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A 25-year-old man states that he feels sad all of the time, he feels lonely, and all of his relationships seem to fail. His last relationship ended just a few weeks ago and only lasted about 9 weeks. He says his relationships always start out great. He and his love interest will spend endless hours together discussing every detail of their lives. A few weeks into the relationship, things always change. His girlfriends always pull away from him, and they stop respecting his needs. He often tells his girlfriends that if they leave him, he will kill himself. These threats are frequently followed by intense displays of anger. He has been hospitalized 1 time for overdosing on medication and 2 times for superficial cuts to his arm.

When asked about his parents, the man states that he rarely speaks with them. They do not seem to understand him or care about him as much as they do his siblings. Although the man went to college for a while, he never seemed able to settle on a major. He has a poor work history, and he frequently changes careers. He states that sometimes the jobs seem like more than he can handle, and he just wants something that does not require so much concentration. He further explains that he does not feel like getting up in the morning, and he has difficulty forcing himself to go to work. He frequently has difficulty sleeping and often spends hours tossing and turning in bed. He says he gets up in the morning feeling just as tired as he was when he went to bed. In accordance with the DSM-IV, what is the Axis II diagnosis for this patient?

Answer Choices
1 Dysthymic disorder
2 Histrionic personality disorder
3 Dependent personality disorder
4 Major depressive disorder
5 Borderline personality disorder
anorexia nervosa
Anorexia nervosa is characterized by"

A refusal to maintain a minimally normal body weight (defined as 85% of what is expected)
An intense fear of gaining weight
A disturbance in one's subjective experience of body weight or shape
A denial of the seriousness of low weight and self-starvation
In females, amenorrhea for at least 3 consecutive cycles
90% of patients reported with this disorder are female, although incidence in males is growing somewhat

This case shows evidence of binge eating, but it is considered "binge-eating/purging type" of anorexia and not bulimia; this is due to the low body weight. The purging common to bulimia (self-induced vomiting, misuse of laxatives and diuretics, or enemas) can be present in anorexia also, as may other inappropriate compensatory behaviors (fasting, excessive exercise).

Pica and rumination are usually seen earlier in childhood; they involve, respectively, the eating of nonnutritive substances and the regurgitation and rechewing of food.

The NOS designation would be used if not all the criteria for any specific eating disorder were met. In this case, it would have been used if all the criteria for anorexia nervosa were met except that she still had regular menses.

Refer to the image - anorexic perception. Much research has found that anorexics have a highly distorted perception of what they see in the mirror, which is similar to what happens in body dysmorphic disorder. However, when this distortion occurs only with reference to "fatness," it is classified as an eating disorder.
major depression, recurrent
There are several indicators of a major depression in older adults. A major depressive disorder must consist of several symptoms for at least 2 weeks. These are: depressed mood, decreased interest in normal activities, significant weight loss or gain, insomnia or hyper-sleeping, psychomotor agitation or retardation, feelings of worthlessness or guilt, and/or poor concentration and possible passive or direct suicidal threats. Depressed mood is an indicator, but not a diagnosis.

Treatment of major depression in older adults is most successful with a combination of antidepressant medications plus interpersonal supportive psychotherapy.

Behavioral, cognitive, and family therapies have shown less promising results. Also, brief or short therapy has shown to be as effective or more effective as long-term psychotherapy. Also, most insurance programs do not fund long-term therapies.

ECT (or electroconvulsive) therapy is a treatment of choice in the elderly if they do not respond to antidepressants or have a vegetative type depression.

Major depression, recurrent is a term used to indicate that the older adult has had a previous episode and was treated.

In diagnosing major depression, it is very important to do a complete medical examination and take a history first; doing so will rule out possible physical causes before drugs are prescribed. In treating depression, older adults usually do not want to see a psychiatrist unless it is indicated, and most older adults see their primary physician first. Psychiatrists are usually brought in to consult or act as a liaison to the primary physician.

Bipolar disorder is characterized by 1 or more maleic episodes or mixed with maleic and depressive episodes. There is usually grandiosity, a decreased need for sleep, psychomotor agitation, and excessive involvement with pleasurable activities such as sex, spending, or traveling.

Older adults with adjustment reactions usually have much less severe symptoms, and these usually occur after a major stress such as a death, change in residence, or other psychosocial stressors.
obsessive compulsive
Obsessive-compulsive personality disorder is characterized by a lifelong pattern of being preoccupied with perfectionism, orderliness, and control. Individuals with obsessive-compulsive disorder have difficulty being open with others, they are unable to be flexible because it means giving up control, and their perfectionism usually makes them very inefficient in their accomplishments. Other symptoms include excessive devotion to work or to other tasks, being overly conscientious about moral or ethical issues, and having restricted expression of affect.

The major features of narcissistic personality disorder are grandiosity (an inflated sense of self importance), a need for admiration, and a lack of empathy for others. If criticized, the narcissistic individual often reacts with rage, and he/she often exploits others. Feelings of grandiosity usually preoccupy the individual, and there is often a profound sense of entitlement.

Borderline personality disorder is most often associated with a pattern of unstable interpersonal relationships. Self-image is poor, affect is often labile or depressed, and these individuals are highly impulsive - especially with regard to self-destructive behaviors. Individuals with borderline personality disorder are chronically bored and empty feeling. They alternate between overly idealizing others and devaluing them. Their emotions are intense. Although individuals with borderline personality disorder are said to have a need to be taken care of, they have difficulty accepting the help of others because they mistrust their intentions.

Individuals with dependent personality disorder, on the other hand, tend be clingy and submissive in their behaviors because their need to be taken care of is so pervasive. They have difficulty making everyday decisions without consulting others, and they agree with others even if they believe the person to be wrong due to their intense fear of rejection. They have difficulty doing things on their own, and their most pervasive fear is that of being abandoned.

Avoidant personality disorder is characterized by social inhibition and feelings of inadequacy. Individuals who suffer from this disorder are extremely sensitive to negative feedback from others. They avoid social activities due to their fear of having to participate.
Risperidone
Adolescents classified as having a diagnosis within the autism spectrum disorder (ASD) will have varying degrees of impairment in their social and behavioral function. Family education, behavioral and educational interventions, and counseling have a significant place in this treatment plan. Pharmacotherapy may be considered, but it should be used as adjunctive therapy to those mentioned above.

In 2006 the US Food and Drug Administration (FDA) approved risperidone, an atypical antipsychotic, in the oral disintegrating tablet form, for the symptomatic treatment of irritability in both children and adolescents with autism spectrum disorder. This is considered the first FDA approved drug treatment for behaviors specifically associated with ASD, and it has been used off-label for many years for these symptoms. Other symptoms that risperidone could be considered to help treat in patients with ASD include aggression and deliberate self-injury.

When beginning any pharmacotherapy for these patients, having a "start low and go slow" regimen is strongly recommended, with consistent follow-up visits for evaluation of alleviation of the symptoms.

Such pharmacologic agents as selective serotonin reuptake inhibitor (SSRI), such as sertraline or fluoxetine, are generally introduced to help alleviate anxiety symptoms. The patient in the above scenario is currently not experiencing or expressing any excessive anxiety.

Although paroxetine is a type of SSRI that is used to treat patients with depression, obsessive-compulsive disorder, anxiety disorder, post-traumatic stress disorder, or premenstrual dysphoric disorder, it is currently not a recommended first-line treatment option for symptomatic behavior in ASD patients.

Patients who express symptoms consistent with hyperactivity and inattention should be treated with methylphenidate, atomoxetine, or clonidine; this is not consistent with the symptoms that were discussed in this patient.