned to the patient or entered into medical records. Various euphemisms are often used to convey that a patient may have HPD. For example: in the National Health Service, many patients with undiagnosed HPD are described as "cluster 8" patients. This is because "Care cluster 8" refers to "Non-psychotic, chaotic and challenging disorders", most commonly, EUPD. 

 

Risk management

•  Patients should be assessed for risk of suicide or self-harm and monitored carefully.

 

Medication

Patients with PDs are often prescribed antidepressants, anxiolytics, anti-psychotics, painkillers, hypnotics, sedatives, and other medications. These are often unnecessary, or even harmful.

As a general rule of thumb for non-specialists, PDs usually benefit more from therapy than medication, whereas bipolar disorder usually benefits from medication more than therapy.

 

Therapy

• DBT: Dialectical Behavioural Therapy. This is the most well-known and well-regarded class of therapy available for HPD patients.
  
• CBT: Cognitive-Behavioural Therapy. This is cheaper, faster, more cost-effective, and more available than DBT. Unfortunately, the nature of HPD makes CBT relatively ineffective in this group, especially if it is not delivered through a guided 1-on-1 course.
• Psychodynamic psychotherapy. This involves a long period of very deep guided introspection and analysis of subconscious processes. This option is relatively expensive, difficult to access and promotes a high degree of dependence on the therapist until completion. 
• Counselling: Relatively cheap and accessible. This usually involves talking about concerns and traumatic events at a superficial level. Counsellors are often self-employed and they are subject to less regulation than other clinicians. 
• There is a risk to the mental health of both the patient and the therapist, if the therapist lacks the skill or knowledge to safely manage PDs.
  

 

Prognosis

• Severe dysfunction often persists until the patient reaches their 40s. Significant progress is only seen once the patient develops a sincere and strong commitment to change themselves.

 

Compare with:

• Bipolar disorder
• Attention deficit hyperactivity disorder
• Other cluster B (dramatic) personality disorders:
  
• Antisocial Personality Disorder
• Emotionally Unstable Personality Disorder
• Narcissistic Personality Disorder
  
• Conduct disorder (a similar disorder of childhood) 

Schizoid Personality Disorder

Disease class: Personality Disorders

Personality disorder cluster: A (Odd)

 

See also:

• Schizophrenia 

Other cluster A (Odd) personality disorders:

• Paranoid Personality Disorder
• Schizotypal Personality Disorder

Schizotypal Personality Disorder

Disease class: Personality Disorders

DSM-V category: Schizophrenia spectrum and other psychotic disorders

Personality disorder cluster: A (Odd) 

 

See also:

• Schizophrenia
  

Other cluster A (Odd) personality disorders:

• Paranoid Personality Disorder
• Schizoid Personality Disorder

Antisocial Personality Disorder

Disease class: Personality Disorders

Personality disorder cluster: B (dramatic) 

Commonly known as:

• ASPD
• Psychopathy
• Sociopathy
  

 

Aetiology / Risk factors

• Severe psychological trauma in childhood, particularly:
• Sexual abuse
• Physical abuse
• Emotional abuse
  
• Neglect
• Loss of a close friend or relative
• Severe physical illness
  
• Inheritance of high-risk genes from parents
  

 

Symptoms and signs

• Recreational drug use
• Hypersexuality  
• Alexithymia (lack of insight into their own emotions) 
• Impulsivity
• Hypersensitivity to criticism
• Irritability
• Attention seeking behaviour 
• Abnormally flirtatious or charismatic behaviour
• Reckless, high-risk behaviour
  
• Criminal activity
• Lack of concern for the feelings and rights of others
  

 

Age of onset

• Signs and symptoms of emerging PDs can be observed throughout childhood and adolescence, with a marked increase in severity between 14-18. 
• Personality disorders are never officially diagnosed in children, as the personality usually changes dramatically during the course of normal development.
• In some children, a diagnosis of Conduct Disorder may be made. CD is often called a precursor to Antisocial Personality Disorder, because of the similarities in the conditions. Most children with CD become less antisocial with normal development, but 25-40% of CD cases later meet the diagnostic criteria for ASPD in adulthood.
  

 

Common co-morbidities

• Substance misuse disorder
• Anxiety disorder
• Depressive disorder 

 

Stigmatising factors

Patients with personality disorders (particularly "psychopaths" and "narcissists") are frequently vilified in the media. Stigma has increased as public awareness of "borderline PD" has increased. Many healthcare workers, including mental health specialists, describe strong feelings of fear or frustration when engaging with most PD patients. For these reasons, a diagnostic label of "personality disorder" may have a negative impact on a patient's self-esteem.

The following stigmatising features can be demonstrated in a significant proportion of the PD population:

• A widespread belief that PDs are 'incurable' or that 'every personality is fixed': Severe dysfunction often persists until the patient reaches their 40s. Significant progress is only seen once the patient develops a sincere and strong commitment to change themselves.
  
• An adversarial affect: PD patients often display aggression, hostility, unpredictability, irrationality, impulsivity, hypersensitivity, and similar traits.
  
• Intentional use of deceptive psychological manipulation techniques. For example: crying loudly, threatening, lying.
  
• Symptoms and signs which are self-inflicted (self-harm; suicide attempts; substance misuse; factitious disorder; malingering) or medically unexplainable (somatic symptom disorder).
  
• Self-destructive behaviours: Gambling, unsafe sexual practices, criminal activities.
• Non-compliance with medication, therapies and other interventions.
• A subconscious resistance to change and fears of 'getting better', becoming 'normalised', or losing support from healthcare providers.
  

 

Management 

PD patients often seek help for physical complaints (e.g. self-harm; suicide attempts; substance misuse; malingering; factitious disorder; somatic symptom disorder). 

Medical doctors have a legal and ethical obligation to investigate them each time they present to healthcare settings (within reason). After excluding any harmful 'organic' diseases, competent doctors should consider possible mental health disorders and document their objective findings thoroughly.

Diagnosis and stigmatisation

Patients with likely PDs often lack an official diagnosis, even if their healthcare providers strongly suspect it. PDs must be diagnosed by specialists after weeks or even months of regular assessment. They can be notoriously to diagnose, for reasons including:

• The huge variety of clinical presentations: 
• Many PD patients demonstrate a 'classic' set of signs, symptoms and risk factors. Experienced clinicians can recognise likely PD in some patients in a matter of minutes. However, many PD patients lack these common features or mimic other conditions. 
• They often lack insight into their condition.
• They often complain of physical problems rather than psychological ones. 
• Substance misuse is common within this group, and it is impossible to make a fair and accurate diagnosis until they are clean and sober.
  
• Frequently poor engagement with healthcare services: frequent incidents of hostility towards healthcare staff, premature self-discharge from hospital or missed appointments (DNA: Did Not Attend).
• Concealment of essential information: signs, symptoms, risk factors, etc. May be intentional or involuntary (e.g. fluctuating emotional states; dissociation; repression of traumatic memories).
  
• Difficulties in defining 'disordered' personalities: There is a broad spectrum of healthy personalities in the population and there is a risk of 'over-medicalising' uncommon, but healthy variations.

Diagnostic labels can be difficult to remove, once mentioned to the patient or entered into medical records. Various euphemisms are often used to convey that a patient may have ASPD. For example: in the National Health Service, many patients with undiagnosed ASPD are described as "cluster 8" patients. This is because "Care cluster 8" refers to "Non-psychotic, chaotic and challenging disorders", most commonly, EUPD. 

 

Risk management

•  Patients should be assessed for risk of suicide or self-harm and monitored carefully.

 

Medication

Patients with PDs are often prescribed antidepressants, anxiolytics, anti-psychotics, painkillers, hypnotics, sedatives, and other medications. These are often unnecessary, or even harmful.

As a general rule of thumb for non-specialists, PDs usually benefit more from therapy than medication, whereas bipolar disorder usually benefits from medication more than therapy.

 

Therapy

• DBT: Dialectical Behavioural Therapy. This is the most well-known and well-regarded class of therapy available for ASPD patients.
  
• CBT: Cognitive-Behavioural Therapy. This is cheaper, faster, more cost-effective, and more available than DBT. Unfortunately, the nature of ASPD makes CBT relatively ineffective in this group, especially if it is not delivered through a guided 1-on-1 course.
• Psychodynamic psychotherapy. This involves a long period of very deep guided introspection and analysis of subconscious processes. This option is relatively expensive, difficult to access and promotes a high degree of dependence on the therapist until completion. 
• Counselling: Relatively cheap and accessible. This usually involves talking about concerns and traumatic events at a superficial level. Counsellors are often self-employed and they are subject to less regulation than other clinicians. 
• There is a risk to the mental health of both the patient and the therapist, if the therapist lacks the skill or knowledge to safely manage PDs.
  

 

Prognosis

• Significant progress is only seen once the patient develops a sincere and strong commitment to change themselves.

 

Compare with:

• Bipolar disorder
• Attention deficit hyperactivity disorder
• Other cluster B (dramatic) personality disorders:
  
• Emotionally Unstable Personality Disorder
• Histrionic Personality Disorder
• Narcissistic Personality Disorder 
• Conduct disorder (a similar disorder of childhood)

Paranoid personality disorder

Disease class: Personality Disorders

Personality disorder cluster: A (Odd)

 

See also:

Other cluster A (Odd) personality disorders:

• Schizoid Personality Disorder
• Schizotypal Personality Disorder

Periostitis

Disease class: bone diseases, Infectious

Schizophrenia spectrum and other psychotic disorders

DSM-V category: Primary category
MeSH category: Mental disorders

MeSH

• affective disorders, Psychotic 
• Capgras syndrome 
• Delusional parasitosis 
• Morgellons disease 
• Paranoid disorders 
• Psychotic disorders 
• Schizophrenia 

DSM-V

• Schizotypal (Personality) Disorder (90)
• Delusional Disorder (90)
• Brief Psychotic Disorder (94)
• Schizophreniform Disorder (96)
• Schizophrenia (99)
• Schizoaffective Disorder (105)
• Substance / Medication-Induced Psychotic Disorder (110)
• Psychotic Disorder Due to Another Medical Condition (115)
• Catatonia Associated With Another Mental Disorder (Catatonia Specifier) (119)
• Catatonic Disorder Due to Another Medical Condition (120)
• Unspecified Catatonia (121)
• Other Specified Schizophrenia Spectrum and Other Psychotic Disorder (122)
• Unspecified Schizophrenia Spectrum and Other Psychotic Disorder (122)  

Appendicitis

Disease class: Caecal diseases
Disease class: Gastroenteritis
Disease class: Intraabdominal Infections

This is an inflammatory condition of the appendix, and is a common surgical emergency,
affecting mainly adolescents and young adults.

It is usually due to a combination of obstruction and infection of the appendix, and has a variable clinical course ranging from episodes of mild self-limiting abdominal pain to life-threatening illness.

Abdominal pain, beginning in the centre of the abdomen but which later shifts position to the right iliac fossa, is the classic symptom. The patient usually has accompanying fever and sometimes nausea, vomiting, loss of appetite, diarrhoea, or even constipation. The precise symptoms vary with the exact location of the appendix within the abdomen. In some individuals the appendix may ‘grumble’ with repeated mild attacks which resolve spontaneously.

In an acute attack, the inflammatory process begins first in the wall of the appendix but, if the disease progresses, the appendix can become secondarily infected and pus may form within it. The blood supply may become compromised and the wall become gangrenous.

Eventually the appendix may rupture, giving rise to a localised abscess in the abdomen or, more rarely, free pus within the abdomen, which causes generalised peritonitis. Rupture of the appendix is a serious complication and the patient may be severely unwell.

Surgeons recognise that in order to make sure patients with appendicitis do not progress to peritonitis, a certain percentage of normal appendixes are removed when clinical signs are suspicious but not diagnostic of disease.

Major depressive disorder

 DSM-V category: Depressive disorders

 

Mesenteric lymphadenitis

Disease class: Lymphadenitis
Disease class: Peritoneal diseases

Definition

This refers to inflammation of the lymph nodes (glands) in the mesentery. 

 

Presentation

• Acute abdomen

 

Symptoms

• Abdominal pain

 

Causes

• Yersinia enterocolitica

Tourette syndrome

Disease class: Basal ganglia diseases

Disease class: heredodegenerative disorders, Nervous system

Disease class: Tic disorders

Also known as

Gilles De La Tourette's syndrome 

 

Differential diagnosis

• Tourettism

α-Synucleinopathies

Disease class: Neurodegenerative diseases

Types 

• Dementia with Lewy bodies
• Multiple system atrophy
• Parkinson disease

 

Pathophysiology  

• A Lewy body is a aggregate of alpha-synuclein protein.
• There is a pathological finding of Lewy bodies in neurons.
• There is a pathological finding of abnormal neurites called Lewy neurites.

Dementia with Lewy bodies

Disease class: α-Synucleinopathies

Disease class: Dementia

Disease class: Neurodegenerative diseases 

Disease class: Parkinsonian disorders

Also known as

DLB, Lewy body disease

 

Pathophysiology

DLB is an alpha-synucleinopathy.

 

Epidemiology

• This is the third most common cause of dementia. 

Differential diagnosis

This is a Parkinson-plus syndrome.

Thrombotic thrombocytopenic purpura

Disease class: Thrombocytopenic purpura

Disease class: Thrombophilia

Also known as 

TTP

Premature Rupture of Fetal Membranes

Disease class: Obstetric labor complications

Also known as PROM.

Dystocia

Disease class: Obstetric labor complications

Dystocia: Slow or difficult labour

Shoulder dystocia

Initially, request senior help and ask the mother to hyperflex their legs (McRobert's manouvere) and apply suprapubic pressure. This method works in 90% of cases.

If this method fails, episiotomy is required. This allows internal manouveres including:

• Wood's screw manouvere
• Grasping and manipulation of the posterior arm. 

Final resorts

• Symphisiotomy
• The Zavanelli manouvere (leading to Caesarean section). By this point fetal damage is often irreversible.

Prenatal injuries

Disease class: Pregnancy complications

Hyperemesis gravidarum

Disease class: Morning sickness

Morning sickness

Disease class: Pregnancy complications

Types

• Hyperemesis gravidarum