Psychiatry and Behavioral Health Rotation

A manic episode with or without a major depressive episodes

Five or more SIEGECAPS for ≥ 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia

• Sadness
• Interest/anhedonia
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor activity
• Suicidal

At least one hypomanic episode and at least one major depressive episode

• There has never been a manic episode

Chronic depressions - depressive symptoms for > 2 years

A chronic mood disorder characterized by episodes of depression and hypomania for at least 2 years.

• This is a less intense but often longer-lasting version of bipolar disorder.
• A person with cyclothymia has both high and low mood, but never as severe as either mania or major depression.

Excessive anxiety and worry occurring more days than not for at least 6 months

The patient has experienced a traumatic event which causes an acute stress reaction.

• Once the symptoms persist past 1 month it is now considered post-traumatic stress disorder (PTSD)

An occurrence of 3 panic attack episodes in three weeks

• At least one of the attacks has been followed by one month (or more) of one or both of the following:
  • Persistent concern or worry about additional panic attacks or their consequences
  • A significant maladaptive change in behavior related to the attacks

Excessive and persistent fear of a specific object, situation or activity that is generally not harmful (fear of flying or fear of spiders).

• Lasts for 6 months or more.
• Patients know their fear is excessive, but they can’t overcome it.

Specific phobia (see specific section)

Social phobia (social anxiety disorder)

• Marked and persistent (>  6 months) fear of social or performance situations in which one is exposed to unfamiliar people or to possible scrutiny by others
• Fear of acting in a humiliating or embarrassing way
  • public speaking, initiating conversation, dating, eating in public
• May coexist with an avoidant personality disorder

Alcohol is a depressant - increases GABAa channel opening. Long-term use leads to downregulation of GABA channels (inhibitory) and upregulation of NMDA (excitatory)

• Intoxication:
  • Dilated pupils; clumsiness; difficulty walking; slurred speech; sleepiness; poor judgment. Talkative, flirtatious, aggressive, moody, disinhibited
• Treatment:
  • Thiamine, folate, MVI, destrose (particularly if chronic alcoholism), and IV fluids. Benzodiazepines.

Delirium Tremens (48 - 96  hours): autonomic instability, disorientation, hallucinations, agitation.

• Suspect in a patient with unknown history followed by DT symptoms 2 days later
•  IV benzodiazepines, preferably in an ICU.

Addiction medications

• Disulfiram - inhibits acetaldehyde dehydrogenase, aversive conditioning
• Naltrexone - decreases desire
• Gabapentin - decreases desire

Patient with CNS depression and a history of anxiety or panic disorder

Anxiolytics are medications such as benzodiazepines used for the treatment of anxiety disorders. They have additive effects with alcohol and tend to have a cumulative effect if doses are repeated indiscriminately.

• The mechanism is through GABAa channel-increased frequency of opening.
• Intoxication: respiratory depression, hypotension, amnesia, ataxia, stupor/somnolence, coma, death.
• Withdrawal: rebound anxiety, seizures (life-threatening) and tremor-most commonly found in short-acting benzos such as alprazolam.

Treatment:

Treat life-threatening intoxication with flumazenil which is a competitive GABA antagonist.

• Treat of withdrawal with a long-acting benzo such as clonazepam with an appropriate taper.

Binds to CB1/CB2 cannabinoid receptors

• Intoxication
  • Euphoria, anxiety, disinhibition, paranoid delusions, perception of slowed time, conjunctival injection, impaired judgment, social withdrawal, ↑ appetite, dry mouth, hallucinations
  • Amotivational syndrome
  • Treatment:
    • No specific treatment
    • Symptomatic treatment only
• Withdrawal
  • Irritability, depression, insomnia, nausea, anorexia
  • Most symptoms peak in 48 hours and last for 5 - 7 days
  • Can be detected in urine up to 1 month after last use
  • Hyperemesis syndrome
    • In chronic cannabis users, individuals can experience chronic severe emesis due to downregulation of CNS cannabinoid receptors and upregulation of gut cannabinoid receptors
    • Treatment: stop smoking marijuana, anti-emetics (ondansetron, metoclopramide)
  • Treatment
    • No specific treatment
    • Symptomatic treatment only

Cocaine: block biogenic amine (Dopamine (DA), norepinephrine (NE) and Serotonin (5-hydroxytryptamine; 5-HT)) reuptake

• Intoxication:
  • Mental status changes
    • Euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations
  • Sympathetic activation
    • ↓ appetite, tachycardia, pupillary dilation, hypertension, angina
    • can cause severe vasospasm
      • MI - coronary vasospasm
      • placental infarction - vasospasm of placental vessels
      • nasal septum perforation - Kiesselbach's plexus vasospasm
      • stroke - CVA
  • Stereotyped behavior
    • Repetitive motions (eg. digging through trash)
  • Treatment
    • pharmacologic
      • antipsychotics (haloperidol)
        • benzodiazepines
        • antihypertensives (labetalol - need alpha-1 blockade)
        • vitamin C - promotes excretion
      • non-pharmacologic
        • do not restrain patients
          • may result in rhabdomyolysis
• Withdrawal
  • severe depression and suicidality
  • hyperphagia, hypersomnolence, fatigue, malaise
  • severe psychological craving
  • treatment
    • pharmacologic
      • bupropion
      • bromocriptine
      • SSRI's for depression

Amphetamines: methamphetamine, dextroamphetamine (Dexedrine), methylphenidate (Concerta).

Simulates biogenic amine (Dopamine (DA), norepinephrine (NE) and Serotonin (5-hydroxytryptamine; 5-HT) release + decreases reuptake (high dose)

• Intoxication
  • Mental status changes
    • euphoria, impaired judgment, delusions, hallucinations, prolonged wakefulness/attention
  • Sympathetic activation
    • psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, cardiac arrhythmias
  • Treatment
    • pharmacologic
      • antipsychotics (haloperidol)
      • benzodiazepines
      • vitamin C (promotes excretion)
      • antihypertensives
      • propranolol (BP + tachycardia control)
    • Non-pharmacologic
      • do not restrain patients
        • may result in rhabdomyolysis

PCP

Patient that is extremely aggressive and becomes enraged when sudden movements or loud sounds are made.

•  Mechanism: NMDA receptor antagonist - Ketamine is a similar drug
• Intoxication
  • Belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia
  • Treatment
    • Pharmacologic
      • antipsychotics (haloperidol)
        
      • benzodiazepines
    • Further management
      • low stimulus environment
      • restraints if needed to prevent patient from hurting self/others
• Withdrawal
  • Depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
  • Treatment: no specific treatment - symptomatic treatment only

LSD

Patient wants to hurt himself.  They say that he has "been freaking out" and seeing things that are not there.

• Mechanism: action at 5-HT receptor
• Intoxication
  • visual hallucinations and synesthesias (e.g., seeing sound as color)
  • marked anxiety or depression, delusions, pupillary dilation
  • "bad trip" panic
• Treatment
  • Pharmacologic
    • antipsychotics (e.g., haloperidol)
    • benzodiazepines
    • talking down, supportive counseling
• Withdrawal
  • largely no withdrawal because it does not affect dopamine
  • flashbacks can occur years later
• Treatment: no specific treatment - symptomatic treatment only

Cigarette smoking is the leading preventable cause of death in the United States.

• Cigarette smoking causes more than 480,000 deaths each year in the United States. This is nearly one in five deaths.
• Smoking causes more deaths each year than the following causes combined:
  • Human immunodeficiency virus (HIV)
  • Illegal drug use
  • Alcohol use
  • Motor vehicle injuries
  • Firearm-related incidents

• Intoxication: restlessness, insomnia, anxiety, arrhythmias
• Withdrawal: irritability, headache, anxiety, weight gain, craving

Treatment for cessation

• Bupropion
• Varenicline (Chantix): Partial nicotine receptor agonist. Mediates partial reward of nicotine yet blocks reward of nicotine
  • Highest success rate of all anti-smoking drugs, particularly when stacked with nicotine patches
• Nicotine administration via other routes

Mechanism: unknown

• Intoxication
  • belligerence, assaultiveness
  • apathy, impaired judgment
  • blurred vision, coma
• treatment
  • no specific treatment
  • antipsychotics (haloperidol) if severe aggression
• Withdrawal
  • not well characterized, no treatment
  • abuse of other drugs commonly seen in these patients often from a low socioeconomic background

• Mechanism: mu receptor agonist
• Examples: morphine, heroin, methadone

Intoxication

• constipation - no tolerance to this side effect
• respiratory depression - life-threatening
• pupillary constriction (pinpoint pupils)
• seizures (overdose is life-threatening)
• for heroin use, look for track marks (needle injections)

pharmacologic

• naloxone/naltrexone
  • opioid receptor antagonist
  • opioid withdrawal is NOT fatal - it is just unpleasant
• symptomatic treatment

Withdrawal

• presentation
  • anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection ("cold turkey"),
  • fever, rhinorrhea, nausea, stomach cramps, diarrhea ("flulike" symptoms)
  • yawning
    • unpleasant but not life-threatening
• treatment of withdrawal
  • clonidine
    • α2 agonist that decreases NE and sympathetic output making autonomic symptoms less intense
  • methadone (long-acting)
  • buprenorphine + naloxone
    • can precipitate withdrawal if given too soon (partial mu agonist)

• treatment of addiction
  • pharmacologic
    • methadone
      • typically oral
      • long-acting IV opiate
      • used for heroin detoxification or long-term maintenance
    • Suboxone (buprenorphine + naloxone)
      • long-acting oral administration with fewer withdrawal symptoms than methadone
      • naloxone + buprenorphine (partial opioid agonist)
      • naloxone is not active when taken orally, so withdrawal symptoms occur only if injected
        • intended to prevent overdose when Suboxone is injected

Otherwise normally functioning person with a belief in something that does not exist.

One or more non-bizarre delusions of thinking—such as expressing beliefs that occur in real life such as being poisoned, being stalked, being loved or deceived, or having an illness, provided no other symptoms of schizophrenia are exhibited.

• No accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect.
• Beliefs lasting > 1-month
• Functioning is otherwise unimpaired

Treatment

• Psychotherapy
• Pharmacologic - atypical antipsychotic agents

Major psychosis for greater than 6 months + difficulty functioning

• Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
  1. Delusions
  2. Hallucinations - auditory (most common), tactile olfactory visual
  3. Disorganized speech/thought processes unable to stay on topic (loose associations) unable to provide answer related to questions (tangential response)
  4. Symptoms impair daily functioning
  5. Disorganized behavior - unpredictable agitation, inappropriate sexual behavior, child-like silliness, catatonic motor behavior, lacking self-care/hygiene
  6. Negative symptoms - blunted affect, poor posture, lack goal-directed activities/initiative
  7. Impairment inability to hold job or maintain relationships
• Continuous signs of the disturbance persist for at least 6 months. 

Treatment:

• Atypical Antipsychotics: (risperidone, olanzapine, aripiprazole, ziprasidone, quetiapine, asenapine, paliperidone) for negative symptoms & fewer side effects
• Clozapine is an atypical antipsychotic that is not considered first line because of the propensity to cause agranulocytosis.
• Typical neuroleptics - dopamine antagonists (haloperidol, chlorpromazine, thioridazine, loxapine, fluphenazine) best for positive symptoms

Resistant cases – clozapine or antipsychotic + another med (benzo, carbamazepine, valproate, lithium)

• Behavior-oriented/group/family therapy
• Watch for side effects: extrapyramidal, parkinsonian symptoms, neuroleptic malignant syndrome, tardive dyskinesia - more likely with typical neuroleptics; clozapine may cause agranulocytosis

A mental health condition including schizophrenia and mood disorder symptoms.

Schizoaffective disorder is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may occur at the same time or at different times.

• Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
• Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.

Treatment:

• Psychotherapy
• Pharmacologic - atypical antipsychotic agents, anticonvulsants, and Selective Serotonin Reuptake Inhibitors (SSRI)

Major psychosis for > 1 week but < 6 months and no social or occupational impairment.

• Schizophrenia and schizophreniform disorder are essentially the same except for the fact that the duration of symptoms found in schizophreniform disorder is longer than 1 week and less than 6 months and there is no social or occupational impairment.

Treatment:

• Psychotherapy
• Medications: atypical antipsychotic as the usual drug of choice.
  • Patients who do not respond to the initial atypical antipsychotic may benefit from being switched to another atypical antipsychotic, the addition of a mood stabilizer such as lithium or an anticonvulsant, or being switched to a typical antipsychotic.

An 8-year old who is disruptive in class, always fidgeting, has difficulty concentrating and does not complete assignments.

Characterized by problems paying attention, excessive activity, or difficulty controlling behavior which is not appropriate for a person's age.

• Hyperactivity, impulsivity, or inattentiveness manifesting prior to age 12 years.
• > 6 symptoms of inattention, hyperactivity-impulsivity, developmentally inappropriate and duration of symptoms > 6 months
• Symptoms must occur in more than one setting (example school and home)

Treatment: Stimulants (methylphenidate, mixed amphetamine salts)

A child is referred to your office for unusual animal cruelty and bullying at school. 

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

• Manifested by the presence of at least three of the following 15 criteria in the past 12 months.
• From any of the categories below with at least one criterion present in the past 6 months.
• It is often seen as the precursor to antisocial personality disorder, which is per definition not diagnosed until the individual is 18 years old.

Aggression to People and Animals

• Often bullies, threatens, or intimidates others.
• Often initiates physical fights.
• Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
• Has been physically cruel to people.
• Has been physically cruel to animals.
• Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
• Has forced someone into sexual activity.

Destruction of Property

• Has deliberately engaged in fire setting with the intention of causing serious damage.
• Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

• Has broken into someone else’s house, building, or car.
• Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
• Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious Violations of Rules

• Often stays out at night despite parental prohibitions, beginning before age 13 years.
• Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
• Is often truant from school, beginning before age 13 years.

Treatment:

The most effective treatment for an individual with conduct disorder is one that seeks to integrate individual, school, and family settings. Additionally, treatment should also seek to address familial conflicts such as marital discord or maternal depression.

A range of conditions classified as neurodevelopmental disorders. Individuals diagnosed with autism spectrum disorder present a developmental delay in socialization, language, and cognition

Autism spectrum disorders (ASD) encompasses

• Autistic disorder - Disruption of social interaction and language at age 3 or earlier
• Childhood disintegrative disorder
• Pervasive developmental disorder-not otherwise specified
• Asperger disorder - A child has normal cognitive development, poor relationships and does not spontaneously seek activities with others - Asperger disorder

DSM V criteria

• Social communication and social interaction deficit in many contexts such as
  • Lack of social-emotional reciprocity
  • Lack of nonverbal communicative behaviors
  • Impairment in developing, maintaining, and understanding relationships
• Restricted and repetitive patterns of behavior, interests, or activities such as
  • Motor movements that are stereotyped or repetitive (e.g., flipping objects)
  • Inflexibility to change
  • Restricted and fixated interests - these are typically with abnormal intensity or focus
  • Hyper- or hyporeactivity or unusual interest in a sensory stimulus (e.g., fascination with lights)
• These symptoms must be present in the patient's early developmental period in the absence of an organic etiology (e.g., hearing dysfunction)
• These symptoms cannot be better explained by other conditions (e.g., intellectual developmental disorder)

Treatment:

• Refer – autism specialists, speech & language pathologist
• Audiology evaluation, +/- EEG
• Behavioral therapy
• Medications:
  • Second generation antipsychotics (risperidone, aripiprazole) for aggression/hyperactivity, mood lability; can also use haloperidol, carbamazepine
  • SSRIs for stereotyped/repetitive behavior

A child is found to backtalk and resist following instruction from parents or authorities.

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

• Frequent temper tantrums
• Arguments with adults and authority figures.
• Does not conform to rules and regulation
• Intentional exasperation of others
• Easily annoyed by others.
• Revenge-seeking & vindictiveness
• Angry attitude
• Harsh and unkind.

Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit.

Treatment:

Psychotherapy: is aimed at helping the child learn to express and control anger in more appropriate ways.

• Cognitive-behavioral therapy aims to reshape the child's thinking (cognition) to improve problem-solving skills, anger management, moral reasoning skills, and impulse control.
• Family therapy may be used to help improve family interactions and communication among family members. Peer group therapy might also be helpful

Pharmacotherapy to control ODD include mood stabilizers, antipsychotics, and stimulants.

• Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.

Sociopath - a lack of remorse and no concern for others

A disregard for and violation of rights of others with lack of remorse which commonly results in criminality

• males > females
• Conduct disorder if < 18 years
  • rule out substance use, sexual abuse, and possible normal behavior
• Classic triad: set fires, torture animals, bedwetting

Concerned about what others think of them and need admiration

Need for admiration, grandiose thoughts, concerned about what others think yet lack empathy

• Sense of entitlement
• Lacks empathy
• Reacts to criticism with rage

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts.

• Patients tend to be hypersensitive to rejection and socially inhibited resulting from feelings of inadequacy
• Desires relationships with others (vs. schizoid)

Focus on obsessions repetition of compulsive behaviors

Two components

• Obsessions: Recurring, intrusive thoughts that cause severe distress and impairment
• Compulsions: Performance of repetitive actions (rituals) in an attempt to neutralize the obsessions
  • e.g., hand washing, checking - the primary goal is to not lose control
  • The disorder is ego-dystonic: behavior inconsistent with one's own beliefs and attitudes - separates OCD from obsessive compulsive personality disorder
• Associated conditions - Tourette's disorder

A beautiful woman is noted to complain that her hands are too big, yet they appear well-formed and appropriate.

Preoccupation with an imagined defect in physical appearance/exaggerated distortion of a minor flaw

• Common concerns – face/hair/skin/breasts/genitalia
• High comorbidity with depressive/anxiety disorders; linked to psychotic disorder & OCD
• Stereotypes of beauty may play a role

Patients tend to be preoccupied with order, perfectionism, and control

• Ego-syntonic: the patient is not aware of their behavior causing issues vs. OCD which is ego dystonic

Black and white perception unstable interpersonal relationship

Borderline personality disorder presents with emotional instability, unstable relationships, and self-harming behavior

• Females > Males
• Splitting is a major defense mechanism
  • Relationships are either all good ("my boyfriend is a perfect angel") or all bad ("my boyfriend is evil and I hate him")

Paranoid personality disorder is characterized by persistent feelings of suspiciousness and mistrust of other people.

• Excessive distrust and suspicion
• Higher incidence in families with schizophrenia

Submissive and clingy with an excessive need to be taken care of resulting from a low self-esteem

Patients tend to have emotional aloofness, indifferent to praise or criticism, without bizarre or idiosyncratic thinking

• Exhibit voluntary social withdrawal 
• Content with social isolation (vs avoidant)
• Limited emotional expression
• No association with schizophrenia

Attention seeking dramatic seductive behaviors

Needs to be the center of attention. Very dramatic. Dresses for attention. Very shallow. Seductive and flirtatious.

• A large concern with appearance

Odd eccentric behavior and discomfort with social relationships

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships

• Presents with eccentric behavior, magical thoughts, odd beliefs and perceptual distortion
• These patients are able to function in society, though struggle to maintain social relationships
• Patients may develop schizophrenia

Patient consciously reports false symptoms, or induces symptoms, with the goal of playing the "sick role.

A condition in which a person, without a motive for reward, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain (for themselves or for another) a patient's role.

Factitious disorder imposed on self (Munchausen syndrome)

• The patient falsifies physical or psychological symptoms or induces injury or disease to themselves
• When in another person (e.g., a child) it is termed factitious disorder imposed on another (Munchausen syndrome by proxy)

Treatment:

• Conjoint confrontation by the PCP and the psychiatrist
• In factitious disorder imposed on another (e.g., in a child)
  • Children must be removed by child protective services

Preoccupation with having a serious illness

• More than 1 somatic symptom(s) which are distressing to the patient or leads to a significant amount of disruption in the patient's life.
• The patient experiences excessive thoughts, feelings, and behaviors in relation to their somatic symptoms or their health concerns.
• The somatic symptom must be persistent for ≥ 6 months although these symptoms don't have to always be present

Treatment

• Have a single clinician as the designated primary caretaker
  • Schedule monthly visits and psychotherapy
  • Avoid unnecessary diagnostic testing unless indicated

Obsession with the idea of having a serious but undiagnosed medical condition.

• Patient's are worried about having or developing a serious illness and
• This preoccupation is present for at least 6 months and
• Is not better explained by another mental disorder (e.g., obsessive-compulsive disorder and somatic symptom disorder)

Treatment:

• Group/insight-oriented therapy
• Regular appts with a provider for reassurance
• Medications: (SSRIs) if concurrent/underlying anxiety or major depressive disorder

Patient who refuses to eat due to fear of being overweight

• Intense fear of becoming fat, even though underweight. Frequent weight checks and denial of emaciated state.
• Weight < 85% of ideal body weight
• Anorexia nervosa can be distinguished from bulimia nervosa by body mass index < 17 or body weight < 85% of ideal body weight.
• The highest suicide rate of eating disorders.

Two types

• Binging/purging
  • Laxatives/diuretics abuse
  • Excessive exercise
• Restricting
  • Eat very little
  • Exercise to excess

Treatment:

• Restore nutritional state
• Hospitalization - if weight is < 75% expected body weight
• Psychotherapy - behavioral therapy
• Pharmacologic - SSRIs;
  • Have added benefit of causing weight gain
  • Have not been proven to be effective in anorexia nervosa
  • Have some efficacy in bulimia nervosa

Patient who has episodes of mass eating followed by self-induced vomiting or intense exercise

Frequent binge eating with or without purging

• Purging commonly performed by self-induced vomiting resulting in - metabolic alkalosis, urinary chloride < 20mEq, and volume depletion
  • May abuse laxatives/diuretics
  • May exercise excessively
• Patients are disturbed by their behavior
• Binging and compensatory behaviors occur at least once a week for 3 months.
• On the exam look for these classic physical findings: scars on knuckles, swollen parotid glands + dental erosions + normal weight +hypokalemia

Treatment:

• First, you must restore the nutritional state.
• Fluoxetine 60 mg PO once/day is recommended (this dose is higher than that typically used for depression). SSRIs used alone often reduce the frequency of binge eating and vomiting.
• Second line medications: TCAs, MAOIs
• Behavioral/family/group therapy

Patient who enjoys walking around the park exposing his genitals to strangers

Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.

• The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Sexual arousal by prepubescent children (generally 13 years or younger)

1. Over a period of at least 6 months.
2. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

Requires absence/reduced of 3 of the following for 6 months that causes distress.

• Interest in sexual activity
• Sexual/erotic thoughts or fantasies
• Initiation of sexual activity/not receptive
• Excitement/pleasure
• Sexual interest/arousal in response to internal or external stimuli
• Genital or nongenital sensations

Must rule out other medical disorders prior to making the diagnosis.

Patient who requires that his partner strangle him and humiliate him in order for him to achieve and maintain an erection.

Arousal from being threatened or hurt during sexual activities

• Over a period of at least 6 months.
• The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in functioning.

Patient insists on being able to see his girlfriends feet while they engage in sexual acts

Sexual arousal obtained by specific objects.

• Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors.

Patient caught spying through the windows of his fellow female dormmates

Recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.

• Over a period of at least 6 months.
• The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress.

Characterized as a lack or absence of sexual fantasies and desire for sexual activity.

• For this to be regarded as a disorder, it must cause marked distress or interpersonal difficulties and not be better accounted for by another mental disorder, a drug (legal or illegal), some other medical condition, or asexuality.
• The symptoms have persisted for a minimum duration of approximately 6 months.