Primary Insomnia

Insomnia (or sleeplessness) is most often defined by an individual’s report of sleeping difficulties. While the term is sometimes used in sleep literature to describe a disorder demonstrated by polysomnographic evidence of disturbed sleep, insomnia is often defined as a positive response to either of two questions: “Do you experience difficulty sleeping?” or “Do you have difficulty falling or staying asleep?”

Thus, insomnia is most often thought of as both a sign and a symptom that can accompany several sleep, medical, and psychiatric disorders, characterized by persistent difficulty falling asleep and/or staying asleep or sleep of poor quality. Insomnia is typically followed by functional impairment while awake. One definition of insomnia is difficulties initiating and/or maintaining sleep, or nonrestorative sleep, associated with impairments of daytime functioning or marked distress for more than 1 month.”

Insomnia can be grouped into primary and secondary, or comorbid, insomnia. Primary insomnia is a sleep disorder not attributable to a medical, psychiatric, or environmental cause. A complete diagnosis will differentiate between:

• insomnia as secondary to another condition,
• primary insomnia co-morbid with one or more conditions, or
• free-standing primary insomnia.

Dyssomnia

Dyssomnias are a broad classification of sleeping disorders that make it difficult to get to sleep, or to remain sleeping.

Dyssomnias are primary disorders of initiating or maintaining sleep or of excessive sleepiness and are characterized by a disturbance in the amount, quality, or timing of sleep.

Patients may complain of difficulty getting to sleep or staying asleep, intermittent wakefulness during the night, early morning awakening, or combinations of any of these. Transient episodes are usually of little significance. Stress, caffeine, physical discomfort, daytime napping, and early bedtimes are common factors.

Disorders in this Category

Insomnia
Hypersomnia
Narcolepsy

Trichotillomania

Trichotillomania is the compulsive urge to pull out one’s own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat.

Trichotillomania may be present in infants, but the peak age of onset is 9 to 13. It may be triggered by depression or stress. Due to social implications the disorder is often unreported and it is difficult to accurately predict its prevalence; the lifetime prevalence is estimated to be between 0.6% (overall) and may be as high as 1.5% (in males) to 3.4% (in females).

The name, coined by French dermatologist François Henri Hallopeau, derives from the Greek: trich- (hair), till(en) (to pull), and mania (“an abnormal love for a specific object, place, or action”).

Pyromania

Pyromania in more extreme circumstances can be an impulse control disorder to deliberately start fires to relieve tension or for gratification or relief. Pyromania and pyromaniacs are distinct from arson and arsonists, whose motivations stem from psychosis, the pursuit of personal, monetary or political gain, or the intent to inflict harm for advantage or revenue. Pyromaniacs start fires to induce euphoria, and often fixate on institutions of fire control like fire stations and firefighters. Pyromania is a type of impulse control disorder.

Pathological Gambling

Problem gambling (ludomania) is an urge to gamble despite harmful negative consequences or a desire to stop. Problem gambling often is defined by whether harm is experienced by the gambler or others, rather than by the gambler’s behavior. Severe problem gambling may be diagnosed as clinical pathological gambling if the gambler meets certain criteria. Although the term gambling addiction is common in the recovery movement pathological gambling is considered to be an impulse control disorder and is therefore not considered by the American Psychological Association to be an addiction.

Intermittent Explosive Disorder

Intermittent explosive disorder (abbreviated IED) is a behavioral disorder characterized by extreme expressions of anger, often to the point of uncontrollable rage, that are disproportionate to the situation at hand. It is currently categorized in the Diagnostic and Statistical Manual of Mental Disorders as an impulse control disorder. IED belongs to the larger family of Axis I impulse control disorders listed in the DSM-IV-TR, along with kleptomania, pyromania, pathological gambling, and others. Impulsive aggression is unpremeditated, and is defined by a disproportionate reaction to any provocation, real or perceived. Some individuals have reported affective changes prior to an outburst (e.g.,tension, mood changes, energy changes, etc.).

Anorexia Nervosa

Anorexia nervosa (AN), also known as simply Anorexia, is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. It is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600–800 calories per day, but extreme cases of complete self-starvation are known. It is a serious mental illness with a high incidence ofcomorbidity and the highest mortality rate of any psychiatric disorder.

Anorexia most often has its onset in adolescence and is most prevalent among adolescent girls. However, more recent studies show that the onset age of anorexia decreased from an average of 13 to 17 years of age to 9 to 12. While it can affect men and women of any age,race, and socioeconomic and cultural background, Anorexia nervosa occurs in females 10 times more than in males.

Parasomnia

Parasomnias are a category of sleep disorders that involve abnormal and unnatural movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep. Most parasomnias are dissociated sleep states which are partial arousals during the transitions between wakefulness and NREM sleep, or wakefulness and REM sleep.

Parasomnias

Nightmare Disorder
Night terror
Sleepwalking Disorder

Shared Psychotic Disorder (Folie à deux)

Folie à deux is a psychiatric syndrome in which symptoms of a delusional belief are projected from one individual to another. The same syndrome shared by more than two people may be called folie à trois, folie à quatre, folie en famille or even folie à plusieurs (“madness of many”). Recent psychiatric classifications refer to the syndrome as shared psychotic disorder (DSM-IV) (297.3) and induced delusional disorder (F.24) in the ICD-10, although the research literature largely uses the original name. The disorder was first conceptualized in 19th century French psychiatry.

This case study is taken from Enoch and Ball’s ‘Uncommon Psychiatric Syndromes’ (2001, p181): Margaret and her husband Michael, both aged 34 years, were discovered to be suffering from folie à deux when they were both found to be sharing similar persecutory delusions. They believed that certain persons were entering their house, spreading dust and fluff and “wearing down their shoes”. Both had, in addition, other symptoms supporting a diagnosis of emotional contagion, which could be made independently in either case.

This syndrome is most commonly diagnosed when the two or more individuals concerned live in proximity and may be socially or physically isolated and have little interaction with other people.

Various sub-classifications of folie à deux have been proposed to describe how the delusional belief comes to be held by more than one person.

• Folie imposée is where a dominant person (known as the ‘primary’, ‘inducer’ or ‘principal’) initially forms a delusional belief during a psychotic episode and imposes it on another person or persons (known as the ‘secondary’, ‘acceptor’ or ‘associate’) with the assumption that the secondary person might not have become deluded if left to his or her own devices. If the parties are admitted to hospital separately, then the delusions in the person with the induced beliefs usually resolve without the need of medication.
• Folie simultanée describes either the situation where two people considered to suffer independently from psychosis influence the content of each other’s delusions so they become identical or strikingly similar, or one in which two people “morbidly predisposed” to delusional psychosis mutually trigger symptoms in each other.

Schizophreniform Disorder

Schizophreniform disorder is a mental disorder diagnosed when symptoms of schizophrenia are present for a significant portion of the time within a one-month period, but signs of disruption are not present for the full six months required for the diagnosis of schizophrenia.

The symptoms of both disorders can include delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and social withdrawal. While impairment in social, occupational, or academic functioning is required for the diagnosis of schizophrenia, in schizophreniform disorder an individual’s level of functioning may or may not be affected. While the onset of schizophrenia is often gradual over a number of months or years, the onset of schizophreniform disorder can be relatively rapid.

Like schizophrenia, schizophreniform disorder is often treated with antipsychotic medications, especially the atypicals, along with a variety of social supports (such as individual psychotherapy, family therapy, occupational therapy, etc.) designed to reduce the social and emotional impact of the illness. The prognosis varies depending upon the nature, severity, and duration of the symptoms, but about two-thirds of individuals diagnosed with schizophreniform disorder go on to develop schizophrenia.

Schizophreniform disorder is a type of mental illness that is characterized by psychosis and closely related to schizophrenia. Both schizophrenia and schizophreniform disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), have the same symptoms and essential features except for two differences: the level of functional impairment and the duration of symptoms. Impairment in social, occupational, or academic functioning is always present in schizophrenia, but such impairment may or may not be present in schizopheniform disorder. In schizophreniform disorder, the symptoms (including prodromal, active, and residual phases) must last at least 1 month but not more than 6 months, while in schizophrenia the symptoms must be present for a minimum of 6 months.

If the symptoms have persisted for at least one month, a provisional diagnosis of schizophreniform disorder can be made while waiting to see if recovery occurs. If the symptoms resolve within 6 months of onset, the provisional qualifier is removed from the diagnosis. However, if the symptoms persist for 6 months or more, the diagnosis of schizophreniform disorder must be revised. The diagnosis of brief psychotic disorder may be considered when the duration of symptoms is less than one month.

The main symptoms of both schizophreniform disorder and schizophrenia can include:^[1]

• delusions,
• hallucinations,
• disorganized speech resulting from formal thought disorder,
• disorganized or catatonic behavior, and negative symptoms, such as
• an inability to show emotion (flat affect),
• an inability to experience pleasure (anhedonia),
• impaired or decreased speech (aphasia),
• a lack of desire to form relationships (asociality), and
• a lack of motivation (avolition).

Delusional Disorder

Delusional disorder is an uncommon psychiatric condition in which patients present with circumscribed symptoms of non-bizarre delusions, but with the absence of prominent hallucinations and no thought disorder, mood disorder, or significant flattening of affect. For the diagnosis to be made, auditory and visual hallucinations cannot be prominent, though olfactory or tactile hallucinations related to the content of the delusion may be present.

To be diagnosed with delusional disorder, the delusion or delusions cannot be due to the effects of a drug, medication, or general medical condition, and delusional disorder cannot be diagnosed in an individual previously diagnosed with schizophrenia. A person with delusional disorder may be high functioning in daily life and may not exhibit odd or bizarre behavior aside from these delusions. The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines six subtypes of the disorder characterized as erotomanic (believes that someone famous is in love with him/her), grandiose (believes that he/she is the greatest, strongest, fastest, most intelligent person ever), jealous (believes that the love partner is cheating on him/her), persecutory (believes that someone is following him/her to do some harm in some way), somatic (believes that he/she has a disease or medical condition), and mixed, i.e., having features of more than one subtypes. Delusions also occur as symptoms of many other mental disorders, especially the other psychotic disorders.

The DSM-IV, and psychologists, generally agree that personal beliefs should be evaluated with great respect to complexity of cultural and religious differences since some cultures have widely accepted beliefs that may be considered delusional in other cultures.

Night terror

A night terror, also known as a sleep terror or pavor nocturnus, is a parasomnia disorder that predominantly affects children, causing feelings of terror or dread. Night terrors should not be confused with nightmares, which are bad dreams that cause the feeling of horror or fear. An estimated 1-6% of children have at least one night terror in their life but have no memory of the occurrence.

Children from age two to six are most prone to night terrors. They affect about fifteen percent of all children, although people of any age can be affected. Episodes may happen for a couple of weeks then suddenly disappear. The symptoms also tend to be different, with the child being unable to recall the experience. While nearly arisen, hallucinations occur.

Children who have night terrors are usually described as ‘bolting upright’ with their eyes wide open, and a look of fear and panic. They will often scream. Further, they will usually sweat, breathe fast and have a rapid heart rate (autonomic signs). Although it seems like children are awake during a night terror, they will appear confused, be inconsolable, and will not recognize others.

Strong evidence has shown that a predisposition to night terrors and other parasomniac disorders can be passed genetically. Though there are a multitude of triggers, emotional stress during the previous day and a high fever are thought to precipitate most episodes. Ensuring the right amount of sleep is an important factor. Special consideration must be used when the subject suffers from narcolepsy, as there may be a link.

Though the symptoms of night terrors in adolescents and adults are similar, the etiology, prognosis and treatment are qualitatively different. These night terrors can occur each night if the sufferer does not eat a proper diet, get the appropriate amount or quality of sleep (e.g. sleep apnea), is enduring stressful events in their life or if they remain untreated. Adult night terrors are much less common, and often respond to treatments to rectify causes of poor quality or quantity of sleep. There is no scientific evidence of a link between night terrors and mental illness. There is some evidence of a link between adult night terrors and hypoglycemia. In addition to night terrors, some adult night terror sufferers have many of the characteristics of depressed individuals including inhibition of aggression, self-directed anger, passivity, anxiety, impaired memory, and the ability to ignore pain. When a night terror happens it is typical that person can wake themself up screaming, kicking, and often can not make out what they are saying. Often the person can even run out of the house (more common among adults) which can then lead to violent actions.

Transvestic Fetishism

Transvestic fetishism is having a sexual or erotic interest in cross-dressing. It differs from cross-dressing for entertainment or other purposes that do not involve sexual arousal and is categorized as a paraphilia in the Diagnostic and Statistical Manual of the American Psychiatric Association. (Sexual arousal in response to donning sex-typical clothing is homeovestism.)

Transvestic fetishism refers specifically to cross-dressing; sexual arousal in response to individual garments is fetishism. Occurrence of transvestic fetishism is uncorrelated to occurrence of gender identity disorder. Most men who have transvestic fetishism do not have a problem with their assigned sex.

Some male transvestic fetishists collect women’s clothing, e.g. nightgowns, babydolls, slips, brassieres, and other types of nightwear,lingerie, stockings, pantyhose, shoes, and boots, items of a distinct feminine look and feel. They may dress in these feminine garments and take photographs of themselves while living out their secret fantasies. According to the DSM-IV, this fetishism has been described only in men.

There are two key criteria before a psychiatric diagnosis of “transvestic fetishism” is made:

1. Recurrent, intense sexually arousing fantasies, urges, or behaviour, involving cross-dressing.
2. This causes clinically significant distress or impairment, whether socially, at work, or elsewhere.

Thus, transvestic fetishism is not diagnosed unless it causes significant problems for the person concerned.

Sadomasochism

Sadomasochism broadly refers to the receiving of pleasure—often sexual—from acts involving the infliction or reception of pain or humiliation. The name originates from two authors on the subject, Marquis de Sade and Leopold von Sacher-Masoch. A subset of BDSM, practitioners of sadomasochism usually seek out sexual gratification from these acts, but often seek out other forms of pleasure as well. While the terms sadist and masochist specifically refer to one who either enjoys giving pain (sadist), or one who enjoys receiving pain (masochist), many practitioners of sadomasochism describe themselves as at least somewhat of a switch, or someone who can receive pleasure from either inflicting or receiving pain.

The acronym S&M is often used for sadomasochism, although practitioners themselves normally drop the & and use the acronym SM or S/M. Sadomasochism should be differentiated from the clinical paraphilias which require that such practices lead to clinically significant distress or impairment for a diagnosis. Similarly, sexual sadism within the context of mutual consent should not be mistaken for acts of sexual violence or aggression.

The combination of sadism and masochism, in particular the deriving of pleasure, especially sexual gratification, from inflicting or submitting to physical or emotional abuse. 1. (Psychology) the combination of sadistic and masochistic elements in one person, characterized by both aggressive and submissive periods in relationships with others 2. sexual practice in which one partner adopts a sadistic role and the other a masochistic one Abbreviation SM Compare sadism, masochism

Pedophilia

As a medical diagnosis, pedophilia (or paedophilia) is defined as a psychiatric disorder in adults or late adolescents (persons age 16 or older) typically characterized by a primary or exclusive sexual interest in prepubescent children (generally age 13 years or younger, though onset of puberty may vary). The child must be at least five years younger in the case of adolescent pedophiles (16 or older) to be termed pedophilia. The term has a range of definitions, as found in psychiatry, psychology, the vernacular, and law enforcement.

The International Classification of Diseases (ICD) defines pedophilia as a “disorder of adult personality and behaviour” in which there is a sexual preference for children of prepubertal or early pubertal age. According to the Diagnostic and Statistical Manual of Mental Disorders(DSM), pedophilia is a paraphilia in which a person has intense and recurrent sexual urges towards and fantasies about prepubescent children and on which feelings they have either acted or which cause distress or interpersonal difficulty. The current DSM-5 draft proposes to add hebephilia to the diagnostic criteria, and consequently to rename it to pedohebephilic disorder.

In popular usage, pedophilia means any sexual interest in children or the act of child sexual abuse, often termed “pedophilic behavior.” For example, The American Heritage Stedman’s Medical Dictionary states, “Pedophilia is the act or fantasy on the part of an adult of engaging in sexual activity with a child or children.” This common use application also extends to the sexual interest in and abuse of pubescent or post-pubescent minors. Researchers recommend that these imprecise uses be avoided; people who commit child sexual abuse commonly exhibit the disorder, but some offenders do not meet the clinical diagnosis standards for pedophilia, which only pertain to prepubescents. Additionally, not all pedophiles actually commit such abuse.

Pedophilia was first formally recognized and named in the late 19th century. A significant amount of research in the area has taken place since the 1980s. Although mostly documented in men, there are also women who exhibit the disorder, and researchers assume available estimates underrepresent the true number of female pedophiles. No cure for pedophilia has been developed, but there are therapies that can reduce the incidence of a person committing child sexual abuse. In the United States, following Kansas v. Hendricks, sex offenders that are diagnosed with certain mental disorders, particularly pedophilia, can be subject to indefinite civil commitment, under various state laws (generically called SVP laws) and the federal Adam Walsh Child Protection and Safety Act of 2006. At present, the exact causes of pedophilia have not been conclusively established. Research suggests that pedophilia may be correlated with several different neurological abnormalities, and often co-exists with other personality disorders and psychological pathologies. In the contexts of forensic psychology and law enforcement, a variety of typologies have been suggested to categorize pedophiles according to behavior and motivations.

Frotteurism

Frotteurism refers to a paraphilic interest in rubbing, usually one’s pelvis or erect penis, against a non-consenting person for sexual gratification. It may involve touching any part of the body including the genital area. A person who practices frotteurism is known as a frotteur. The majority of frotteurs are male and the majority of victims are female, although female on male, female on female, and male on male frotteurs exist. Adult on child frotteurism can be an early stage in child sexual abuse. This activity is often done in circumstances where the victim cannot easily respond, in a public place such as a crowded train or concert.

Usually, such nonconsensual sexual contact is viewed as a criminal offense: a form of sexual assault albeit often classified as a misdemeanor with minor legal penalties. Conviction may result in a sentence or psychiatric treatment.

Exhibitionism

Exhibitionism refers to exposing bare female breasts and/or buttocks of either a male or female. When genitalia is exposed the behavior is more commonly described as indecent exposure. Exhibitionism is an overall psychosocial concept that, when applied to physical actions, denotes two separate phenomena.

The first, colloquially referred to as flashing, involves the exposure of a person’s “private parts” to another person, in a nonthreatening manner, in a situation where these would not normally be exposed, such as in a social situation (in front of other people) or in a public place. The act of flashing, particularly when done by females involving the breasts but also when involving her vagina and also her buttocks, may be at least partially sexual in intention, i.e. to prompt the sexual arousal of those being flashed (in turn giving the flasher an ego boost). However, flashing may also simply be intended to attract the non-aroused ‘attention’ of another or others, or for shock value.

The second, indecent exposure, involves the same sorts of exposure done in a threatening manner or in a manner perceived by those being exposed-to as threatening. Indecent exposure, when it is assessed to be this, is sometimes prosecuted under laws designed to criminalise it, such as public nuisance laws and indecent-exposure laws. Such laws vary by locality worldwide, including within different parts of the United States.

There is somewhat of a double standard here as concerns the two different types of exhibitionism, since “indecent exposure” has a tendency in the Western world to be equated with a male exposing his genitalia to a female, when such acts are perceived by the female as threatening, while at the same time a female exposing her breasts (“flashing”) to male or female viewers is almost always seen as nonthreatening and in fact is often even requested to occur by those wanting to see bare breasts, such as the non-parade-related celebrations surrounding Mardi Gras and other similar festivals.

Exhibitionism is not automatically a compulsion, but some people do have a distinct psychological tendency to sexually expose themselves, whether it is to “flash” (the nonthreatening form) or to “indecently expose” (the threatening form). When it is a compulsion, it is a condition sometimes called apodysophilia.

Substance-Related Disorder

A substance-related disorder is an umbrella term used to describe several different conditions (such as intoxication, harmful use/abuse, dependence, withdrawal, and psychoses or amnesia associated with the use of the substance) associated with several different substances (such as alcohol or opiods).

Substance-related disorders can be subcategorized into “substance use disorders” (SUD) and “substance-induced disorders” (SID).

Though DSM-IV makes a firm distinction between the two, SIDs often occur in the context of SUDs.

Disorders in this Category

• Substance Abuse
• Substance Dependence

Somatization Disorder

Somatization disorder (also Briquet’s disorder or, in antiquity, hysteria) is a psychiatric diagnosis applied to patients who persistently complain of varied physical symptoms that have no identifiable physical origin. The disorder must begin before the patient turns 30 years of age and could last for several years, resulting to either medical seeking behavior or significant treatment. One common generaletiological explanation is that internal psychological conflicts are unconsciously expressed as physical signs. Patients with somatization disorder will typically visit many doctors in pursuit of effective treatment.

Examples of manifestations of Pychosomatic disorder are as such: a child itches in response to family issues, and experiencing repressed anger and/or fear. Thus, The child grows and wakes up itching in the same locations, though not aware of the repressed memory causing the suffering in later life, or the patient is engaged in seeking psychotherapy for somatization.

Somatization disorder is a somatoform disorder. The DSM-IV establishes the following five criteria for the diagnosis of this disorder:

• a history of somatic symptoms prior to the age of 30
• pain in at least four different sites on the body
• two gastrointestinal problems other than pain such as vomiting or diarrhea
• one sexual symptom such as lack of interest or erectile dysfunction
• one pseudoneurological symptom similar to those seen in Conversion disorder such as fainting or blindness.

Pain Disorder

Pain disorder is when a patient experiences chronic pain in one or more areas, and is thought to be caused by psychological stress. The pain is often so severe that it disables the patient from proper functioning. Duration may be as short as a few days or as long as many years. The disorder may begin at any age, and more women than men seem to experience it. This disorder often occurs after an accident or during an illness that has caused pain, which then takes on a ‘life’ of its own.