What is the term for a Sleeplike state marked by reduced sensitivity to stimuli loss or alteration of knowledge and the substitution of automatic for voluntary motor activity?

MENTAL DISORDERS (see also diseases of the central nervous system)

Table of contents :

Epidemiology : a national survey of US citizens has found that 6% of them have a debilitating mental illness. More startling, almost 50% of those surveyed were found to have had a mental disorder at some point during their lives; > 25% had had 1 in the year before the interview. Treatment is hard to get, and often not sufficient when available. Only about 33% of those in care receive "minimally adequate treatment", such as the appropriate drugs or a few hours of therapy over a period of several monthsref1, ref2, ref3, ref4. The statistics are nearly impossible to compare with previous studies, thanks to constantly changing definitions of mental illness, but in general things don't seem to have changed much over the past decade. > 9,000 US adults, chosen randomly, were visited in their homes as part of the National Comorbidity Survey, which looks at the incidence of multiple mental disorders. An interview then probed to see whether they had mental difficulties as determined by the latest Diagnostic and Statistical Manual of Mental Disorders. The study also classified the severity of disorders, separating them into severe, moderate or mild conditions. The definition of disorders used by the study was quite broad. A few instances of road rage, for example, might qualify as an intermittent explosive disorder. Such a wide net may not be any use in determining who needs medication or treatment, but the survey does provide some useful information. It reveals, for example, that 50% of those with a mental disorder encountered problems before their 14th birthday. This indicates that watching for signs of mental distress in early years could help to avert larger problems in the future. Progress will be made in finding biological markers that can help distinguish children who are simply shy or have a quick temper from those whose difficulties are likely to degenerate into illness, perhaps through an analysis of genes or brain scans. Meanwhile, the first order of business is to improve the quality of treatment. The prevalence of mental disorders did not change during the decade (29.4% between 1990 and 1992 and 30.5% between 2001 and 2003), but the rate of treatment increased. Among patients with a disorder, 20.3% received treatment between 1990 and 1992 and 32.9% received treatment between 2001 and 2003. Overall, 12.2% of the population 18 to 54 years of age received treatment for emotional disorders between 1990 and 1992 and 20.1% between 2001 and 2003. Only about half those who received treatment had disorders that met diagnostic criteria for a mental disorder. Significant increases in the rate of treatment (49.0% between 1990 and 1992 and 49.9% between 2001 and 2003) were limited to the sectors of general medical services (2.59 times as high in 2001 to 2003 as in 1990 to 1992), psychiatry services (2.17 times as high), and other mental health services (1.59 times as high) and were independent of the severity of the disorder and of the sociodemographic characteristics of the respondents. Despite an increase in the rate of treatment, most patients with a mental disorder did not receive treatment. Continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatmentsref.
Web resources : Do I Need Therapy online test
 

psyche : the human faculty for thought, judgment, and emotion; the mental life, including both conscious and unconscious processes; the mind in its totality, as distinguished from the body.

situation : the combination of factors with which an individual is confronted. In psychology, the total sum of physical, psychological, and sociocultural factors that act on a person and influence his behavior

ego-syntonic : denoting aspects of a person's thoughts, impulses, attitudes, and behavior that are felt to be acceptable and consistent with the rest of their personality.

ego-dystonic : denoting aspects of a person's thoughts, impulses, attitudes, and behavior that are felt to be repugnant, distressing, unacceptable, or inconsistent with the rest of their personality.

psychiatry : that branch of medicine which deals with the study, treatment, and prevention of mental disorders.

• geriatric psychiatry / geropsychiatry : a subspecialty of psychiatry dealing with mental illness in the elderly.
• neuropsychiatry : the branch of medicine which includes both neurology and psychiatry.

• addiction psychiatry : a subspecialty concerned with the diagnosis and treatment of addiction and other problems related to substance use.
• administrative psychiatry : that concerned with the organization and management of mental health programs and facilities, including public and private hospitals, clinics, and centers.
• biological psychiatry : that which emphasizes biochemical, neurological, and pharmacological causes and treatment approaches.
• community psychiatry : the branch of psychiatry concerned with the detection, prevention, and treatment of mental disorders as they develop within psychosocial, cultural, or geographical areas, with emphasis given to environmental factors.
• consultation liaison psychiatry : that which connects psychiatry with other areas of medicine, bringing a psychosocial approach to the biological treatment of organic illness
• cross-cultural or transcultural psychiatry : the study of mental illness and mental health among different societies, nations, and cultures
• descriptive psychiatry : psychiatry based on the study of observable symptoms and behavioral phenomena, rather than underlying psychodynamic processes
• dynamic psychiatry : psychiatry based on the study of the unconscious mechanisms, conflicts, and other emotional processes that motivate and underlie human behavior, rather than the more observable behaviors themselves
• existential psychiatry : that based on the existential philosophy of Kierkegaard, Heidegger, Jaspers, and others, holding the view that a person takes responsibility for his own existence.
• forensic psychiatry : psychiatry which deals with the legal aspects of mental disorders.
• industrial or occupational psychiatry : that concerned with the diagnosis and prevention of mental illness in the work setting, including aspects of absenteeism, accident proneness, personnel policies, occupational fatigue, substance abuse, vocational adjustment, retirement, interpersonal relations, and related phenomena.
• military psychiatry : the study and treatment of psychiatric problems done under the auspices of military organizations such as induction centers, training facilities, and military hospitals; it includes emergency and nonemergency treatment for active-duty and retired military personnel and their dependents.
• orthomolecular psychiatry : that based on the theory that psychiatric illnesses are due to disturbances in the molecular environment of the brain and can be cured by restoration of optimal concentrations of substances normally present in the body, such as vitamins (orthomolecular therapy).
• preventive psychiatry : that broadly concerned with the amelioration, control, and limitation of psychiatric disability. It is often categorized as primary�measures to prevent a disorder; secondary�therapeutic measures to limit a disorder; and tertiary�measures and intervention to reduce impairment or disability following a disorder.
• social psychiatry : that concerned with the cultural, ecologic, and sociologic facts that engender, precipitate, intensify, prolong, or otherwise complicate maladaptive patterns of behavior and their treatment.
• orthopsychiatry : an interdisciplinary field that combines psychiatry with principles of psychology, sociology, social work, and other fields in the study and practice of maintaining or restoring mental health, emphasizing a prophylactic approach to mental disease.

psychobiology / biopsychology : a field of study examining the relationship between brain and mind, studying the effect of biological influences, including biochemical, neurological, and pharmacological factors, on psychological functioning or mental processes. Adolf Meyer's school of psychiatric thought, in which the human being is viewed as an integrated unit, incorporating psychological, social, and biological functions, with behavior a function of the total organism.

mental disorder : any clinically significant behavioral or psychological syndrome characterized by the presence of distressing symptoms, impairment of functioning, or significantly increased risk of suffering death, pain, disability, or loss of freedom. Mental disorders are assumed to be the manifestation of a behavioral, psychological, or biological dysfunction in the individual. The concept does not include deviant behavior, disturbances that are essentially conflicts between the individual and society, or expected and culturally sanctioned responses to particular events

• emotional illness : a colloquialism roughly equivalent to �mental disorder,� but not usually applied to those with a specific organic etiology or to mental retardation.
• organic mental disorder : a term formerly used to denote any mental disorder with a specifically known or presumed organic etiology; now discouraged because of the implication that other mental disorders do not have an organic basis. The term was also sometimes used to denote an organic mental syndrome. Current classification divides these disorders into :
• delirium, dementia, amnestic and other cognitive disorders
• mental disorders due to a general medical condition
• substance-related disorders
• organic hallucinosis : a term used in a former system of classification, denoting an organic mental syndrome characterized by the presence of hallucinations caused by a specific organic factor and not associated with delirium. Such disorders are now mainly classified as substance-induced psychotic disorders and psychotic disorders due to general medical condition
• disorders of consciousness
• quantitative (hypnoid) alterations
• increased consciousness (secondary to stress or mania)
• restriction of consciousness
Aetiology :
• pharmacological (ethanol
  , cannabinoids)
• epilepsy
• psychiatric disorders
• loss of consciousness
• qualitative alterations (disorders of structuration of consciousness)
• disorientation
• confusional state (delirium)
• crepuscolar state
• dreamy or oniroid state : a state of altered consciousness lasting for a few minutes and accompanied by hallucinations; associated with temporal lobe lesions
• expansion of consciousness (trance, psychostimulant substances)
• disorders of self consciousness (depersonalization : alteration in the perception of the self so that the usual sense of one's own reality is lost, manifested in a sense of unreality or self-estrangement, in changes of body image, or in a feeling that one does not control his own actions and speech; seen in disorders such as depersonalization disorder, depression, dissociative disorders, hypochondriacal neurosis / hypochondriasis, temporal lobe epilepsy
  , schizophrenic disorders, and schizotypal personality disorder. Some do not draw a distinction between depersonalization and derealization, using depersonalization to include both.
• autopsychic depersonalization : experiences are felt as foreign
• somatopsychic depersonalization : the body or some parts seem not self, detached, or died
• allopsychic depersonalization / derealization : a loss of the sensation of the reality of one's surroundings; the feeling that something has happened, that the world has been changed and altered, that one is detached from one's environment. It is seen most frequently in schizophrenic disorders.
• déjà entendu [Fr. �already heard�] : the feeling that one has heard or perceived something previously although it is in fact new to one's experience
• déjà éprouvé [Fr. �already tested�] : a feeling that one has previously engaged in or experienced something when one has not
• déjà fait [Fr. �already done�] : a feeling that what is happening has happened before.
• déjà pensé [Fr. �already thought�] : a feeling that one has thought the same thoughts before.
• déjà raconté [Fr. �already told�] : a feeling when telling someone about an experience that one had previously related the same experience either to them or to someone else, when in fact one had not.  2. a feeling that a long-forgotten event which is being recalled was told to one before, when it was not.
• déjà vécu [Fr. �already lived�] . a feeling that a new experience has been encountered before, in a previous existence.
• jamais vécu [Fr. �never lived�] : a feeling that a common experience has never been encountered before
• déjà voulu [Fr. �already desired�] : a feeling that one has entertained the same desires before.
• déjà vu [Fr. �already seen�] : an illusion in which a new situation is incorrectly viewed as a repetition of a previous situation
• jamais vu [Fr. �never seen�] : the sensation that familiar surroundings are strangely unfamiliar; the illusion that one has never seen anything like that before.
• disorders of attention
• hyperprosexia : a condition in which the mind is occupied by one idea to the exclusion of others, e.g. in mania
• hypoprosexia : distraction, difficult concentration, attention deficit
• disorders of memory
• asemia / asemasia / asymbolia : aphasia with inability to employ or to understand either speech or signs
• aphasia : any of a large group of speech disorders involving defect or loss in thought <=> speech conversion (the power of expression by speech, writing, or signs, or of comprehending spoken or written language), due to injury or disease of the brain or to psychogenic causes in patients who had acquired the ability of speech. Less severe forms are known as dysphasia.

An inability to process language needn't stop you from doing maths : 3 men with severe aphasia, a linguistic impairment, can understand 'grammatical' rules in mathematics even though they cannot handle analogous rules in language. Aphasia leaves people unable to use or comprehend words, and is often triggered by stroke or other brain injuries. The discovery challenges a commonly held view that linguistic and mathematical mental processing draw on the same cognitive resources. According to the view of cognition developed by linguist Noam Chomsky, language processing is a fundamental skill that is used for related grammatical tasks in the brain, such as certain mathematical ones. Previous studies of the relationship between linguistic and mathematical ability have lent some support to this notion. For example, brain-imaging studies have shown that some areas of the brain involved in language processing also become active when people are performing mathematical tasks. But it has been unclear whether this use of neural language centres is essential for maths: there are also indications that the two mental functions can work independently. All 3 of their patients were aged between 50 and 60 and were well educated; one had been a university professor before incurring a brain lesion. The 3 men were almost entirely unable to communicate verbally or in writing, but they clearly retained much of their higher mental functioning and could communicate, for example, through "highly expressive" drawings. Their impairments left them unable to decode the grammatical relationships of simple sentences. For example, they had great difficulty distinguishing subject and object in the phrase "The boy chased the girl," which they were unable to differentiate from "The girl chased the boy." Analogous object-relation problems are posed by mathematical expressions such as 90 ÷ 30 and 30 ÷ 90. More complex expressions might involve problems of nesting, such as the use of brackets (90 - [(3 + 17) x 3]), which mirror linguistic sub-clauses and embedded relations, such as in the phrase "The man who killed the lion was angry." Although the patients were unable to decode such linguistic expressions, they were all able to perform the mathematical calculations accurately with pen and paper. They could interpret Arabic numerals correctly even though they struggled to understand number words such as 'three' or 'ninety', when spoken or written. It might be possible to use this capacity for mathematical grammar to help the patients find a way to interpret speech and the written word.
• monophasia : aphasia with ability to utter but one word or phrase
• paraphasia / paragrammatism / paraphemia / paraphrasia : a type of dysphasia in which the patient employs wrong words or uses words in wrong and senseless combinations
• central paraphasia : that due to a brain lesion.
• literal paraphasia / paralalia literalis : utterance of certain consonant sounds, often as part of stuttering
• thematic paraphasia : incoherent speech characterized by wandering from the subject.
• agrammatism / agrammatologia / dysgrammatism : inability to speak grammatically because of brain injury
  or disease, usually with simplified sentence structure (telegraphic speech) and errors in tense, number, and gender
• syntactical aphasia : a type of agrammatism in which some necessary elements for coherent sentences are lacking.
• acquired epileptic aphasia / Landau-Kleffner syndrome (LKS) : an epileptic syndrome in which children, usually 3-8 years of age who have developed age-appropriate speech, experience language regression with verbal auditory agnosia, abnormal epileptiform activity, behavioral disturbances, and sometimes overt partial or generalized seizures, psychomotor abnormalities, and aphasia progressing to mutism. The EEG from bilateral temporal regions is abnormal, with spikes like those of benign rolandic epilepsy.

Therapy : there are no controlled clinical trials investigating the therapeutic options for LKS. Only open-label data are available. Early diagnosis and initiation of prompt medical treatment appear to be important to achieving better long-term prognosis. Several antiepileptic drugs have been reported to be beneficial in treating this syndrome. These include valproic acid, diazepam, ethosuximide, clobazam, and clonazepam. Reports on the efficacy of lamotrigine, sultiame, felbamate, nicardipine, vigabatrin, levetiracetam, vagal nerve stimulation, and a ketogenic diet are few and more experience is needed. Carbamazepine and possibly phenobarbital and phenytoin have been reported to occasionally exacerbate the syndrome. As initial therapy, valproic acid or diazepam is often empirically chosen. Subsequently, other antiepileptic drugs, corticosteroids, or IVIG
therapy are often used. GR agonists
therapy should probably not be delayed > 1-2 months after the initial diagnosis. Various corticosteroid regimens including oral prednisone and, recently, high doses of intravenous pulse corticosteroids, as well as ACTH
have been reported to be effective in LKS. Oral corticosteroids are used more often and usually need to be maintained for a long period of time to prevent relapses. The use of IVIG has been associated with an initial dramatic response in only a few patients. In our experience, a long-term worthwhile improvement has been noted in only 2 of 11 patients. These two patients had an immediate response to IVIG initially and after relapses before eventually achieving a long-term sustained remission.Surgical treatment by multiple subpial transection, which is reserved for patients who have not responded to multiple medical therapies, has been followed in selected cases by a marked improvement in language skills and behavior. However, a widely accepted consensus about suitable candidates for this surgery and about its efficacy is still lacking. Speech therapy, including sign language, and a number of classroom and behavioral interventions are helpful in managing LKS, and should be used in all patientsref
• anomic, amnesic, amnestic or nominal aphasia / aphasia nominnum / anomia : defective recall of names of objects or words to verbalize his/her own thought, with intact abilities of comprehension and repetition, due to lesions of temporoparietooccipital carrefour. It is diagnosed when found in > 20% of spontaneous speech
• tactile aphasia : anomic aphasia characterized by inability to name objects that are touched
• acalculia : inability to do simple arithmetical calculations

Aetiology : Gerstmann's syndrome
• dyscalculia : impairment of the ability to do mathematical problems because of brain injury
  or disease

Aetiology : Turner's syndrome

Laboratory examinations :
• cognitive tests.
• MRI
  detects abnormal pulses of activity in the right intraparietal sulcus
Diagnosis is further complicated because many people simply dislike maths. This might be due to mediocre teaching or low motivation
• central aphasia : a term that has been used as a synonym for various aphasias that involve disturbance in word selection, grammar, and sentence structure apart from elementary auditory or visual comprehension and the ability to write legible characters and speak aloud. Many are presumed to be due to lesions of brain centers (motor speech areas)
• global, central, complete, expressive-receptive, total or mixed aphasia : aphasia involving all the functions of spoken or written language and comprehension, due to large lesions in speech areas
• Broca's expressive, anterior, motor, frontocortical or nonfluent aphasia / logaphasia : aphasia in which there is impairment of the ability to speak (inertia, mutism) and write, owing to a lesion in the insula and surrounding operculum, including Broca's motor speech area. The patient understands many written and spoken words but has difficulty uttering the words (loss of prosodia) => nosognosia => anger and depression. Often associated with manifest hemiplegia => the patient is asked to write with the left hand as the right one is paretic.

Symptoms & signs : Dejerine-Lichtheim sign or phenomenon : in some types of motor aphasia the patient cannot speak but can indicate with fingers the number of syllables in a word being thought of
• Wernicke's receptive, impressive, posterior or sensory aphasia : inability to understand written, spoken, or tactile speech symbols, due to disease of the auditory and visual word centers. The speech is began without difficulties and no motor deficiency is usually associated.
• acoustic or auditory aphasia / word deafness : a form of receptive aphasia in which sounds are heard but convey no meaning to the person affected, due to disease of the subcortical pathways leading to the main auditory center of the brain, or disease of the center itself => hypo- or anosognosia => anger as he/she feels ununderstood
• fluent aphasia: a type of receptive aphasia in which speech is well articulated with satisfactory melodic intonation, syllable stress, and phrasing but has gross errors in grammatical structure and is lacking in content => "word salad" (phonemic, verbal and semantic (within the same category) paraphasias, neologisms)
• semantic aphasia : aphasia characterized by a lack of recognition of the full significance of words and phrases, or faulty use of words, phrases, or sentences; words heard, seen, spoken, or written are misunderstood or used incorrectly in place of other words in the same class.
• associative, commissural or conduction aphasia : a type of aphasia characterized by normal comprehension and speech but inability to repeat words correctly; said to be caused by lesions in the pathways connecting Broca's motor speech area and Wernicke's area (arciform fasciculus)
• transcortical aphasia : a type of conduction aphasia believed to be caused by a lesion of a pathway between the speech center and other cortical centers, but often reflecting large lesions in brain areas other than the perisylvian region of the hemisphere dominant for speech and language. The patient may repeat words (echolalia
  ) but cannot speak independently.
• transcortical motor aphasia : due to lesions of anterior marginal areas (premotor and prefrontal areas; secondary, marginal or accessory areas). Symptoms are similar to those seen in Broca's aphasia (good comprehension and reduced spontaneous speech), but repetition is impaired
• transcortical fluent aphasia : due to lesions of posterior marginal areas. Symptoms are similar to those seen in Wernicke's aphasia
• conduite d'approche
• phonemic
• semantic
• combined aphasia : aphasia of 2 or more forms occurring concomitantly in the same person.
• graphomotor aphasia / agraphia : impairment or loss of the ability to write; it takes 2 forms, one involving poor morphology of written letter forms and the other a reflection of the aphasia also observed in spoken language
• absolute or literal agraphia / agraphia atactica : loss of the power to form even single letters.
• acoustic agraphia : loss of the power of writing from dictation.
• jargon agraphia / agraphia amnemonica : agraphia in which the patient can write correctly formed letters but forms only senseless combinations of letters or words.
• cerebral or mental agraphia : agraphia due to inability to put thought into phrases.
• motor agraphia : inability to write because of lack of motor coordination.
• musical agraphia : loss of the power to write musical symbols.
• optic agraphia : inability to copy written or printed words, but with ability to write from dictation.
• verbal agraphia : ability to write single letters, with loss of ability to combine them into words or sentences
• dysgraphia : difficulty in writing
• echographia / pseudoagraphia : a type of dysgraphia in which the patient can copy writing, but cannot write to express ideas
• micrographia : a dysgraphia in which handwriting is tiny or decreases in size from normal to minute, seen in parkinsonism
Aetiology : Gerstmann's syndrome
• gibberish or jargon aphasia / jargonaphasia : utterance of meaningless phrases, either neologisms or incoherently arranged known words; it is sometimes a symptom of certain types of schizophrenia
• bradylalia / bradylogia / bradyarthria / bradyphasia : abnormally slow utterance of words due to a brain lesion or mental disorder (e.g. parkinsonism
  )
• visual aphasia / alexia
Aetiology :
• functional aphasia : aphasia associated with a psychogenic disorder.
• intellectual or true aphasia : aphasia due to a lesion of any one of the speech centers
• acute : TIA
• chronic : space-occupying lesions
Laboratory examinations :
• Lichtheim test : if a patient is able to indicate the number of syllables in a word which he cannot utter, it indicates that the cortex is less involved than the association fibers.
• Broadbent's test (for cerebral dominance of language function) : different numbers (or words) are presented simultaneously to the 2 ears; right-handed persons tend to report first the words going into the right ear.
Web resources : National Aphasia Association
• Liepmann's apraxia : loss of ability to carry out familiar, purposeful movements in the absence of paralysis or other motor or sensory impairment
• akinetic apraxia : loss of ability to carry out spontaneous movement.
• amnestic apraxia : loss of ability to carry out a movement on command as a result of inability to remember the command, although ability to perform the movement is present.
• Bruns' apraxia of gait / Bruns' frontal ataxia
• Cogan's congenital oculomotor apraxia : an absence or defect of horizontal eye movements, so that when the patient tries to look at an object off to one side, the head must turn to bring the eyes into line with the object and the eyes exhibit nystagmus; the cause is probably a brain lesion
• constructional apraxia : a type of deficit in motor skills characterized by lack of ability to copy simple drawings or to reproduce patterns created with building blocks or matchsticks.

Aetiology : Gerstmann's syndrome
• dressing apraxia : inability to dress oneself properly, often on just one side, as a result of a lesion in the parietal lobe, usually on the nondominant side
• buccofacial or facial apraxia : apraxia of the facial muscles with inability to carry out movements for expression, articulation, and other functions; caused by a lesion in either the supramarginal gyrus or the motor association area on the dominant side. It may be associated with ideokinetic apraxia
• classic, ideokinetic, ideomotor or transcortical apraxia / apraxia : inability to carry out movements that are part of normal activities when requested, in imitation of a demonstration, or even when the person spontaneously wishes to do them. The name is derived from the older concept that ideas were not linked to movements
• innervatory or motor apraxia : impairment of skilled movements that is greater than or different in form from that caused by weakness of the affected parts; the patient appears clumsy rather than weak
• sensory or ideational apraxia : loss of ability to make proper use of an object, due to lack of perception of its proper nature and purpose or to gross disorganization of a plan of usage
• apraxia of speech / aphemia : a speech disorder similar to motor aphasia, due to apraxia of mouth and neck muscles because of a lesion interfering with coordination of impulses from Broca's motor speech area
• hemiapraxia : apraxia affecting one side of the body only.
• sensory or unilateral neglect / selective inattention : hemiapraxia with failure to pay attention to bodily grooming and stimuli on one side but not on the other, usually due to a lesion in the CNS, as after a stroke
• agnosia / pragmatagnosia :
• pragmatamnesia / visual agnosia :
• dysmnesia : properly said memory disorders, impaired memory, as in the amnestic syndrome
• quantitative disorders
• hypermnesia : extreme retentiveness or unusual clarity of memory
• permanent hypermnesia (e.g. Pico della Mirandola)
• idiot savant
• transient hypermnesia : mania, hypomania, hysteria
• hypomnesia : defective memory
• amnesia : lack or loss of memory; inability to remember past experiences.
• circumscribed or localized amnesia : loss of memory for all events during a discrete, specific period of time
• generalized amnesia : loss of memory encompassing the individual's entire life.
• continuous amnesia : loss of memory for all events after a certain time, continuing up to and including the present.
• tactile amnesia / astereognosis
• visual amnesia / alexia
According to chronological succession of memories :
• global amnesia
• lacunar or localized amnesia : partial loss of memory; amnesia for certain isolated experiences.
• anterograde or fixation amnesia : impairment of memory for events occurring after the onset of amnesia; inability to form new memories
• retrograde or reevocation amnesia : inability to recall events that occurred before the actual onset of amnesia; loss of memories of past events
• retroanterograde amnesia
According to kinds to impaired memories :
• simple amnesia : all kined of memories are impaired
• systematic or selective amnesia : loss of memory for a group of related events but not for other events occurring during the same period of time.
• episodic amnesia : amnesia for a particular episode or a small area of experience.
Aetiology :
• paramnesia : qualitative disorders, a disturbance of memory in which reality and fantasy are confused
• allomnesia / memory illusion : deformation of actual memories, incomplete memories, or inadequate in spatiotemporal location, alterated in meaning, easily correctable (e.g. holothymic thought, paranoid states, ...)
• pseudomnesia / memory hallucination : not correctable
• false identifications : new situations are seen as memories (dejà vu)
• false memories : incapacity to differentiate between fantasy and reality (e.g. confabulation, false memories in holothymic or delirating thought)
• disorders of intelligence
• bradyphrenia / bradyphrasia / mental insufficiency : stable slowness of thought or fatigability of initiative, resulting from depression or CNS disease
• dementia: generally evolutive deficiency
• axis I : symptomatology, monothetic diagnosis (all criteria have to be fulfilled => many false negatives => repetibility = 80%) : developmental disorders, delirium, dementia, and amnestic disorders, substance-related disorders, psychoses, neuroses, factitious disorders, sleep disorders, impulse control disorders, adjustement disorders
• axis II : behavioural, polytethic diagnosis (only some criteria have to be fulfilled => many false positives => repetibility = 50%) : personality disorders, mental retardation
• axis III : general medical conditions
• axis IV : psychosocial and environmental problems
• problems with main supporting group
• problems related to social environment
• learning disorders
• job problem
• house problem
• economical problems
• problems with access to health care services
• problem related with interaction with legal system or criminality
• other psychosocial or environmental problems
• axis V : global assessment of functioning (GAF) scale : a rating of psychiatric status from 1 (lowest level of functioning) to 100 (highest level), assessing psychological, social, and occupational functioning; widely used in studies of treatment effectiveness (actual, at admission, at dimission, higher level in last year)
• Social and Occupational Functioning Assessment Scale (SOFAS) : one that describes the level of an individual's social and occupational functioning, either present or past; unlike the GAF scale, it is not directly influenced by the severity of the individual's psychological symptoms

disorders usually diagnosed for the first time in infancy, childhood, or adolescence / developmental disorders : a former classification of chronic disorders of mental development with onset in childhood; such disorders are now classified as ...

• mental retardation : a mental disorder characterized by significantly subaverage general intellectual functioning associated with impairments in adaptive behavior and manifested before age 18. It is classified on the basis of severity as ..
• borderline mental retardation : borderline intellectual functioning, that in which IQ is between 70 and 89.
• mild mental retardation : that in which IQ is between 50�55 and 69; the person can develop social and communication skills during the preschool period, has minimal sensorimotor impairment, by the late teens can acquire academic skills up to the sixth grade level, and usually achieves social and vocational skills adequate for minimal self-support.
• moron : obsolete, offensive term for a person with mild mental retardation
• imbecile : obsolete and offensive name for a person with an intermediate level of mental retardation, now split into...
• moderate mental retardation : that in which IQ is between 35�40 and 49�55; the person may talk or learn to communicate but has poor social awareness and only fair motor development, is unlikely to progress to the second grade level in academic skills, but can profit from vocational training and with moderate supervision can perform personal care.
• severe mental retardation : that in which IQ is between 20�25 and 34�40; the person has poor motor development and minimal speech in the preschool period, may learn to talk by the late teens, can be trained in elementary hygiene skills, and as an adult may learn to perform simple work under close supervision.
• idiot savant [Fr. �learned idiot�] : a person with severe mental retardation in some respects, yet has a particular mental faculty that is developed to an unusually high degree, as memory, mathematics, or music.
• profound mental retardation : that in which IQ is < 20�25; the person has limited sensorimotor development, may achieve very limited self-care, and requires a highly structured environment with constant supervision.
• idiot : obsolete, offensive name for a person with profound mental retardation
• mongolian idiot : former name for a person affected with Down syndrome
  ; now considered offensive
• mental retardation-not otherwise specified (NOS)
Aetiology : Laboratory examinations : Denver Developmental Screening test : a test for identification of infants and preschool children with developmental delay.
Differential diagnosis :
• normal variations in school results
• lack of opportunities
• poor teaching
• cultural factors
• visual or auditory insufficiency
Web resources : Mental retardation at CDC
• learning disorders : a group of disorders characterized by academic functioning that is substantially below the level expected on the basis of the patient's age, intelligence, and education, interfering with academic achievement or other functioning. Included are :
• reading disorder : a learning disorder in which the skill affected is reading ability, including accuracy, speed, and comprehension
• mathematics disorder : a learning disorder in which the skill affected is mathematical calculation or reasoning.
• disorder of written expression : a learning disorder in which the affected skill is written communication, characterized by errors in spelling, grammar, or punctuation, by poor paragraph organization, or by poor story composition or thematic development.

Differential diagnosis :
• poor graphia
• developmental coordination disorder
• motor skills disorder : any disorder characterized by inadequate development of motor coordination severe enough to limit locomotion or restrict the ability to perform tasks, schoolwork, or other activities. Included is
• developmental coordination disorder : problematic or delayed development of gross and fine motor coordination skills, not due to a neurological disorder or to general mental retardation; affected children appear to be clumsy rather than grossly impaired. It may persist into adulthood.

Differential diagnosis :
• specific neurological disorder (e.g. cerebral palsy, progressive cerebellar lesions)
• mental retardation
• pervasive developmental disorders
• attention-deficit/hyperactivity disorder (ADHD)
• communication disorders : mental disorders characterized by difficulties in speech or language, severe enough to be a problem academically, occupationally, or socially; included are
• expressive language disorder : a communication disorder occurring in children and characterized by problems with the expression of language, either oral or signed. It includes difficulties such as limited speech or vocabulary, vocabulary errors, difficulty or hesitation in word selection, oversimplification of grammatical or sentence structure, omission of parts of sentences, unusual word order, and slowed acquisition of language skills. Two types are recognized, acquired and developmental.

Differential diagnosis :
• mixed receptive-expressive language disorder
• autistic disorder
• mental retardation
• auditory or other sensory deficit
• word motory deficit
• severe environmental deprivation
• disorder of written expression
• selective mutism
• acquired aphasia associated with general medical condition
• mixed receptive-expressive language disorder : a communication disorder involving both the expression and the comprehension of language, either spoken or signed. Patients have difficulties with language production, such as in the selection of words and the creation of appropriate sentences, and also have trouble understanding words, sentences, or specific types of words

Differential diagnosis :
• expressive language disorder
• autistic disorder
• mental retardation
• auditory or other sensory deficit
• word motory deficit
• severe environmental deprivation
• disorder of written expression
• selective mutism
• acquired aphasia associated with general medical condition
• phonological disorder : a communication disorder of unknown etiology, characterized by failure to use age- and dialect-appropriate sounds in speaking, with errors occurring in the selection, production, or articulation of sounds. The most common errors are omissions, substitutions, and distortions of speech sounds

Differential diagnosis :
• mental retardation
• auditory or other sensory deficit
• severe environmental deprivation
• stuttering
• communication disorder-not otherwise specified (NOS)
• stuttering / psellism

Epidemiology : 5% of people in the USA at some time in their lives. Stuttering usually begins in the preschool years, and there is a higher incidence in males. Stuttering usually starts in the third and fourth years of life, after a period of apparently normal speech development. Around 5% of children begin to stutter (Bloodstein O. A handbook on stuttering. San Diego, CA: Singular Publishing Group, 1995). Although the recovery rate without professional intervention is 74%ref, the natural recovery rate of cases presenting to clinics has not been researched. To date, sex and family history of recovery are the major identified predictors of natural recovery. Girls are more likely to recover than boys, and children with a family history of recovery are more likely to recover than those without such a history. Natural recovery does not seem to be related to severity of stutteringref.
Aetiology : a complex interaction among many factors, including genetic, language, motor and emotional. These findings will help reduce the stigma � such as the myth that the disorder is the result of poor parenting or a psychological problem � often associated with stuttering
Pathogenesis : adults who stutter often have great language skills, meaning they don't have problems with rules of grammar or with the sounds we use to code the words of our language. When they speak, however, their motor output falters, so they pause or trip over words. The study of their brain activity when they were not stuttering and, in fact, when they were not having to engage their speech motor systems shows that individuals who stutter are using right hemisphere brain areas to a greater extent to accomplish the rhyming tasks than those who don't stutterref
Symptoms & signs : a speech disorder involving 3 factors:
• dysfluency with repetition of words and parts of words, prolongations of sounds, interjections of sounds or words, and long pauses
• listener reaction, considering the dysfluency to be abnormal or unacceptable
• the speaker's reaction to the dysfluency and to the listener's reaction, with a self-conception as a stutterer.
Differential diagnosis :
• auditory or other sensory deficit
• word motory deficit
• normal fluency anomalies that often occur in little babies
Therapy : the consensus now is that stuttering should be treated in the preschool years, primarily because it becomes less tractable as children get older. This is presumably because neural plasticity decreases with age. Also, it is not possible to know in advance whether an individual child will recover naturally. Early intervention in the preschool years is therefore essential. Once stuttering becomes chronic, communication can be severely impaired, with devastating social, emotional, educational, and vocational effectsref1, ref2. Several treatments for early stuttering are currently available (Onslow M, Packman A, eds. The handbook of early stuttering intervention. San Diego, CA: Singular Publishing Group, 1999), but only one, the Lidcombe programme, has been studied with phase I and II clinical trials (Onslow M, Packman A, Harrison E, eds. The Lidcombe program of early stuttering intervention: a clinician's guide. Austin, TX: Pro-Ed, 2003). This programme is a behavioural treatment developed specifically for stuttering in children of preschool age (younger than 6). Considerable research into the programme has been conducted. Preliminary studies have produced positive outcomes, and stuttering has been shown to be no longer present, or remaining at very low levels, two to seven years after treatmentref1, ref2, ref3 (Lincoln M, Onslow M. Long-term outcome of an early intervention for stuttering. Am J Speech-Language Pathol 1997;6: 51-8). The social validity and safety of the programme have been shown (Lincoln M, Onslow M, Reed V. Social validity of an early intervention for stuttering; the Lidcombe program. Am J Speech-Lang Pathol 1997;6: 77-84). It does not seem to change children's behaviour other than speech or affect the attachment of children and parents or use of languageref1, ref2. Duration of treatment and its predictors have been investigated in two independent file audits of preschool children attending specialist clinics, one in Australiaref and one in the United Kingdomref. Outcomes of the Lidcombe programme have consistently been shown to be positiveref1, ref2, ref3, ref4, ref5, ref6, ref7 (Lincoln M, Onslow M. Long-term outcome of an early intervention for stuttering. Am J Speech-Language Pathol 1997;6: 51-8; Lincoln M, Onslow M, Reed V. Social validity of an early intervention for stuttering; the Lidcombe program. Am J Speech-Lang Pathol 1997;6: 77-84) even in a randomised controlled trialref. Waiting for an extended period to see if natural recovery occurs is not acceptable because it seems that the Lidcombe programme is less efficacious once children move into the school age years (Lincoln M, Onslow M, Wilson L, Lewis C. A clinical trial of an operant treatment for school-age stuttering children. Am J Speech-Lang Pathol 1996;5: 73-85). In addition, delaying treatment until the school age years is not a viable option because of the negative social and cognitive consequences of stuttering at this ageref. If the disorder persists into the school age years a child is exposed to the unacceptable risk of experiencing the disabling effects of chronic and intractable stuttering throughout life.
• stammering : a speech disorder marked by involuntary pauses; sometimes used synonymously with stuttering, especially in Great Britain.
• communication disorder-not otherwise specified (NOS)
• rhotacism / pararhotacism : a speech disorder consisting of imperfect pronunciation of the r sound
• pervasive developmental disorders (PDD) / autistic spectrum disorders (ASD) : a group of disorders characterized by impairment of development in multiple areas, including the acquisition of reciprocal social interaction, verbal and nonverbal communication skills (e.g declarative pointing, gaze monitoring, gaze escape, mimicking), and imaginative activity and by stereotyped interests and behaviors

Epidemiology : prevalence = 4-5 cases every 1,000 people
• autism / autistic disorder / infantile autism / Kanner's syndrome : a severe pervasive developmental disorder with onset usually before 3 years of age and a biological basis related to neurologic or neurophysiologic factors
• autistic thinking / autism : self-absorption; preoccupation with inner thoughts, drives, and idiosyncratic logic; egocentric, subjective thinking lacking objectivity and preferring a narcissistic, inner, private reality to that which is externally validated. Used interchangeably with dereistic thinking, although differing in emphasis
• dereistic thinking / dereism : thinking not in accordance with the facts of reality and experience and following illogical, idiosyncratic reasoning. Used interchangeably with autistic thinking, although not an exact synonym: dereistic emphasizes disconnection from reality and autistic emphasizes preoccupation with inner experience.
Epidemiology : frequency of the disorder increased from approximately 2.5 cases every 10,000 in 1960-1970s to 1 every 1,000 children in 1990s, with a male to female ratio of 4:1.
Aetiology : Pathogenesis : mirror neurons are brain cells in the premotor cortex. First identified in macaque monkeys in the early 1990s, the neurons -- also known as "monkey-see, monkey-do cells" -- fire both when a monkey performs an action itself and when it observes another living creature perform that same action. Though it has been impossible to directly study the analogue of these neurons in people (since human subjects cannot be implanted with electrodes), several indirect brain-imaging measures, including EEG, have confirmed the presence of a mirror neuron system in humans. The human mirror neuron system is now thought to be involved not only in the execution and observation of movement, but also in higher cognitive processes -- language, for instance, or being able to imitate and learn from others' actions, or decode their intentions and empathize with their pain. Suppression of m rhythm (8�13 Hz) over sensorimotor cortex correlates with mirror neuron activity and is defective in subjects with autism spectrum disorders : one therapeutic possibility suggested by the study's findings is biofeedback. Another possible therapy would involve ordinary mirrorsref
Symptoms & signs : affected individuals look normal at birth, and the symptoms manifest at the first 2-3 years of life (median : 13.8 months), with medical diagnosis at median 2.7-6.8 years (differential diagnosis with mental retardation or language disorders is stable if done before age 2, sure since month 18). The spectrum of clinical symptoms and the severity of the disorder are variable even among siblings. Qualitative impairment in reciprocal social interaction (e.g., lack of awareness of the existence of feelings of others, failure to seek comfort at times of distress, lack of imitation), in verbal and nonverbal communication, and in capacity for symbolic play, and by restricted and unusual repertoire of activities and interests. Other characteristics sometimes include cognitive impairment (> 66% have some degree of mental retardation), hyper- or hyporeactivity to certain stimuli, stereotypic behaviors, neurological abnormalities such as seizures or altered muscle tone, sleeping or eating pattern abnormalities, and severe behavioral problems. As adults they develop OCD and mental retardation (higher functioning PDD : high IQ in adulthood).
Laboratory examinations : several screening instruments have been developed to quickly gather information about a child's social and communicative development within medical settings. Among them are
• Checklist of Autism in Toddlers (CHAT)ref
• modified Checklist for Autism in Toddlers (M-CHAT)
• Screening Tool for Autism in Two-Year-Olds (STAT)ref
• Social Communication Questionnaire (SCQ)ref (for children 4 years of age and older).
Some screening instruments rely solely on parent responses to a questionnaire, and some rely on a combination of parent report and observation. Key items on these instruments that appear to differentiate children with autism from other groups before the age of 2 include pointing and pretend play. Screening instruments do not provide individual diagnosis but serve to assess the need for referral for possible diagnosis of ASD. These screening methods may not identify children with mild ASD, such as those with high-functioning autism or Asperger syndrome.
Differential diagnosis :
• Rett syndrome
• childhood disintegrative disorder
• Asperger's syndrome
• schizophrenia
• selective mutism
• expressive language disorder
• mixed receptive-expressive language disorder
• mental retardation
Therapy : Web resources : Autism at CDC
• Rett syndrome (RTT / RTS) / cerebroatrophic hyperammonemia : a PDD affecting the gray matter of the brain

Epidemiology : 1:10,000 individuals, occurring exclusively in females and present from birth
Aetiology : dominant mutations in the MECP2
gene, a X-linked transcriptional repressor, or its controlled genes, including BDNF
or UQCRC1. A severe early-onset Rett phenotype that often includes seizures or infantile spasms can be caused by mutation in the CDKL5 gene
Pathogenesis : the timing of the period of regression in RTT--during ages 1 to 2 years--parallels the period of intense synaptic development. The effects of the MECP2 mutation also increases concomitantly with peak synaptogenesis. Neuropathological findings in Rett include the selective reduction of dendritric spines in the pyramidal cells of RTT brains; this feature has also been reported in autism. Studies have observed that MECP influences the expression of brain-derived neurotrophic factor and thus may influence synaptic plasticity. Abnormalities in synapse maintenance and modulation may contribute to regression in RTT and autism. A recent study observed abnormal expression of MeCP2 in RTT and other neurodevelopmental disorders such as autism. Although the genetic background and certain clinical features differ in RTT and autism, a similar mechanism involving MeCP2 regulation and expression may contribute to regressionref.
Symptoms & signs : progressive and is characterized by autistic behavior (but a preserved speech variant exists), ataxia, dementia, seizures, and loss of purposeful use of the hands, with cerebral atrophy, mild hyperammonemia, and decreased levels of biogenic amines. During the regression stage, RTT girls display many autistic features, such as loss of communication and social skills, poor eye contact, and lack of interest, and initially may be given the diagnosis of autism.
Differential diagnosis :
• autistic disorder
• childhood disintegrative disorder
• Asperger's syndrome
Experimental animal models : the phenotype of one mouse model includes features such as regression and abnormal behavioral and social interactions.
• childhood disintegrative disorder : pervasive developmental disorder characterized by marked regression in a variety of skills, including language, social skills or adaptive behavior, play, bowel or bladder control, and motor skills, after at least 2, but less than 10, years of apparently normal development.

Differential diagnosis :
• autistic disorder
• Rett syndrome
• Asperger's syndrome
• dementia
• Asperger's syndrome : a pervasive developmental disorder resembling autistic disorder, being characterized by severe impairment of social interactions and by restricted interests and behaviors, but lacking the delays in development of language, cognitive function, and self-help skills that additionally define autistic disorder. It may be equivalent to a high-functioning form of autistic disorder.

Laboratory examinations : during the last few years, screening instruments have been devised to screen for Asperger syndrome and higher functioning autism. The Autism Spectrum Screening Questionnaire (ASSQ)ref, the Australian Scale for Asperger's Syndromeref, and the most recent, the Childhood Asperger Syndrome Test (CAST)ref, are some of the instruments that are reliable for identification of school-age children with Asperger syndrome or higher functioning autism. These tools concentrate on social and behavioral impairments in children without significant language delay.
Differential diagnosis :
• autistic disorder
• Rett syndrome
• childhood disintegrative disorder
• obsessive-compulsive disorder (OCD)
• schizoid personality disorder
• pervasive developmental disorder-not otherwise specified (PDD-NOS)
• silent-treatment : a temporary act of teenage rebellion, usually the result of being confronted by a parent; extended silence used to avoid discussion about a drug or drinking problem
• attention-deficit/hyperactivity disorder and disruptive behavior disorders
• attention-deficit / hyperactivity disorder (ADHD) / hyperkinetic disorder (HKD) or syndrome : a childhood mental disorder

Epidemiology : prevalence = 3% to 10% of the pediatric population. Datamonitor estimates that 23 million children and adolescents across the 7 major pharmaceutical markets suffer from ADHD, a physician perceived prevalence rate of about 15%. However currently only 12% of those, or only 1.8% of children in the total population, are actually correctly diagnosed with ADHD. Despite the availability of numerous longer-acting therapies, currently only 20% of newly diagnosed patients receive such drugs as a first-line treatment, falling to 3% at second-line.
Pathogenesis : the number and density of DATs and DAT binding sites are increased by up to 70 %
Symptoms & signs : inattention (such as distractibility, forgetfulness, not finishing tasks, and not appearing to listen), by hyperactivity and impulsivity (such as fidgeting and squirming, difficulty in remaining seated, excessive running or climbing, feelings of restlessness, difficulty awaiting one's turn, interrupting others, and excessive talking) or by both types of behavior. The disorder is subtyped as
• combined type
• predominantly inattentive type (attention-deficit disorder (ADD))
• predominantly hyperactive-impulsive type
Behavior must interfere with academic, social, or work functioning, with impairment existing in at least two settings. Onset is before age 7 but it can persist into adulthood.
Differential diagnosis :
• behaviour adequate to gorgeous babies
• mental retardation
• poorly stimulating environments
• oppositional defiant disorder
• other mental disorders
• pervasive developmental disorders
• psychotic disorder
• substance-related disorders-NOS
Chemotherapy :
• stimulants, which, because of their addictive properties and potential for abuse, are controlled substances. The 14-month, controlled Multimodal Treatment Study of Children with Attention Deficit�Hyperactivity Disorder (MTA study), sponsored by the National Institute of Mental Health, revealed a high rate of response to stimulants (> 70%) and large effect sizes (0.6 to 1.2 standard deviations), with significantly lower rates of improvement for subjects who underwent psychotherapyref1, ref2, ref3. Although these drugs are the mainstay of treatment for ADHD, nearly one third of patients may not respond to or be able to tolerate them. The FDA advisory committee heard testimony indicating that 2.5 million children now take stimulants for ADHD, including nearly 10% of all 10-year-old boys in the USAref. The committee also learned that the use of these agents is much less prevalent in European countries, where the diagnosis of ADHD is relatively uncommon. Even more strikingly, 1.5 million adults now take such stimulants on a daily basis, with 10% of users older than 50 years of age. The diagnosis of "adult" ADHD is a relatively recent phenomenon and has resulted in the most rapid growth in the use of such agentsref. The vast increase in the diagnosis of ADHD and the frequency of treatment for the condition in children is, unfortunately, no longer a phenomenon specific to the United States. According to the latest Drug Prescription Report (Schwabe U, Paffrath D. Arzneiverordnungsreport 2005. Berlin: Springer-Verlag, 2005), the number of daily doses of methylphenidate that are prescribed in Germany has reached 26 million per year. Although the population-adjusted volume in the USA is still 8 to 10 times that amount, the number of prescriptions for the drug for German children rose by a factor of 20 during the past 10 years, with no signs of abating. The use of methylphenidate by adults is similarly on the rise.
• amphetamines :
• NRI
  (atomoxetine
  ), a nonstimulant approved by the US Food and Drug Administration
Web resources : Attention-deficit / hyperactivity disorder (ADHD) at CDC
• attention-deficit / hyperactivity disorder (ADHD)-not otherwise specified (NOS)
• disruptive behavior disorders : a group of mental disorders of children and adolescents consisting of behavior that violates social norms, is disruptive, and may be illegal, often distressing others more than it does the person with the disorder. It includes :
• conduct disorder : a type of disruptive behavior disorder of childhood and adolescence characterized by a persistent pattern of conduct in which rights of others or age-appropriate societal norms or rules are violated, with misconduct including aggression to people or animals, destruction of property, deceitfulness or theft, and serious violations of rules; depending on whether the behavior begins before or after the age of 10, it is classified as
• childhood-onset
• adolescent-onset
Differential diagnosis :
• oppositional defiant disorder
• attention-deficit/hyperactivity disorder (ADHD)
• mania
• adjustement disorders
• antisocial behaviour of child or adolescent
• antisocial personality (disorder)
• oppositional defiant disorder : a type of disruptive behavior disorder characterized by a recurrent pattern of defiant, hostile, disobedient, and negativistic behavior directed toward those in authority, including such actions as defying the requests or rules of adults, deliberately annoying others, arguing, spitefulness, and vindictiveness that occur much more frequently than would be expected on the basis of age and developmental stage

Differential diagnosis :
• conduct disorder
• mood disorders
• psychotic disorder
• attention-deficit/hyperactivity disorder (ADHD)
• mental retardation
• compromised language comprehension
• deafness
• mixed receptive-expressive language disorder
• typical characteristic of certain developmental stages (early childhood, adolescence, ...)
• disruptive behavior disorder-not otherwise specified (NOS)
• feeding and eating disorders of infancy or early childhood : any of several disorders in which abnormal feeding habits are associated with psychological factors
• tic disorders
• Gilles de la Tourette's syndrome
  (lasting > 12 months)
• chronic motor or vocal tic disorder (lasting > 12 months)
• transient tic disorder (lasting 1 < x < 12 months)
• single episode
• relapsing
• tic disorder-not otherwise specified (NOS) : lasting < 1 month, onset > 18 years, or single motor or vocal tic)
Differential diagnosis :
• evacuation disorders
• other infancy, childhood, or adolescence disorders
• separation anxiety disorder
• selective mutism : a mental disorder of childhood characterized by continuous refusal to speak in social situations by a child who is able and willing to speak to selected persons.
• nyctaphonia : elective mutism with loss of voice during the night.
Differential diagnosis :
• communication disorders
• pervasive developmental disorders
• lack of knowledge of language in immigrants
• psychotic disorder
• severe mental retardation
• reactive attachment disorder : a mental disorder of infancy or early childhood, characterized by notably unusual and developmentally inappropriate social relatedness, usually associated with grossly pathological care. It may be :
• inhibited type, with failure to initiate or respond to social interactions
• disinhibited type, with indiscriminate sociability or attachment.
Differential diagnosis :
• pervasive developmental disorders
• mental retardation
• attention-deficit/hyperactivity disorder (ADHD)
• stereotypic movement disorder : a mental disorder characterized by repetitive nonfunctional motor behavior, such as hand waving, rocking, head-banging, or self-biting, which often appears to be driven and can result in serious self-inflicted injuries

Differential diagnosis :
• pervasive developmental disorders
• mental retardation
• obsessive-compulsive disorder (OCD)
• complex motor tic disorders
• trichotillomania
• factitious disorder with main physical signs and symptoms
• automutilation associated with certain psychotic disorder and personality disorders
• involuntary movements associated with neurological conditions
• behaviours of self-stimulation appropriated to little babies developmental stage (e.g. thumb suction, head hurting, ...)
• behaviours of self-stimulation in subjects with sensory deficiencies (e.g. blindness)
• infancy, childhood, or adolescence disorder-not otherwise specified (NOS)

delirium, dementia, amnestic disorders, and other cognitive disorders

• delirium / acute (organic) brain syndrome : an acute, transient disturbance of consciousness accompanied by a change in cognition and having a fluctuating course. Characteristics include reduced ability to maintain attention to external stimuli and disorganized thinking as manifested by rambling, irrelevant, or incoherent speech; there may also be a reduced level of consciousness, sensory misperceptions, disturbance of the sleep-wake cycle and level of psychomotor activity, disorientation to time, place, or person, and memory impairment.

Aetiology : conditions that result in derangement of cerebral metabolism, including
• delirium due to general medical condition
• systemic infection
• cerebral tumor
• seizures or head trauma
• metabolic disturbances such as fluid, electrolyte, or acid-base imbalance
  , hypoxia
  , hypoglycemia
  , or hepatic or renal failure
• febrile delirium : the delirium of fever
  .
• postcardiotomy delirium / postcardiotomy psychosis syndrome : anxiety, confusion, and perceptual disturbances occurring > 3 days after open heart surgery
  .
• senile delirium : a form of senile dementia, usually of acute onset and characterized by disorientation, restlessness, insomnia, hallucinations, and aimless wandering.
• traumatic delirium : that which follows severe head injury; superficially the patient is alert, but there is marked disorientation, memory defect, and confabulation.
• substance-induced delirium
• delirium due to multiple aetiologies
• delirium-not otherwise specified (NOS)
Grading :
• acute delirium : a suddenly appearing and severe delirium lasting only a short time.
• low delirium : delirium marked by confusion of ideas and slowness of mental action rather than by excitement.
Differential diagnosis :
• dementia
• susbtance intoxication
• substance withdrawal
• psychotic disorder
• mood disorders with psychotic features
• malingering
• factitious disorder
• dementia : literally out of mind, loss of self, i.e. a general acquired loss of intellectual and cognitive abilities, including impairment of memory
  as well as one or more of other abilities in subjects that have reached normality (on the contrary of mental retardation).

Epidemiology : 24.3 million people have dementia today, with 4.6 million new cases of dementia every year (one new case every 7 seconds). The number of people affected will double every 20 years to 81.1 million by 2040. Most people with dementia live in developing countries (60% in 2001, rising to 71% by 2040). Rates of increase are not uniform; numbers in developed countries are forecast to increase by 100% between 2001 and 2040, but by more than 300% in India, China, and their south Asian and western Pacific neighboursref.
Aetiology :
• primary or degenerative dementias
• cortical dementias
• dementia of the Alzheimer type (DAT) / Alzheimer-type dementia (ATD) (43.6-60% of all dementias) : that occurring in Alzheimer's disease
  , being of insidious onset and gradually progressive course, with histopathological changes characteristic of Alzheimer's disease and not due to other CNS, systemic, or substance-induced conditions known to cause dementia. It is subcategorized on the basis of accompanying features, including
• delirium
• delusion
• depression
• behavioral disturbances
• none (uncomplicated)
Patients lose their ability to encode new memories, first of trivial and then of important details of life => both declarative and nondeclarative memory become profoundly impaired, and the capacities for reasoning, abstraction, and language slip away.
• presenile dementia / dementia of the Alzheimer type, early onset : occurring before age 65
• senile dementia / dementia of the Alzheimer type, late onset : occurring after age 65
• frontotemporal dementias (FTD) (10%; higher in presenile cases, i.e. < 65 years) : due to atrophy of frontal and eventually also temporal lobes
Symptoms & signs : behavioural and appetite disinhibition, emotive flattening, irritability, bulimia, weight gain, preserved memory, copying, calculation, memory, socially inadequate behaviours or isolation => rigidity and mutism (aphasia, echolalia
), impaired judgements and propriety sense, generally euphoric, hypocritical, logorrheic, agitated, and with primitive reflexes.
• primary progressive (nonfluent) aphasia (PPA) : the primary symptoms of the disease are problems speaking or understanding speech, and these problems gradually get worse over time. People with PPA also may develop difficulty with math. Most other functions remain normal for at least two years after the language symptoms appear, but the disease may eventually cause other changes, such as problems with memory, reasoning, and spatial abilities. PPA sometimes runs in families : 85% of cases have PRNP codon 129 heterozigosityref
• subcortical dementias :
• diffuse Lewy body
  dementia (DLBD) (15.4%, the second most common degenerative dementia; DLBD is diagnosed only when they are not associated with Alzheimer's disease
  or idiopathic Parkinson's disease
  ) is a neuropathological entity, characterized by abundant LBs not only in the basal ganglia and brain-stem but in the cerebral cortex, combined with senile changes. Juvenile onset DLBD is called pure form of DLBD because of no or few senile changes. The LBs are present in the amygdala, nucleus basalis of Meynert, hypothalamic nuclei, substantia nigra, nucleus paranigralis, locus caeruleus, dorsal vagal nucleus and reticular nuclei. The cerebral LBs are numerous in the parahippocampal gyrus, cingular gyrus, and insular, frontal and temporal cortices. The LBs show immunoreactivity to ubiquitin and the ubiquitin-immunoreactive neurites in the CA2-3 region appear to be specific for DLBD. The clinical features of DLBD in the senium are progressive dementia, psychotic state (delirium, visual > auditory hallucinations), falls, potentially fatal hazard of neuroleptics and benzodiazepines
  , parkinsonism and autonomic signs. In general, progressive dementia is an initial symptom, followed by parkinsonism in the later stage. Some show progressive autonomic failure. A few present respiratory failure or vocal cord palsy resulting in sudden death in DLBD. DLBD is characterized neurochemically by severe affection of multiple neurotransmitters networks. In DLBD an impairment of the innominato-cortical cholinergic and mesocortical dopaminergic system, differentiating from Alzheimer's disease
  and idiopathic Parkinson's disease
  , may play an important role in developing disease process
• neurosyphilis
• idiopathic Parkinson's disease
  . It is estimated that dementia occurs in approximately 40% of people with PD and that it may affect up to 80% of PD patients as the disease further progresses. Previous studies suggest that patients with PD have up to a 6-fold increase in the risk of developing dementia compared to elderly patients without PD

Therapy : rivastigmine
tartrateref
• amyotrophic lateral sclerosis-Parkinsonian dementia complex (ALS-PDC)
• fragile X-associated tremor/ataxia syndrome (FXTAS)
• Huntington's disease
• Steele-Richardson-Olszewski syndrome / progressive supranuclear palsy (PSP)
• corticobasal degeneration (CBD)
• multiple sclerosis
• progressive myoclonic epilepsy
• Hallervorden-Spatz disease (HSD) / neurodegeneration with brain iron accumulation type I (NBIA-I) / pantothenate kinase associated neurodegeneration (PKAN) / late infantile neuroaxonal dystrophy is a rare neurodegenerative disorder characterized by progressive extrapyramidal dysfunction (dystonia, rigidity, choreoathetosis), pyramidal sign, schizophreniform psychotic symptoms, and dementia due to mutations in pantothenate kinase 2 (PANK2), which is allelic with hypoprebetalipoproteinemia, acanthocytosis, retinitis pigmentosa, and pallidal degeneration (HARP) syndrome. Onset is most commonly in late childhood or early adolescence. The disease can be familial or sporadic. In these patients, chronic repeated dystonic movements, especially of the head and neck, can lead to excessive stress on the cervical spine, resulting in early degenerative changes and myelopathy. This is an a-synucleinopathy
  : a-synuclein is present in axonal spheroids
  , Lewy-related dystrophic neurites
  , glial cytoplasmic inclusions (GCI)
  and neuronal cytoplasmic inclusions (NCI)

Pathogenesis : dopamine-neuromelanine system ; disturbances of vitamin B5
metabolism ?
Laboratory examinations : MRI
shows bilaterally symmetrical hyperintense signal changes (due to gliosis, demyelination, neuronal loss, and axonal swelling) in the external segment of globus pallidus and substantia nigra, with surrounding hypointensity (caused by loss of signal secondary to iron deposition) on T2wi. These imaging features are fairly diagnostic and have been termed the "eye-of-the tiger sign"
• secondary dementias
• Creutzfeld-Jakob disease (CJD)
• hypothyroidism
• AIDS dementia complex
• Klüver-Bucy syndrome : bizarre behavior disturbances seen in monkeys following experimental bilateral temporal lobectomy which destroys important limbic structures; reported in humans after large injuries, usually from trauma, affecting the undersurface of the anterior temporal lobes. It is characterized by a tendency to examine objects orally, depression of drive and emotional reactions, hypermetamorphosis, and lack of sexual inhibitions.
• leukaraiosis : diffuse alterations of subcortical white matter at MRI
• posttraumatic dementia : dementia following head trauma
  ; it may last from a few months to years
• boxer's dementia / dementia pugilistica / punch-drunk encephalopathy / punchdrunk : a syndrome more serious than boxer's traumatic encephalopathy, the result of cumulative head trauma in boxers; characterized by forgetfulness, slowness in thinking, dysarthric speech, and slow, uncertain movements, especially of the legs
• CNS infections
• substance-induced persisting dementia / toxic dementia
• dementia due to general medical conditions not listed above
• dementia due to multiple aetiologies
Causes of dementias with onset after age 65 :
• dementia of the Alzheimer type (50-60%, more common in females)
• multi-infarct dementia (MID) / vascular dementia (VaD) (10-20%, more common in males)
• mixed form (10-20%)
• other dementia (5-15%)
Pathogenesis : widespread cerebral damage or dysfunction. Age-related memory decline is thought to be triggered by chronic stress, such as that caused by a long-term illness. This raises levels of the stress hormone cortisol
in the brain : humans with chronically high cortisol levels have smaller hippocampi
Course :
• acute
• subacute
• chronic
• progressive dementia
• regularly progressive
• irregularly progressive
• not progressive
Symptoms & signs : variable due to background and remodeling
• reversible
• partially reversible
• irreversible
• cognitive symptoms :
• amnesia
• temporospatial disorientation
• apraxia
• aphasia
• alexia
• agraphia
• acalculia
• abstract thinking, logic, and judgement deficiency
• visuospatial deficiency
• noncognitive symptoms
• psychosis
• delirium (37.5% in mild dementia, 42.6% in moderate dementia, 43.8% in severe dementia)
• hallucinations (18.7% in mild dementia, 27.8% in moderate dementia, 53.1% in severe dementia)
• sudden mood changes
• depression (56.3% in mild dementia, 70.4% in moderate dementia, 46.9% in severe dementia)
• euphoria (43.7% in mild dementia, 13% in moderate dementia, 9.4% in severe dementia)
• lability
• anxiety (25% in mild dementia, 46.3% in moderate dementia, 53.1% in severe dementia)
• neurovegetative symptoms
• sleep
• appetite
• sexual behaviour
• psychomotricity (afinalistic movements, akathisia) : crystallization of thought (stereotypization and dogmatism), amplification of characters
• agitation (56.9% in mild dementia, 59.3% in moderate dementia, 71.9% in severe dementia)
• aggressivity
• vocalization
• personality
• indifference
• disinhibition (25% in mild dementia, 20.4% in moderate dementia, 28.1% in severe dementia)
• apathy (87.5% in mild dementia, 85.2% in moderate dementia, 90.6% in severe dementia)
• irritability
• episodical memory disturbances and mild behavioural modifications of common finding (forget object or daily actions), easy irritability, loss of initiative and interests => inability to remember recent events, diffiicult comprehension, ideation and capacity to form sentences, sudden mood changes => difficult of spoken word => mutism, inability to read, decreased response to uditive stimuli, complete extraneity from surrounding world, probably without a remaning "inner world".
Differential diagnosis :
• delirium
• pseudodementia
• amnestic disorders
• mental retardation
• schizophrenia
• malingering
• factitious disorder
• depression
• age-related cognitive decline
Laboratory examinations :
• CBC
• urinalysis
• thyroid hormones
• vitamin B12
  and folic acid
• syphilis
• chest X-ray
• EKG
• SPECT/PET
• cognitive tests for assessment of neurocognitive function (NCF)
• Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) (score : 0-70)
• Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus) (score : 1-7; improved = 1, 2, or 3; steady = 4; worsened = 5, 6, or 7)
• Alzheimer's disease Cooperative Study Activities of Daily Living Inventory, modified for more severe dementia (ADCS-ADL-sev)
• Global Deterioration Scale (GDS) (score = 1-7)
• Progressive Deterioration Scale (PDS) (score = 0-100 in instrumental and elementary activities of daily living)
• Mini-Mental State Examination (MMSE) (score = 0-30; pathological if < 23; orientation, memory, attention, denomination, praxia, comprehension, concentration)
• Cohen-Mansfield Agitation Inventory (CMAI)
• Caregiver's Burden Inventory (CBI)
• CGI Severity of Alzheimer's disease (CGI-S AD)
• Instrumental Activities of Daily Living (IADL) scale
• Milan overall dementia assessment (MODA)
Therapy :
• support (even to caregivers)
• carbenoxolone
  improves by 10% mental functioning in healthy elderly men and cognitively impaired type-2 diabetic patients by lowering levels of cortisol in the brainref.
• pseudodementia : a disorder resembling dementia but that is not due to organic brain disease and is potentially reversible by treatment; usually due to depression or other psychiatric disorder.
• depressive pseudodementia : dementia syndrome of depression; the term is discouraged as technically incorrect because the cognitive deficits are now believed to be real, if reversible.
• amnestic disorders : mental disorders characterized by acquired impairment in the ability to learn and recall new information, sometimes accompanied by inability to recall previously learned information, and not coupled to dementia or delirium. The disorders are subclassified on the basis of etiology as :
• amnestic disorder due to a general medical condition
• substance-induced persisting amnestic disorder
• amnestic disorder not otherwise specified (NOS)
DSM-IV eliminates the distinction between this term and amnestic syndrome.
Differential diagnosis :
• delirium
• dementia
• dissociative disorders
• susbtance intoxication
• substance withdrawal
• malingering
• factitious disorder
• age-related cognitive decline
• cognitive disorder-not otherwise specified (NOS)

mental disorders due to general medical condition-not otherwise classified

• catatonic disorders due to ...
• personality modification due to ...
• labile type
• disinhibited
• aggressive type
• apathic type
• paranoid type
• different type
• combined type
• unspecified type

toxicomanias / drug abuse / chemical substance dependence : a state of periodic or chronic intoxication, detrimental to the individual and to society, produced by the repeated administration of a drug.

• drug habituation : psychic dependence with no physical dependence
• drug addiction : physical and psychic dependences

Drugs of abuse can be classified according to ...

• country laws
• legal drugs
• illegal drugs
• danger
• "light" drugs
• heavy drugs
• source
• pharmacodynamics and side effects

Multiple simultaneous variables affecting onset and continuation of drug abuse and addiction

• agent (drug)
• availability
• cost
• purity / potency
• mode of administration
• speed of onset and termination of effects (pharmacokinetics: combination of agent and host)
• reinforcement : ability of drugs to produce effects that make the user wish to take them again
• host (user)
• heredity
• metabolism of the drug
• psychiatric symptoms
• prior experience/expectations
• propensity for risk-taking behavior
• environment
• social setting
• community attitudes
• peer influence, role models
• availability of other reinforcers (sources of pleasure or recreation)
• employment or educational opportunities
• conditioned stimuli: environmental cues become associated with drugs after repeated use in the same environment

drug of abuse	acquired (nonspontaneous) tolerance / assuefaction	reverse tolerance / sensitization	dependence (depending on drug of abuse, consumer, and social environment)	toxic psychoses from dose-dependent psychotogens
acute tolerance	chronic tolerance		physical dependence : continued administration of the drug is required to maintain normal function => temporarywithdrawal syndrome when administration is terminated (symptoms tend to be opposite to the original effects produced by the drug before tolerance developed)	=> DA in the "shell" of nucleus accumbens => positive reinforcing effect (e.g. conditioned place preference) => psychological dependence : psychic abstinence syndrome crash (hours/days : craving, compulsion, depression, anxiety) withdrawal (weeks: dysphoric syndrome, apathy,..)  extintion (months/years)	social substance dependence
amphetamines (neurotoxicity : autooxidation of DA to 6-hydroxyDA or hyperactivity of Glu-ergic circuits => DA-ergic neurons)	+	+	+ (hypermotility, stereotypia, psychoses)		+		paranoideal psychosis  chorea-like syndrome  dysautonomic syndrome (anxiety, collapse, seizures)
LSD					+		+
cocaine			may involve conditioning after long-term exposure, has been linked to paranoid, psychotic manifestations	dysphoria, depression, sleepiness, fatigue, bradycardia	+		+
heroin		+		+	+	+
psilocybin					+
cannabinoids				seen clinically only in persons who use marijuana on a daily basis and then suddenly stop	+		+
mescaline					+
inhalants					+
nicotine				irritability, impatience, hostility, anxiety , dysphoric or depressed mood, difficulty concentrating, restlessness, bradycardia, hyperphagy or weight gain	with 10 puffs per cigarette, the one-pack-per-day smoker reinforces the habit 200 times daily	although > 80% of smokers express a desire to quit, only 35% try to stop each year, and < 5% are successful in unaided attempts to quit
caffeine / teine				fatigue, sedation, headache, nausea and vomiting	+
PCP				somnolence, tremor, seizures, diarrhea , piloerection, bruxism , and vocalizations			schizophrenia
opioids				regular withdrawal : mydriasis , restlessness, irritability, hyperalgesia, sweating, piloerection , tachycardia, nausea and vomiting , gastritis, colic, diarrhea , myalgia, systemic arterial hypertension , dysphoria, yawning, insomnia, anxiety, fever , strabismus, rhinorrhoea, crying, cough ;  protracted withdrawal (up to 6 months): anxiety, insomnia, cyclic changes in weight, pupil size, respiratory center sensitivity	+
chloral hydrate				+	+
paraldehyde				+	+
glutethimide				+	+
BDZ				moderate doses : anxiety, paresthesias (photophobia, increased sensitivity to sound), muscle cramps, myloclonic jerks, sleep disturbance, dizziness; high-doses :  seizures, delirium
meprobamate					+
barbiturates				+	+
ethanol				tremor, irritability, nausea and vomiting , sleep disturbance, tachycardia, systemic arterial hypertension , sweating, perceptual distortion, seizures (12-48 hrs after last drink); in conjunction with infection, trauma, malnutrition, or electrolyte imbalance => delirium tremens	+
SSRI				+

 substance-related disorders : any of the mental disorders associated with excessive use of or exposure to psychoactive substances, including drugs of abuse, medications, and toxins. DSM-IV includes specific disorders for the classes

• alcohol
• amphetamines or similarly acting sympathomimetics
• caffeine
• cannabis
• cocaine
• hallucinogens
• inhalants
• nicotine
• opioids
• PCP or similarly acting substances
• sedatives
• hypnotics
• anxiolytics
• not otherwise specified (NOS)

The group is divided into substance use disorders and substance-induced disorders, each of which is specified on the basis of etiology, e.g., alcohol use disorders.

• substance-induced disorders : a subgroup of the substance-related disorders comprising a variety of behavioral or psychological anomalies resulting from ingestion of or exposure to a drug of abuse, medication, or toxin. Specific disorders or groups are named on the basis of etiology, e.g., alcohol-induced disorders, alcohol intoxication
• substance intoxication : a type of substance-induced disorder comprising reversible, substance-specific, maladaptive behavioral or psychological changes directly resulting from the physiologic effects on the central nervous system of recent ingestion of or exposure to a psychoactive substance. Specific cases are named on the basis of etiology, e.g., alcohol intoxication. DSM-IV recognizes specific syndromes for these drugs: alcohol, amphetamines or related substances, caffeine, cannabis, cocaine, hallucinogens, inhalants, opioids, PCP or related substances, and sedatives, hypnotics, or anxiolytics.
• alcohol intoxication : substance intoxication occurring during or shortly after ingestion of alcohol and characterized by maladaptive psychological or behavioral changes combined with physiologic responses such as slurred speech, incoordination, impaired memory or attention, unsteady gait, stupor, or coma.
• alcohol idiosyncratic intoxication / pathological intoxication : a term previously used for maladaptive behavioral change, usually belligerence, produced by ingestion of amounts of alcohol insufficient to cause intoxication in most persons. It is no longer considered to be separate from alcohol intoxication because evidence for a distinction is lacking.
• substance withdrawal / withdrawal, withdrawal symptoms or syndrome / abstinence symptoms or syndrome : a substance-specific mental disorder that follows the cessation of use or reduction in intake of a psychoactive substance that had been regularly used to induce a state of intoxication. DSM-IV includes specific withdrawal syndromes for alcohol; amphetamines or similarly acting sympathomimetics; cocaine; nicotine; opioids; and sedatives, hypnotics, or anxiolytics
• alcohol withdrawal syndrome :
• minor withdrawal syndrome : 6-8 hours-10 days after withdrawal, tremors, irritability, anxiety, tachycardia, systemic arterial hypertension
  , gastrointestinal disturbances
• alcohol or alcoholic hallucinosis : hallucinations occurring in a clear sensorium in alcoholics with a long history of dependence and heavy intake, usually following a bout of unusually heavy drinking. After 24 hours since withdrawal, as above + visual hallucinations, behavioural modifications (agitation, insomnia, confusion, disorientation), microzoopsia
• alcohol withdrawal delirium
• substance-induced delirium : that associated with
• substance intoxication delirium : that which can occur during intoxication with any of a variety of substances
• alcohol withdrawal delirium / delirium tremens : delirium caused by cessation or reduction in alcohol consumption, typically in alcoholics with 10 years or more of heavy drinking. Clinical manifestations include autonomic hyperactivity, such as tachycardia, sweating, and systemic arterial hypertension
  ; a coarse, irregular tremor, and delusions, vivid hallucinations; wild, agitated behavior, fever
  , diarrhea
  , and mydriasis. The onset is usually 2 or 3 days after cessation of drinking; the delirium and other withdrawal symptoms usually resolve in 3 or 4 days
• amphetamines
• cannabinoids
• cocaine
• hallucinogens
• inhalants
• opioids
• phencyclidine and related substances
• anxiolytics / sedatives / hypnotics
Specific disorders are named for the substance involved.
• substance withdrawal delirium : that which can occur during withdrawal from any of a variety of substances, including alcohol and sedatives, hypnotics, and anxiolytics; specific disorders are named for the substance involved.
• medication side effects
• toxic delirium : delirium caused by poisons.
Individual cases are named for the specific substance involved, e.g., digitalis-induced delirium.
• substance-induced persisting dementia / toxic dementia : that due to excessive exposure to a toxic substance, but persisting long after exposure to the substance ends, usually with permanent and worsening deficits. Individual cases are named for the specific substance involved.
• substance-induced sexual dysfunction
• with compromised desire
• with compromised arousal
• with compromised orgasm
• with sexual pain
• with onset during intoxication
• substance-induced anxiety disorder : an anxiety disorder characterized by prominent anxiety, panic attacks, obsessions, or compulsions and directly due to the physiological effects of a psychogenic substance, including drugs of abuse, medications, and toxins. Individual cases are named for the specific substance involved.
• abstinence
• caffeine
• CNS stimulating drugs
• substance-induced mood disorder : a prominent and lasting disturbance of mood, either manic, depressive, or both, due to direct physiological effects of a psychoactive substance, including medications, drugs of abuse, and toxins. Individual cases are named for the specific substance involved.
• with depressive manifestations
• with maniac manifestations
• with onset during intoxication
• with onset during abstinence
• substance-induced persisting amnestic disorder : disorder caused by the lasting effects of a drug of abuse, medication, or toxic substance, often remaining stable or even worsening long after exposure to the substance has ended. Individual cases are named for the specific substance involved.
• substance-induced psychotic disorder : persistent delusions or hallucinations related to the use of a psychoactive substance, the patient being unaware of their etiology. Individual cases are named for the specific substance involved.
• hallucinogen-induced persisting perceptive disorder
• substance-induced sleep disorder : a disturbance of sleep due to the direct physiological effects of a psychoactive substance, including drugs of abuse, medications, and toxins; usually manifest as hypersomnia or insomnia but sometimes as a parasomnia or of mixed type. Individual disorders are named for the specific substance involved.
• insomnia type
• hypersomnia type
• parasomnia type
• mixed type
• with onset during intoxication
• with onset during abstinence
• substance use disorders : a subgroup of the substance-related disorders in which psychoactive substance use or abuse repeatedly results in significantly adverse consequences. The group comprises substance abuse and substance dependence; specific disorders or groups of disorders are named on the basis of etiology, e.g.,
• alcohol use disorders
• alcohol abuse
• alcohol dependence.

Differential diagnosis :

• nonpathological substance use (e.g. society drinking)
• use of drugs for appropriate therapeutic uses
• mental disorders not induced by substances
• symptoms of previous mental disorders exhacerbated by substance intoxication or withdrawal

Laboratory examinations : Structured Clinical Interview for the Spectrum of Substance Use (SCI-SUBS)
Web resources :

• National Institute on Drug Abuse (NIDA)
• Talk to Frank

psychotic disorders / psychoses : a mental disorder characterized by gross impairment in reality testing as evidenced by delusions, hallucinations, markedly incoherent speech, or disorganized and agitated behavior, usually without apparent awareness on the part of the patient of the incomprehensibility of his behavior (anosognosia); called psychotic disorder in DSM-IV. The term is also used in a more general sense to refer to mental disorders in which mental functioning is sufficiently impaired as to interfere grossly with the patient's capacity to meet the ordinary demands of life. Historically, the term has been applied to many conditions, e.g., manic-depressive psychosis, that were first described in psychotic patients, although many patients with the disorder are not judged psychotic.

• functional psychosis : a psychosis for which organic disease or dysfunction cannot be found to play a causative role.
• organic psychosis : a psychotic disorder with a known or presumed organic etiology.
• toxic psychoses : a psychosis due to the ingestion of toxic agents (e.g., alcohol, opium) or to the presence of toxins within the body.
• alcoholic psychoses : psychoses associated with alcohol use and involving organic brain damage, a category that includes
• alcohol withdrawal delirium
• Korsakoff's psychosis
• alcohol hallucinosis
• alcoholic paranoia (concurrent paranoia and alcoholism).
• drug psychosis : any psychosis associated with drug use.
• cannabis
• emigration
• 14-24-year-olds have a 15% chance of showing psychotic symptoms at some point during the 4 years even if they did not smoke cannabis and had no predisposition to psychosisref
• postpartum psychosis : a psychotic episode occurring in the postpartum period.
• prison psychosis : any psychosis for which a prison environment has been a precipitating factor.
• affective psychosis : one in which a disturbance in mood is the prominent characteristic
• bipolar psychosis or disorder / manic-depressive psychosis
• depressive psychosis : older term for a psychosis characterized by severe depression; now more commonly described as a form of major depressive disorder.
• senile psychosis : depressive or paranoid delusions or hallucinations or other mental disorders due primarily to degeneration of the brain in old age, as in senile dementia.

Laboratory examinations : Redlich-Fisher miliary plaques (thickened, dark colored areas in the neuroglia reticulum of the brain, seen in cases of senile psychoses)
• manic psychosis : the manic phase of bipolar psychosis or disorder / manic-depressive psychosis
• unipolar psychosis : a mood disorder characterized by recurrent major depressive episodes
• paraphrenia : older term for a condition theoretically lying midway between paranoia and schizophrenia, in which there are fantastic, absurd, well-systematized delusions without severe personality deterioration; use of this term is discouraged
• borderline, latent or prepsychotic schizophrenia : a type of schizophrenia characterized by clear symptoms of schizophrenia but no history of a psychotic schizophrenic episode; it includes conditions that have been called ambulatory, borderline, prepsychotic, pseudoneurotic, and pseudopsychopathic schizophrenia in which has there has been no acute psychotic episode. Patients described by these terms do not fit the DSM-IV definition of schizophrenia; most would be classified as having schizotypal personality disorder
• simple schizophrenia : a form characterized by gradual, insidious loss of drive, social withdrawal, and emotional apathy, but without prominent psychotic features
• schizophrenia : a mental disorder or heterogeneous group of disorders (the schizophrenias or schizophrenic disorders) comprising most major psychotic disorders and characterized by disturbances in form and content of thought (loosening of associations, delusions, and hallucinations), mood (blunted, flattened, or inappropriate affect), sense of self and relationship to the external world (loss of ego boundaries, dereistic thinking, and autistic withdrawal), and behavior (bizarre, apparently purposeless, and stereotyped activity or inactivity). The definition and clinical application of the concept of schizophrenia have varied greatly. The DSM-IV criteria emphasize marked disorder of thought (delusions, hallucinations, or other thought disorder accompanied by disordered affect or behavior), deterioration from a previous level of functioning, and chronicity (duration > 6 months), thus excluding from this classification conditions referred to by others as simple schizophrenia, acute schizophrenia, borderline or latent schizophrenia. Originally called dementia praecox and characterized as a psychosis with adolescent onset and a chronic course ending in deterioration. The term schizophrenia was introduced by Bleuler because neither early onset nor terminal deterioration is an essential feature; he emphasized the splitting and lack of personality integration seen in the disorder

Types :
• paranoid schizophrenia : a type of schizophrenia characterized by preoccupation with one or more systematized delusions or with frequent auditory hallucinations but without disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.
• disorganized schizophrenia / hebephrenia / hebephrenic schizophrenia : a type that is characterized by frequent incoherence, marked loosening of associations, or grossly disorganized behavior and flat or grossly inappropriate affect and that does not meet the criteria for the catatonic type; associated features include extreme social withdrawal, grimacing, mannerisms, mirror gazing, inappropriate giggling, and other unusual behavior.
• catatonic schizophrenia : a type of schizophrenia characterized by marked psychomotor disturbance, including some combination of motoric immobility (stupor, catalepsy), excessive motor activity, extreme negativism, mutism, echolalia, echopraxia, and peculiarities of voluntary movement such as posturing, mannerisms, grimacing, or stereotyped behaviors.
• catatonic disorder : catatonia due to the physiological effects of a general medical condition and neither better accounted for by another mental disorder nor occurring exclusively during delirium

Experimental animal models : bulbocapnine experiment : the experimental injection of the alkaloid bulbocapnine into animals, which produces in them the motor phenomena typical of catatonia.
• undifferentiated schizophrenia : a type of schizophrenia characterized by the presence of prominent psychotic symptoms but not classifiable as catatonic, disorganized, or paranoid.
• residual schizophrenia : a type of schizophrenia characterized by a history of one or more episodes of schizophrenia with prominent psychotic symptoms, current lack of such symptoms, but continuing presence of other schizophrenic symptoms, such as blunted or inappropriate affect, social withdrawal, eccentric behavior, illogical thinking, or loosening of associations.
• ambulatory schizophrenia : mild schizophrenia sufficiently well compensated so that the patient can maintain himself in the community without hospitalization.
• childhood schizophrenia : schizophrenia-like symptoms with onset before puberty, characterized by autistic, withdrawn behavior, failure to develop an identity separate from the mother's, and gross developmental immaturity, a category that formerly included all types of childhood �psychosis� including symbiotic psychosis and infantile autism. DSM-IV, taking the position that there is no clear relationship between these disorders and adolescent and adult schizophrenia and other psychotic disorders, calls them pervasive developmental disorders
• process schizophrenia : a subset of schizophrenias assumed (like the original concept of dementia praecox) to have endogenous origin and poor prognosis as compared to other cases, termed reactive schizophrenia, that are assumed to be caused by predisposing or precipitating environmental factors and to have a better prognosis.
• pseudoneurotic schizophrenia : a form characterized by all-pervasive anxiety and a wide variety of neurotic symptoms that initially mask underlying psychotic tendencies, which may be manifest as occasional, brief psychotic episodes. It is often considered to be more of a personality disorder
• pseudopsychopathic schizophrenia : a term applied to patients in whom antisocial, impulsive, or sociopathic tendencies initially mask underlying psychotic tendencies typical of schizophrenia
• reactive schizophrenia :  a subset of schizophrenias assumed to be caused by predisposing or precipitating environmental factors and to have a more favorable prognosis than process schizophrenia.
• schizoaffective schizophrenia or disorder
Epidemiology : worldwide prevalence = 24 million; incidence = 1% (between age 15-54)
Aetiology :
• intrinsic : some consider schizophrenia the low-fitness, unattractive version of a sexually selected fitness indicator that evolved through mutual mate choice. This hypothesis may explain schizophrenia's adolescent and early adult onset; why it slashes rates of marriage and reproduction; why it persists despite reproductive disadvantage; why it affects males earlier and more severely; why neurodevelopmental abnormalities are common; why it is associated with fetal hypoxia, viral infection and famine; why dopamine antagonists are therapeutic; and why affected individuals are socially stigmatizedref
• SNPs in
• at least 11 oligodendrocyte genes are suppressed => impaired myelin and glycolysis
• extrinsic :
• offspring of mothers whose blood topped 150 mg/L of lead
  are twice as likely to develop schizophrenia as those whose blood levels were below this threshold. If the finding holds up in other groups, as many as 25% of all schizophrenia cases in this same age group might be explained by leadref. In the 1950s and 60s, lead exposure in California was relatively high because of the use of leaded gasoline
• babies born to malnourished
  mothers are twice as likely to develop schizophrenia. Most agree it is likely to have both genetic and environmental triggers. Researchers first saw a link between schizophrenia and hunger when investigating the Dutch 'hunger winter' of 1944-45, when the Nazis blocked food supplies to much of the Netherlands. Babies born that year were twice as likely to become schizophrenic, according to a 1992 studyref. But as only 25 people in the sample were diagnosed with the illness, the result could have been a statistical fluke. Now another famine, halfway across the world, has lent support to the link between famine and schizophrenia. In China around 1960, a combination of bad weather and Mao Zedong's Great Leap Forward - in which farmland became industrial, and ineffective new agriculture was tried - plunged the country into famine. One of the hardest-hit areas was Anhui province in 1959-61. The researchers selected one area in that province and gathered data from the local psychiatric hospital. Just as in the Netherlands, the risk of children developing schizophrenia doubled during the famine years: hundreds of children per year were later diagnosed with the disease, putting their risk at 2%, compared to 1% for children born in easier timesref. The finding is unlikely to much affect the total number of schizophrenics, as fewer babies overall survive during famines. Although the link between malnurishment in the womb and schizophrenia is clear, the mechanism by which they are related is still unknown. Nobody knows what is going on, but we are beginning to think of it as a gene-environment interaction. One popular idea is that a deficiency of folic acid is to blame. Lack of this nutrient, found in leafy greens and some vitamin supplements, is also implicated in developmental defects in the baby's spinal cord. Researchers are looking at genes for folic acid metabolism and how these might relate to mental illness. It is difficult to find natural experiments in which to conduct such studies, as the famines must be at least 40 years old in order to give schizophrenia a chance to develop. Epidemiologists and medical researchers can take satisfaction in the fact that they can take something so catastrophic and wring from it scientific knowledge that would otherwise be unavailable. Wonderful as that is, lets none of us forget that we should be active in the present to prevent further catastrophes.
• prenatal maternal infections from
• experiences
Pathogenesis : increased activity of mesolimbic tract, decreased activity of nigrocortical tract. Amphetamine, LSD or PCP each specifically targets one of the suspect neurotransmitter systems, but has similar effects on brain and behaviour. Each hallucinogen alters the same brain protein, DARPP-32 / PPP1R1B : animals develop schizophrenic symptoms - in mice, this involves repetitive grooming and nervousness. Mice lacking DARPP-32 are immune to the drugs' psychotic effects
• derailment : disordered thought or speech characteristic of schizophrenia and marked by constant jumping around from one topic to another before the first is fully realized, the topics often being clearly but obliquely related or unrelated. The term is sometimes used synonymously with loosening of associations.
• intrapsychic ataxia : the separation of ideas and affect seen in schizophrenic disorders; inappropriateness of affect.
Crow's classification :
• type I : more acute disorder, positive symptoms
• delusions
• hallucinations
• magical thinking
• thought disorder (a disturbance in the thought process that is most narrowly defined as disorganized thinking with altered associations, as is characteristic of schizophrenia. The term is often used much more broadly to include any disturbance of thought, such as confusion, hallucinations, or delusions, which affects possession, quantity, or content of thought)
• glossolalia : speech in unknown or imaginary language, simulating coherent speech, seen in some types of schizophrenia
• verbigeration / cataphasia : stereotyped and meaningless repetition of words and phrases; seen in some cases of schizophrenia
• logorrhea / agitolalia / agitophasia / pressured speech / tachylalia / tachyphasia / verbomania : excessive volubility, with rapid, pressured speech; as seen in manic episodes of bipolar disorder and in some types of schizophrenia
• perseveration : the inappropriate persistence or repetition of a thought or act after the causative stimulus has ceased or in response to different stimuli, e.g., answering a question correctly and then inappropriately repeating that answer to succeeding questions; most often associated with brain lesions but also seen in schizophrenia
• asyndesis : a pattern of language in which words and phrases are juxtaposed without grammatical linkage; seen in schizophrenic and other mental disorders.
• metonymy : a disturbance of language seen in schizophrenic disorders in which an inappropriate but related term is used instead of the correct one
• parabulia
..., normal CT scan, positive prognosis, positive treatment response, no intellectual impairment, due to dopamine hypertone
• type II : more chronic disorder, negative symptoms
• blunted or flat affect
• anhedonism
• avolition
• alogia
..., atrophy at CT scan, negative prognosis, negative treatment response, intellectual impairment, due to structural alteration with normal dopaminergic function
Liddle's symptoms : psychomotor poverty, disorganization, and reality distortion
double bind : a situation in which one person receives conflicting messages from another and in which response to either message, recognition of the conflict, or withdrawal is met with rejection or disapproval; thought to be a characteristic mode of interaction in some families of schizophrenics and in other dysfunctional families.
Differential diagnosis :
• psychotic disorder due to a general medical condition
• delirium
• dementia
• mood disorder with psychotic manifestations
• schizoaffective disorder
• bipolar disorder-not otherwise specified (NOS)
• mood disorder with catatonic manifestations
• pervasive developmental disorders
• communication disorders
• attention-deficit/hyperactivity disorder (ADHD)
• schizotypal personality (disorder)
• schizoid personality (disorder)
• paranoid personality (disorder)
Laboratory examinations :
• Positive and Negative Syndrome Scale (PANSS).
Therapy :
• D2
  antagonists are effective after 7-15 days
• the addition of risperidone to clozapine did not improve symptoms in patients with severe schizophreniaref
Prognosis : compared with the general population, life expectancy in patients with schizophrenia is shorter by as much as 20%, attributable to higher rates of suicide, accidental deaths, and natural causes such as cardiovascular disease, infectious disease, and endocrine disorders
• acute schizophrenia : acute schizophrenic episode; a condition characterized by acute onset of schizophrenic symptoms; since DSM-IV defines schizophrenia as a chronic disorder, such conditions must now be classified in another psychotic syndrome, such as :
• schizophreniform disorder : a mental disorder with the signs and symptoms of schizophrenia but duration < 6 months
• acute delusional psychosis / bouffée délirante : a reactive psychosis resembling schizophrenia but having a duration of < 3 months and a favorable prognosis. It is roughly the French counterpart to schizophreniform disorder
Differential diagnosis :
• brief psychotic disorder
• brief psychotic disorder : an episode of psychotic symptoms (incoherence, loosening of associations, delusions, hallucinations, disorganized or catatonic behavior) with sudden onset, lasting < 1 month. If it occurs in response to a stressful life event, it may be called brief reactive psychosis.

Differential diagnosis :
• psychotic disorder due to a general medical condition
• delirium
• dementia
• substance-induced psychotic disorder
• schizophreniform disorder
• paranoia / delusional disorder
• mood disorder with catatonic manifestations
• psychotic disorder-not otherwise specified (NOS)
• factitious disorders with main psychological signs and symptoms
• malingering
• personality disorders
• schizoaffective disorder or psychosis : a mental disorder in which a major depressive episode, manic episode, or mixed episode occurs along with prominent psychotic symptoms characteristic of schizophrenia, the symptoms of the mood disorder being present for a substantial portion of the illness, but not for its entirety, and the disturbance not being due to the effects of a psychoactive substance.
• bipolar type
• depressive type
Differential diagnosis :
• psychotic disorder due to a general medical condition
• delirium
• dementia
• paranoia / delusional disorder : a mental disorder marked by well-organized, logically consistent delusions but lacking other psychotic symptoms. Most functioning is not markedly impaired, the criteria for schizophrenia have never been satisfied, and symptoms of a major mood disorder have been present only briefly if at all. DSM-IV distinguishes 6 types on the basis of the predominant delusional theme:
• persecutory
• jealous
• erotomanic
• somatic
• grandiose
• mixed
Differential diagnosis :
• psychotic disorder due to a general medical condition
• delirium
• dementia
• substance-induced psychotic disorder
• schizophrenia
• schizophreniform disorder
• psychotic disorder-not otherwise specified (NOS)
• depressive disorder-not otherwise specified (NOS)
• bipolar disorder-not otherwise specified (NOS)
• shared psychotic disorder
• brief psychotic disorder
• hypochondriacal neurosis / hypochondriasis
• body dysmorphic disorder
• obsessive-compulsive disorder (OCD)
• paranoid personality (disorder)
• shared psychotic disorder : a delusional system that develops in one or more persons as a result of a close relationship with someone who already has a psychotic disorder with prominent delusions. Most commonly it involves 2 people and is called folie à deux. Involvement of 3 people would be folie à trois and so on.

Differential diagnosis :
• schizophrenia
• paranoia / delusional disorder
• schizoaffective disorder
• mood disorder with psychotic manifestations
• psychotic disorder due to general medical condition
• with delirium
• with hallucinations
Aetiology :
• neurological conditions
• endocrine conditions
• metabolic conditions
• hydroelectrolyte disequilibrium
• liver or renal diseases
• autoimmune CNS diseases (e.g. SLE
  )
• infectious diseases :
Differential diagnosis :
• delirium
• dementia of the Alzheimer type
• multi-infarct dementia
• substance-induced psychotic disorder
• mood disorder with psychotic manifestations
• psychotic disorder-not otherwise specified (NOS)
• hypnagogic or hypnopompic hallucinations while falling sleep or awakening
• substance-induced psychotic disorder
• psychotic disorder-not otherwise specified (NOS)

Pathogenesis : increased activity of mesolimbic tract => alterations in perceptions of time, place, sounds and colors.

• childhood psychoses : disorders of cytoarchitecture
• aduthood psyschoses : atrophy of frontal cortex

Symptoms :

• positive
• delusion : false beliefs
• �Alice in Wonderland� syndrome : a delusional state manifested by depersonalization, alteration in the sense of the passage of time, distorted perception of objects, hallucinations, and other delusions or illusions. It may be associated with schizophrenia, epilepsy, migraine, diseases of the parietal lobe, hypnagogic states, or the use of hallucinogenic drugs
• delirium
• hallucinations
• intepretation of hallucination
• negative
• autism

Therapy :

neuroses :  former name for a category of mental disorders characterized by anxiety and avoidance behavior. In general, the term refers to disorders in which the symptoms are distressing to the person (ego-dystonic), reality testing is intact (conscious disorder), behavior does not violate gross social norms, and there is no apparent organic etiology (no fever, no anatomical injuries). Classified in DSM-IV under anxiety disorders, dissociative disorders, mood disorders, sexual disorders, and somatoform disorders.

• actual neurosis : Freud's term for a neurosis caused by sexual excitement without adequate gratification
• anxiety neurosis : Freud's term for conditions now reclassified as panic disorder and generalized anxiety disorder.
• anxiety state : the condition of experiencing undue anxiety, as in anxiety disorders. It was temporarily the official replacement for the term anxiety neurosis
• neurasthenia : a term introduced by Beard in 1869, and now virtually obsolete, to refer to a syndrome of chronic mental and physical weakness and fatigue, which was supposed to be caused by exhaustion of the nervous system
• psychoneurosis : Freud's term for a neurosis caused by childhood experiences
• hysteria : [Gr. hystera womb, from the antiquated belief that wandering of the uterus caused mental disturbances]  a now somewhat nebulous term formerly used widely in psychiatry. Its meanings have included :
• classic hysteria (now somatization disorder)
• hysterical neurosis (now divided into :
• conversion hysteria (now conversion disorder)
• fixation hysteria : a form of conversion disorder in which the symptoms are based on an existing or previous organic disease or injury, as the persistence of a nervous cough after pertussis.
• dissociative hysteria (now dissociative disorders)
• anxiety hysteria : Freud's term for phobias, reflecting his view that the same defense mechanisms, repression and displacement, and the same unconscious conflicts involving infantile sexuality are involved in both hysteria and phobias
• hysterical personality (now histrionic personality)
• major hysteria : la grande hystérie of Charcot, hysteria with dramatic epileptiform attacks involving intense emotional display
• hysteroepilepsy : hysteria with attacks imitating epileptic seizures.
• psychasthenia : a term used by Janet to cover all psychoneuroses not classified as hysteria; it mainly included what would now be called anxiety disorders.
• obsessions
• phobias
• cardiac neurosis / neurocirculatory asthenia
• character neurosis : a type of character or personality disorder with some neurotic characteristics, particularly one of a predominantly obsessive-compulsive or hysterical nature
• compensation or pension neurosis : an obsolete term for a factitious disorder following injury and motivated in part by prospects of financial compensation.
• obsessional or compulsion neurosis / obsessive-compulsive neurosis / obsessive-compulsive disorder
• conversion neurosis / conversion disorder
• depersonalization neurosis / depersonalization disorder
• depressive neurosis / dysthymic disorder
• experimental neurosis : state produced in an experimental animal, usually by exposure to frustration or conflict, that resembles human neuroses.
• hypochondriacal neurosis / hypochondriasis
• hysterical neurosis : former name for a group of conditions now divided between conversion disorder and dissociative disorders
• phobic neurosis / phobia
• transference neurosis : a phenomenon occurring during psychoanalysis, in which transference causes the patient to undergo, with the analyst as the object, an intense repetition of childhood conflicts and traumas, reexperiencing impulses, feelings, and fantasies that originally developed in relation to the parents.
• traumatic neurosis / post-traumatic stress disorder
• vegetative neurosis / acrodynia.
• affective disorders / mood disorders : disturbance of mood
• dysphoric mood : one that is unpleasant.
• elevated mood : one characterized by an exaggerated sense of well-being, cheerfulness, or elation.
• euthymic mood : one in the range of normal, being neither elevated nor depressed.
• expansive mood : one characterized by a lack of restraint in expressing one's feelings, often with an overestimation of self-importance or significance.
• irritable mood : one that is easily annoyed or provoked to anger.
In those mood disorders with psychotic features :
• mood-congruent psychotic features are grandiose delusions or related hallucinations occurring in a manic episode or depressive delusions or related hallucinations in a major depressive episode
• mood-incongruent psychotic features are delusions or hallucinations that either contradict or are inconsistent with the prevailing emotions, such as delusions of persecution or of thought insertion in either a manic or a depressive episode.
Pathological temperaments :
• dysthymia : depressive temperament
• hyperthymia : expansive temperament
• cyclothymia
• dysphoria : mixed temperament; disquiet; restlessness; malaise.
• gender dysphoria : unhappiness with one's biological sex or its usual gender role, with the desire for the body and role of the opposite sex.
... manifested as one or more episodes of mania, hypomania, depression, or some combination. Functional mood disorders are subclassified as :
• hypermania : severe mania
• hypomania : an abnormality of mood resembling mania (persistent elevated or expansive mood, hyperactivity, inflated self-esteem, etc.) but of lesser intensity (neither megalomania nor delirium).

Therapy : CCBs
:
• mania / manic syndrome : a phase of bipolar disorder characterized by expansiveness, elation, agitation, hyperexcitability, hyperactivity, and increased speed of thought and speech (flight of ideas : a nearly continuous flow of rapid speech that jumps from topic to topic, usually based on discernible associations, distractions, or plays on words, but in severe cases so rapid as to be disorganized and incoherent. It is most commonly seen in manic episodes but may also occur in other mental disorders such as in manic phases of schizophrenia)
• euphoric mania :
• dysphoric mania :
• mania with main psychomotory alterations
• psychotic mania
• mania with alterations of consciousness
• mono- or oligoasymptomatic mania (expecially in the elderly)
• chronic mania
• secondary mania
• delirious mania / hypermania : intense mania with overwhelming tensions, marked disorientation, and incoherence
• unproductive mania : a manic episode with some signs and symptoms of depression, such as repression of thought and speech.
• monomania : a form of mental disorder characterized by preoccupation with one subject or idea.
• oligomania : obsession with a few thoughts or ideas
• megalomania : unreasonable conviction of one's own extreme greatness, goodness, or power; the ideas in megalomania are known as delusions of grandeur.
• biting mania : a 15th-century epidemic of mass psychogenic illness in which the compulsive urge to bite people spread among groups throughout Germany, Holland, and Italy.
• ablutomania : mania for washing oneself
• aboulomania : pathological indecisiveness
• agromania : intense desire to be in open spaces
• anglomania : craze or obsession with England and the English
• anthomania : obsession with flowers
• aphrodisiomania : abnormal sexual interest
• arithmomania : obsessive preoccupation with numbers; compulsive counting, as paces when walking, steps in a staircase, etc., a common symptom in obsessive-compulsive disorder.
• balletomania : abnormal fondness for ballet
• bibliomania : craze for books or reading
• bruxomania : compulsion for grinding teeth
• cacodemomania : pathological belief that one is inhabited by an evil spirit
• catapedamania : obsession with jumping from high places
• chinamania : obsession with collecting china
• choreomania : dancing mania or frenzy
• clinomania : excessive desire to stay in bed
• copromania : obsession with feces
• dacnomania : obsession with killing
• demonomania : pathological belief that one is possessed by demons
• dinomania : mania for dancing
• dipsomania : abnormal craving for alcohol
• discomania : obsession for disco music
• doramania : obsession with owning furs
• doromania : obsession with giving gifts
• drapetomania : intense desire to run away from home
• dromomania : compulsive longing for travel
• ecdemomania : abnormal compulsion for wandering
• egomania:  irrational self-centered attitude or self-worship
• eleutheromania : manic desire for freedom
• empleomania : mania for holding public office
• enosimania : pathological belief that one has sinned
• entheomania : abnormal belief that one is divinely inspired
• epomania : craze for writing epics
• ergasiomania : excessive desire to work; ergomania
• ergomania : excessive desire to work; workaholism
• etheromania : craving for ether
• ethnomania : obsessive devotion to one's own people
• eulogomania : obsessive craze for eulogies
• flagellomania : abnormal enthusiasm for flogging
• florimania : craze for flowers
• francomania : craze or obsession with France and the French
• gallomania : craze or obsession with France and the French
• gamomania : obsession with issuing odd marriage proposals
• Graecomania : obsession with Greece and the Greeks
• graphomania : obsession with writing
• gynaecomania : abnormal sexual obsession with women
• habromania : insanity featuring cheerful delusions
• hagiomania : mania for sainthood
• Hellenomania : obsession with Greece and the Greeks; Graecomania
• hexametromania : mania for writing in hexameter
• hieromania : pathological religious visions or delusions
• hippomania : obsession with horses
• hydromania : irrational craving for water
• hylomania : excessive tendency towards materialism
• iconomania : obsession with icons or portraits
• idolomania : obsession or devotion to idols
• infomania : excessive devotion to accumulating facts
• islomania : craze or obsession for islands
• Italomania : obsession with Italy or Italians
• logomania  pathological loquacity
• lypemania  extreme pathological mournfulness
• macromania  delusion that objects are larger than natural size
• melomania  craze for music
• methomania  morbid craving for alcohol
• metromania  insatiable desire for writing verse
• micromania  pathological self-deprecation or belief that one is very small
• morphinomania  habitual craving or desire for morphine
• musomania  obsession with music
• mythomania  lying or exaggerating to an abnormal extent
• narcomania : uncontrollable craving for narcotics
• necromania : sexual obsession with dead bodies; necrophilia
• nosomania  :delusion of suffering from a disease
• nostomania : abnormal desire to go back to familiar places
• oenomania : obsession or craze for wine
• oniomania : mania for making purchases
• onomamania : mania for names
• onomatomania : irresistible desire to repeat certain words
• onychotillomania : compulsive picking at the fingernails
• opiomania : craving for opium
• opsomania : abnormal love for one kind of food
• orchidomania : abnormal obsession with orchids
• parousiamania : obsession with the second coming of Christ
• pathomania : moral insanity
• peotillomania : abnormal compulsion for pulling on the penis
• phagomania : excessive desire for food or eating
• phaneromania : habit of biting one�s nails
• pharmacomania : abnormal obsession with trying drugs
• phonomania : pathological tendency to murder
• photomania : pathological desire for light
• phyllomania : excessive or abnormal production of leaves
• phytomania : obsession with collecting plants
• planomania : abnormal desire to wander and disobey social norms
• plutomania : mania for money
• polemomania : mania for war
• politicomania : mania for politics
• polkamania : craze for polka dancing
• polymania : mania affecting several different mental faculties
• poriomania : an irresistible impulse to travel, run away, or wander off.
• erotomania : abnormally powerful sex drive. Whereas traditional psychiatry has considered erotomania to be almost entirely restricted to women, recent studies have revealed that criminal offenses associated with the condition occur much more frequently in men. Secondary erotomania has mainly been associated with functional psychosis (especially schizophrenia) and bipolar disorder. Traditionally, erotomania has been considered chronic and refractory to treatment, although cases of secondary erotomania with response to benzodiazepines, lithium, anticonvulsivants, antipsychotic drugs and electroconvulsive therapy have been described.
• pornomania : obsession with pornography. Most children escape almost uninjured from visualization of pornography. However some are either traumatized, or precipitated in a strict perversion. The consequences on adolescents are similar, though more complex. The hypersexualization of teenagers may become complicated by addiction (so called internet addiction disorder (IAD)), isolation, and perversionref. Men's sexual arousal is dependent upon the attractiveness of the female actor, feeling interested, and both "imagining oneself as a participant" and "watching as an observer." For women, with all variables entered, only "imagining oneself as a participant" contributed to sexual arousal ratingsref. The stark contrasts between romance novels and pornography, both multibillion dollar global industries, underscore how different male and female erotic fantasies actually are. These differences reflect the different selection pressures males and females faced over human evolutionary history and highlight the utility of using unobtrusive measures to study aspects of human nature.
• slash : the depiction of a romantic or sexual relationship between typically heterosexual male television protagonists, such as Kirk and Spock from Star Trek
A sexually inappropriate family environment, use of pornography during childhood and adolescence, and deviant sexual fantasies during childhood and adolescence are related to the development of deviant sexual preferencesref, e.g. sexual violence against children (sexual abuse, child pornography, rape, and incest). Generally, women who suffer negative events, many of which are traumatic, are more likely to see both pornography and having a homosexual friend or family member as acceptableref. The Internet has become an important tool for finding health information, especially among adolescents. Many computers have software designed to block access to Internet pornography. Because pornography-blocking software cannot perfectly discriminate between pornographic and nonpornographic Web sites, such products may block access to health information sites, particularly those related to sexuality. Blocking settings have a greater impact than choice of blocking product on frequency of health information blocking. At their least restrictive settings, overblocking of general health information poses a relatively minor impediment. However, searches on some terms related to sexuality led to substantially more health information blocking. More restrictive blocking configurations blocked pornography only slightly more, but substantially increased blocking of health information sitesref.
• potichomania : craze for imitating Oriental porcelain
• potomania : abnormal desire to drink alcohol
• pseudomania : irrational predilection for lying
• pteridomania : passion for ferns
• pyromania : craze for starting fires
• rhinotillexomania : compulsive nose picking
• rinkomania : obsession with skating
• satyromania : abnormally great male sexual desire; satyriasis
• scribbleomania : obsession with scribbling
• sebastomania : religious insanity
• shopping mania : mania for shopping
• sitiomania : morbid aversion to food
• sophomania : delusion that one is incredibly intelligent
• squandermania : irrational propensity for spending money wastefully
• stampomania : obsession with stamp-collecting
• syphilomania : pathological belief that one is afflicted with syphilis
• technomania : craze for technology
• Teutomania : obsession with Teutonic or German things
• thanatomania : belief that one has been affected by death magic, and resulting illness
• theatromania : craze for going to plays
• theomania : belief that one is a god
• timbromania : craze for stamp collecting
• tomomania : irrational predilection for performing surgery
• toxicomania : morbid craving for poisons
• trichotillomania : neurosis where patient pulls out own hair

Epidemiology : prevalence = 3-5%
Aetiology : mutations in SLITRK1ref
Symptoms & signs : noticeable hair loss or patches of baldness, often accompanied by other psychiatric conditions, such as anxiety, depression, obsessive compulsive disorder or Tourette syndrome
• tulipomania : obsession with tulips
• typhomania : delirious state resulting from typhus fever
• typomania : craze for printing one�s lucubrations
• uranomania : obsession with the idea of divinity
• verbomania : craze for words
• xenomania : inordinate attachment to foreign things
• zoomania : insane fondness for animals
Chemotherapy : mood-stabilizing drugs
• in crises : benzodiazepines :
• in chronic therapy :
• in drug-refractory mania : electroconvulsive therapy (ECT) / electroshock therapy (EST)
Differential diagnosis :
• mood disorder due to a general medical condition
• substance-induced mood disorder
• hypomania
• depressive episodes with predominant irritable mood
• attention-deficit/hyperactivity disorder (ADHD)
• depressive disorders
• unipolar depression : mood disorders unaccompanied by episodes of mania or hypomania, as in major depressive disorder or dysthymic disorder; the term is sometimes used to denote the former specifically. According to Akiskal soft bipolar spectrum no unipolar depression exists.
• major depressive disorder (MDD) / major, primary or endogenous depression (formerly including melancholia) : a type of depression caused by somatic or biological factors rather than environmental influences, in contrast to a reactive depression. It is usually identified with a specific symptom and may have sudden or gradual onset. It may occur in childhood (infantile depression), adolescence (adolescent depression), middle or late age (senile depression).
• double depression : a major depressive episode superimposed for a time on a chronic dysthymic disorder; after the episode ends the patient returns to the usual dysthymic state.
• retarded depression : major depressive disorder with psychomotor retardation.
• psychotic depression : in the strict sense, major depressive disorder with psychotic features, such as hallucinations, delusions, mutism, or stupor. However, this term is commonly used in a broader sense to cover all severe depressions causing gross impairment of social or occupational functioning, i.e., as a rough equivalent of major depressive disorder or of endogenous depression
• agitated depression : major depressive disorder with psychomotor agitation
• stuporous depression
• anxious depression
• depression with cognitive disorder (differential diagnosis with dementia and pseudodemential melancholia)
• Cotard's syndrome : paranoia with delusions of negation (patients can't feel his/her organs and feels empty), a suicidal tendency, and sensory disturbances.
• atypical depression : better at morning and worse at evening, lethargy
  , hyperphagia and carbohydrate craving => weight gain, substance abuse; hypersensitivity to denial; reactivity of mood
• hysteroid dysphoria : patients maintain consumatory pleasure when it is offered to them, but they don't look for it
• hyperparathyroidism
• obesity
Symptoms & signs :
• psychomotor symptoms : psychomotor retardation, early morning awakening, weight loss, lack of reactivity to the environment, slowing, abulia, adynamia, asthenia, reduced and fragmented mimic
• affective symptoms : loss of interests, habits (family, job, hobbies, friends) and vital force, moral pain and shiness, irritability, irrequietude, anxiet, taedium vitae, desperation, apathy, depersonalization, anhedonism, excessive guilt
• cognitive symptoms : desire of death and suicide, congruous / secondary (guilt, ruine) or uncongruous / primary (persecution) delirium, dementia syndrome of depression (reversible dementia occurring in association with depression in the elderly, the cognitive deficits resolving with treatment of the depression), visual and uditive hallucinations
• vegetative symptoms : insomnia or hypersomnia, inapettency or hyperphagy, reduction of libido, constipation, headache
  , daily or seasonal alternance (usually worse at morning, better at evening)
Differential diagnosis : Complications :
• suicide attempt
• substance abuse
• hydroelectrical disequilibrium
• physical disease
It has variable duration (acute => chronic) and remission may be sudden or gradual => remnant phenomena.
• dysthymic disorder : a mood disorder characterized by depressed feeling (sad, blue, low), loss of interest or pleasure in one's usual activities, and by at least some of the following: altered appetite, disturbed sleep patterns, lack of energy, low self esteem, poor concentration or decision-making skills, and feelings of hopelessness. Symptoms have persisted for most of the daytime for most of the days for > 2 years but are not severe enough to meet the criteria for major depressive disorder.

Prognosis :
• 2-year risk of relapse according to onset at age
• 20 : 20%
• 30 : 50%
• > 50 : 80%
• 3-year risk of relapse after
• 1st episode : 50%
• 2nd episode : 70%
• 3rd episode : 80%
• 4th or subsequent episode : 90%
• reactive, exogenous or situational depression : a physiological, transient depression that is precipitated by a stressful life event or other environmental factor, in contrast to an endogenous depression, with an absence of significant vegetative disturbances
• postpartum depression
• anaclitic depression : impairment of an infant's physical, social, and intellectual development resulting from absence of mothering
• neurotic depression : any depression that is not a psychotic depression; used sometimes broadly to indicate any depression without psychotic features and sometimes more narrowly to denote only milder forms of depression, which would be diagnosed as dysthymic disorder by DSM-IV criteria or as reactive (rather than endogenous) depression.
• depressive disorder-not otherwise specified (NOS)
• late luteal phase or premenstrual dysphoric disorder (PMDD) or syndrome (PMS)

Epidemiology : 2-10% of fertile females are severely affected, 30-80% mildly
Aetiology : unknown cause, conditioned by maternal imprinting and axpiration to emancipation; chances of having symptoms are more likely for heavier women with a higher BMI
and less likely for women using hormonal contraception

Pathogenesis : reduced luteal development => Symptoms & signs (typically occurring in the period between ovulation and the onset of menstruation, lasting up to 2 weeks; occurring anamnestically for most of menstrual cycles for many years and confirmed in the 2 following cycles) : feelings of depression, hopelessness, aggressiveness, increased fatigue or lethargy
, anxiety, or anger, emotional lability (tendence to crying and social isolation, decreased libido), bloating, diffuse edema with increased body weight and sense of tenderness, pelvic pains and headache
, mammary tenderness or mastodynia, heat flushes, intestinal alterations, acne, seborrhea, foruncles, changes in appetite or cravings for selected foods, breast swelling and tenderness, constipation, and decreased ability to concentrate. Rarely hyperthymic disorder.
Laboratory examinations :
• Moos menstrual distress questionnaire
• premenstrual assessment form
Therapy :
• seasonal affective disorder (SAD) / mood disorder with seasonal pattern / seasonal mood disorder : a cyclically recurring mood disorder characterized by depression, extreme lethargy
  , increased need for sleep, hyperphagia, and carbohydrate craving; it intensifies in one or more specific seasons, most commonly the winter months, and is hypothesized to be related to melatonin
  levels
• minor depressive episode (> 2 weeks)
• brief recurrent depressive episode (2 days < x < 2 weeks)
• postpsychotic depressive disorder of schizophrenia
• major depressive episode overlapped with paranoia / delusional disorder, psychotic disorder-not otherwise specified (NOS) or active phase of schizophrenia
Epidemiology : longlife prevalence = 16-20% in females; 12-14% in males. The WHO has identified depression as the fourth leading cause of disease burden, which is defined as years patients must live with a disability. Since the disorder is now being diagnosed more frequently, the WHO estimates that depression will become the first cause of disease burden worldwide by the year 2020. Depression is a common condition, contributing 12% of the total burden of nonfatal global diseaseref. Variations in its treatment within the NHS are striking and perplexingref. We welcome these guidelines and recent advice from the Medicines and Healthcare products Regulatory Agency (MHRA) concerning the prescription of antidepressantsref1, ref2. The methods underpinning the guidelines were rigorous and produced a definitive summary of current evidence. However, the uncertainty of many recommendations is disappointing. The guidelines advocate a stepped care approach, but the weakness of evidence supporting structured interventions for mild to moderate depression limits the value of recommendations referring to initial steps. To advance further the management of what is termed mild to moderate depression, we need a better understanding of the interaction that occurs when individuals seek medical help for an emotional problem. 2 trends deserve attention. Firstly, changes in social networks leave the vulnerable with limited access to informal emotional support. Secondly, professionals providing support are increasingly obliged to restrict interventions to those with evidence of effectiveness. On the whole these are limited to those evaluated from a medical perspective. As a result distress may be defined as depression by patients as a necessary means to access support and by doctors as a way of legitimising the provision of such support. The  idea that societal change influences diagnosis is not new. This medicalisation of unhappiness would benefit from sociological as well as clinical researchref
Aetiology : Pathogenesis : decrease in activity of CNS noradrenergic
and serotoninergic
systems => decrease in BDNF
synthesis => decreased trophism of limbic system. Experimentally induced by reserpine
.
Symptoms & signs usually last 4-6 months and can chronicize when lasting > 2 years. They range from normal feelings of �the blues� through dysthymic disorder to major depressive disorder. It in many ways resembles the grief and mourning that follow bereavement; there are often feelings of low self-esteem, guilt, and self-reproach, withdrawal from interpersonal contact, and somatic symptoms such as eating and sleep disturbances. There is only mild social or workplace impairment.
Grading :
• LSAS and Clinical Global Impression (CGI)
• 29-item Hamilton Rating Scale for Depression (HRSD-29)
• Hamilton Depression Rating Scale (HAM-D) : one designed to score the severity of depression on the basis of a semistructured interview eliciting depression-related symptoms.
• Montgomery-Asberg depression rating scale (MADRS)
Therapy :
• chemotherapy
Therapy varies according to efficacy, side effects, concomitant somatic disorders (e.g. anticholinergic drugs should not be used in patients with BPH), other drugs, previous positive responses in the patient himself or previous patients, kind of depression, psychiatric comorbidity, lifestyle, job, costs. They could slatentize panic attacks. The most common fears about antidepressants are : pharmacophobia, fear of modification of personality in prolonged use, pseudoallergies, sedation, pill ingestion, injection, and expecially weight gain. Therapy is needed when :
• transverse evaluation: moderate or severe symptoms (risk of suicide), melancholy (guilt, ruine), psychotic symptoms (congruous or incongruous delirium)
• longitudinal evaluation : chronicity, previous episodes, previous substance abse
• psychotherapy
  : cognitive therapy, when provided by an experienced therapist, may be as effective as antidepressant medications in the initial treatment of moderate to severe major depressionref
• interpersonal psychotherapy : mourning, role transition, interpersonal deficit, interpersonal contrast
• familial psychotherapy : lifestyle modfiication of affected member reflect on healthy members
• cognitive psychotherapy : hopelessness, helplessness
• psychodynamic psychotherapy
Web resources : World Health Organization: Depression
• bipolar disorder (BPD) / manic-depressive psychosis : mania alternated to depression : mood disorders characterized by a history of manic, hypomanic or mixed (depression with manic motricity; accelerated ideation with depressive setting; .... Often it has an organic cause) episodes, usually with concurrent or previous history of one or more major depressive episodes :
• bipolar I disorder : a type of bipolar disorder characterized by one or more manic or mixed episodes, often with a history of one or more major depressive episodes.
• + recent hypomanic episode
• mild, moderate, or severe without psychotic manifestations
• severe with psychotic manifestations
• in partial or complete remission
• + recent manic episode
• mild, moderate, or severe without psychotic manifestations
• severe with psychotic manifestations
• in partial or complete remission
• + recent mixed episode
• + recent depressive episode
• mild or moderate
• severe without psychotic manifestations
• severe with psychotic manifestations
• in partial or complete remission
• + recent unspecified episode
• fast cycles (> 4 episodes / year)
• bipolar II disorder : a type of bipolar disorder characterized by one or more major depressive episodes accompanied by at least one hypomanic episode but without any manic or mixed episodes.
• hypomanic current or most recent episode
• depressive current or most recent episode
• fast cycles (> 4 episodes / year)
• cyclothymic disorder / cyclothymia : a mood disorder characterized by numerous alternating short cycles of hypomanic and depressive periods with symptoms like those of manic and major depressive episodes but of lesser severity for > 2 years (> 1 year in babies and adolescents)

Differential diagnosis :
• mood disorder due to a general medical condition
• substance-induced mood disorder
• bipolar I disorder fast cycles
• bipolar II disorder fast cycles
• borderline personality (disorder)
• bipolar disorder-not otherwise specified (NOS)
• cycloid : characterized by alternating moods of elation and depression. The terms cycloid, cyclothymic, and manic-depressive overlap in meaning, although cycloid would generally be used for the least severe, and manic-depressive for the most severe conditions.
Epidemiology : prevalence = 1 person in 100, since age 20
Aetiology : SNPs in BDNF
, GRK3
Pathogenesis : up to 40% less grey matter than normal in brain regions associated with mood
Mood Disorder Questionnaire (MDQ) by AstraZeneca
Therapy : Prognosis : without some form of therapy, up to 20% of sufferers will commit suicide. But up to 80% of sufferers have a positive reaction to lithium, and the suicide rate is reduced by a factor of 8
• mood disorder due to a general medical condition
• with depressive manifestations
• with major depressive-like episode
• with mixed manifestations
Aetiology :
• substance-induced mood disorder
• mood disorder-not otherwise specified (NOS)
• acute agitation
Laboratory examinations :
• Structured Clinical Interview for Mood Spectrum (SCI-MOODS) and self-report version (MOODS-SR) (intraclass correlation coefficients (ICC) ranged from 0.88 to 0.97)
• Structured Clinical Interview for Mood Spectrum, lifetime version (SCI-MOOD/LT)
• Self-Report instrument for Mood Spectrum, lifetime version (MOODS-SR/LT)
• Self-Report instrument for Mood Spectrum, last month version (MOODS-SR/LM)
• Self-Report instrument for Mood Spectrum, last week version (MOODS-SR/LW)
• anxiety disorders : a group of neuroses (conscious disorders) in which anxiety and avoidance behavior (due to anticipatory anxiety) predominate. A stressor causes a stress that breaks the internal and external equilibria of the patient
• anxiety : the unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict(on the contrary of fear, the unpleasant emotional state consisting of psychological and psychophysiological responses to a real external threat or danger, including agitation, alertness, tension, and physiological mobilization of the alarm reaction).
• psychological concomitants ("cortical anxiety") include feelings of
• impending danger
• powerlessness
• apprehension
• tension
• Da Costa's syndrome / neurocirculatory asthenia
• physiological concomitants (anguish / "bulbar anxiety") : noradrenergic discharges leading to a "fight or fly reaction" include
• increased heart rate
• altered respiration rate
• sweating
• trembling
• weakness
• fatigue
• panic disorder (PD) with and without agoraphobia / panic attack : an anxiety disorder characterized by recurrent panic (anxiety) attacks, episodes of intense apprehension, fear, or terror, usually occurring while relaxed (unexpected, "out of the blue") or after long periods of stress or hyperactivity (expected), in places where previous panic attacks occurred (=> phobia for risk situations, including claustrophobia), e.g. in hospitals, dentists (fear of anaesthesia (fear to fall asleep) and entrapment), sexual activity, restaurants, queues, unless forced self-exposure is required by job.
• subjective manifestations
• malaise
• self-annihilation experiences
• somatic symptoms
• dyspnea or sensation of fatigue / asphyxia
• palpitations
• dizziness
• vertigo
• faintness
• shakiness
• tremors
• nausea or abdominal disturbance
• paresthesias of light and sound sensations
• chills or heat => sweating
• hyperthermia
• pollakiuria
• diarrhea
• tachycardia
• polypnea
• forced inspiration
• increased systolic blood pressure
• psychological or psychosensorial symptoms (mimicking temporal lobe epilepsy
  )
• acceleration of thoughts
• impaired distance perception
• slowing down of time course
• maintenance of self-control, sometimes interruption of activities and escape
• feelings of unreality ("hippocampal crisis")
• depersonalization
• derealization
• fears of dying
• fears of going crazy
• fears of losing control
According to number of symptoms :
• < 2 limited symptoms : minor panic attack
• > 3 symptoms (cardiovascular, vestibular, vegetative, and/or cognitive symptoms) : major panic attack
There is usually chronic nervousness and tension between attacks (anticipatory anxiety) => avoidance behavior (agoraphobia and claustrophobia) => secondary social phobia (fear to show the disease to others) => demoralization in the post-critical phase lasting minutes to days, with dizziness, alienation, unstable equilibrium, alertness and hypervigilance due to fear of relapse => high risk of suicide (20% when associated with mood disorders). The patient can mantain self-control or may interrupt activities to escape (rarely practices uncontrolled acts). They usually need an accompanying friend (high sensitivity to rassicuration), wear protective objects (hats, umbrellas, sunglasses, bikes, ...), practice superstitious acts, and believe to be affected by organic lesions in respiratory, cardiovascular or nervous systems (hypochondriasis). They are very sensitive to drugs and hence avoid psychostimulants while are commonly addicted by depressant drugs (e.g. ethanol, cannabinoids, heroin, ...). Sometimes associated with hematophobia, pillophobia. It is almost always associated with agoraphobia (panic disorder with agoraphobia) but DSM-IV also recognizes panic disorder without agoraphobia. This disorder does not include panic attacks that may occur in phobias when the patient is exposed to the phobic stimulus.
Aetiology : Associated diseases :
• limited avoidnat behaviour
• secondary social phobia
• agoraphobia
• secondary demoralization or depression
• bipolar disorder (BPD)
Differential diagnosis : Laboratory examinations : Therapy (also to prevent complications : drug and/or substance abuse, suicide, ...) :
• pet therapy
• BDZs
  => trycyclic antidepressants (TCA)
  => SSRI (imipramine
  (10-300 mg 3 times a day) => trimipramine
  (25-200 mg 3 times a day; side effects : sleepiness and weight gain, diarrhea, tachycardia due to anticholinergic effects); nowadays the drugs of choice are paroxetine
  > sertraline
  . Fluoxetine
  has disinhibiting effects). Cholinergic blockers are associated (sulpirides cause decreased libido and limit erection and ejaculation : once side effects were treated with testosterone
  and gonadotropins
  , but that caused increased PRL => gynecomastia and galactorrhea)
• psychotherapy
  for anticipatory anxiety (educational, existential, psychoanalytic, group, cognitive psychotherapy, meditation, relaxation, biofeedback, behavioural)
• succeeding attacks (status panicosus) : i.v. BDZs
  + trycyclic antidepressants (TCA)
Prognosis :
• 30% has no response to treatment
• 30% has partial response
• phobia : intense fear of a specific evolutionarily conserved object, activity, or situation (the phobic stimulus), fear that is recognized as being excessive or unreasonable by the individual himself. When a phobia is a significant source of distress or interferes with social functioning (counterphobia : the state of seeking out of situations or objects which one fears or has feared, consciously or unconsciously), it is considered a mental disorder (sometimes called a phobic disorder); in DSM-IV phobias are subclassified as ...
• agoraphobia : intense, irrational fear of open spaces, characterized by marked fear of being alone or of being in public places where escape would be difficult or help might be unavailable. It may be ...
• associated with panic attacks (panic disorder with agoraphobia)
• agoraphobia without history of panic disorder : agoraphobia with fear of having an attack of one or only a few incapacitating or embarrassing symptoms, which the person may or may not have had in the past, rather than a full panic attack.

Differential diagnosis :
• major depressive episodes
• social phobia
• specific phobia
• obsessive-compulsive disorder (OCD)
• separation anxiety disorder
• paranoia / delusional disorder
• realistic preoccupations
• panphobia : fear of everything; a vague and persistent dread of some unknown evil.
• simple or specific phobia : an anxiety disorder characterized by persistent and excessive or unreasonable fear of a circumscribed, well-defined object or situation. Common specific phobias involve
• acarophobia : irrational fear of mites or of other minute animate (insects, worms) or inanimate (pins, needles) objects, sometimes accompanied by fear of parasites crawling beneath the skin
• acrophobia : irrational fear of heights.

Therapy : after 2 sessions of behavioural therapy, patients reported a 10% decrease in anxiety levels. When the sessions were supplemented with D-cycloserine (DCS)
, their anxiety dropped 50%
• aerophobia : irrational fear of drafts or fresh air, often connected with the idea of harmful airborne influences.
• amathophobia : irrational dread of dust.
• anemophobia : irrational fear of wind or of drafts.
• anthropophobia : irrational dread of human society.
• apiphobia : irrational fear of bees.
• astrapophobia / astraphobia : irrational fear of thunder and lightning
• belonephobia : irrational fear of pins, needles, and other sharp objects
• cancerphobia / cancerophobia : irrational fear of cancer.
• chronophobia : extreme, irrational fear of time; because it is so common in prisoners, it is sometimes called prison neurosis
• claustrophobia : irrational fear of being shut in; fear of enclosed spaces, such as elevators and tunnels, MRI machines, tight ties, rings, or belts.

Aetiology : primitive fear of lack of O2 during life into caves :
• smoke
• floods
• heat of blankets
• ingestion of food
• mother separation anxiety disorder
• coitophobia : fear of sexual intercourse
• cynophobia : irrational fear of dogs.
• demonophobia : irrational fear of demons
• eremophobia : irrational fear of being alone.
• erotophobia : fear of love, especially of sexual feelings and activity
• ereutophobia : irration fear to become red in face
• erythrophobia : irrational fear of the color red, often accompanied by fear of blood (hematophobia).
• gamophobia : fear of marriage
• haphephobia : irrational fear of being touched.
• harmatophobia : fear of sexual incompetence or making a mistake
• helminthophobia : morbid fear of worms.
• homophobia : fear of same gender sex partner
• hydrophobia : irrational fear of water (differential diagnosis with paralytic hydrophobia : choking, gagging, and fear on attempts to drink in the acute neurologic phase of rabies
  , caused by pain from spasms of the pharynx or larynx)
• kathisophobia : intense, irrational fear of sitting down.
• glossophobia / lalophobia : irrational fear of speaking
• mysophobia : irrational fear of dirt and contamination.
• necrophobia : irrational fear of death or of dead bodies.
• neophobia : irrational fear of novel but non-threatening situations such as meeting a stranger or entering a new room. As many as 15% of children are thought to suffer from it and they also have higher levels glucocorticoids : neophobic scaredy-rats die an average of 3 months younger than their outgoing brothers � equivalent to 10 years shaved off a human life
• nyctophobia : irrational fear of darkness
• parthenophobia : irrational fear of girls.
• pathophobia / nosophobia : phobia of contracting a sexually transmitted disease
• pharmacophobia : irrational fear of drugs or medicines
• phobophobia : irrational fear of one's own fears or of acquiring a phobia.
• phonophobia : irrational fear of sounds or of speaking aloud
• photophobia
• sitophobia : irrational fear of eating or of food
• spermatophobia : fear of semen loss
• syphilophobia : irrational fear of syphilis
• tocophobia : irrational fear of childbirth.
• taphephobia : irrational fear of being buried alive
• zoophobia : irrational fear of animals
• dogs
• herpetophobia : irrational fear of reptiles or amphibians.
• insects
• arachnophobia : irrational fear of spiders.
• mice
• xenophobia : irrational fear of strangers
Differential diagnosis :
• traumatic neurosis / post-traumatic stress disorder
• social phobia
• obsessive-compulsive disorder (OCD) (contraphobic measures are not considered obsessions)
• separation anxiety disorder
• hypochondriacal neurosis / hypochondriasis
• anorexia nervosa
• bulimia nervosa
• psychotic disorder
• social phobia / social anxiety disorder (SAD) : an anxiety disorder characterized by fear and avoidance of social or performance situations in which the individual fears possible embarrassment, defeat and humiliation, e.g., fears of speaking, performing, or eating in public => low education, can't look into speaker's eyes; usually excusating, low voice, flexed head. Panic attacks may occur.
• phobia of speaking in public
• nongeneralized social phobia (< 3 situations)
• generalized social phobia (> 3 situations)
• performance anxiety : a social phobia characterized by extreme anxiety and episodes of panic when performance, particularly public performance, is required.
• avoidant disorder of childhood or adolescence : former name for a disorder that would now be included under the diagnosis of social phobia
Epidemiology : prevalence = 13-14% (underextimated as shiness leads to reluctance to ask medical help), more common in females due to evolutionarily preserved need to seem pretty in order to be chosen by males; 80% has onset before age 18; usually diagnosed after > 20 years (in the meanwhile complicances (toxicomanias, alcoholism, agoraphobia, depression, ...) may mask the primary disease). Familiarity may be due to elective affinities between parents or parental imprinting.
Symptoms & signs : antisocial behaviour (delays at work, dismissals, brawls, )
Laboratory examinations :
• Liebowitz social anxiety scale (LSAS) contains 24 items, 13 concerning performance anxiety and 11 concerning social situations. Each item is rated separately for fear (0 to 3 = none, mild, moderate, severe) and avoidance behavior (0 to 3 = never, occasionally, often, usually). Thus, the LSAS provides an overall social anxiety severity rating, and scores on 4 subscales: 1) performance fear, 2) performance avoidance, 3) social fear, and 4) social avoidance.
• Structured Clinical Interview for Social Phobia Spectrum, lifetime version (SCI-SHY/LT)
• Self-Report instrument for Social Phobia Spectrum, lifetime version (SHY-SR/LT)
• Self-Report instrument for Social Phobia Spectrum, last month version (SHY-SR/LM)
• Self-Report instrument for Social Phobia Spectrum, last week version (SHY-SR/LW)
Aetiology :
• primary : familiarity (patients couple with similar patients, so that severity may increase in children)
• shiness (prevalence = 20-30%)
• selective mutism
• secondary
• panic disorder
• body dysmorphic disorder
• eating disorders
• obsessive-compulsive disorder (OCD)
Co-morbidity :
• depression (35%)
• phobia
• ethanol
  addiction (> 20%; used as autotherapy)
• agoraphobia (20%)
• panic disorder (< 20%)
• substance abuse/dependence (> 15%)
Differential diagnosis :
• separation anxiety disorder
• specific phobia
• pervasive developmental disorders
• schizoid personality disorder
• avoidant personality (disorder)
• manifestation of other mental disorders
• performance anxiety
• set fear
• shyness
Therapy :
• castration anxiety or complex : in psychoanalytic theory, unconscious thoughts and motives stemming from fear of loss of genitals as punishment for forbidden sexual desires.
• free-floating anxiety : severe, generalized anxiety having no apparent connection to any specific object, situation, or idea.
• cognitive dissonance : anxiety or other unpleasant feelings resulting from a lack of agreement between a person's established ideas, beliefs, and attitudes and some more recently acquired information or experience.
• transient situational disturbance : acute stress reaction
• separation anxiety disorder : excessive, prolonged (> 4 weeks), developmentally inappropriate anxiety and apprehension in a child before age 18 (early if before age 6) concerning removal from parents, home, or significant familiar surroundings. On the contrary of dependence (a state of relying on or requiring the aid of something, particularly for support or maintenance), patients make their own choices. Only 3% of mammalian species has stable bonds.

Aetiology : deficiency of socializing hormone(s) (oxytocin
, ADH
(e.g. high in montane vole (Microtus montanus : asocial, minimally parental, low separation distress), low in prairie vole (Microtus ochrogaster : highly social, biparental, high separation distress, high bonds)), opiates
, peptides, 
, ACTH
, PRL
, melatonin
, noradrenalin
, and serotonin
). Mating increases ADH
in males and oxytocin
in females.
Kinds of separation anxiety : Comorbidity : sometimes accompanied by depression and/or bipolar disorder. In adulthood patients may develop partner separation anticipatory anxiety disorder, inhability to separate from object the patient would like to go away, or panic disorder.
Differential diagnosis :
• pervasive developmental disorders
• psychotic disorder
• panic disorder with agoraphobia
• agoraphobia without history of panic disorder
• conduct disorder
• sepration anxiety adequate to developmental level
Laboratory examinations : Structured Clinical Interview for Separation Anxiety Spectrum, lifetime version (SCI-SAS/LT)
• acute stress disorder : an anxiety disorder characterized by development of anxiety and dissociative and other symptoms within one month following exposure to an extremely traumatic event, the symptoms including reexperiencing the event, avoidance of trauma-related stimuli, anxiety or increased arousal, and some or all of the following: a subjective sense of diminished emotional responsiveness, numbing, or detachment, derealization, depersonalization, and amnesia
  for aspects of the event.

Differential diagnosis :
• brief psychotic disorder
• major depressive disorder
• exhacerbation of preexisting mental disorder
• traumatic neurosis / post-traumatic stress disorder
• adjustement disorders
• malingering
If persistent, it may become ...
• posttraumatic stress disorder (PTSD) : an anxiety disorder caused by exposure to an intensely traumatic event; characterized by reexperiencing the traumatic event in recurrent intrusive recollections, nightmares, or flashbacks, by avoidance of trauma-associated stimuli, by generalized numbing of emotional responsiveness, and by hyperalertness and difficulty in sleeping, remembering, or concentrating. The onset may be delayed for months to years after the event. Terms formerly used for disorders of this type include gross stress reaction, shell shock, and combat (or battle or war) exhaustion, fatigue, or neurosis. E.g. train-drivers that can't prevent suicide on railways.
• acute operational stress disorders
• acute combat stress disorder
• conversion reactions
• counter-disaster syndrome
• peacekeeper's acute stress syndrome
• Stockholm syndrome / traumatic or terror bonding : bonding with an abusive partner. It seems to be an automatic, probably unconscious emotional response to the traumatic experience of being a victim, which becomes an efficient propagandist. It affects hostage being kidnapped for ransom and hostage-taker alike and serves to unite both, being victims of the siege environment, against outsiders. This positive emotional bond between victim and subject is a defense mechanism of the ego under stress. The priority in dealing with hostage situations is the survival of all participants. The Stockholm syndrome may save the life of victim and subject alike, as it reduces the subjects tendency towards violence and thus the possible necessity for a seizure by the security forcesref1, ref2,ref3, ref4, ref5.
• post-traumatic disorders :
• classic PTSD : during the Civil War it was seen but didn't have a name, other than 'malingering.' Guys never came back to themselves after the war
  Longer engagements made PTSD more common. A soldier would be hunkered down in a trench, hearing explosions day after day, with little hope. After 30 days new guys would come in. But nobody put it together until after World War I, when it was dubbed "battle shock". By World War II it had become "battle fatigue", then later "post-Vietnam syndrome" before PTSD. Vietnam was a milestone. No nation had rigorously conducted an epidemiological survey of males and females in the theater, but scrutiny was delayed. It was done in the mid-1980s, but the conflict raged in the 1960s and 1970s. For the first Gulf War, PTSD research began 5 years later. The US military has already questioned 2,530 soldiers in Iraq and 3,671 in Afghanistan about PTSD symptoms pre- and postdeployment. The most telling finding is that only 23% to 40% of those affected sought help, fearing stigmatizationref. Since in the past symptoms typically peaked 2 years postengagement, current figures may be an underestimate.
• combat neurosis : an older term used for forms of PTSD in which the traumatic event is combat-related.
• war neurosis : older term for a form of PTSD in which the traumatic event is war-related.
• chronic fatigue syndrome (CFS)
• Gulf War syndrome (GWS)
• peacekeeper's stress syndrome
• survivor's guilt syndrome
• syndrome of lifestyle and cultural change
• occupational psychology
• mobbing : to crowd about, as a mob, and attack or annoy; as, to mob a house or a person. It is diagnosed in employees without previous psychiatric diagnoses and continued relationship with his/her employer
• burn-out : a sudden change from enthusiasm to demotivation, cinism, depersonalization, occupational isolation and drop in productivity after a shocking experience (seen in resuscitators, oncologists, people assisting end-stage ill patients, ...)

Laboratory examinations : Mosloch burnout inventory (MBI)
Occupational stressing factors :
• work organization :
• too much or too few to do
• incessant rhytms
• work fragmentation
• inadequate pauses
• kind of work
• absent or excessive responsability
• night workers : at least 3 hours comprised in 7 continuative hours including the period between 12 p.m. and 5 a.m. (i.e. from 10 p.m. to 5 a.m., from 11 p.m. to 6 a.m., or from 12 p.m. to 7 a.m.) for at least 80 days per year => effect on
• sleep/awake cycle (reduced duration of phase 2 and REM sleep => chronic fatigue, anxiety, depression, and disruptive behaviours => psychoactive drugs use)
• working effectiveness (decreased vigilance and attention => increased risk of injuries)
• health status :
• fast foods, excessive ingestion of stimulating drinks (tea and coffee), cigarette smoke => dyspepsia, constipation/diarrhea, pyrosis, abdominal pain
• cardiovascular apparatus
• menses alterations
• family and social life
• psychological
• unsafety in front of modern technologies
• frustration because of lack of progression in career
• alienation
• fear of injuries
• failure
• fear of unemployment
• interpersonal factors :
• troubles with colleagues
• gerarchies
• roles
• mobbing
• biological : consciousness of employment in activities noxious for health
Symptoms & signs : general adaptation syndrome : prevalence of orthosympathetic system in front of pleasant (eustress) or unpleasant (dystress) stimuli altering body homeostasis.
• alarm reaction : aspecific and proportional to extent of stimuli
• resistance stage
• exausting stage
• cenesthopathies and neurovegetative disorders
• fatigue
• malaise
• hypochondriasis
• neurosis, schizophrenia, bipolar disorder, toxicomanias (including alcoholism), senile psychosis
• psychosomatic disease
• psychogenic or traumatic shock
• gastroduodenitis
  , peptic ulcer
  , ulcerative colitis
• arteriosclerosis
  , systemic arterial hypertension
• endocrine and metabolic disorders : diabetes mellitus
  , hypoglycemia
  , hyperinsulinism, hyperthyroidism
  , hypothyroidism
  , Cushing disease
• allergy (bronchial asthma), infections, connective tissue diseases
• renal, gynecological, cutaneous, and ocular diseases
Laboratory examinations :
• subjective (occupational psychologist)
• interview
• dialogue
• inquiry with personal or collective questionnaires (on a representative sample of workers)
• mental tests
• qualitative : inventory : a comprehensive list of personality traits, aptitudes, and interests.
• Beck Depression Inventory : a self-report questionnaire for measuring the symptoms of depression, focusing on the cognitive symptoms.
• California Personality Inventory (CPI) : a self-report, true-false test designed to measure aspects of personality style; generally used in counseling situations or for less than severe psychopathology.
• Millon Clinical Multiaxial Inventory (MCMI) : a self-report inventory designed to produce a profile of the personality style and structure underlying mental disorders.
• Minnesota Multiphasic Personality Inventory (MMPI) : a self-report, true-false test designed to evaluate personality and particularly to assess psychopathology.
• Rorschach test (10 tables with symmetrical black&white spots that the subject has to interpret)
• IQ
• psychotechnics : the employment of psychological methods in studying sociological and other problems; study of human attitudes (perception, memory, attention, manual ability, reaction times) to employments requiring particular intellectual abilities, e.g. pilots, public transport drivers, soldiers, airport control-towers workers, train engine-driver, workers in high-risk employments requiring high precision
• biological
• direct metabolic markers
• ACTH
• corticosterone, cortisol
• 17-ketosteroids and 17-hydroxysteroids
• free catecholamines
• metanephrine and normetanephrine
• vanylmandelic acid (VMA)
• indirect metabolic markers
• glycemia
• lipidemia
• uricemia
• protidemia
• serum and urine electrolytes
• azotemia
• creatininemia
• functional markers
• arterial pressure
• heart rate
• cardiac output
• vigilance level
Epidemiology : first described in survivors of Vietnam war; prevalence = 0.5-1%; 10% in urban USA communities; 60-70% in communities exposed to disasters.
A bout of PTSD may do damage to the brain that kick-starts memory problems, scientists have discovered. Even patients who had recovered from a period of stress started to get age-related memory difficulties about a decade earlier than non-traumatized people. Post-traumatic stress, a condition that can cause patients to feel physical pain on remembering a traumatic event, is known to have a number of effects on the mind and body. One of the side effects is that patients tend to be forgetful, unable to remember a story or a list of words after they've heard it, for example. This problem, which could come from emotional distraction and an inability to concentrate, can interfere with everyday tasks. The link between PTSD and memory problems was investigated by looking at what happens to 3 groups of people as they age (Yehuda R., et al. Biol. Psychiatry, (in the press) (2006)) : Holocaust survivors with continued PTSD, survivors who had recovered from their trauma, and a control group who had not lived through the Holocaust and had never had PTSD. The researchers looked at the study participants' ability to remember associations between common words such as 'desk and chair', a task that is known to become more difficult as we age. They tested their participants at the age of 67, and again at 72. Those who had PTSD, even if they had subsequently recovered, could only come up with answers for half of the questions by the age of 72, a score that's usually expected from those over 80 years old. And they had showed a marked deterioration in scores from when they were 67. Those who had not had a trauma consistently got most, or all, of the questions right at both ages. Having PTSD early in life seems to set up future problems. It's like getting sunburnt at 15 and developing melanoma later. Researchers aren't sure how this might happen. Some think that stress hormones called glucocorticoids, which erupt in the body after a traumatic event such as fighting in a war, attack the hippocampus, a brain area that is key for memory. Some studies have shown the hippocampus of PTSD patients being unusually small, perhaps because it has been eaten away by stress hormones. Others think that people with a naturally small hippocampus may be predisposed to both memory problems and PTSD. Perhaps it isn't trauma that shrinks this part of the brain, but a small hippocampus that increases the likelihood of a stress disorder after a trauma. There's another possible explanation: perhaps some other factor, such as diet, was very different between the Holocaust survivors and the control group. The study didn't look at nutrition or weight loss in the Holocaust survivors, and this could be linked to their memory problems now. But it is stress that's to blame. Not all of the cognitive functions were worse in the Holocaust survivors. The ability to learn and repeat back a list of words, for example, a skill linked to the pre-frontal cortex, was actually better in patients who had recovered from PTSD, as though their brain was compensating for difficulties in the hippocampus. Ageing and trauma will nibble away at memory performance but the brain will be able to compensate to a point. The team's next steps are to look at soldiers who fought in wars to see whether they show the same pattern of decline. They are also going to look at young people who have been through trauma and follow them up later in life
Onset of symptoms :
• type I : 1-3 months
• type II : > 3 months
• type III :
Laboratory examinations :
• Structured Interview for PTSD (SI-PTSD)
• Clinician-Administered PTSD Scale (CAPS)
Differential diagnosis :
• exhacerbation of pre-existing disease on axis I
• avoidant, torpid, increased arousal symptoms before exposure to stressor
• acute stress disorder
• obsessive-compulsive disorder (OCD)
• adjustement disorders
• dissociative disorders
• somatoform disorders
• personality disorders
• psychotic disorders
• malingering
Co-morbidity :
• somatization disorder
• schizophrenia
• major depressive disorder
• panic disorder
• obsessive-compulsive disorder (OCD)
• dysthymic disorder
Complicances :
• compromised social adaptation
• secondary depression
• alcohol or other substance abuse
Prognosis : if stress was severe it may last whole life
Therapy : Web resources :
• The Stress Monitor Web Site
• The Stress Site
• situational anxiety : that occurring specifically in relation to a situation or object.
• generalized anxiety disorder (GAD) : an anxiety disorder characterized by the presence of excessive, uncontrollable anxiety and worry about > 2 life circumstances, for > 6 months, accompanied by some combination of restlessness, fatigue, muscle tension, irritability, disturbed concentration or sleep, and somatic symptoms.
• childhood hyperanxiety disorder
Differential diagnosis :
• anxiety disorder due to a general medical condition
• substance-induced anxiety disorder
• panic disorder (PD)
• social phobia
• obsessive-compulsive disorder (OCD)
• anorexia nervosa
• hypochondriacal neurosis / hypochondriasis
• somatization disorder
• traumatic neurosis / post-traumatic stress disorder
• adjustement disorders
• mood disorders
• psychotic disorders
• nonpathological anxiety
Laboratory examinations : Hamilton Anxiety scale (HAMA)
Therapy : escitalopram
oxalate
• obsessive-compulsive disorder (OCD) : an anxiety disorder characterized by recurrent obsessions or compulsions, which are severe enough to interfere significantly with personal or social functioning. Performing compulsive rituals may release tension temporarily, and resisting them causes increased tension. This disorder is not the same as obsessive-compulsive personality disorder. Patients may develop depression
• obsession : a recurrent, persistent thought, image, or impulse that is unwanted and distressing (ego-dystonic) and comes involuntarily to mind despite attempts to ignore or suppress it. Common obsessions involve thoughts of ...
• contamination from dirty objects
• self-doubt (closures of gas plants, keys, ...)
• phylosophical-existential : essence and reasons of world
• contrast ideas : fear of hurting
• sexual : sexual proposals, incestuous impulses
• violence
• numerical-mathematical
• religious : fear to commit sin, swearing
• compulsion : a compulsive act or ritual; a repetitive and stereotyped action, such as hand-washing, touching, counting, and checking, that is engaged in response to an obsession for an unknown or unconscious purpose.
• repetition compulsion : in psychoanalytic theory, the impulse to reenact earlier emotional experiences or traumatic behavior
• cleaning
• order
• symmetry
• numerical compulsion
• ...
• resistance : conscious or unconscious defenses that prevent material in the unconscious, as repressed thoughts, from coming into awareness
• interference : opposition to or hampering of an action or procedure
• obsessive slowness : global slowing of all activities and latent reactions
Epidemiology : prevalence in general population = 5.5%
Aetiology : SNPs in SLC6A5 / SERT

Symptoms & signs : doubtful facing new situations or situations implying an even minimal risk of failure
• uncertainty : cognitive component
• insecurity : affective component
• indecision : volitive component
• hypercontrol : they leave others decide for them (with no sense of guilt on the contrary of patients with social phobia or depression)
• emotional control
• heterodirected control
• conformism to traditional values
• magical thinking : that characterized by the belief that thinking or wishing something can cause it to occur; it is normal in childhood and dreams but also occurs in schizophrenia and OCD.
• temporal alterations : hyperechonomic or antiechonomic time gestion
• perfectionism
• precision
• order
• symmetry
• completeness
• repetition and automatism
Co-morbidity : other anxiety disorder (current risk = 30%; lifetime risk = 42%)
Differential diagnosis :
• anxiety disorder due to a general medical condition
• substance-induced anxiety disorder
• body dysmorphic disorder
• social phobia
• specific phobia
• trichotillomania
• major depressive disorder
• generalized anxiety disorder
• hypochondriacal neurosis / hypochondriasis
• delirium
• psychotic disorder-not otherwise specified (NOS)
• tic disorders
• schizophrenia
• obsessive-compulsive disorder (OCD)
• stereotypic movement disorder
• eating disorders
• paraphilias
• pathological gambling
• alcohol dependence or abuse
• obsessive-compulsive personality (disorder)
• superstition
• repetitive control movements
Laboratory examinations :
• Structured Clinical Interview for Obsessive Compulsive Spectrum, lifetime version (SCI-OBS/LT)
• Self-Report instrument for Obsessive Compulsive Spectrum, lifetime version (OBS-SR/LT)
• Self-Report instrument for Obsessive Compulsive Spectrum, last month version (OBS-SR/LM)
• Self-Report instrument for Obsessive Compulsive Spectrum, last week version (OBS-SR/LW)
Prognosis :
• panic disorder => bipolar disorder (78%)
• bipolar disorder => panic disorder (22%)
• substance-induced anxiety disorder
• anxiety disorder due to a general medical condition
• anxiety disorder-not otherwise specified (NOS)
Symptoms & signs (anxiety syndrome) : palpitation of the heart, rapid and shallow respiration, sweating, pallor, and a feeling of panic
Laboratory examinations :
• Structured Interview for Disorders of Extreme Stress (SIDES)
• Defensive Functioning Scale : a scale comprising defense mechanisms used to prevent or allay anxiety.
• relative stress scale (RSS)
Chemotherapy
(diazepam and imipramine)
Experimental animal models :
• mouse marble burying test
• zero maze
• somatoform disorders : mental disorders characterized by symptoms suggesting a general medical condition but neither fully explained by a general medical condition, the direct effects of a psychoactive substance, or another mental disorder nor under voluntary control; this category includes
• somatization disorder / Briquet's syndrome : a mental disorder characterized by multiple somatic complaints that cannot be fully explained by any known general medical condition or the direct effect of a substance, but are not intentionally feigned or produced, beginning before the age of 30 and occurring over several years. Complaints comprise a combination of at least multiple pain symptoms, multiple gastrointestinal symptoms, a sexual symptom, and a neurological symptom. They are often presented in a dramatic, vague, or exaggerated way; many physicians become involved in the medical care; and numerous diagnostic evaluations and unnecessary medical treatment or surgery may be performed

Differential diagnosis :
• general medical condition
• schizophrenia
• panic disorder
• generalized anxiety disorder
• major depressive disorder
• pain disorder associated with psychological factors
• sexual dysfunction
• conversion disorder
• dissociative disorders
• hypochondriacal neurosis / hypochondriasis
• factitious disorder with main physical signs and symptoms
• malingering
• somatoform disorder-not otherwise specified (NOS)
• undifferentiated somatoform disorder : one or more physical complaints, not intentionally produced or feigned and persisting for > 6 months, that cannot be fully explained by a general medical condition or the direct effects of a substance; the category comprises persisting disorders that do not completely satisfy the criteria for other somatoform disorders.

Differential diagnosis :
• somatoform disorder-not otherwise specified (NOS)
• major depressive disorder
• anxiety disorders
• adjustement disorders
• factitious disorder with main physical signs and symptoms
• malingering
• conversion disorder : a mental disorder characterized by conversion symptoms (loss or alteration of voluntary motor or sensory functioning suggesting physical illness, such as seizures, paralysis, dyskinesia
  (hysterical chorea
  ), hysterical anesthesia
  , blindness, or aphonia) having no demonstrable physiological basis and whose psychological basis is suggested by (1) exacerbation of symptoms at times of psychological stress, (2) relief from tension or inner conflicts (primary gain) provided by the symptoms, or (3) secondary gains (support, attention, avoidance of unpleasant responsibilities) provided by the symptoms. Many patients exhibit �la belle indifférence� [Fr. �beautiful indifference�], an inappropriately complacent attitude (lack of concern) toward their condition and impairment caused by the symptoms ; histrionic personality traits are also common. Symptoms are neither intentionally produced nor feigned, and are not limited to pain or sexual dysfunction.
• with motor symptoms or deficiencies
• with epileptiform attacks or seizures
• with sensory symptoms or deficiencies
• with mixed symptomatology
Differential diagnosis :
• occult neurologic or general medical condition
• substance related aetiologies
• pain disorder
• sexual dysfunction
• somatization disorder
• hypochondriacal neurosis / hypochondriasis
• body dysmorphic disorder
• dissociative disorders
• hallucinations within the context of a psychotic disorder
• pain disorder : a somatoform disorder characterized by a chief complaint of severe chronic pain that causes substantial distress or impairment in functioning; the pain is neither feigned nor intentionally produced, and psychological factors appear to play a major role in its onset, severity, exacerbation, or maintenance. It is subdivided into
• pain disorder associated with psychological factors
• pain disorder associated with both psychological factors and a general medical condition
• pain disorder  associated with a general medical condition is not considered a mental disorder.
Differential diagnosis :
• somatization disorder
• dyspareunia
• conversion disorder
• other mental disorders
• factitious disorder with main physical signs and symptoms
• malingering
• hypochondria / hypochondriasis / hypochondriacal neurosis [so called because it was supposed by the ancients to be due to disturbed function of the organs of the upper abdomen; see also regio hypochondriaca]  a somatoform disorder characterized by a preoccupation with bodily functions and the interpretation of normal sensations (such as heart beats, sweating, peristaltic action, and bowel movements) or minor abnormalities (such as a runny nose, minor aches and pains, or slightly swollen lymph nodes) as indications of serious problems needing medical attention. Negative results of diagnostic evaluations and reassurance by physicians only increase the patient's anxious concern about his health, although the concern is not of delusional intensity

Differential diagnosis :
• general medical condition
• somatic symptoms in babies
• preoccupations for health in elderlies
• panic disorder
• generalized anxiety disorder
• specific phobia
• obsessive-compulsive disorder (OCD)
• major depressive disorder
• body dysmorphic disorder
• separation anxiety disorder
• psychotic disorder
• body dysmorphic disorder / dysmorphophobia : a mental disorder in which a normal-appearing person is either preoccupied with some imagined defect in appearance or is overly concerned about some very slight physical anomaly.

Differential diagnosis :
• normal preoccupations for physical apperance
• other mental disorder
• anorexia nervosa
• gender identity disorder
• major depressive disorder
• obsessive-compulsive disorder (OCD)
• delirium, somatic type
• koro : a culture-specific acute delusional syndrome occurring in south and east Asia in which the patient believes that the penis or the vulva and nipples are shrinking and may disappear into the abdomen, causing death.
• somatoform disorder-not otherwise specified (NOS)
• pseudocyesis / pseudogestation / false or spurious pregnancy : absence of the menses and presence of other signs of pregnancy, without occurrence of conception and development of an embryo. It may be due to psychogenic factors, to a tumor or mole, or to endocrine disorders
• hypochondriacal symptoms lasting < 6 months
• unjustified physical complaints lasting < 6 months and not related to other mental disorder
• dissociative disorders : mental disorders characterized by sudden, temporary alterations in identity, memory, or consciousness, segregating normally integrated memories or parts of the personality from the dominant identity of the individual. This category includes :
• dissociative identity disorder (DID) / multiple personality disorder / double or dual personality : a dissociative disorder characterized by the existence in an individual of 2 or more distinct personalities, each having unique memories, characteristic behavior, and social relationships. At least 2 of the personalities control the patient's behavior in turns, the transition often being abrupt. The host personality usually is totally unaware of the alternate personalities, experiencing only inexplicable gaps of time and inability to recall important personal information. Alternate personalities may or may not have awareness of the others. Alternative personalities are typically developed by children who suffer severe trauma or abuse and appears to help people cope by cutting off difficult memories, making them seem as if they happened to someone else. In one persona, patients recognize the traumatic history as their own, and it triggers emotional centres in their brain. In the other personality, they do not consciously recognize the tale as autobiographical, and it fires up a wider brain network including regions involved in self-awareness or conscious experience (medial prefrontal cortex (MPFC) and the posterior associative cortices). These regions would not be expected to be active in people with a single personality hearing stories that are not about themselves. The brain has to actively suppress the traumatic information : these additional brain regions stifle the autobiographical memories and erase them from that personality's perceived pastref.

Differential diagnosis :
• direct physiological consequence of a specific general medical condition
• dissociative symptoms due to partial complex epilepsy
• direct physiological effects of a substance
• dissociative fugue
• depersonalization disorder
• dissociative amnesia
• dissoc
• maniac episode
• schizophrenia
• malingering
• factitious disorders
• dissociative or psychogenic fugue : a dissociative disorder characterized by an episode of sudden, unexpected travel away from home or business, with amnesia for the past and partial to total confusion about identity or assumption of a new identity; the disorder is usually related to emotional conflicts due to some traumatic, stressful, or overwhelming event, remits spontaneously, and rarely recurs. A.k.a.... :
• pibloktoq / Arctic hysteria : a culture-specific syndrome seen chiefly among Eskimo women (Greenland Inuit people), marked by sudden, short-lived attacks (of up to 30 minutes' duration) of screaming, crying, running naked through the snow, and other dangerous or irrational acts, sometimes with suicidal or homicidal tendencies, often followed by convulsive seizures and coma lasting 12 or more hours
• cathard of Polynesia
• mal de pelea of Puerto Rico
• our own Western "anorexia nervosa" and "bulimia nervosa"
• grisi siknis / grisi munaia (literally 'going crazy') by Miskito of Honduras and Nicaragua in 2005. Between December 2003 and March 2004 > 150 people over a vast area of the North Atlantic Autonomous Region of Nicaragua, including the 2 main towns, were affected. It is more common in the very isolated villages of the upper and middle sections of the Coco River, which marks the border between the Nicaraguan and Honduran Miskito and Sumo regions. Typically the syndrome affects teenage or young women, who suddenly enter a catatonic-type state, alternating with episodes of agitation and panic attacks. Although news media reports have mentioned violent episodes, that has not been my experience. The people affected might, during the agitation phase, try to flee while screaming in panic. I did learn of a few cases in which the women had grabbed a stick or other "weapon" to try to "fight off" the supposed "attackers", since the sufferers seem to be having hallucinations of people and/or animals trying to harm them. But by far the main danger is to the patients themselves, who in their agitated state might suffer falls, run into trees, or even drown in the river while trying to escape their "pursuers". Most of the time, though, the patient remains in a catatonic-like state, which may last from hours to several days. Despite 250 years of contact with Europeans, including Christian missionaries and western medicine, traditional beliefs are extremely strong in Miskito society. These are deeply spiritual people who typically attend Christian churches and actively participate in services, but under the surface keep their traditional animist beliefs very much alive and well. Central to these are beliefs in a host of creatures, including the souls of deceased relatives or neighbors who have died violently or suddenly, as well as those of animals (e.g. the evil Lhasa, or Jaguar's Soul) and mythological creatures, like Liwa Mairin or Evil Siren. The experts who are called upon to deal with this protean range of spirit creatures are almost as many as the spirits themselves: ukuly or prophets, sukias or witchdoctors, uhuras or curanderos (herbalists), and dilman or evil witchdoctors, to mention just a few. The local belief is that the cause of grisi siknis, better known among the locals as pauka prukan, is a sorcery put into the person by an evil witchdoctor or dilman. No Western medicines, including anticonvulsants or antidepressants, seem to have any effect, the most effective "treatment" involves the intervention of the "good witches": sukias and ukuly. Treatment involves a range of interventions including chants, rituals, as well as local botanicals, which might contain psychoactive chemicals. In the Honduran Mosquitia in 1985 there was indeed considerable psychological stress from the contra war and Nicaraguan refugee resettlement at that time. There were reported attacks of grisi siknis as well in Mocoron. Latin America has a number of folk diagnoses which cannot be directly translated into ICD-9 code, because certain features do not exactly match. Many of these are folk explanations of syndromes we would attribute to physical causes (ancias = anxiety disorder; empacho = bowel obstruction), while others would translate into anger, fright, or fugue-like states (coraje = extreme anger with violence; bilis = unexpressed anger associated with bile in the classic Greek sense). I have seen, in Honduras, temporal (?) lobe epilepsy in a woman attributed to "coraje" because she would become unreasonably angry -- to the extent that she would convulse. She had such a convulsion while waiting in line for medical care at an Army medical action project. Phenytoin abolished the episodes. The psychosis described, under the stressful conditions described, strongly suggests a shared psychological disorder due to stress, upheaval, and despair. An epidemiological study would likely show an index case in a stressed locale, if this is a "new" syndrome. If it is recognized in folklore, it might arise simultaneously in several such areas.
• frenzy witchcarft by Navajo
• amok / amuck [Malay �furious attack�] : a culture-specific syndrome first reported in the Malay people (now in many Western Pacific Islanders), almost always male, consisting of a sudden outburst of indiscriminate aggressive or homicidal fury provoked by a perceived slight or insult or possibly unprovoked (running amuck)
For more in-depth and expert information you might want to contact Philip Dennis, a Professor of Anthropology at Texas Tech University, who has performed some important research on ethnological and anthropological aspects of Miskito culture, including grisi siknis : he wrote a useful article on the topic that was published in a volume on "The Culture-Bound Syndromes" appearing about 1985 (edited by White & Marsella). Teenage women are particularly prone to mass hysterical episodes worldwide : this is taken severely to task by a supporter of women's rights for libeling the gender, but it just happens to be a fact -- between 1973 and 1993, there were 70 reports of mass hysteria in medical journals (see ProMED post 20020605.4409: Unexplained rash illness - USA (multistate)(06).
Differential diagnosis :
• direct physiological consequence of a specific general medical condition
• partial complex epilepsy
• mental disorder-not otherwise specified due to general medical condition
• direct physiological effects of a substance
• dissociative identity disorder
• depersonalization disorder
• dissociative amnesia
• dissociative disorder-not otherwise specified (NOS)
• schizophrenia
• bipolar disorder, fast cycles
• anxiety disorders
• somatization disorder
• personality disorders
• malingering
• dissociative or psychogenic amnesia : a dissociative disorder characterized by a sudden loss of memory for important personal information, usually circumscribed or selective amnesia, rarely generalized or continuous amnesia, and which is not due to the direct effects of a psychogenic substance or a general medical condition; the amnesia may follow severe psychological stress or may be an unconscious response to internal conflicts or an intolerable life situation; complete recovery of memory almost always occurs.

Differential diagnosis :
• amnestic disorder due to general medical condition
• amnestic disorder due to head trauma
• accessual disorder
• delirium
• dementia
• substance-induced persisting amnestic disorder
• susbtance intoxication
• dissociative fugue
• dissociative identity disorder
• depersonalization disorder
• traumatic neurosis / post-traumatic stress disorder
• acute stress disorder
• somatization disorder
• malingering
• age-related cognitive decline
• nonpathological amnestic forms
• depersonalization disorder : a dissociative disorder characterized by one or more severe episodes of depersonalization (feelings of unreality and strangeness in one's perception of the self or one's body image) not due to another mental disorder, such as schizophrenia. The perception of reality remains intact; patients are aware of their incapacitation. Episodes are usually accompanied by dizziness, anxiety, fears of going insane, and derealization.

Differential diagnosis :
• direct physiological consequence of a specific general medical condition
• direct physiological effects of a substance
• susbtance intoxication
• substance withdrawal
• panic disorder
• specific phobia
• social phobia
• traumatic neurosis / post-traumatic stress disorder
• acute stress disorder
• schizophrenia
• major depressive episodes
• dissociative disorder-not otherwise specified (NOS)
• clinical pictures where there are not at least 2 different personality statuses or there is no amnesia for important personal informations
• derealization accompanied by depersonalization in adults
• dissociation statuses in persons subjected to prolonged and intense forced persuasion periods (e.g. brain-washing, thought reconditioning, or prisoners)
• dissociative trance disorder : a dissociative disorder characterized by an involuntary state of trance that is not a normal function of the person's cultural or religious practice and that causes impairment or distress. A.k.a. :
• amok (Indonesia)
• piblokto (Artic)
• bebainan (Indonesia)
• falling-out : a culture-specific syndrome occurring primarily in southern United States and Caribbean groups, characterized by an episode of sudden collapse, sometimes without forewarning, with temporary inability to speak, see, or move
• jumping disease : any of several culture-specific disorders characterized by exaggerated responses to small stimuli, muscle tics including jumping, automatic obedience even to dangerous suggestions, and sometimes coprolalia or echolalia. It is unclear whether they are neurogenic or psychogenic in origin
• jumping Frenchmen of Maine syndrome : a form of jumping disease observed in a group of lumbermen of French-Canadian descent working in a remote area of Maine; affected individuals had exaggerated startle responses, automatic obedience, and often echolalia. It is believed to have represented a form of operant conditioning rather than a true diseaseref.
• Gilles de la Tourette's syndrome
• latah : a culture-specific type of jumping disease seen chiefly among the Malays and other people of Southeast Asia, characterized by hypersuggestibility, echolalia, echopraxis, coprolalia, disorganization, and automatic obedience. It may be identical to myriachit.
• myriachit / miryachit : a variety of jumping disease seen in Siberia, possibly identical to latah
• ataque de nervios (Latin America)
• possession (India)
• trance : a state of altered consciousness characterized by heightened focal awareness and reduced peripheral awareness; a sleeplike state of reduced consciousness and activity.
• hypnotic trance : the state induced by hypnosis
• ecstasy : a state of rapture and trancelike elation
• loss of consciousness, stupor, or coma not attributable to a general medical condition
• Ganser syndrome : the giving of inappropriate, ridiculous, or approximate answers to questions, sometimes associated with amnesia, disorientation, perceptual disturbances, and conversion symptoms; it is most commonly seen in malingering prisoners feigning psychosis.
• vorbeireden : the giving of approximate or otherwise ridiculous answers or talking past the point, as occurs in Ganser syndrome and other mental disorders but which also may occur in tired or stressed but otherwise mentally healthy individuals.
Laboratory examinations : structured clinical interview for DSM-IV dissociative disorders (SCID-D)
• sexual disorders : any disorders involving sexual functioning, desire, or performance. More specifically, any such disorders that are caused at least in part by psychological factors (psychosexual disorders)
• sexual dysfunctions : decrease or other disturbance of sexual response cycle
• sexual desire disorders : sexual dysfunctions characterized by alteration in sexual desire
• hypoactive sexual desire disorder (HSDD) : a sexual dysfunction consisting of persistently or recurrently low level or absence of sexual fantasies and desire for sexual activity, causing pronounced distress or interpersonal difficulties.

Aetiology : women who have had bilateral oophorectomy
typically experience a 50% drop in circulating testosterone
, which is associated with HSDD
Having too little sexual desire is the most common sexual issue among women, reported by 10 to 51% of women surveyed in various countriesref1, ref2 (Matthiesen S, Hauch M. Wenn sexuelle erfahrungen zum problem warden. Familiendynamik 2004;29:136-60). Data from these surveys, as well as from other sources, indicate that a low level of desire is usually accompanied by low levels of arousal and sexual excitement and infrequent orgasms and is frequently associated with sexual dissatisfactionref1, ref2, ref3, ref4 (Davis SR, van der Mooren MJ, van Lunsen RHW, et al. The efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo controlled-trial. Menopause). Current definitions of sexual dysfunction in women reflect a change in our understanding of normal sexual responseref. Rather than the traditional view of a sexual response progressing through discrete phases in sequence (desire, arousal, orgasm, and resolution), it is now recognized that these phases overlap and that the sequence can vary. Also recognized is the importance to sexual satisfaction of the subjective experience and of an environment and stimuli that are conducive to sexual feelingsref. Women have many motivations and reasons for engaging in sex, including a desire for emotional closeness, whereas sexual desire is an infrequent reason for women in established relationshipsref. Among the 2400 multiethnic women (Hispanic, white non-Hispanic, African American, Chinese, and Japanese) in six U.S. cities in midlife who completed baseline questionnaires in the prospective Study of Women's Health across the Nation (SWAN), 40% reported that they never or infrequently felt sexual desireref. Nevertheless, the majority reported being capable of arousal, and only 13% expressed discontent with their sexual experiences.
The prevalence of the sexual desire/interest disorder, diagnosed when a woman fails to feel desire at any stage during the sexual experience, is uncertain. Studies have focused on a lack of desire at the initiation of and between sexual experiences, as well as on a lack of sexual thoughts. However, sexual thoughts are infrequent in many women without apparent sexual dissatisfactionref, and the frequency of sexual fantasies or sexual thoughts has little correlation with sexual satisfaction in womenref1, ref2. Arousal disorders are categorized according to whether there is a lack of subjective arousal alone or a lack of both subjective arousal and awareness of genital congestion. No objective measurements are used to establish diagnoses. Arousal disorders also have an uncertain prevalence; most studies focus only on vaginal lubrication. In a survey of 979 British women who were 18 to 70 years of age, 17% identified problems with arousal (defined as distinct from vaginal dryness)ref; 5% of women in SWAN did as wellref
Definitions of sexual dysfunction :

APA definition	AUA definition	comments
hypoactive sexual desire disorder : persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. Judgement of deficiency is made by the physician, taking into account factors that affect sexual functioning (such as age and context of the person's life)	sexual desire/interest disorder : absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies, and a lack of responsive desire. Motivations for attempting to become sexually aroused are scarce or absent. Lack of interest goes beyond a normal lessening with increasing age and relationship duration	minimal spontaneous sexual thinking or minimal desiring of sex ahead of sexual experiences does not necessarily constitute a disorder (according on data on women in sexually satisfactory, established relationships). Lack of desire triggered during the sexual encounter (i.e., responsive desire) is integral in the AUA Foundation diagnosis
lack of subjective arousal : no DSM-IV definition addresses the lack of subjective arousal	combined arousal disorder : absent of markedly reduced feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of stimulation, and absent or impaired genital sexual arousal (vulval swelling and lubrication)	there is no sexual excitement in the mind and no awareness of reflexive genital vasocongestion
lack of subjective arousal : no DSM-IV definition addresses the lack of subjective arousal	subjective arousal disorder : absent of markedly reduced feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of stimulation. Vaginal lubrication and other signs of physical response still occur	there is no sexual excitement in the mind, but there is awareness of adequate lubrication
female sexual arousal disorder : persistent or recurrent inability to attain, or to maintain until completion of sexual activity, adequate lubrication  and swelling response to sexual excitement	genital arousal disorder : absent or impaired genital sexual arousal (minimal vulval swelling or vaginal lubrification from any type of sexual stimulation, and reduced sexual sensations when genitalia are caressed). Subjective sexual excitement still occurs from nongenital sexual stimuli.	the presence of subjective arousal (sexual excitement) from nongenital stimuli (e.g. erotica, stimulation of the partner, receiving breast stimulation, kissing) is key to receiving the AUA Foundation diagnosis
female orgasmic disorder : persistent or recurrent delay or absence of orgasm after a normal sexual excitement phase	orgasmic disorder : lack of orgasm, markedly diminished intensity of orgasmic sensations, or marked delay or orgasm from any kind of stimulation, despite self-reported high sexual arousal or excitement	women with arousal disorders rarely or never experience orgasm and are frequently given a misdiagnosis of orgasmic disorder

Factors influencing desire and arousal : the basis of desire and perceived arousal in women is poorly understood, but it appears to involve interactions among multiple neurotransmitters, sex hormones, and environmental factors.
• physiologic factors : genital vasocongestive responses occur in women within seconds after erotic stimulationref. Both parasympathetic and sympathetic nerves release nitric oxide and vasointestinal polypeptide, which mediate vasodilatation, and acetylcholine, which blocks noradrenergic, vasoconstrictive mechanisms and promotes endothelial release of nitric oxide. Pelvic sympathetic nerves also release norepinephrine, which is predominantly vasoconstrictive. The mediators of vaginal vasocongestion are less clear but include vasoactive intestinal polypeptide. The relaxation of vaginal smooth muscle permits vaginal expansion, and arteriolar dilatation increases the transudation of interstitial fluid, which promotes lubrication.
• estrogen levels : although low estrogen levels and vaginal atrophy are associated with reduced measures of vaginal congestion when the woman is not receiving sexual stimulation, the percent increase in congestion in response to erotic stimuli is similar in the presence of low and high estrogen levelsref. Similarly, changes in the volume of the vaginal wall and clitoris and the relative volume of regional blood in response to sexual stimulation are similar before and after menopauseref. Estrogen deficiency does not necessarily preclude adequate lubrication, provided that stimulation is sufficientref. However, up to 40% of women may have symptomatic vaginal atrophy that adversely affects sexual functionref.
• subjective arousal is poorly correlated with genital response. For example, increases in genital vasocongestion in response to erotic videos are similar among women who report problems with arousal and women who report no problems with arousal.15 Also, there is a low correlation between brain activation in areas controlling genital response (as assessed by functional magnetic resonance imaging of the brain) and simultaneous ratings of subjective arousalref.
• indirect evidence suggests that testosterone and dopamine play a role in modulating sexual response, since testosterone supplementation or treatment with a dopaminergic agonist can augment responseref1, ref2, ref3, ref4 (Davis SR, van der Mooren MJ, van Lunsen RHW, et al. The efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo controlled-trial. Menopause). Underproduction of androgen in women � as may occur with adrenal disease, after bilateral oophorectomy, or during normal aging � is sometimes associated with reduced desire and arousal. However, large population studies have failed to find the expected positive correlations between sexual function and serum testosterone levelsref1, ref2. One possible explanation is that serum levels do not reflect the intracellular production of testosterone from adrenal and ovarian precursorsref
• other factors : several factors have been associated with reduced subjective arousal. These include distractions, expectations of a negative experience (e.g., as a result of dyspareunia, the partner's sexual dysfunction, or negative experiences in the past), sexual anxiety, fatigue, and depression. Medications including selective serotonin-reuptake inhibitorsref and oral contraceptivesref have also been implicated. Oral contraceptives increase levels of sex hormone�binding globulin, which in turn reduces free testosterone levels; it is hypothesized that some women are particularly sensitive to these effects, which may be prolonged (Panzer C, Wise S, Fantini G, et al. Impact of oral contraceptives on sex hormone-binding globulin and androgen levels: a retrospective study in women with sexual dysfunction. J Sex Med 2006;3:104-13). In a 1-year prospective study, 19 of 79 women who received oral contraceptives reported a decline in sexual desire; 37 discontinued oral contraceptive use within 12 months, many because of sexual side effectsref
• On the basis of survey data, several factors have been closely linked to women's sexual satisfaction and desire. These include stable past and current mental healthref1, ref2, ref3, positive emotional well-being and self-imageref, rewarding past sexual experiencesref, positive feelings for the partnerref1, ref2, and positive expectations for the relationshipref1, ref2. The partner's sexual dysfunctionref, increased perceived stressref, a history of infertility especially after extensive investigationref, and increased duration of the relationshipref1, ref2 are all linked with reduced desire. Certain diseases such as multiple sclerosisref, renal failureref, and premature menopause induced by chemotherapyref are associated with a high incidence of sexual dysfunction. In women, unlike men, vascular disease related to age does not appear to correlate with reduced sexual satisfactionref.
Symptoms & signs :
• a detailed history is the main tool in the assessment and diagnosis of sexual dysfunction and is usually obtained from both partners. Important aspects of the history include the quality of the couple's relationship, the woman's mental and emotional health, the quality of past sexual experiences, specific concerns related to sexual activity (such as insufficient nongenital and nonpenetrative genital stimulation), and the woman's thoughts and emotions during sexual activity.
• details from the couple :
• sexual problem and reason for seeking help at this time : ask patients to describe problems in their own words, request clarification with direct questions, provide options rather than ask leading questions, provide support and encouragement, acknowledge their embarassement, and reassure patients that sexual problems are common
• duration, consistency and priority of problems : clarify whether problems are present in all situations. If there is more than one problem, which is most troubling ?
• context of sexual problems : assess the emotional intimacy of the couple, activity of behaviour just before sexual activity, degree of privacy they have during sexual activity, degree of sexual communication, time of day and fatigue level when sexual activity occurs, use of birth control (adequacy, type), risk of sexually transmitted diseases, usefullness of sexual stimulation, and sexual knowledge
• each partner's sexual response other than that related to the problem : elicit this information with respect to the present and the period before the onset of the problem
• reaction of each partner to the problem : determine how each has reacted emotionally, sexually, and behaviorally
• previous help sought by either partner : assess compliance with the previous recommendations and their effectiveness
• details from each partner when seen alone :
• partner's own assessment of the problem : symptom severity (e.g. total lack of desire) may be easier to disclose in the partner's absence
• sexual response to self-stimulation : also inquire about sexual thoughts and fantasies
• past sexual experiences : discuss positive and negative aspects
• developmental history : determine relationships to others in the home during childhood and adolescence. Were there losses or traumas ? Was he or she emotionally close to anyone ?Was he or she given physical affection, love and respect ?
• past or current sexual, emotional, or physical abuse : explains that questions about abuse are routine and do not necessarily imply causation of sexual problems. It is helpful to ask whether the partner has ever felt hurt or threatened in the current relationship, and, if so, whether he or she wishes to give more information
• physical health, especially conditions leading to debility and fatigue, impaired mobility, or difficulties with self-image (e.g., from the presence of stomas, disfiguring surgery, or incontinence) : ask specifically about medications with known sexual side effects, including SSRI, b-blockers, antiandrogens, GnRH agonists, and oral contraceptives.
• evaluation of mood : correlation of sexual function and mood (including anxiety and depression) warrants routine screening for a mood disorder, by means of either a questionnaire (e.g. the Beck Depression Inventory) or a semistructured series of question
• a physical examination, including a pelvic examination, is part of routine care, but it infrequently identifies a cause of sexual dysfunction. Its usefulness may be greater when there is associated dyspareunia. For some women with a history of coercive or abusive sexual experiences, pelvic examination may cause anxiety; explanation of what will and will not be done may reduce such anxiety.
• nongenital :
• signs of systemic disease (e.g. anemia or bradycardia of hypothyroidism), which could lead to low levels of energy, desire or arousability
• signs of connective tissue diseases (such as Sjogren's syndrome) that are associated with vaginal dryness
• disabilities that might preclude movements involved in caressing a partner, self-stimulation, or intercourse
• disfigurements, stomas or catheters that may decrease sexual self-confidence and lead to low levels of sexual desire or arousability
• external genitalia : sparsity of pubic hair, suggesting low adrenal androgen levels
• vulval skin disorders (including lichen sclerosus) that may result in soreness on sexual stimulation
• cracks or fissures in the interlabial folds, suggesting chronic candidiasis
• labial abnormalities that may cause embarassement or sexual hesitancy (e.g. particularly long or asymmetric labia)
• introitus :
• vulval disease involving the introitus
• pallor, friability, or loss of elasticity and moisture from vulval atrophy
• lichen sclerosus
• recurrent splitting of the posterior fourchette, evident as just-visible white lines perpendicular to the fourchette edge
• abnormalities of the hymen
• adhesions of the labia minora
• swelling in the area of the major vestibular glands
• allodynia of the crease between the outer edge of the hymen and the inner edge of the labia minor, typical of vestibulitis
• cystocele, rectocele, or prolapse that predispose women to incontinence and reduce sexual self-image
• inability to tighten and relax perivaginal muscles, often associated with hypertonicity of pelvic muscles and midvaginal dyspareunia
• abnormal vaginal discharge associated with burning dyspareunia
• internal
• increased tone of pelvic muscles
• presence of "tender" trigger points on palpation of deep levator ani muscle, due to hypertonicity
• full bimanual
• fixed retroversion of uterus or nodules, tenderness, or both in the cul-de-sac, fornix vaginae, or along uterosacral ligaments, causing deep dyspareunia
• tenderness on palpation of posterior bladder wall from anterior vaginal wall, suggesting bladder disease
Differential diagnosis :
• substance-induced sexual dysfunction
• sexual dysfunction due to a general medical condition
• other disorder in axis I
• occasional problems of sexual desire
Laboratory examinations :
• Sexual Activity Log (SAL) measures a woman's overall sexual satisfaction
• Profile of Female Sexual Function measures desire, pleasure, arousal, responsiveness, self-image and quality of orgasm
• Personal Distress Scale measures sexually-related personal distress
The possibility that laboratory testing will identify causes of sexual dysfunction is low. Estrogen deficiency, for example, is best detected by taking a history and performing an examination. Even when signs of estrogen deficiency are present, it is not necessarily the cause of sexual dysfunction. In addition, as noted, serum levels of testosterone do not correlate with sexual function.20,21 Measurement of prolactin or thyrotropin is warranted if other symptoms or signs suggest the presence of abnormal levels.
Therapy : the management of sexual dysfunction in women is guided by the history. Data from randomized trials that support the use of any particular intervention are limited.
• psychological interventions : cognitive behavioral therapy focuses on identifying and modifying factors that contribute to sexual dysfunction, such as maladaptive thoughts, unreasonable expectations, behaviors that reduce the partner's interest or trust (such as disrespectful behavior or lack of honesty), insufficient erotic stimuli, and insufficient nongenital physical stimulation. Strategies are suggested to improve the couple's emotional closeness and communication and to enhance erotic stimulation. The sessions vary in number and usually include both partners. Sex therapy for couples is focused on similar issues but also includes sensate focus techniques, consisting initially of nonsexual physical touch, with gradual progression toward sexual touch; partners are encouraged to alternately touch each other and to provide feedback about what touches are pleasurable. These techniques help change the undue focus on a performance goal (e.g., one partner's orgasm or mutual orgasms). Controlled studies that provide support for the use of this approach are scant, but in one that combined both cognitive behavioral therapy and sex therapy, 74% of women had improved sexual and marital satisfaction (Trudel G, Marchand A, Ravart M, Aubin S, Turgeon L, Fortier P. The effect of a cognitive-behavioral group treatment program on hypoactive sexual desire in women. Sex Relat Ther 2001;16:145-64). Satisfaction was maintained in 64% of women at one year, as compared with minimal improvement in a control group. Another intervention is short-term psychotherapy, generally focused on poor sexual self-image and on nonsexual experiences in childhood that are considered to relate to current sexual function (e.g., a chaotic upbringing that predisposed a woman to need to be in control could interfere with her "letting go" sexually as an adult). Data regarding the benefits of this approach are lackingref.
• pharmacologic interventions : other than estrogen therapy for dyspareunia related to genitourinary atrophy, no medications are currently approved by the Food and Drug Administration for the treatment of sexual dysfunction in women. Several off-label uses of drugs have been considered, although data about effectiveness are sparse
• nonhormonal therapies : the involvement of nitric oxide in neurogenic vasodilatation suggests that phosphodiesterase inhibitors may ameliorate genital arousal disorder. In a small, laboratory-based, randomized trial, a single 50-mg dose of sildenafil (Viagra, Pfizer) increased subjective arousal, genital sensations, and ease of orgasm in some women with genital arousal disorderref. The benefit was observed only among women who had a marked reduction in the normal vasocongestive response to subjectively arousing visual erotic stimulation. In 2 large, randomized clinical trials involving 781 women in whom arousal and desire disorders (rather than genital arousal disorder) were diagnosed, sildenafil improved no measure of sexual desire, sensation, lubrication, or satisfactionref
• hormonal therapies :
• androgen therapies : supraphysiologic androgen therapy has been prescribed for sexual dysfunction since the 1930s, but more recently, testosterone at lower doses than originally prescribed have been studied in randomized trials. In one recent randomized, controlled trial involving 218 women who had undergone a natural or surgically induced menopause and who received 0.625 µg of esterified estrogens daily, the addition of 1.25 mg of methyltestosterone improved sexual responsiveness and the level of desire, as reported on one of two validated questionnaires usedref. However, the frequency of desire was not affected, and measures of desire and composite sexual function were not significantly improved, according to responses on the second questionnaire. Also, the women who had undergone natural menopause were not prescribed progestin, which limited the clinical relevance of these results. Methyltestosterone is known to lower high-density lipoprotein (HDL) cholesterol, and in this study, levels fell by a mean of 12.5 mg per deciliter (0.3 mmol/l) after four months of treatment. The results of 4 recent placebo-controlled, randomized trials involving a total of 1619 women who had undergone surgically induced menopause show the efficacy of a 300-µg testosterone patch applied twice weeklyref1, ref2, ref3 (Davis SR, van der Mooren MJ, van Lunsen RHW, et al. The efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo controlled-trial. Menopause). All participants were treated with estrogen (delivered transdermally in one study (Davis SR, van der Mooren MJ, van Lunsen RHW, et al. The efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo controlled-trial. Menopause) orally in anotherref, and by either route in 2 studiesref1, ref2), and the number of sexually satisfying events at baseline ranged from one to three per month. Pooling the data revealed that women receiving testosterone reported 1.9 more sexually satisfying events per month than they had at baseline, as compared with 0.9 more among those receiving placebo. Scores from validated questionnaires in each of the four studies showed a significant increase in sexual desire and response, and scores in three of the studies showed significant reductions in sexual distressref1, ref2 (Davis SR, van der Mooren MJ, van Lunsen RHW, et al. The efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo controlled-trial. Menopause). One study also evaluated a twice-weekly patch containing 450 µg of testosterone; in contrast to the results for the lower-dose patch, no benefits were foundref. Unwanted androgenic effects, including hirsutism and acne, were uncommon in all studies, but depilation rates were not assessed. Unlike with methyltestosterone, there were no significant changes in lipid levels. Important limitations of these four studies include their brevity (which is of particular importance, given the expected long-term use of the drug) and that their results are generalizable only to women in whom menopause was surgically induced and who also receive estrogen therapy. In some women who have undergone natural menopause, the ovaries continue to be an important source of androgens (Davison SL, Bell R, Donath S, Montalto JG, Davis SR. Androgen levels in adult females: changes with age, menopause, and oophorectomy. J Endocrinol Metab 2005;90:3847-53), and thus, the effects of androgen supplementation may differ from those in women whose ovaries have been surgically removed. Furthermore, risks associated with the long-term use of conjugated estrogens arouse concern about the use of any postmenopausal estrogen therapy over time. Prescribing testosterone alone to women who lack estrogen would raise their already high ratios of androgen to estrogen. There are no safety or efficacy data for testosterone supplementation for estrogen-deficient women. A chief concern with long-term androgen use is a potential increase in insulin resistance, which could predispose a woman to the metabolic syndrome or exacerbate the syndrome if it is already present. In SWAN, low levels of sex hormone�binding globulin and higher circulating levels of androgen were strongly associated with markers of the metabolic syndrome, including a high body-mass index; a high waist-to-hip ratio; presence of glucose intolerance, hypertriglyceridemia, or hypertension; and a low level of HDL cholesterolref
• dehydroepiandrosterone : because middle-aged and older women have a physiologic decrease of as much as 70% in the amount of dehydroepiandrosterone producedref, some researchers have suggested that supplementation with the steroid may improve sexual function. However, rigorous data that support such supplementation are lacking. Even among women with adrenal insufficiency, the results of randomized trials of dehydroepiandrosterone supplementation have been inconsistentref1, ref2, ref3
• estrogen : the role of systemic estrogen in increasing desire and subjective arousal remains unclear. In patients with vasomotor symptoms and insomnia or reduced levels of desire because of dyspareunia due to genital atrophy, it is logical to conclude that estrogen supplementation would increase sexual motivation, although this has not been rigorously tested. In the Women's Health Initiative trial, no significant differences were found between the estrogen and placebo groups in reported satisfaction after sexual activityref. However, sexual dysfunction was not a primary focus of the trial, and the assessment tool was inadequate.
Off-label uses of drugs for investigational treatment of sexual dysfunction :

type of sexual dysfunction	drug	comments
sexual desire/interest disorder, subjective and combined arousal disorders	bupropion (a dopamine and norepinephrine agonist)	in one small, four-months study, nondepressed, premenopausal women showed increased arousability and sexual response but not initial desireref
testosterone (plus estrogen)	in 6-months randomized trialsref1, ref2, ref3 (Davis SR, van der Mooren MJ, van Lunsen RHW, et al. The efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo controlled-trial. Menopause), women had improved "total satisfying sexual activity" and improved measures of desire and responses, as reported on questionnaires. No long-term safety data on women lacking estrogen are available a transdermal patch that delivers the equivalent to 300 mg of testosterone. At the end of 24 weeks, there was a 74% increase in total satisfying sexual activity scores in the testosterone group compared with 33% in the placebo group. Sexual desire scores improved by 56% and 29%, respectively, and personal distress scores decreased by 65% and 40%, respectively. Improvements were seen after at least 4 weeks of starting therapy and all were highly significant. Around 70% of women had at least some adverse reaction related to treatment, including site irritation (30%), as well as acne and hirsutism, observed in approximately 6% of the treated women. Deepening of the voice was reported in slightly > 2%. About 8% of treated women found the adverse events serious enough to drop out of the study. These adverse events were seen early in the study
dehydroepiandrosterone (a precursor of estradiol and testosterone)	data from trials involving women with adrenal insufficiency are conflictingref1, ref2, ref3. A study of perimenopausal women with reduced feelings of well-being and low level of desire showed no benefitref
tibolone (an estrogenic, progestogenic, androgenic steroid)	data from small trials of postmenopausal women show improved sexual function, as compared with those receiving placebo or a regimen of 17b-estradiol (1 mg daily) plus norethindrone (1 mg daily). The drug has not been studied in women with diagnosed sexual dysfunction and is associated with a possible increased risk of breast cancerref
phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil)	in large multicenter trials involving pre- and postmenopausal women, no benefit from sildenafil was reportedref
yohimbine (a centrally acting noradrenergic agent) plus arginine (a precursor of nitric oxide)	in one randomized, controlled crossover laboratory study of 24 women, yohimbine (6 mg) plus arginine (6 g) increased vaginal congestion, but not subjective arousal, in response to an erotic filmref.
ephedrine (agonist of a- and b-adrenergic receptors)	in one randomized, controlled crossover laboratory study of 20 women, yohimbine (50 mg) increased vaginal congestion, but not subjective arousal, in response to an erotic filmref.
genital arousal disorder despite estrogen-replete status	phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil)	in one laboratory randomized trial, it was shown that only some women given a diagnosis of genital arousal disorder have demonstrably reduced genital congestion, and they alone showed evidence of benefit. It was not possible clinically to distinguish this subgroupref. In one randomized study of neurogenic genital arousal disorder from multiple sclerosis, treatment with sildenafil led to increased lubricationref.

Sexual dysfunction associated with antidepressants : the prevalence of sexual disorders that are associated with the use of antidepressants in women is estimated at 22 to 58%, with higher rates reported for selective serotonin-reuptake inhibitors and lower rates reported for bupropion than for other drugsref. A recent Cochrane review of strategies to ameliorate dysfunction associated with antidepressants did not recommend any particular drug, although the potential advantages of adding bupropion were notedref. A drug holiday (e.g., halting the use of shorter-acting selective serotonin-reuptake inhibitors over the weekend) seems to be a logical strategy but is not recommended, owing to withdrawal symptoms and compromise of compliance.
Areas of uncertainty : a better understanding is needed of the endogenous and environmental factors that mediate sexual desire and arousal. Randomized clinical trials are also needed to assess the effects of psychological and pharmacologic therapies alone and in combination. The risks and benefits of long-term testosterone therapy require further study, including studies of women with a complete loss of arousal and desire.
Guidelines : recommendations for the evaluation and management of sexual dysfunction in women have been put forth by the American College of Obstetricians and Gynecologists (Basson R. Sexuality and sexual disorders in women. Clinical updates in women's health care monograph. Vol. 2. No. 2. Washington, D.C.: American College of Obstetricians and Gynecologists, 2003:1-94), the Society of Obstetricians and Gynaecologists of Canada (Blake J, Belisle S, Basson R, et al. Canadian Consensus Conference on Menopause 2006 update. J Obstet Gynecol Can 2006;28:Suppl:1-92), the North American Menopause Societyref, and the members of the 2003 International Consensus on Sexual Medicine (organized by the International Consultation on Urological Disease, the International Society for Urology, and the International Society for Sexual Medicine) (Basson R, Althof S, Davis S, et al. Summary of the recommendations on sexual dysfunctions in women. J Sex Med 2004;1:24-34). These organizations advocate attention to mental and overall health and to both interpersonal and personal psychological issues. Local estrogen therapy is recommended for dyspareunia that is associated with vulval atrophy that results in reduced sexual motivation. The Society of Obstetricians and Gynaecologists of Canada notes that testosterone therapy should be viewed as investigational and should be prescribed only by clinicians who are knowledgeable about sexual dysfunction in women (Blake J, Belisle S, Basson R, et al. Canadian Consensus Conference on Menopause 2006 update. J Obstet Gynecol Can 2006;28:Suppl:1-92). The recent position statement of the North American Menopause Society provides cautious support for the use of testosterone "in appropriate post-menopausal women via transdermal patches or topical gels or creams administered at the lowest dose for the shortest time that meets treatment goals"ref. Counseling about the potential risks and benefits of testosterone use is also advocated, as is evaluation for causes of low levels of desire (including physical and psychosocial factors and medications) before treatment.
Conclusions and Recommendations : for women with desire and arousal disorders, such as the woman described in the vignette, the evaluation involves taking a detailed history of sexual difficulties from both partners, preferably seen individually as well as together. Also included are an assessment of the woman's mental health (including self-image), feelings about the relationship, medical history, and her thoughts and emotions during sexual activity. On the basis of clinical experience and limited data on outcomes, I would recommend a combination of cognitive behavioral therapy and sex therapy (typically three to six sessions). Sessions should be focused on altering maladaptive thoughts, unreasonable expectations, and misinformation about women's sexuality, as well as on discussing strategies for improving the couple's emotional closeness and communication and enhancing erotic stimulation. If the couple is excessively focused on intercourse (as is common if there is a history of infertility), they should be advised to emphasize nongenital stimulation first. Any apparent interpersonal problems should be addressed before further sexual therapy is pursued. At the present time, I would not recommend any pharmacologic therapy, pending the availability of more (and longer-term) data in support of such treatment.

• sexual aversion disorder : feelings of repugnance for and active avoidance of genital sexual contact with a partner, causing substantial distress or interpersonal difficulty.

• permanent or acquired
• generalized or situational
• due to psychological or combined factors
Differential diagnosis :
• other disorder in axis I
• erotophobia
• saltuary sexual aversion
• sexual arousal disorders : sexual dysfunctions characterized by alterations in sexual arousal
Pathogenesis : person's sex drive may be proportional to the size of their amygdala : chronic temporal lobe epilepsy
typically dampens sex drive and patients with the greater amount of amygdala left intact after surgery have a larger sex drive. It is intimately linked to other brain regions, including the hypothalamus, which sets off physical responses to arousal, such as erectionsref.
Differential diagnosis :
• substance-induced sexual dysfunction
• sexual dysfunction due to a general medical condition
• other disorder in axis I
• occasional problems of arousal
• orgasmic disorders : sexual dysfunctions characterized by inhibited or premature orgasm
• female orgasmic disorder : a sexual dysfunction characterized by consistently delayed or absent (coital anorgasmia) orgasm in a female, even after a normal phase of sexual excitement and accounting for her age and sexual experience and the amount of stimulation, and causing significant distress or interpersonal difficulty. When women try to reach orgasm through masturbation, 51% of their chance of success depended on their genes. But for other methods of reaching orgasm, environmental factors are more important than genetic factors. When they have penetrative sex, genes account for just 31% of their chance of success, and 37% when a women and her partner used other methods. Women do not need to climax in order to conceive and give birth, a fact that makes the evolutionary cause of their orgasm slightly mysterious. In contrast, men who cannot orgasm miss the chance to pass on their genes and fall victim to natural selection. So what function does the female orgasm serve? As well as making women more interested in the activity of procreation, recent investigations have found the contractions it involves can bring sperm closer to the egg, increasing the chance of conception. Evolutionary psychologists have also suggested that the female orgasm might help women to select caring partners: those who are particularly attentive in the bedroom may also be more supportive in other aspects of life. But studies of other primates suggest otherwise : female stump-tailed macaques have orgasms too � but mainly during female-female mountings, which hardly supports the fertility or mate-selection idea. Bonobos engage in highly promiscuous sex and mutual masturbation, complete with orgasms, a practice that is thought to promote group cohesion. This supports yet another theory: that orgasm is important in bonding. But even if orgasm does play this role, it cannot be crucial in humans. The finding that many women cannot achieve orgasm because they do not have the genes for it shows that the ability to orgasm is not a trait for which there has been strong evolutionary selection. This supports her theory that as far as orgasms are concerned, women have been riding on the genetic coat-tails of male evolution, and that the female orgasm is merely an accidental echo of the male one, the equivalent of male nipples. A 2003 study showed that > 50% of British women reported at least one sexual problem lasting > 1 month during the previous year, and around 25% rarely had orgasms, at best, in the previous 3 months. Orgasmic dysfunction in females is commonly reported in the general population with little consensus on its aetiology. A classical twin study was performed to explore whether there were observable genetic influences on female orgasmic dysfunction. Adult females from the TwinsUK register were sent a confidential survey including questions on sexual problems. Complete responses to the questions on orgasmic dysfunction were obtained from 4037 women consisting of 683 monozygotic and 714 dizygotic pairs of female twins aged between 19 and 83 years. 14% always achieved orgasm during intercourse, while 32% reported never (16%) or infrequently (16%) achieving orgasm during intercourse. More women were able to orgasm during masturbation: 34% always reached orgasm. 21% were still unable to orgasm more than a quarter of the time, two-thirds of whom never achieved orgasm during masturbation. There was no difference between the proportion of identical and nonidentical twins who never or infrequently reached orgasm by either method. However, there was less variation for the frequency of orgasm during intercourse and masturbation in identical compared with nonidentical twins, suggesting a clear genetic influence for both. 34 (overall)-45% (during masturbation) of the variation in ability to orgasm can be explained by underlying genetic variation, with little or no role for the shared environment (e.g. family environment, religion, social class, or early education). This number could go even higher if one could account for other variables, such as the different techniques of the women's partners. Genetic influences have been seen to account for as much as 60% of variability in other complex traits, such as obesityref. Only 30% of women experience orgasm with penovaginal intercourse. If you can experience orgasm through other ways such as oral sex, self-stimulation, or other, that is great and normal. For you to achieve orgasm during intercourse, you are going to need to have sufficient clitoral stimulation. If it is important for you to achieve orgasm during intercourse, I would encourage you to focus on increasing the level of foreplay prior to sex and try positions that increase clitoral stimulation and even consider incorporating a vibrator : that being said, you should not feel pressured to achieve orgasm during sex. The findings also challenge the notion that the failure to achieve orgasm represents �female sexual dysfunction�, an idea popular with companies keen to sell remedies for this so-called disorder. What definition of �normal� could possibly justify labelling a third of women as �abnormal�? Even if struggling to achieve orgasm is nothing unusual, it might be possible to find ways to make it easier.

Web resources :
• Twin Research
• Medicinenet.com: the orgasm wars
• Medicinenet.com: orgasm disorder
• retarded ejaculation / male orgasmic disorder : a sexual dysfunction characterized by consistently delayed or absent (coital anorgasmia) orgasm in a male, even after a normal phase of sexual excitement and stimulation that is adequate for his age in focus, duration, and intensity, and which causes significant distress or interpersonal difficulty.
• permanent or acquired
• generalized or situational
• due to psychological or combined factors
• premature ejaculation (PE) / ejaculatio praecox / preblysis / tachorgasmia : ejaculation consistently occurring either prior to, upon, or immediately after penetration and before it is desired, taking into account factors such as age, novelty of the specific situation, and recent frequency of the sexual act. Used officially [DSM-IV], it denotes also significant resulting distress or interpersonal difficulty.

Therapy :
• squeeze technique : one used for the treatment of premature ejaculation, in which a man is repeatedly aroused almost to the point of ejaculatory inevitability and then the the thumb and first two fingers are used to forcibly squeeze the head of the penis, preventing ejaculation
• xenobiotics
Differential diagnosis :
• substance-induced sexual dysfunction
• sexual dysfunction due to a general medical condition
• other disorder in axis I
• occasional problems of orgasm
• no disorders of resolution phase exist
• sexual pain disorders : sexual dysfunctions characterized by pain associated with intercourse; they include
• dyspareunia (in males or females) not due to a general medical condition
• noncoital sexual pain disorder (in females)
• vaginismus
  (in females) not due to a general medical condition.
• sexual dysfunction due to a general medical condition
Aetiology :
• neurologic disorders
• endocrine disorders
• vascular disorders
• genitourinary disorders
• substance-induced sexual dysfunction
• sexual dysfunction-not otherwise specified (NOS)
• paraphilia / divertissement / sexual aberration or anomalies : a psychosexual disorder characterized by recurrent intense sexual urges, by sexually arousing fantasies, or by behavior involving use of a nonhuman object, the suffering or humiliation of oneself or one's partner, or children or other nonconsenting partners; included are
• sexual deviation or deviance : sexual behavior or fantasy outside that which is morally, biologically, or legally sanctioned, often specifically one of the paraphilias; practice that deviates from the majority of society
• exhibitionism / peodeiktophilia : a paraphilia characterized by recurrent intense sexual urges and sexually arousing fantasies of exposing the genitals to an unsuspecting stranger. Exhibitionism occurs almost exclusively in males.
• fetishism : a paraphilia characterized by recurrent, intense sexual urges and sexually arousing fantasies of the use of inanimate objects (fetishes), most commonly articles of feminine clothing such as shoes, earrings, or undergarments, as a preferred or necessary adjunct to sexual arousal or orgasm.
• autophagy : fetish for eating one's own skin
• fetishes : an object that replaces people as primary object of love
• exophilia : neophilia; fetish for the unusual or bizarre
• organofact : fetish for some part of the body
• altocalciphilia : high heel fetish
• alvinolagnia : stomach fetish
• crurofact : leg fetish
• cyesolagnia : pregnant woman fetish
• foot fetish : podophilia
• genofact : genital fetish
• mastofact : breast fetish
• nasophilia: nose fetish
• oculophilia : eye fetish
• odontophilia : arousal from tooth extractions or tooth fetish
• phallophilia : large penis fetish or preference
• pygmalionism / agalmatophilia / statuophilia / galateism : the falling in love with an object made by oneself; arousal from statues or manikins : statue fetishism where person rubs their body against statue
• retifism : shoe fetish
• trichophilia : hair fetish
• frotteurism / frottage : a paraphilia in which sexual arousal or orgasm is achieved by rubbing up against another person, usually in a crowded place with an unsuspecting victim, or by fantasies of such actions
• toucherism : a paraphilia in which sexual arousal or orgasm is achieved by touching or fondling or by such fantasies
• pedophilia : a paraphilia in which an adult has recurrent, intense sexual urges or sexually arousing fantasies of engaging in or repeatedly engages in sexual activity with a prepubertal child.
• sexual masochism : a paraphilia in which sexual gratification is derived from being hurt, humiliated, or otherwise made to suffer physically or psychologically.
• sadism : the act or instance of gaining pleasure from inflicting physical or psychological pain on another; the term is usually used to denote sexual sadism
• anal sadism : in freudian theory, the destructive and aggressive manifestations of anal erotism, such as aggressiveness, selfishness, and stinginess.
• oral sadism : in freudian theory, a sadistic form of oral erotism manifested by fantasies of chewing, biting, or otherwise using the mouth, lips, or teeth aggressively or destructively.
• phallic sadism : in freudian theory, the aggressive and destructive tendencies associated with the childhood phallic stage of development, stemming from the child's interpretation of sexual intercourse as aggressive and violent.
• sexual sadism : a paraphilia in which sexual gratification is derived from hurting, humiliating, or otherwise inflicting physical or psychological suffering on another.
• necrosadism : mutilation of a corpse for the purpose of exciting or gratifying sexual feelings.
• sadomasochism : a state characterized by both sadistic and masochistic tendencies.
• transvestic fetishism / transvestism : a paraphilia of heterosexual males, characterized by recurrent, intense sexual urges, arousal, or orgasm associated with fantasized or actual cross-dressing
• cross dressing / cross-dressing : the wearing of clothing specific to or characteristic of the opposite sex
• voyeurism / inspectionism / parascopism : a paraphilia characterized by recurrent, intense sexual urges or arousal involving real or fantasized observation of unsuspecting people who are naked, disrobing, or engaging in sexual activity (peeping Tom)
• paraphilia-not otherwise specified
• necrophilia / necrophilism : fascination or obsession with death, usually specifically sexual attraction to or sexual contact with dead bodies
• coprophilia : an absorbing interest in feces or filth, particularly a paraphilia in which sexual arousal or activity is linked to feces.
• coprolagnia : sexual excitement occurring in association with feces or defecation
• urophilia : a paraphilia in which sexual arousal or activity is linked to urine
• urolagnia : sexual excitement associated with the sight or thought of urine or urination
• kleptolagnia : sexual gratification produced by theft
• telephone scatologia : a paraphilia in which sexual arousal or activity is linked to the placing of obscene phone calls using vulgar language, or trying to elicit a reaction from the other party
• partialism : a paraphilia characterized by exclusive focus on a body part of the sexual partner.
• klismaphilia : a paraphilia in which sexual arousal or activity is linked to enema
• fixation : in psychiatry, a term with 2 related meanings: (a) arrest of development at a particular stage, which if temporary is a normal reaction to difficulties but if continued is a cause of emotional problems; and (b) a close and suffocating attachment to another person, especially a childhood figure, such as a parent. Both meanings are derived from psychoanalytic theory and refer to �fixation� of libidinal energy either in a specific erogenous zone, hence fixation at the oral, anal, or phallic stage, or in a specific object, hence mother or father fixation
• erotism : a sexual instinct or desire; the expression of one's instinctual energy or drive, especially the sex drive.
• anal erotism : fixation of libido at (or regression to) the anal phase of infantile development, said in psychoanalytic theory to produce egotistic, dogmatic, stubborn, miserly character.
• genital erotism : achievement and maintenance of libido at the genital phase of psychosexual development, said in psychoanalytic theory to permit acceptance of normal adult relationships and responsibilities.
• oral erotism : fixation of libido at (or regression to) the oral phase of infantile development, said in psychoanalytic theory to produce passive, insecure, sensitive character
• erotomania / old maid's insanity / psychose passionelle / De Clerambault's syndrome : a disorder in which the subject believes that a person, usually older and of higher social status, is deeply in love with them; failure of the object of the delusion to respond to the subject's advances are rationalized, and pursuit and harassment of the object of the delusion may occur
• erogenous or erotogenic zone : in psychoanalytic theory, an area of the body through which the libido expresses itself and which is therefore susceptible to erotic excitation upon stimulation; the primary sites are the oral, anal, and genital regions, but the other body orifices, breasts, and skin are also included.
• hypersexuality : abnormally increased sexual desire or activity
• nymphomania / andromania / arrhenothigmophilous / clitoromania / furor uterinus / lagnoperissia / hysteromania / cytheromania : abnormal, excessive, insatiable sexual desire in the female
• satyriasis / satyromania : abnormal, excessive, insatiable sexual desire in the male
• Don Juanism : hypersexuality in a man
Differential diagnosis :
• nonpathological use of sexual fantasies, behaviours or object as stimulus for sexual arousal
• mental retardation
• dementia
• personality modifications due to a general medical condition
• substance intoxication
• maniac episode
• schizophrenia
• public micturition
• gender identity disorders
• gender identity disorder : a disturbance of gender identification in which the affected person has an overwhelming desire to change their anatomic sex or insists that they are of the opposite sex, with persistent discomfort about their assigned sex or about filling its usual gender role; the disorder may become apparent in
• childhood
• adolescence or adulthood
• sexually attracted by males
• sexually attracted by females
• sexually attracted by both males and females
• sexually attracted by neither males nor females
Individuals may attempt to live as members of the opposite sex and may seek hormonal and surgical treatment to bring their anatomy into conformity with their belief.
• transsexualism : the most severe manifestation of gender identity disorder in adults, being a prolonged, persistent desire to relinquish their primary and secondary sex characteristics and acquire those of the opposite sex; particularly describing those persons who go so far as to live as members of the opposite sex through dress, hormonal treatments, or surgical reassignment.
• gender identity disorder-not otherwise specified (NOS)
• sexual disorder-not otherwise specified (NOS)
• unusual sex practices
• abrasions : scratching or rubbing off skin
• acomoclitic : preference for hairless genitals
• acousticophilia : arousal from sounds
• acrophilia : arousal from heights or high altitudes
• acrotomophilia : sexual preference for amputees
• actirasty : arousal from exposure to sun's rays
• acupressure : pressure points on body that induce certain responses, some sexual
• adolescentilism : cross-dressing or playing the role of an adolescent
• adultery / apistia / open marriage  : having sex outside a marriage
• agenobiosis : married couple who consent to live together without sex
• agonophilia : person who is aroused by partner pretending to struggle
• agoraphilia / bushie mall : arousal from open spaces or having sex in public
• agrexophilia : arousal from others knowing you are having sex
• albutophilia : arousal from water
• algophilia : arousal from experiencing pain
• aliphineur : person using lotion to arouse partner
• alloerasty : use of nudity of another person to arouse partner
• allopellia : having orgasm from watching others engaging in sex
• allorgasmia : arousal from fantasizing about someone other than one's partner
• allotriorasty : arousal from partners of other nations or races
• alphamegamia : arousal from partner of different age group
• amaurophilia : preference for a blind or blindfolded sex partner
• amomaxia : sex in a parked car
• amelotasis : attraction to absence of limb
• amokoscisia : arousal or sexual frenzy with desire to slash or mutilate women
• amychesis : act of scratching partner during sexual passion
• anaclitism : arousal from items used as infant
• analinctus / analingus / hedralingus : licking anus
• anophilemia : kissing anus
• anasteemaphilia : attraction to taller or shorter partners
• androidism : arousal from robots with human features
• androminetophilia : arousal from female partner who dresses like male
• anisonogamist : attraction to either older or younger partner
• gerontophilia : attraction to a partner whose age is that of different generation
• anililagnia / chronophilia / graophilia / matronolagnia : arousal from older female partner
• anocratism / arsometry / buggery / coitus analis / pederasty / proctophallism / sotadism : anal sex
• anomeatia : anal sex with a female partner
• corephallism : anal sex with young girl
• anophelorastia : arousal from defiling or ravaging a partner
• anoraptus : rapist who only attacks elderly women
• antholagnia : arousal from smelling flowers
• anthropomorphism : attributing human characteristics to half-human half-animal characters
• anthropophagy : cannibalism
• apellous : circumcision
• aphrodisiacs : drugs stimulating a sexual response
• apotemnophilia : person who has sexual fantasies about loosing a limb
• arachnephilia : arousal from spiders
• asceticism : religious self-denial often including celibacy
• celibacy / aphallatia / lagnocolysis : abstinence from sex
• asynodia : celibacy particularly due to impotence
• sexual asphyxiaphilia / Koczwarism : a life threatening eroticizing behavior practiced in women, as in men, in order to heighten sexual excitement and to achieve orgasm, which is in some women accompanied by expulsions of fluid from the urethra (female ejaculation
  ). The relatively easily achieved orgasm induced by the mechanism of asphyxia is hypothesized to be the common reason for repetitive deviant asphyxiophilic behavior. Moreover, in women of the ejaculatory type (female ejaculators), the desire to induce ejaculatory orgasm by asphyxia may also come into play as this kind of orgasm is usually assessed as sensation of greater delight than orgasm without ejaculationref.
• oxygen regulation : regulating intake of oxygen for sexual enhancement
• autoerotic asphyxia : arousal from oxygen deprivation and sometimes risk of dying
Complications : strangulation
• asthenolagnia : arousal from weakness or being humiliated
• autagonistophilia : exhibitionism, arousal from exposing naked body or genitals to strangers while on stage or while being photographed
• autassassinophilia : arousal from orchestrating one's own death by the hands of another
• autogynephilia : arousal from crossdressing
• automasochism / deliberate self-harm syndrome : arousal from inflicting intense sensations or pain on one's own body
• autoerotica : self induced arousal (i.e. fantasies or other aids)
• mysophilia : abnormal interest in dirt or filth, with a desire for contact with it that may encompass a paraphilia; arousal from soiled clothing or foul decaying odors
• automysophilia : arousal from being dirty or defiled
• autonepiophilia : infantilism ; arousal from dressing or being treated like infant
• autopederasty : person inserting their own penis into their anus
• autophagy: self-cannibalism or eating own flesh
• autosadism : infliction of pain or injury on oneself
• avisodomy : breaking neck of bird while penetrating it for sex
• axillism : penis penetrating an arm pit
• ball dancing / bell dancing; self flagellation by hanging fruit from hooks in skin
• basoexia : arousal from kissing
• bath house : commercial baths, some of which allow sex on premises
• bed of nails : lying on a bed of nails for sensory enhancement
• bee stings : the use of bees, such as to sting genitals
• bell dancing : self-flagellation with bells or other ornaments hanging the skin
• belonephilia : arousal from use of needles
• bestiality : zoophilia; sex with animals
• bestialsadism : cruelty or mutilation of animals
• bigynist : sex between 1 male and 2 females
• Bihari surgery : cutting ligament above penis to make it appear longer
• bindings : wrapping feet or genitals with string or lace
• bivirist : sex between 1 female and 2 males
• blastolagnia : person aroused by young females
• blindfolding : covering the eyes
• borderline self-mutilator : automasochism
• body worship : sex game where partner is made to adore another's body
• bondage : physical or mental restriction of partner
• bottom : passive partner who experiences stimuli during sex games, masochist, slave, submissive
• brachioprotic eroticism : a deep form of fisting where the arm enters the anus
• bradycubia : slow movement during penetration
• branding : burning patterns or initials into flesh
• bundling : partners sleeping together clothed and without sex
• candaulism : spouse who watches partner having sex with someone else
• caning : whipping that uses a switch or cane to discipline partner
• capnolagnia : arousal from watching others smoke
• cat fighting : women fighting without rules and often tearing off each other's clothing
• cataphilist : male submitting to female
• catatasis : stretching of the penis
• catheterophilia : arousal from use of catheters
• chaperon : person who escorts a young couple to ensure they don't engage in sex
• charms : objects used to bring good luck and ward off evil
• chastity : sexual abstinence
• chastity belts : leather or metal belts used to prevent genital penetration
• chemise cagoule : long heavy night shirt with hole for penis
• choreophilia : dancing to orgasmic release
• chrematistophilia : person aroused by having to pay for sex or having sex partner steal from them (see also harpaxophilia)
• chronophilia : arousal from passage of time
• chubby chasers : people who are aroused by obesity in partner
• clamps : metal, plastic, or wood fasteners used on nipples or genitals
• claustrophilia : arousal from being confined in small space
• clitorilingus : licking a clitoris
• cock rings : rings placed around the base of the male genitals to maintain erections
• cocktails : drinking of body secretions from a glass
• coitobalnism : sex in a bathtub
• coitolimia : tremendous sexual drive
• coitus a cheval : couple having sex on the back of an animal or one acting out role of horse
• coitus a mammilla : penetration of penis between breasts
• coitus a unda : sex or sex games in water
• coitus intrafemoris : penetration between legs
• colobosis : mutilation or castration of penis
• compulsive cruising : compulsive search for sex partners
• computer sex : the use of computers for sex games, communication, and erotic photography
• concubinage : use of female slaves as sex partners; living with sex partner without being married
• confessions : admitting a sin; in some cases to arouse potential partner
• coprography : writing obscene words or phrases, usually in public toilets
• coprolagnia : arousal from feces
• coprolalia : arousal from using obscene language or writing
• coprophilia / scat : arousal from playing with feces
• coproscopist : arousal from watching a person defecate
• corsetting : body modification or oxygen restriction from using corsets
• couvade : custom where male mimics child birth or is confined at time of wife's delivery
• couvade syndrome / chipil : a male who experiences symptoms of pregnancy in sympathy for wife
• cratolagnia : arousal from strength of partner
• cross dressing : a person who wears the apparel of the opposite sex
• cryptoscopophilia : desire to see behavior of others in privacy of their home, not necessarily sexual
• cunnilalia : to talk about female genitals
• oral or oro-genital sex : contact between the mouth and genitals; use of the mouth in sex play. Oral sex is a common sexual practice between both heterosexual and homosexual couples. Oro-genital sex is implicated as a route of transmission for Neisseria gonorrhoeae
  , Treponema pallidum subsp. pallidum
  , Chlamydia trachomatis
  , Haemophilus ducreyi
  , and Neisseria meningitidis
  . Other respiratory organisms such as streptococci, Haemophilus influenzae
  , and Mycoplasma pneumoniae
  could also be transmitted by this route. A link between oro-genital sex and bacterial vaginosis is currently being studied. In view of the increased practice of oral sex this has become a more important potential route of transmission for oral, respiratory, and genital pathogensref.
• cunnilingus / gamahucheur : oral stimulation of the female genitalia.

Side effects :
• anilingus : sexual stimulation of the anus with the lips or tongue. Oro-anal sex is implicated in the transmission of various enteric infections.
• fellatio [L. fellare to suck] / corvus / irrumatio / penosugia : oral stimulation or manipulation of the penis on a male. It  confers risk for acquisition of infection by the oral partner
• autofellatio : fellatio performed on oneself
Compared with white men, black men attending a genitourinary medicine clinic were much more likely to be unemployed, to have commenced intercourse earlier and to have urethral infection. They were much less likely to practice fellatio, cunnilingus, or anal intercourse. However, there was no difference between the two racial groups in respect of numbers of sexual partners and condom useref.
• cynophilia : arousal from sex with dogs
• cyprieunia : sex with a prostitute
• dacnolagnomania : lust murder
• dacrylagnia : arousal from seeing tears in the eyes of a partner
• dacryphilia : person who is aroused by seeing their partner cry
• dame de voyage : dolls designed for genital penetration, often used by sailors
• danse du ventre : erotic or fertility dancing; belly dance
• dating services : agencies arranging for strangers to meet each other, usually for a fee
• day belts : chastity device used for short day excursions
• defecolagnia : arousal from defecation
• defilement : arousal from partner or self becoming dirty or wet
• dendrophilia : arousal from tree or fertility worship of them
• depilation : shaving, waxing, or other type of hair removal
• dermagraphism : marks left on the skin of a partner by biting, scratching or sucking
• dermaphilia / doraphilia : sexual stimulus from skin
• dippoldism : sexual arousal from abusing children
• docking : slipping one partner's foreskin over the glans penis of another
• dogging : couples who engage in sex in their car while others watch from outside
• doleros : algophilia; arousal from pain
• dominance/submission : power exchange between partners
• doraphilia : arousal from animal fur, leather, or skin
• douches : rinsing out the anus or vagina with liquids
• enema : the insertion and expulsion of fluids into the anus
• golden enemas and douches : urine deposited into anus or vagina
• enema cocktail : drinking purged contents of enema
• dungeons : rooms that are decorated for SM play
• dysmorphophilia : arousal from deformed or physically impaired partners
• ecdemolagnia : arousal from traveling or being away from home
• ecdyosis : arousal from removing clothes in front of others
• ecorchement : flagellation
• ecouteurism : listening to others having sex without consent
• ederacinism : to tear out sex organs by the roots as in a frenzy or to punish oneself for sexual cravings
• electric shock : using electric shock for sensory enhancement
• electrophilia: arousal from electrical stimulus
• electrolysis: an electrical method of removing hair
• elopement: hasty and clandestine marriage without consent of family members
• endytolagnia / endytophilia : arousal only from partners who are clothed
• entomocism : the use of insects
• zooerasty / zoophilia : arousal from animals
• entomophilia : arousal from insects or using, them in sex play
• formicophilia : sex play with ants
• eonism (from the French Chevalier D'Eon) : crossdressing
• eopareunia : engaging in sex while young
• ephebophilia : attraction to adolescent sex partner
• episioclisia : suturing of the labia majora; infibulation
• eproctolagniac : person aroused by flatulence
• eproctophilia : arousal from flatulence
• flatuphilia : arousal from having partner pass gas
• erotica : sexual literature and photos
• erotographomania : arousal from writing love poems or letters
• erotomania : people who develop an unreasonable love of a stranger or person not interested in them
• erotophonophilia : lust murder
• essayeurs : men who were hired by bordellos to become sexual with women so that timid clients would follow their lead
• eunuchs : castrated men
• executions : a legal death sentence, some people become aroused by watching executions
• exmuliebrate : castration
• fainting : passing out or losing consciousness
• famulus : slaves, family
• fantasy : mental image or illusion, sometimes sexual
• fantasy play : acting out sexual fantasies
• felching : sucking semen out of vagina or anus; or inserting animals into anus or vagina
• female impersonators : men who dress in women's clothing, often for pay
• fibula : bar that runs through foreskin of male and attaches to semi-circle device, used by Romans to prevent intercourse
• fisting : inserting a fist or hand into the vagina or anus
• flagellation : striking a person with an object
• flirting : pretending to have affection for another person
• florentine girdle : chastity belt
• foot binding : the wrapping of feet, done by Chinese and others
• fornicatory dolls : plastic blow up, rubber, or mechanical dolls used for penetration
• inflatable dolls : plastic dolls that are designed for genital penetration
• furtling : the use of fingers underneath cut-outs in genital areas of photos for arousal
• gang bangs : sex with a series of waiting partners
• gendermap : "A developmental representation or template synchronously in the mind and brain depicting the details of one's G-I/R. It includes the lovemap but is larger, insofar as it incorporates whatever is gender coded vocationally, educationally, recreationally, sartorially, and legally as well as in matters of etiquette, grooming, body language, and vocal intonation." (John Money)
• gendoloma : the use of sexual fantasies to hasten orgasm
• genuphallation : insertion of penis between the knees of a partner
• girdle of Venus : chastity belt
• glory holes: a hole in a partition that allows a person on the other side to engage in sexual activity
• goddess worship : a toilet scene using Witchcraft rituals
• gomphipothic : arousal by the sight of teeth
• graffiti : drawing or inscription on public walls, sometimes sexual; coprography
• graphelagnia: arousal from photographs of nudity or sex
• gregomulcia: arousal from being fondled in a crowd
• groping: feeling of unknown or unidentified person in boxes, suits, etc.
• group sex / martymachlia / orgies : sex with more than one partner or in close proximity of others
• groupies: erotomania; people who are devoted to or who follow celebrities
• gymnocryptosis: females talking about sex life of husbands
• gymnophilia: arousal from nudity
• gynandromorphous: hermaphrodite
• gynecomania : compulsive desire for female sex partners
• gynelophilous : arousal from pubic hair
• gynelophism : scalping hair on pubic area, usually done by lust murders
• gynemimesis : male-to-female cross dressing
• gynemimetophilia: person aroused by a male impersonating a female
• gynephonia: effeminate voice
• gynonudomanic : compulsion to rip clothes off others
• handkerchief codes : color codes to identify sexual preferences
• haptosis : non-consensual sexual touching
• harmatophilia : arousal from sexual incompetence or mistakes, usually in female partner
• harnesses : body harnesses used in suspension or penis restriction
• harpaxophilia : arousal from being robbed or burglarized
• hebephilia : men aroused by teenage boys
• hedonism : act of indulging in pleasure
• hedonophilia : sexual arousal from engaging in pleasurable activity
• hemerotism: daydreaming or fantasizing about sex or nudity
• hemotigolagnia : arousal from bloody sanitary pads
• hierophilia : arousal from sacred objects
• hirsutophilia : arousal from armpit hair
• hodophilia : arousal from traveling
• homilophilia : sexual arousal from hearing or giving sermons
• homoeroticism / homophilia / invert / iterandria / sexual inversion / lung-yang / uranism / zwischenstufe : sexual arousal from person of same sex
• humiliation : degrading partner to establish sexual power
• hybristophilia : love of someone who has committed an outrage
• hygrophilia : arousal from body fluids or moisture
• hymenoclasis : surgical defloration of virgin
• hymenorrhexis: defloration of hymen
• hymenorrhaphy : suturing of the hymen; infibulation
• hyperphilia : compulsive desire for sex
• hyphephilia : arousal from touching skin, hair, leather, fur or fabric
• iantronudia : arousal from exposing oneself to a physician, usually by faking an ailment
• iconolagny : arousal from pictures or statues of nude people
• idiosyncrat : compulsive desire for sex
• idrophrodisia : arousal from the odor of perspiration, especially from the genitals
• incest : sexual intercourse or other sexual activity between persons so closely related that marriage between them is legally or culturally prohibited.
• matrincest : sex with one's mother
• fratrilagnia : arousal from having sex with one's brother
• sororilagnia : sex with one's own sister
The prevalence and seriousness of incestuous abuse: stepfathers vs. biological fathers. Analysis of interviews obtained from a random sample of 930 adult women in San Francisco revealed that 17% of women who had a stepfather as a principal figure in her childhood years, was sexually abused by him. The comparable figures for biological fathers were 2%. In addition, when a distinction was made between very serious sexual abuse (including experiences ranging from forced penile-vaginal penetration to non-forceful attempted fellatio, cunnilingus, and anal intercourse) and other less serious forms, 47% of the cases of sexual abuse by stepfathers were at the very serious level of violation compared with 26% by biological fathersref.
• infibulation : closing penis/vagina with suture or ring
• intergenerational : sex between partners with > 20 years age difference
• inunction: anointing or rubbing person with oil or lather
• ischolagny: avoidance of women to prevent arousal
• Jack gagger: a husband that procures men to pay for sex with his wife
• jactitation: a false boast that causes harm to others, sometimes sexual
• juvenilism: dressing or acting out role of a juvenile, sometimes sexual
• Kegel exercises : exercise of the pelvic muscles that control orgasm
• kleptophilia: arousal from stealing
• knismolagnia: arousal from tickling
• kokigami : the wrapping of the penis in a paper costume
• kolpeuryntomania : stretching of the vagina
• labiorrhaphy: suturing of the labia
• lacing: suturing body parts to another object for bondage
• lactaphilia : arousal from lactating breasts
• lagnolalia : discussion of sexual subjects
• lagnonector : person who kills in order to have sex with corpse
• lap dancing : squatting above a sitting person and rubbing against them to create arousal without touching genitals
• lectamia : bundling
• leptosadism : mild form of sadism
• levirate marriage : marriage of widow without a son to deceased husband's brother
• love map : "A developmental representation or template in the mind and in the brain depicting the idealized lover and the idealized program of sexuoerotic activity projected in imagery or actually engaged in with that lover." (John Money)
• love potions : potions that are thought to increase a person's sexual desire
• lubricants : a substance that reduces friction, often used to facilitate penetration
• lust murder : murdering a person one feels a sexual attraction toward
• lygerastia : tendency to only be aroused in darkness
• lacrogenitalism : arousal from large genitals
• maieusiophilia : arousal from pregnant women
• mammagymnophilia : arousal from female breasts
• maschalophilous : arousal from armpits
• mastigothymia : flagellation
• mastix : female sadist
• masturbation : self-stimulation of the genitals for sexual pleasure and orgasm not involving penetration of partner
• chezolagnia : masturbating while defecating
• onanism [Onan, son of Judah] : coitus interruptus or masturbation
• manuxorate : male using his hand to masturbate
• penetration toys : devices used for penis insertion during masturbation
• pompoir : vaginal muscle control that masturbates penis when inserted
• sacofricosis : cutting a hole in pant pocket to facilitate masturbation in public
• maritate : female masturbating alone
• amatripsis : masturbation by rubbing labia together
• syntribate : rubbing thighs together to masturbate
• bouginonia : female masturbation from the use of objects such as dildos that stretch open the vagina
• olisbos / paraphallus / dildos and plugs : instruments used for genital penetration
• botulinonia : using a sausage as a dildo
• godemiche : dildo in the shape of a penis with scrotum used for masturbation
• sybian : a vibrating dildo that sits on top of an object that resembles a saddle
• triborgasmia : wife who masturbates husband
• siphnianize : anal masturbation
• butt plugs : anal inserts used for masturbation
• mazoperosis : mutilation of breasts
• mazophallate : rubbing penis between breasts
• meatotomy : dilating urethra with a medical dilating device, the urethra is stretched to eventually facilitate a finger or a penis
• medocure : the clipping or perfuming of the penis
• medolalia : talking about the penis
• melolagnia : arousal from music
• menage a trois : a husband and wife having sex with a third party
• menophilist : arousal from menstruating women
• menstrual taboo : separation of spouses during female's menstrual cycle
• merinthophilia : arousal from being bound
• merlin : an artificial vagina used for penetration
• miscegenation: sex between races
• misogynist: a man who hates women
• misogyny: hatred of women by either sex
• mixoscopia : a paraphilia in which gratification is obtained by the sight of the object of one's desire engaged in sexual intercourse with another
• moriaphilia: arousal from telling sexual jokes
• morphophilia: arousal from person with a different physique
• mummification : wrapping the full body in a manner that prevents movement
• Munchausen's syndrome : arousal from reopening a wound
• mutilation: tearing the skin or otherwise deforming a person's body
• manophilia: sexual attraction to a short partner
• maphephilia: arousal from touching or being touched
• narratophilia : person who is aroused by discussing sex with others
• nasolingus : arousal from sucking nose of partner
• mucophagy : consuming mucous secretions as in nasolingus
• necrochlesis: sex with a female corpse
• necrocoitus: penetration of corpses
• necrophagia: cannibalism of corpses
• necrophilia: sex with corpses
• necrosadism: sadism or mutilation of corpses
• neophilia : arousal from novelty or change
• nepiolagnia / nepiophilia : arousal by infants of opposite sex
• nepiphtherosis: attempted sex with an infant
• nepirasty: arousal from handling infant often experienced by childless females
• niddah: abstaining from sex 1/3 of the time to create arousal during rest of month
• nomavalent : arousal from traveling or new places, usually impotent at home
• nonmonogamy: multiple sex partners
• normophilia: those only aroused by acts considered normal by their religion or society
• nosolagnia / nosophilia : arousal from knowing partner has terminal illness
• recreational nudity : nudity in group settings, beaches, nudist camps, etc.
• nudomania / omolagnia : arousal from nudity
• nympholepsy : trance state induced by erotic fantasies
• nymphophilia : adult males who are attracted to young females
• ochlophilia : arousal from being in a crowd
• oculolinctus : licking partner's eyeball
• odaxelagnia : arousal from biting
• olfactophilia : arousal from odors
• ondinisme : arousal from urine
• oneiropornism: dreaming about prostitutes or sex
• ophidicism : use of snakes, sometimes for sexual purposes
• ophidiophilia : arousal from snakes
• ordune : arousal from photographs of nudes or sex
• osculocentric : arousal from kissing
• osmolagnia / osmophilia / ozolagnia : arousal from odors
• osphresiolagnia : arousal from odors
• Othello's syndrome: jealousy
• oageism : male submitting to female
• pareunomania : compulsive desire for sex
• parthenophagy : cannibalism of young girls
• parthenophilia : sexual desire for virgins
• passivism : submission
• patrolagnia : sex with one's own father
• pecattiphilia : arousal from sinning or possibly guilt
• pediophilia : arousal from dolls
• penis ligation : the tying of the foreskin of a penis
• penis modification : physical alteration of penis
• perogynia : mutilation of females
• personal ads : advertisements designed to attract sex partners
• petticoat discipline : the use of cross dressing adolescent boys by their mothers as a form of control
• phallolalia : talking about penises
• philemanmania : compulsion to kiss
• phobophilia : arousal from fear
• phone sex : verbal sex between partners on a phone
• phygephilia : sexual arousal from being a fugitive
• pictophilia : arousal from pictures, video or movies with a sexual subject
• pie throwing : arousal from being hit with a pie
• piercing: inserting needles into skin for arousal
• podophilia: arousal from feet
• polyandry: one wife with multiple husbands
• polygamy: one person with multiple marriage partners
• polygyny: one person with multiple wives
• polyiterophilia : arousal only after having sex with a series of partners
• proctotitillia: tickling anus
• professional dominatrix: woman hired to function as a top or sadist
• psycholagny : the experiencing of sexual enjoyment from imagining or thinking of sexual acts.
• psychrophilia: arousal from being cold or watching others freeze
• psychrotentiginous: arousal from cold weather
• pubephilia : arousal from pubic hair
• pubic dressing: coloring or adding ornaments to pubic hair
• pudendacure: pubic dressing for female
• pygophilemania: arousal from kissing buttocks
• pygophilia: arousal from contact with buttocks
• pygotripsis: arousal from rubbing buttocks
• pyrophilia : arousal from fire or of its use in sex play
• queening : sitting on the side of a person's face as a form of bondage
• rape : nonconsensual sex involving coercion, empowerment or anger; nonconsensual sexual penetration of an adolescent or adult, obtained by force or threat, or in cases in which the victim is not capable of consent.
• rape rack : bondage device which leaves victim's genitals exposed for sex or rape
• anthropophagolagnia : rape with cannibalism
• biastophilia : those preferring to violently rape their victims
• raptophilia: arousal only from raping a victim
• renifleur: person aroused die smell of urine or by sniffing underwear
• rhabdophilia: arousal from being flagellated
• rimming : penetration of anus with tongue
• ringing: insertion of permanent jewelry into a body piercing
• ritual sex: sex performed with specific rules of conduct (i.e., Wicca, weddings, slave training)
• sadomasochism by proxy : arousal from watching others disciplined; Dippoldism
• salirophilia : person ingesting human sweat or saliva (fluids with a salt content)
• sapphosadism: lesbian sadism
• sarmassophilia: arousal from kneading flesh
• Satan worship: religious rituals performed to Satan as a god
• scarfing: the use of a scarf in strangulation for sexual arousal
• scopophilia: arousal from being stared at oneself
• scoptolagnia : arousal from seeing the genitals of the opposite sex
• scoptophilia : arousal from looking at sexually stimulating scenes
• scrotal infusion : infusion of saline into the scrotal sack so that it enlarges
• selgolalia : telling stories that include sex
• sensory deprivation : using lack of sensations to create desire
• sensory enhancement : increasing arousal by increased body sensations
• sergeism : infliction of injury to suppress arousal, automasochism, based on story of Sergius by Tolstoy
• sex addiction : compulsion to have sex
• sex magick : the use of witchcraft rituals for sexual purposes
• sex play
• hot wax : sex game where hot wax is melted onto partner
• torture : inflicting pain to get information or for revenge, also used in
• terror play : sex play using terror or fear for arousal
• stapling : inserting a U-shaped wire into skin during sex play
• robotism : attraction to or the use of robots in sex play
• infantilism : cross-dressing as a young child for sex play
• abduction : to kidnap or carry a person away by force, also used in sex play
• medical scenes : sex play that involves using medical instruments or settings as props
• sex toys : mechanical objects used to assist in masturbation or sex play
• play room : room equipped with sex paraphernalia and used primarily for sex play
• sex rings : organized groups of children being sexually exploited by one or more adults
• sex surrogates : people who are trained to help people overcome sexual dysfunctions
• sexautism : tendency to be preoccupied with sexual thoughts
• sexercise : exercises designed to improve muscles used for sex
• snapping pussy: constrictions of muscles used for orgasm; sexercise
• sexual sadist killer : lust murderer
• shaving : removing the hair with a razor of a partner or oneself for arousal
• pubic hair sculpturing : removing pubic hair so that the remainder forms a pattern (i.e. a heart)
• showers : depositing body fluids onto a partner's body
• Roman showers / emetophilia : arousal from vomiting on partner, usually after drinking urine or wine
• golden showers : urinating onto a partner's body
• shunammitism : bundling
• siderodromophilia : arousal from trains
• sitophilia : arousal from food
• slapping : slapping partner for arousal
• sleeping princess syndrome : those aroused by partner who appears to be asleep
• slings : swings or other forms of support for suspension from which a person may engage in sex
• snuff films : films that portray the actual murder and mutilation of one of the actors
• sodomy : oral or anal intercourse involving penetration with male, female, or animal
• somnophilia : fondling stranger in their sleep
• sororate marriage : right of spouse to engage in sex with sisters-in-law or sometimes brothers-in-law
• sounding : insertion of an object into the urethra
• spanking : using hand to slap partner's buttocks for sensory enhancement and arousal
• spay : castration
• spectrophilia : either coitus with spirits or arousal from image in mirrors
• speculum : dilating device used by physicians when doing pelvic exams and in SM medical scenes
• sphagia : a sacrifice used to placate the gods, the whole offering was completely burned
• splitting : splitting the penis from the glans toward the base
• stabbing : insertion of a sharp object into flesh
• stag parties : private parties where only men and possibly a female stripper or entertainer are permitted
• sthenolagnia: arousal from demonstration of strength or muscles
• stigmatophilia: arousal from partner who is stigmatized (i.e., tattoos, piercings, scars)
• strabismus : arousal from eyes of partner
• stretching: stretching body or genitals for arousal
• string bondage: constrictions; wrapping string around body at certain intervals for arousal
• strip poker: card game where the losers remove articles of clothing
• strip search: interrogation process where sex partner is stripped and searched
• stripping: removal of clothes, sometimes performed on stage in an erotic manner
• stuffing : insertion of objects into vagina or anus
• subincision : cutting part of the glans penis from the tip toward the base
• suspension : suspending body for sensory deprivation and bondage
• suttee : religious practice of killing wife upon husband's death and burial
• swinging : group sex or wife swapping
• swing : an object that allows a person to be suspended and move back and forth
• switch : people who play either the top or bottom role (sadist or masochist)
• symphorophilia: arousal from arranging a disaster, crash, or explosion
• tantalolagnia : arousal from teasing
• tantra : yoga type sexual discipline
• Kabbazah sex : tantra sex, male passive, female active
• taphephilia : arousal from being buried alive
• tattooing : tattooing for arousal and marking
• teasing : to excite sexually but without fulfilling implied message
• teledildonics : arousal from computer sex games
• telegony : belief that first man impregnating woman will be the father of any subsequent children
• telephonicophilia : arousal from using phone calls for sexual conversations
• teratophallic : large penises
• thalpotentiginy : arousal from heat
• thesauromania : compulsion to collect objects or clothing belonging to females
• thlipsosis : arousal from pinching others
• 3-legged bloomers : bondage underwear garment that has sleeve for head that opens to genitals of partner
• thygatria : sex between father and daughter
• tickling : light touch that sometimes causes a laughter response
• timophilia : when a person's primary arousal comes from gold or wealth
• titillagnia : arousal from tickling
• tithiolagnia : having an orgasm while nursing
• toilet training : urinating or defecating on a partner as a form of slave training
• top : term used for partner who controls stimuli during sex games
• tourniquets: a device that compresses blood vessels to control bleeding, sometimes sexual
• toucheurism : touching a stranger for arousal
• tragolimia : compulsive desire for sex regardless of attraction of partner
• transvestophilia : arousal from crossdressing
• traumaphilia : arousal from wounds or trauma; automasochism
• tribadism [Gr. tribein to rub] : 1. lesbianism; usually used to denote that in which heterosexual intercourse is simulated; sometimes used to refer to the use of an artificial penis.  2. mutual friction of the genitals between women.
• tripsolagnia : arousal from having hair shampooed
• tripsolagnophilia : arousal from massage
• tripsophilia : arousal from massage
• troilism : arousal by being third party in sex scene
• undinism : arousal from water
• urethral self-instrumentation : sounding; inserting object into urethra for arousal
• urolagnia : arousal from urine
• urtication : the use of nettles to create extra sensation
• vampirism : consuming blood of partner for arousal
• vertigo : dizziness, sometimes used to enhance sex acts
• vicarphilia : arousal from other people's exciting experiences
• vincilagnia : arousal from bondage
• virimimism : adoption of masculinity
• weight training : the use of hanging weights on genitals or hooks for arousal
• whipping : striking or flagellating a partner for sensory enhancement
• wife swapping : exchanging spouses with another couple for sexual purposes
• wrestling : a physical struggle between two or more people, used as sexual arousal by some
• xenodynamic : person who is only potent with strangers
• xenolimia / xenophilia : arousal from strangers
• zelophilia : arousal from jealousy
• gender role identity disorder
• effemination / feminization : the induction or development of female secondary sex characters in the male
• aim identity disorders
• homosexuality / commasculation : sexual orientation toward or activity with those of the same sex, as distinguished from heterosexuality.
• lesbianism / sapphism / cymbalism / gynecozygosity / Harem effect [Gr. Lesbios of Lesbos, a Greek island in the Aegean Sea, home of the poetess Sappho and her followers] : homosexuality between women
• androsodomy : anal sex with a male partner
• pathicant : a minor who engages in anal sex with an adult
• catamites / bardajes : young gay male lovers
• pathicus : passive recipient in gay anal sex
• drag queens : gay men who dress in female attire
Aetiology :
• estrinsic
• a significantly increased incidence of prenatal stress was found in bisexual and, particularly, in homosexual menref. War induces stress in pregnant women and stress might causes a drop in fetal androgen levels which in turn leads to the development of a homosexual "orientation". Out of 865 homosexual males who were registered by venerologists in 6 districts of the GDR highly significantly more homosexuals were born during the stressful war and early postwar period of the Second World War, i.e. between 1941 and 1947 (with a maximum of relative frequency in 1944-1945), than in the years before or after this critical periodref. A replication not only failed to support this conclusion but also found that even those cities that suffered the most severe bombing during World War II showed no evidence of increased numbers of homosexualsref.
• intrinsic :
• male and female fruitflies have been engineered to switch courtship roles, through the manipulation of a single gene. The mating behaviours of the Drosophila fruitfly are a far cry from intricate Hollywood romance. The male performs a series of tapping and tilting movements, to which the female usually responds if she has not recently mated. Females, in contrast, never court at all. But this behaviour has been reversed by designing female flies with the male version of a gene called fruitless. These insects initiated courtship with other females as often as their male counterparts did. The tweaked female flies could only be encouraged to court males if the males were designed to emit female pheromones, a form of natural chemical attractant. When male flies were given the female version of the fruitless gene, they stopped courting and became passive about sex. Scientists are still struggling with the question of how this gene affects sexual behaviour so strongly. It does not influence fly morphology: the insects do not look any different. Instead, it seems the gene influences the insect's nervous system. Homosexuality has been documented in > 400 species, including many mammals, and research has linked this behaviour to everything from social factors to maternally inherited genes. It's pretty clear that the survival of a species depends heavily on its ability to reproduce. So that's something that you'd want programmed into the genes, but controls on a fruitfly's sexual behaviour are undoubtedly different from our own. In the case of humans, sexual behaviours are not irreversibly set by genes, but that doesn't mean the genes have no influenceref
• the same genes that are proposed to predispose to homosexuality may also boost reproduction in women, solving the apparent Darwinian paradox of why these genes have not been removed by natural selection. Maternal relatives of homosexual men tend to produce more offspring than those of heterosexuals. This suggests that the mothers and maternal aunts of homosexuals have a genetic advantage - but one that reduces reproduction when passed to male offspring. The trait is probably multigenic as if the effect were down to a single gene it would probably spread easily throughout the population, and homosexuality would presumably be much more common. But whatever the genes are, the X chromosome is almost certainly involved. Besides having more fecund mothers and aunts, homosexual men had more fellow homosexuals in their maternal family, again hinting that their sexuality is influenced by their mother's genes. What's more, homosexual men were more likely to have older brothers, which supports a separate theory that homosexuality is linked to changes in the mother's immune system during previous male pregnancies. Overall, about 14% of the variation between homosexual and heterosexual men is accounted for by increased maternal reproduction, and about 6% by the trend to have older brothers. The remaining 80% could perhaps be due to formative sexual and social experiences during early life or even childhoodref
• about 60% of these brothers shared identical DNA on 3 chromosomes - chromosome 7q36 (equivalent maternal and paternal contributions), 8p12 (equivalent maternal and paternal contributions) and 10q26. If it were down to chance, only 50% of these stretches would be shared. The region found on 10q26 correlated with sexual orientation only when it was inherited from the mother. No linkage with Xq28 has been confirmedref.
Complications : gay bowel syndrome
• bisexuality / ambisexuality / amphisexuality / androgynophilia / sexoschizia : sexual attraction to persons of both sexes; exhibition of both homosexual and heterosexual behavior.
• alloeroticism : sexual feeling directed to another person. The final stage in the development of object relationships, a state of maturity, characterized both by direction of erotic energies to another and also by the ability to form a love relationship with that other
• autoeroticism : sexual self-gratification or arousal without the participation of another person, such as masturbation. In psychoanalytic theory, the most primitive stage in the development of object relations, preceding the narcissistic stage
• heteroeroticism : sexual feeling directed toward someone of the opposite sex. A stage in the development of object relationships in which the erotic energy is directed toward objects other than oneself, specifically to those of the opposite sex
• misogyny : hatred of women.
• misogamy : hatred of or aversion to marriage
The statistical profile of adolescent sexual activity in the US in 1993 indicates that over 50% of teenagers are virgins until at least 17 years of age. 20% of boys and 24% of girls are virgins by the age of 20 years. Only 6.9% of men 18-59 years old and 21% of women 18-59 years old were still virgins on their wedding night. However, among a sample of high school students, over 33% of male and female virgins had engaged in some form of heterosexual genital sexual activity in the preceding year. 29% of virgins had masturbated a partner of the opposite gender. 31% had been masturbated by a partner of the opposite gender. 9% had engaged in fellatio with ejaculation with a partner of the opposite gender. 10% had engaged in cunnilingus with a partner of the opposite gender. 1% had engaged in anal intercourse with a partner of the opposite gender. Comprehensive sex education aims to help adolescents postpone sexual intercourse until they are ready for mature relationships by helping them develop interpersonal skills to resist premature sexual involvement. Messages include information about sexual abstinence, contraception, and safer sex. A 1993 study found that sexual abstinence messages were one of the most frequently covered topics in state curricula and guidelines. Other key topics were families, decision making, and sexually transmitted diseases including AIDS. The least covered topics were sexual identity, shared sexual behavior, sexual response, masturbation, and abortion. There were only six studies of abstinence-only programs, of which at least two showed no impact on sexual or contraceptive behavior. The National Institute of Health says that abstinence-only programs ignore the success of other programs and conflict with scienceref.

malingering : the willful, deliberate, and fraudulent feigning or exaggeration of the symptoms of illness or injury, done for the purpose of a consciously desired end.

factitious disorder : a mental disorder characterized by repeated, intentional simulation of physical or psychological signs and symptoms of illness for no apparent purpose other than obtaining treatment. It differs from malingering in that there is no recognizable motive for feigning illness. It is subtyped on the basis of whether the predominant signs and symptoms are

• factitious disorder with main physical signs and symptoms : Munchausen syndrome : a condition characterized by habitual presentation for hospital treatment of an apparent acute physical illness, the patient giving a plausible and dramatic history, all of which is false
• laparotomaphilia : Munchausen syndrome in which the patient desires abdominal surgery.
• factitious disorder with main psychological signs and symptoms
• factitious disorder with both psychological and physical signs and symptoms
• factitious disorder by proxy : a form of factitious disorder in which one person intentionally fabricates or induces signs and symptoms of one or more physical (Munchausen syndrome by proxy) or psychological disorders in another person under their care and subjects that person to needless and sometimes dangerous or disfiguring diagnostic procedures or treatment, without any external incentives for the behavior. The dyad is usually that of mother and child.
• factitious disorder-not otherwise specified (NOS)

Differential diagnosis :

• actual general medical condition
• actual mental disorder
• somatoform disorders
• malingering

eating disorders : any of several disorders in which abnormal feeding habits are associated with psychological factors. Often the consequences of eating disorders worsen them (e.g. mucositis)

Epidemiology : mostly females aged 12-25 years

• bulimia : episodic binge eating usually followed by behavior designed to negate the excessive caloric intake, most commonly purging behaviors such as self-induced vomiting
  or laxative abuse but sometimes other methods such as excessive exercise or fasting. While it is usually associated with bulimia nervosa, it may also occur in other disorders, such as anorexia nervosa.
• bulimia nervosa (BN)

Epidemiology : occurring predominantly in females with high economical level, with onset usually at age 12-35; prevalence = 1-2% of general population, 5-9% of universitary or high-school population
Aetiology : autoimmune disease

Symptoms & signs : episodic subjective or objective (20,000-30,000 cal) binge eating > 2 times a week for > 3 months, followed by binge behaviors designed to prevent weight gain, including purging, vomiting, fasting, diuretics (very dangerous !) and/or excessive exercise. Episodes of binge eating involve intake of quantifiably or subjectively excessive quantities of food alone within a short, discrete period (more times a day) as well as a sense of loss of control over food intake during these periods. The person with bulimia nervosa has a preoccupying pathological fear of becoming overweight, feels an unusually strong tie between self-worth and local body shape and size (hips, buttocks, thighs, ...), is aware that the eating pattern is abnormal, and frequently experiences feelings of self-recrimination. In contrast to persons with anorexia nervosa, patients with bulimia nervosa tend to be somewhat older, more socially inclined, have less obsessive characteristics (cyclothymic disorder), dress appariscent when happy and do not exhibit extreme weight loss; it is not diagnosed in the presence of anorexia nervosa. 50% have transient amenorrhea
Prognosis : mortality due to hyperkalemia, suicide, self-lesionism, substance abuse
Differential diagnosis :
• anorexia nervosa binge-eating / purging type
• Klein-Levine syndrome
• major depressive disorder with atypical manifestations
Therapy (relapses are frequent) :
• anorexia : lack or loss of the appetite for food.
anorexia nervosa (AN) : refusal to maintain a normal minimal body weight (<15% of ideal body weight), intense fear of gaining weight or becoming obese, and a disturbance of whole body image resulting in a feeling of being fat or having fat in certain areas even when extremely emaciated, undue reliance on body weight or shape for self-evaluation, and amenorrhea for > 3 months. Associated features often include denial of the illness and resistance to psychotherapy, depressive symptoms, markedly decreased libido, and obsessions or peculiar behavior regarding food, such as hoarding. The disorder is divided into 2 subtypes :
• restricting type : weight loss is achieved primarily through diet or exercise
• binge-eating / purging type : binge eating or purging behavior (enteroclysm, laxatives, diuretics) also occur regularly; the latter type resembles bulimia nervosa, which is not diagnosed in the presence of anorexia nervosa
Epidemiology : 90-95% are females (rarely "reverse anorexia" in males using anabolizing hormones and practicing a lot of physical exercise), usually with onset at age 14-18; prevalence = 1 every 800
Aetiology : high-risk job (models) and sports (dancers)
Symptoms & signs
• due to malnutrition :
• due to purging behaviour :
Complications : edemas (also in intestinal loops, distended by vegetarian diet => the abdominal wall is soft, also due to muscle atrophy), dementia, cardiac arrest due to gastric pressure over heart
Prognosis : mortality = 5-20% (33% due to cardiac complications : prolongation of the QT interval and cases of sudden death)
Differential diagnosis :
• anorexia due to a general medical condition
• upper mesenteric artery syndrome
• major depressive disorder
• schizophrenia
• social phobia
• obsessive-compulsive disorder (OCD)
• body dysmorphic disorder
Therapy (relapses are frequent) :
• < 20 kg : immediate feeding with nasogastric probe
• beginning of symptoms : propose adequate diet
• 30 kg, affected by many years : fair approach making the patient understand therapy wants to preent or correct the complications of malnutrition, improve her beauty and avoiding uncomfortable feelings (e.g. cold)
Regimens :
• day hospital : study protocols, eat together with other patients, drink nutritional mixes together with an assistant, receive polysaline or glucosated infusions (lipid suspesions may cause fatty embolism and frighten the patients)
• hospital admission for severe complications, risk of suicide, weigth < 62% of ideal (ie. BMI < 12 kg/m2), nasogastric tube feeding, TPN with CVC; side effect : refeeding syndrome
• binge-eating disorder (BED) : an eating disorder characterized by repeated episodes of binge eating (> 2 days per week for > 6 months), as in bulimia nervosa, but not followed by inappropriate compensatory behavior such as purging, fasting, or excessive exercise
• eating disorder, not otherwise specified (NOS)
• anorexia nervosa with normal weight
• anorexia nervosa with menses
• anorexia nervosa with < 2 binge-eating episodes per week or for < 3 months
• small compensating food quantities
• chewing and throwing

Laboratory examinations :

• Structured Clinical Interview for Eating Disorders Spectrum, lifetime version (SCI-ABS/LT)
• Self-Report instrument for Eating Disorders Spectrum, lifetime version (ABS -SR/LT)
• Eating Attitudes Test (EAT)
• Eating Disorder Inventory (EDI)

sleep disorders : chronic disorders involving sleep

• primary sleep disorders

Aetiology : approximately 50% of the variation in sleeping disorder symptoms can be pinned on genetic factors. For disruptive snoring it is 42%, daytime sleepiness 45%, restless legs 54% and legs jerking 60%.
• dyssomnia : a category of disorders consisting of disturbances in the quality, amount, or timing of sleep, due to abnormalities in the mechanisms generating the sleep/wake state or of the timing of sleep and wakefulness; included are :
• insomnia : inability to sleep; abnormal wakefulness compromising daytime activities. The National Sleep Foundation has defined insomnia as any of the following: difficulty falling asleep, waking a lot during the night, waking too early with inability to get back to sleep or waking up feeling tired.
Epidemiology : prevalence of insomnia in 48% of USA according to NSF
Aetiology : nocturnal frontal epilepsy, narcolepsy, psychiatric disorders, neurological diseases, drugs, obesity, SNPs in T-type calcium channel
(genetically altered rodents showed a loss of delta waves and exhibited a higher incidence of brief awakening) which selects painful stimuli from each part of the body and relays them to the cortices of the brain
Duration :
• transient insomnia : a few days
• short-term insomnia : < 4 weeks
• chronic insomnia : > 4 weeks
Associated diseases : Laboratory examinations : Therapy :
• hypersomnia / hypersomnolence / excessive daytime sleepiness (EDS) : excessive sleeping or sleepiness, as in any of a group of sleep disorders with a variety of physical and psychogenic causes. The presence of EDS is more strongly associated with depression and metabolic factors (obesity
  /diabetes
  ) than with sleep-disordered breathing or sleep disruption per seref
• primary hypersomnia : a dyssomnia consisting of persistent excessive sleepiness and sleeping, with prolonged sleep episodes or regularly occurring voluntary or involuntary napping, and not due to any other psychological or physical condition.
• sleeptalking / somniloquism / somniloquy : talking during sleep.
• periodic hypersomnia
Laboratory examinations :
• multiple sleep latency test (MSLT) : measurement of the speed at which an individual falls asleep when given multiple opportunities to sleep throughout the day and instructed not to resist doing so; used as a measure of physiological sleepiness.
• maintenance of wakefulness test (MWT) : measurement of the length of time for which an individual can remain awake in a dark, quiet room; used as a measure of physiological sleepiness
Chemotherapy : psychostimulants
(modafinil activates orexins)
Web resources : Narcolepsy and Overwhelming Daytime Sleep Society of Australia (NODSS)
• circadian rhythm sleep disorder / sleep-wake schedule disorder : a sleep disorder of the dyssomnia group, consisting of a lack of synchrony between the schedule of sleeping and waking required by the external environment and that of a person's own circadian rhythm. It usually has an environmental cause such as rotating shift work or long-distance air travel, although some individuals simply have natural circadian rhythms sharply different from the predominant one of their society.
• delayed sleep phase syndrome (DSPS)

Aetiology : shorter PER3 gene (75%) or mutations in arylalkylamine N-acetyltransferase (AANAT)
Pathogenesis : natural cycle is thought to be much longer than 24 hours
Symptoms & signs : people sleep late into the day and feel alert only when burning the midnight oil
Therapy : melatonin
• familial advanced sleep phase syndrome

Aetiology : mutations in PER2 and CKId
Symptoms & signs : sleep for the same length of time as non-sufferers but typically are wide awake and raring to go long before everyone else is up and about
• clock jump type
• work type
• unspecified type
• dyssomnia-not otherwise specified (NOS)
• parasomnia : a category of sleep disorders in which abnormal physiological or behavioral events occur during sleep, due to inappropriately timed activation of physiological systems; it includes :
• arousal parasomnias
• confused awakening
• nightmare disorder / dream anxiety disorder : a sleep disorder of the parasomnia group, consisting of repeated episodes of nightmares that awaken the sleeper, who rapidly becomes fully oriented and alert and can vividly recall the dreams. Onset is usually in childhood or adolescence, and children often outgrow the disorder
• day residue : the thoughts, feelings, and ideas related to the events of the day that appear in or shape the contents of the dreams that night.
• sleep terror disorder : a sleep disorder of the parasomnia group, consisting of repeated episodes of pavor nocturnus (sleep terrors) lasting 30"-3'

Differential diagnosis : epilepsy
• sleepwalking disorder : a sleep disorder of the parasomnia group, consisting of repeated episodes of somnambulism
• sleepwalking (SW) / somnambulism / noctambulation / somnambulance : rising out of bed and walking about or performing other complex motor behavior during an apparent state of sleep, usually occurring in the first third of the night and lasting a few minutes to a half hour. The individual is relatively unresponsive, not alert, not easily awakened, and usually amnesic for the episode later

Aetiology : autoimmune somnambulism
• vigilambulism : an ambulatory automatism resembling somnambulism but occurring in the waking state
Differential diagnosis :
• epilepsy
• dissociative fugue
• parasomnias of the sleep-awakening transition
• REM sleep behavior disorder (RBD) : a sleep disorder of the parasomnia group characterized by abnormal EMG
  activity (absence of muscular atonia), altered dreams (> 90%), and violent behaviors out the dreams they are having during REM sleep (thrash, talk, sometimes pummel their bed partner, >70% leading to self-injury); 3.1% develop Parkinson's disease

Aetiology : autoimmune
?
Epidemiology : prevalence : 0.5%
• parasomnia-not otherwise specified (NOS)
• secondary sleep disorders
• general medical condition
• other mental disorder
• insomnia related to ...
• hypersomnia related to ...
• psychoactive substance
• other sleep disorders
• sleep disorder due to ...
• insomnia type
• hypersomnia type
• parasomnia type
• mixed type
• substance-induced sleep disorder
• shift-work sleep disorder

Symptoms & signs : chronic excessive sleepiness during night work and insomnia when attempting to sleep during the day
Therapy : 200 mg of modafinilref

During sleep, noise signals which are associated with danger (i.e. lorry noise) have the potential to trigger stress reactions even if the noise level is low and increases of cortisol in the first half of the night, which increases significantly with increasing traffic load, increases relative risks of asthma, chronic bronchitis and neurodermitisref
Adolescents and young adults are often excessively sleepy. This excessive sleepiness can have a profound negative effect on school performance, cognitive function, and mood and has been associated with other serious consequences such as increased incidence of automobile crashesref. Sleep research data indicate that adolescents and even young adults under 21 still require 9-10 hours' sleep a night. But since the 1980s, the average sack time for both college and high school students has diminished to 6-7 hours nightly. Youngsters who are aged 9-10 years tend to sleep, on average, for about 10 hours on school nights and usually not more (and many times a lot less!) on weekends. But teenagers typically begin to enjoy sleeping in on the weekends. This trend increases during the high school years. As teens also develop a yen for late-night activities, their sleep debt increases daily. Developmental changes in circadian rhythms, endocrine and neurobehavioral systems, not to mention busier schedules, earlier start times for school, and parental supervision, also contribute to the problem of a teenager's getting less sleep. Regardless of the causes, however, this scenario often proves far more serious than a mere yawn or a brief encounter in slumber land. Current high school start times contribute to sleep deprivation among adolescents. Consistent with a delay in circadian sleep phase, students performed better later in the day than in the early morning. However, exposure to bright light in the morning did not change the sleep/wake cycle or improve daytime performance during weekdays. Both short-term and long-term strategies that address the epidemic of sleep deprivation among adolescents will be necessary to improve health and maximize school performanceref.
In USA the percentage of people who typically sleep < 6 hours was : 12% in 1998; 13% in 2001; 15% in 2002; 16% in 2005. People who sleep > 10 hours per night have an average BMI = 26.4 kg/mBSA2, while people sleeping 2-4 hours per night have a BMI = 30.1 kg/mBSA2ref
Therapy : chronotherapy : treatment of certain sleep disorders by capitalizing on the natural phase delay in adults; the bedtime is successively advanced by one to several hours each day until the individual can retire, sleep, and arise at appropriate times.
 

impulse control disorders : a group of mental disorders characterized by repeated failure to resist an impulse to perform some act harmful to oneself or to others. The person feels tension or an irresistible urge to perform the act which, even though ego-dystonic, gives pleasure or emotional release upon performance.

• intermittent explosive disorder : an impulse control disorder characterized by multiple discrete episodes of loss of control of aggressive impulses resulting in serious assault or destruction of property that are out of proportion to any precipitating stressors; behavior in between such episodes lacks impulsiveness or aggressiveness
• isolated explosive disorder : a former classification used to denote a single violent catastrophic act performed for no apparent reason and not attributable to any other disorder.
• catathymic crisis : an isolated, nonrepetitive act of violence that develops as a result of intolerable tension.
• dyscontrol syndrome / episodic dyscontrol : a pattern of episodic, abnormal, and often violent and uncontrollable social behavior with little or no provocation; it may result from diseases of the limbic system or the temporal lobe or may accompany abuse of alcohol or some other psychoactive substance
Differential diagnosis :
• delirium
• dementia
• personality modification due to a general medical condition, aggressive type
• susbtance intoxication
• substance withdrawal
• oppositional defiant disorder
• conduct disorder
• antisocial personality (disorder)
• borderline personality (disorder)
• maniac episode
• schizophrenia
• deliberated behaviour
• malingering
• kleptomania / klopemania : an uncontrollable impulse to steal objects unnecessary for personal use or monetary value, the act being preceded by tension and followed by pleasure or relief, and not caused by anger, delusion, vengeance, or hallucination.

Differential diagnosis :
• common thefts in markets or elsewhere
• malingering
• conduct disorder
• antisocial personality (disorder)
• maniac episode
• schizophrenia
• dementia
• pyromania : an impulse control disorder characterized by the compulsion to set or watch fires in the absence of monetary or other gain, the act being preceded by tension or arousal and resulting in pleasure or relief.

Differential diagnosis :
• profit, sabotage, vendict; violation occultment; political revendication; attention or recognition
• developmental stage
• conduct disorder
• antisocial personality (disorder)
• maniac episode
• schizophrenia
• dementia
• mental retardation
• susbtance intoxication
• pathological gambling : an impulse control disorder consisting of persistent failure to resist the urge to gamble (betting money or other valuables on the outcome of a game or event.), to such an extent that personal, family, and vocational life are seriously disrupted.

Differential diagnosis :
• socially accepted gambling
• professional gambling
• maniac episode
• antisocial personality (disorder)
• Internet addiction disorder (IAD) : 2 groups are at greatest risk from Internet addiction disorder. The first are teenagers. But more surprisingly, the second are women and men in their mid-50s suffering from the loneliness of an "empty nest." The symptoms of Internet addiction in both groups are vague and are often difficult to diagnose. Sufferers may experience loss of sleep, anxiety when not online, isolation from family and peer groups, loss of work, and periods of deep depression.
• trichotillomania : hair pulling

Differential diagnosis :
• other causes of alopecia
• other mental disorder
• obsessive-compulsive disorder (OCD)
• stereotypic movement disorder
• factitious disorder with main physical signs and symptoms
• impulse control disorder-not otherwise specified (NOS)
• potomania / dipsomania / alcoholism : an intense persistent desire to drink alcoholic beverages to excess

adjustment disorder : a maladaptive reaction to identifiable stressful life events, such as divorce, loss of job, physical illness, or natural disaster; this diagnosis assumes that the condition will remit when the stress ceases or when the patient adapts to the situation

• adjustment disorderwith depressed mood
• adjustment disorder with anxiety
• adjustment disorder with mixed depressed mood and anxiety
• adjustment disorder with behaviour alteration
• adjustment disorder with mixed behaviour and emotional alteratio
• unspecified adjustment disorder
• acute unspecified adjustment disorder
• chronic unspecified adjustment disorder

Differential diagnosis :

• acute stress disorder
• traumatic neurosis / post-traumatic stress disorder
• psychological factors influencing a medical condition
• mourning
• nonpathological reactions to stress

personality disorders : a category of mental disorders characterized by enduring, inflexible, and maladaptive personality traits that deviate markedly from cultural expectations, are self-perpetuating, pervade a broad range of situations, and either generate subjective distress or result in significant impairments in social, occupational, or other functioning. Onset is by adolescence or early adulthood.

• group A personality disorders : odd cluster
• paranoid personality (disorder) : a personality disorder marked by a view of other people as hostile, devious, and untrustworthy and a combative response to disappointments or to events experienced as rebuffs or humiliations. Notable are a questioning of the loyalty of friends, the bearing of grudges, a tendency to read threatening meanings into benign remarks, and unfounded suspicions of the fidelity of a partner. Unlike delusional disorder or paranoid schizophrenia, in which delusional or hallucinatory persecution occurs, it is not characterized by psychosis.
• schizoid personality (disorder) / seclusive personality / shut-in personality : a personality disorder marked by detachment from social relationships and a restricted range of emotional experience and expression. Qualifying characteristics include lack of capacity for, or interest in, social relationships or family life, coldness, aloofness, consistent preference for solitary activities, lack of pleasure in activities, flattened affectivity, and indifference to praise, criticism, or the feelings of others.
• schizotypal personality (disorder) : a personality disorder characterized by marked deficits in social and interpersonal competence and eccentricities in ideation, appearance, and behavior; ideas of reference are common, as are odd beliefs or magical thinking, cognitive or perceptual distortions, little capability or desire for close relationships, excessive social anxiety, suspiciousness, and occasional paranoid ideation. It differs from schizophrenia, to which it is related, in having only transient psychotic episodes, if any.
• group B personality disorder : dramatic cluster
• antisocial personality (disorder) / sociopathy : a personality disorder characterized by continuous and chronic antisocial behavior in which the rights of others or generally accepted social norms are violated; associated personality traits include impulsiveness, egocentricity, inability to tolerate boredom or frustration, irritability and aggressiveness, recklessness, disregard for truth, and inability to maintain consistent, responsible functioning at work, at school, or as a parent. The concept of a personality disorder that predisposes an individual toward criminality has a long history. Among the terms that have been applied to this disorder are moral insanity, psychopathic personality, and sociopathic personality.
• borderline personality (disorder) : a personality disorder marked by a pervasive instability of mood, self-image or sense of self, and interpersonal relationships; impulsive and self-damaging acts are common, as are uncontrolled anger, fears of abandonment, chronic feelings of emptiness, recurrent self-mutilating behavior and suicide threats, and transient, stress-induced periods of paranoia and dissociation. 20% have bulimia or bipolar disorder.
• histrionic personality (disorder) / hysterical personality : a personality disorder marked by excessive emotionality and attention-seeking behavior; there is overconcern with physical attractiveness, sexual seductiveness, intolerance of delayed gratification, and rapid shifting and shallow expression of emotions.
• depressive personality (disorder) : a personality disorder characterized by a persistent and pervasive pattern of depressive cognitions and behaviors, such as chronic unhappiness, low self-esteem, pessimism, critical and derogatory attitudes toward oneself and others, feelings of guilt or remorse, and an inability to relax or feel enjoyment.
• narcissistic personality (disorder) : a personality disorder characterized by grandiosity (in fantasy or behavior), a lack of social empathy combined with a hypersensitivity to the judgment of others, interpersonal exploitiveness, enviousness, arrogance, a sense of entitlement, and a need for constant signs of admiratio (narcissism / ipserotism)
• group C personality disorders : anxious cluster
• avoidant personality (disorder) : a personality disorder characterized by social discomfort, hypersensitivity to criticism, low self-esteem, and an aversion to activities that involve significant interpersonal contact; there is a proclivity to anxiety, an exaggeration of difficulties, a desire for affection and acceptance that is restrained for fear of rejection, and an avoidance of risks or new activities for fear of embarrassment.
• dependent personality (disorder) : a personality disorder marked by an excessive need to be taken care of, with submissiveness and clinging and preoccupation with fears of being abandoned; features include need for advice and reassurance in decision making, yielding of responsibility, initiative, and independence, avoidance of disagreement for fear of loss of support, voluntarily undertaking unpleasant tasks to ensure further care, and discomfort or helpless feelings when alone, with an indiscriminate rush to a new relationship.
• obsessive-compulsive personality (disorder) / anancastic, obsessive or compulsive personality : a personality disorder characterized by an emotionally constricted manner that is unduly conventional, serious, rigid, stubborn, and stingy, by preoccupation with trivial details, rules, order, organization, schedules, and lists to the extent that the major point of an activity is lost or task completion is delayed, by reluctance to delegate tasks or work cooperatively unless everything is done one's own way, and by excessive devotion to work and productivity to the detriment of interpersonal relationships. This is not the same as obsessive-compulsive disorder, which is an anxiety disorder.
• passive-aggressive personality (disorder) / negativistic personality (disorder) : a personality disorder characterized by an indirect resistance to demands for adequate social and occupational performance, such as by obstructionism, procrastination, or forgetfulness, and by negative, defeatist attitudes.
• sadistic personality (disorder) : a pervasive pattern of cruel, demeaning, and aggressive behavior; satisfaction is gained in intimidating, coercing, humiliating, and inflicting pain and suffering on others.
• self-defeating personality (disorder) : a persistent pattern of behavior detrimental to the self, including being drawn to problematic situations or relationships, failing to accomplish tasks crucial to life objectives, excessive self-sacrifice, inviting criticism and anger, undermining of pleasurable experiences, and inability to enjoy the rewards of success.
• split personality : an obsolete term formerly used colloquially for either schizophrenia or dissociative identity disorder.
• as-if personality : one resembling normalcy but lacking real, enduring emotion, the person adopting and appearing to express ordinary characteristics but then able to summarily discard them and adopt others as situations change.
• cyclothymic personality : a temperament characterized by rapid, frequent swings between sad and cheerful moods
• personality disorder-not otherwise specified (NOS)

other factors that influence a medical condition

additive codes

• unspecified (nonpsychotic) mental disorder
• no diagnosis or condition on axis I
• diagnosis or differed condition on axis I
• no diagnosis on axis II
• differed diagnosis on axis II

reaction : the mental and/or emotional state elicited in response to any particular situation.

• acute situational or stress reaction / transient situational disturbance : a transient, self-limiting acute emotional reaction to severe psychological stress; it is variably defined as comprising one or more of the following DSM-IV categories: adjustment disorder, brief reactive psychosis, acute stress disorder, and posttraumatic stress disorder
• alarm reaction / fight-or-flight reaction : the physiologic effects in response to acute stress, fright, or rage (increased blood pressure and cardiac output, increased blood flow to skeletal muscles, decreased flow to the viscera, increased rate of glycolysis and blood glucose concentration), mediated by sympathetic nervous system discharge and release of adrenal medullary hormones
• anniversary reaction : abnormal behavior, symptoms, illness, or dreams occurring on the anniversary of a disturbing event.
• anxiety reaction : a reaction characterized by abnormal apprehension or uneasiness
• associative reaction : a reaction in which the response is withheld until the idea presented has suggested an associated idea.
• depressive reaction : depression; the term is sometimes used to denote specific types of depression, such as reactive depression, or any of various mood disorders in which depression plays the predominant role
• psychotic depressive reaction : psychosis characterized by depressed mood resulting from a specific event, usually in a patient without prior history of severe depression; the condition has been incorporated into major depressive disorder
• stress reaction : any of the biological reactions to adverse stimuli, physical, mental, or emotional, internal or external, that tend to disturb the organism's homeostasis; should these compensating reactions, physiological or psychological, be inadequate or inappropriate, they may lead to disorders.

nyctophilia : a preference for darkness or for night.

Erickson's 8 psychosexual stages of man

• oral-sensory (birth to 18 mo.) : trust/mistrust crisis
• anal-muscular (18 mo. to 3 years) : autonomy/shame, self-doubt crisis
• genital-locomotor control (3 to 5 years) : initiative/guilt crisis
• latency (5 to 13 years) : industry, competence/inferiority, failure crisis
• puberty (13 to 21 years) : identity/role confusion crisis
• genitality (young adulthood, 21 to 40 years) : intimacy/isolation crisis
• productivity (adulthood. 40 to 60 years) : generativity/self-absorption, stagnation crisis
• maturity (60 years to death) : integrity, self-worth/despair crisis
• oral stage : in psychoanalytic theory, the earliest stage of psychosexual development, lasting from birth to about 18 months, during which the oral zone is the center of the infant's needs, expression, and pleasurable erotic experiences
• anal stage : in psychoanalytic theory, the second stage of psychosexual development, occurring between the ages of 1 and 3 years, during which the infant's activities, interests, and concerns are on the anal zone
• phallic stage : in psychoanalytic theory, the third stage in psychosexual development, lasting from age 2 or 3 years to 5 or 6 years, during which sexual interest, curiosity, and pleasurable experiences are centered on the penis in boys and the clitoris in girls
• latency stage : in psychoanalytic theory, the period of relative quiescence in psychosexual development, lasting from age 5 or 6 years to adolescence, during which interest in persons of the opposite sex ceases and the child tends to associate mainly with persons of his own sex
• genital stage : in psychoanalytic theory, the last stage in psychosexual development, occurring during puberty, during which the person can achieve sexual gratification from genital-to-genital contact and is capable of a mature relationship with a person of the opposite sex

complex : a group of interrelated ideas, mainly unconscious, that have a common emotional tone and strongly influence a person's attitudes and behavior

• Oedipus complex : in psychoanalytic theory, the feelings and conflicts occurring in a child during the phallic phase of psychosexual development that result from sexual attraction to the opposite-sex parent, including envious, aggressive feelings toward the same-sex parent.
• Electra complex : the counterpart in females of the Oedipus complex, which was originally applied only to males, involving the daughter's love for her father and jealousy or resentment toward her mother; the term is now rarely used since Oedipus comlplex has come to be applied to both sexes.
• inferiority complex : unconscious feelings of inadequacy, producing timidity or, as a compensation, exaggerated aggressiveness and expression of superiority; based on Alfred Adler's concept that everyone is born with a feeling of inferiority stemming from real or imagined physical or psychological deficiency, with the manner in which the inferiority is handled determining behavior

conflict : in psychiatry, a psychic struggle, often unconscious, arising from the clash of incompatible or opposing impulses, wishes, drives, or external demands.

• approach-approach conflict : conflict resulting from 2 available goals which are desirable but incompatible.
• approach-avoidance conflict : conflict resulting from a single goal having both desirable and undesirable consequences or qualities.
• avoidance-avoidance conflict : conflict resulting from the desire to avoid 2 equally distasteful alternatives.
• extrapsychic conflict : conflict between a person's wishes or needs and the expectations or desires of others.
• intrapersonal or intrapsychic conflict : conflict between incompatible and often unconscious wishes, impulses, needs, thoughts, or demands within one's own mind

euphoria : an exaggerated feeling of physical and mental well-being, especially when not justified by external reality. Euphoria may be induced by drugs such as opioids, amphetamines, and alcohol and is also a feature of mania

homicide : the taking of the life of one person by another

• patricide : homicide of father
• matricide : homcide of mother
• fratricide : homicide of brother/sister
• uxoricide : homicide of wife
• genocide : homicide of a whole race

suicide : the taking of one's own life. Only a small minority has a rational base.

• psychic suicide : the termination of one's own life without employment of physical agents.

Epidemiology :

	suicide	failed suicide
age	mature/advanced	< 35
female-to-male ratio	3:1	1:3
suicide way	violent	drugs (> 80%)
diagnosis	major depression  alcohol  schizophrenia  somatic disease psychogenous reaction	personality disorder  depressive reaction psychogenous reaction  alcoholism
stressors	no	yes
premeditation	yes	no
aid possibility	accidental	yes
aid request	no	yes
aim	self-repression	manipulatory

Suicide rates for the elderly > 65 years continue to be the highest for any age group

• average prevalence of lifetime occurrence of suicide idea : 10%
• average lifetime failed suicide attempt (quasi-completed suicides) prevalence : 3 every 1,000. Those firing at foreface survive with "angel face".
• average lifetime suicide prevalence : 10 every 100,000
• suicide rates among doctors are higher than those in the general population. The gap in suicide rates evidently begins as early as medical school, where overall suicide rates are higher than in the age-matched populationref
• suicide rates in different countries :
• high rates (> 25 every 10,000) : Austria, Czech Republic, Hungary, Germany, Japan (< 15,000 in the late 1960s, but it increased to > 20,000 (which is as twice as the number of death by traffic accidents) in 1970s, which has not been reduced up to the present and the highest number 256,000 was recorded in 1986), Sweden, Denmark, Finland
• suicide is the fifth leading cause of death in China, where < 287,000 people were victims of suicide annually between 1995 and 1999. In most countries suicides are most common among males, but in China, suicides and suicide attempts were most common among young Chinese women between the ages of 15 and 30
• intermediate rates (10-25 every 100,000) : France, Yugoslavia
• USA suicide rate among all age groups also has dropped in recent years, although it rose from 10.44 deaths per 100,000 in 2000 to 10.69 per 100,000 in 2001. The suicide rate for those ages 10 to 19 fell from 6.2 deaths per 100,000 people in 1992 to 4.6 per 100,000 in 2001. The number of suicides also fell in that period, from 2,151 to 1,883. The decrease in gun suicides was most dramatic among children 10 to 14, dropping from 172 in 1992 to 90 in 2001. Among those 15 to 19, deaths from self-inflicted shootings dropped from 1,251 to 838 during the same period. New safety measures for keeping guns out of children's hands and greater acceptance of gays may have played important roles (sexual orientation has been a factor in many suicides among young males). Trigger locks, lock boxes and other measures for keeping guns out of youngsters' hands have become more common in recent years, but CDC officials said they did not know whether that accounts for the decrease in suicides. The number of suicides by hanging or other forms of suffocation, meanwhile, rose among young people from 1992 to 2001. Such methods of suicides -- including use of belts, ropes or plastic bags -- rose from 96 to 163 in that period among youngsters 10 to 14. Among teens ages 15 to 19, suicides by suffocation rose from 333 deaths to 551. CDC researchers said they were surprised by the switch in suicide methods and said they first noticed the trend in the early 1990s. By the end of the decade, suffocations had surpassed self-inflected shootings. Suicide remains the third leading cause of death among young people in this country. Other youth-related findings included these:
• 1 in 20 high school students reported both suicide attempts and involvement in physical fights in the past year. Students who reported attempting suicide in the past 12 months were nearly 4 times as likely to report involvement in physical fights.
• of the lethal acts of school violence carried out by students between July 1, 1994, and June 30, 1999, > 20% were suicides. 25% suicide victims injured or killed someone else before their suicide.
• hispanic males were almost six times as likely to die by suicide as Hispanic females, representing 85% of the 8,744 Hispanic suicides between 1997 and 2001. Hispanic youth are the fastest growing segment of the U.S. population and account for 25% of all Hispanic suicide deaths
• low rates (> 10 every 100,000) : Italy, Spain, Israel

Aetiology :

• psychiatric disorders (30-50% of all suicides in the younger and prime generations)
• mood disorders (48%)
• depression (19% of all depressed patients, mainly after age 50; RR = 30)
• psychoses (mainly before age 50)
• schizophrenia (11%)
• substance abuse
• ethanol (20%)
• other psychiatric disorders (15%)
• panic disorder
• no psychiatric disorders (6%)
• pain of sickness (60-70% in the aged group)
• mefloquine
  ?

Most frequently used method for committing suicide :

• hanging
• inhalation of car exhaust
• drowning oneself
• taking poisons : Tanax or T-61, a euthanasia solution commonly used in veterinary medicine, has been often involved in suicide attempts (humans) and malicious intoxications (animals). For forensic reasons, the identification of one or more of the 3 components (embutramide, mebenzonium iodide, and tetracaine hydrochloride) of Tanax is needed to confirm the hypothesis of intoxication.ref
• firearms
• self-stabbing (craft knives, swords and recreational knives, fragments of glass, carpenter's tools and surgical knives were used almost exclusively by men, while more than 80% of women used kitchen knives or razors). The majority of fatally wounded body sites are in the neck, chest, abdomen, wrists and forearms

Prevention :

• betterment of home life
• mental independence
• death education
• forced intervention by psychiatrists
• hot line : telephone assistance for those in need of crisis intervention (q.v.), as in suicide prevention, usually available 24 hours a day, seven days a week, and staffed by nonprofessionals with mental health professionals serving as advisors or in a back-up capacity
• since even one previous attempt multiplies suicide risk by 38-40 times and suicide is the fourth leading cause of death for adults under 65, a proven way to prevent repeat attempts has important public health implications. Recent suicide attempters treated with cognitive therapy were 50% less likely to try to kill themselves again within 18 months than those who did not receive the therapyref

oedipism [from Oedipus, King of Thebes, who blinded himself after unknowingly killing his father and marrying his mother] : intentional injury of one's own eyes

borderline state :a diagnostic term used when it is difficult to determine which of two states are indicated by the presenting symptoms, generally for a state that has some characteristics of psychosis but in which the patient has some contact with reality.

Epstein's symptom : a symptom seen in nervous infants, consisting of failure of the upper lid to move downward, giving the child a frightened expression

chronotaraxis : disorientation for time; observed as a transient symptom following thalamic or frontal lobe lesions.

formal thought disorder : disturbance in the form, rather than the content, of thought; disruption in the flow of ideas or speech; inability to follow the normal semantic or syntactic rules in someone with adequate intelligence and education and the cultural background to do so.

asceticism : a way of life or character trait described by the elimination of pleasurable effects associated with experiences and characterized by renunciation, self-denial, withdrawal from society, and sometimes dedication to an unattainable ideal or to eradication of some specific evil.

psychataxia : a disordered mental condition marked by confusion and inability to concentrate

psycholepsy : a sudden, intense lowering of mood level, usually of short duration, in individuals with unstable psychic tension

hallucination : abnormal sensation

• auditory hallucination (AH) can arise not only in psychotic disorders, but also in neurological conditions affecting the parts of the brain used to process and monitor speechref1, ref2, which are thought to include frontal motor areas, the primary auditory cortex, and Wernicke's arearef. Brain injury can cause epilepsy; moreover, some psychotropic medications can increase neuronal excitability, and lower the threshold for seizuresref
• hallucinosis : a state characterized by the presence of hallucinations without other impairment of consciousness
• pseudohallucination : 1. an image perceived to be occurring externally but which the subject knows to be generated within the mind.  2. a hallucination which is perceived as unre

illusion : a false or misinterpreted sensory impression; a false interpretation of a real sensory image

delusion : a false belief that is firmly maintained in spite of incontrovertible and obvious proof or evidence to the contrary and in spite of the fact that other members of the culture do not share the belief.

• bizarre delusion : a delusion that is patently absurd and has no possible basis in fact, such as delusions of being controlled or thought broadcasting.
• delusion of control / delusion of being controlled : the delusion that one's thoughts, feelings, and actions are not one's own but are being imposed by someone else or by some external force.
• depressive delusion : a delusion that is congruent with a predominant depressed mood, such as a delusion that one is being persecuted because of one's sinfulness or inadequacy, somatic delusions of serious illness, nihilistic delusions, or delusions of poverty.
• delusion of negation / nihilistic delusion : a depressive delusion that the self or part of the self, part of the body, other persons, or the whole world has ceased to exist.
• encapsulated delusion : a delusion that has no significant effect on behavior.
• erotomanic delusion : a delusional conviction that some other person, usually of higher status and often famous, is in love with the individual; it is one of the subtypes of delusional disorder.
• fragmentary delusions : unconnected delusions not organized around a coherent theme.
• paranoid delusions : an older term (its use is discouraged) denoting ...
• delusion of grandeur / grandiose or expansive delusion : a delusion involving an exaggerated concept of one's importance, power, or knowledge or that one is, or has a special relationship with, a deity or a famous person; it is one of the subtypes of delusional disorder. Seen in megalomania
• delusion of persecution / persecutory delusion : a delusion that one is being attacked, harassed, cheated, persecuted, or conspired against; it is one of the subtypes of delusional disorder.
• delusion of jealousy : a delusional belief that one's spouse or lover is unfaithful, based on erroneous inferences drawn from innocent events imagined to be evidence and often resulting in confrontation with the accused. It is one of the subtypes of delusional disorder.
• mixed delusion : one in which no central theme predominates; one of the subtypes of delusional disorder.
• mood-congruent delusion : a delusion occurring as a manifestation of a mood disorder; see also mood-congruent.
• mood-incongruent delusion : a delusion occurring as a manifestation of a psychotic disorder; see also mood-incongruent.
• delusion of poverty : delusion that one is, or soon will be, bereft of material possessions.
• delusion of reference :  a delusional conviction that ordinary events, objects, or behaviors of others have an unusual or peculiar meaning specifically for oneself. When less frequent or intense, or if not organized or systematized, such beliefs are called ideas of reference.
• somatic delusion : a delusion that there is some alteration in a bodily organ or its function; it is one of the subtypes of delusional disorder.
• systematized delusions : a group of delusions organized around a common theme.
• thought broadcasting : the delusion that one's thoughts are being broadcast to the environment.
• thought insertion : the delusion that thoughts that are not one's own are being inserted into one's mind.
• thought withdrawal : the delusion that someone or something is removing thoughts from one's mind.
• eviration : a delusional belief of a man that he has become a woman.
• delusional parasitosis / Eckbom syndrome / Morgellons disease : a false belief of infection or infestation with parasites

Epidemiology : aas of February 2006, more than 2,000 reports of the disease have been reported on the Foundation's website. Reports come from all 50 U.S. states and 15 nations, including Canada, the UK, Australia and The Netherlands. The majority of reports have come from Texas, California and Florida. Interest in the disease was recently rekindled after afflicted Texas teenager Travis Wilson committed suicide in April 2006ref.
Symptoms & signs : feelings of insects or parasites scuttling beneath their skin and open lesions that heal slowly and which ooze out blue and white fibers, some as thick as spaghetti strands. Attempts to remove the fibers are said to elicit shooting pains radiating from the site. The lesions range from minor to disfiguring in appearance and fibers appear either as single strands or as bundles. Patients also sometimes report the presence of fibers or black granular specks on their skin even in the absence of lesions. Some patients even report symptoms of the disease in their pets�dogs mostly, but also cats and horses. About 95% of patients also report suffering from disabling fatigue, or "brain fog," that hinders their ability to pay attention. Other reported symptoms include joint pain, sleep disorders, hair loss, decline in vision, and even the "disintegration" of perfectly healthy teeth. It appears that once patients contract the disease, they have it for life. To date, there have been no reports of spontaneous remissions. A preliminary analysis of the fibers suggests they are more than just lint from household materials such as clothing, carpets or bedding. The fibers are not common textiles, nor are they black specks of pepper, as several dermatologists have proposed. Further deepening the mystery, some analyses suggest the fibers might be made of cellulose, a molecule generally found in plants. They're basically fibers that you wouldn't expect to see in humans. The disease is named after a medical condition described in 1674 by the British author Thomas Browne. Known as "Morgellons," the disorder caused children to "critically break out with harsh hairs on their backs�" It is doubtful that the 17th century disease is related in any way to modern day Morgellons. The "matchbox sign" of delusional parasitosis, when patients bring in hair, skin or clothing lint, sometimes in matchboxes, that they claim contain the insects or parasites responsible for their torment. However, when examined, the samples reveal no such thing. The lesions and scratches sometimes seen on patients with delusional parasitosis are usually self-inflicted.
Laboratory examinations : skin biopsies to rule out infections
Therapy : anti-psychotic or anti-anxiety medicines
Web resources : Morgellons Research Foundation, a non-profit organization devoted to raising public awareness about the disease.

misidentification : failure to identify correctly persons or objects known to the subject, caused by confusion or memory loss.

• delusional misidentification : that due to the mistaken belief that a person or object has been transformed physically or mentally
• Capgras' syndrome : a form of delusional misidentification in which the patient believes that other persons in the environment are not their real selves but doubles
• Frégoli's phenomenon : a form of delusional misidentification in which the subject believes that a stranger, particularly a persecutor, is disguised as various people familiar to the subject

culture-specific syndrome : a form of disturbed behavior highly specific to certain cultural systems and that does not conform to Western nosologic entities; examples are amok, koro, piblokto, falling-out, and windigo.

windigo / witigo [Ojibwa a cannibalistic monster of the mythology of Eskimos and certain Native Americans] : a culture-specific syndrome characterized by delusions of being possessed by the windigo, with fears of becoming cannibalistic and agitated depression

Kleine-Levin syndrome : episodic periods of excessive sleep and overeating lasting for several weeks, with amnesia for the attacks; it usually occurs in adolescent boys.

maternal deprivation syndrome : failure to thrive with severe growth retardation, unresponsiveness to the environment, depression, retarded mental and emotional development, and behavioral problems resulting from loss, absence, or neglect of the mother or other primary caregiver.

organic personality syndrome : a term used in a former system of classification, denoting an organic mental syndrome characterized by a marked change in behavior or personality, caused by a specific organic factor and not associated with delirium or dementia. The most common causes are space-occupying lesions of the brain, head trauma, and cerebrovascular disease.

social breakdown syndrome : deterioration of social and interpersonal skills, work habits, and behavior seen in chronically hospitalized psychiatric patients; due to the effects of long-term institutionalization rather than the primary illness. Symptoms include excessive passivity, assumption of the chronic sick role, withdrawal, and apathy. Such effects are also seen in long-term inmates of prisons or concentration camps.

acathexis : a lack of the emotional charge (cathexis) with which an object or idea would normally be invested; detachment of feelings from thoughts and ideas.

taboo [Tongan tabu forbidden, set apart] : any of the negative traditions, objects, or behaviors that are generally regarded as harmful to social welfare and are therefore prohibited

mores : the traditions and habits which are generally regarded as conducive to social welfare.

psychic determinism : the concept, originated by Freud, that mental events do not occur by chance but have their antecedent mental causes, that even accidents, slips of the tongue, or whims commonly felt to be inexplicable result from unconscious mental processes.

stigma : a distinguishing personal trait that is perceived as or actually is physically, socially, or psychologically disadvantageous

psychic overtone : the consciousness of a fringe or halo of associated relations that surrounds every image presented to the mind

organic drivenness : hyperactivity seen in brain-damaged individuals as a result of injury to and disorganization of cerebellar structures.

 

Laboratory examinations :

• Diagnostic Interview Schedule-IV (DIS-IV)
• Objective Structured Clinical Examination (OSCE)
• Self-Report instrument for General Spectrum Measures, lifetime version (GSM V -SR/LT)
• Semi-structured Clinical Interview for Children and Adolescents (SCICA)
• Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)
• Structured Clinical Interview for DSM-IV Axis I Disorders-clinician version (SCID-CV)
• Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)
• Brazelton behavioral scale : a method for assessing infant behavior by its responses to environmental stimuli.
• Brief Psychiatric Rating Scale (BPRS) : a rating scale for assessing psychopathology on the basis of a small number, usually 16 to 24, items encompassing psychosis, depression, and anxiety symptoms.
• Columbia Mental Maturity Scale : a test of specific kinds of mental function and general abilities, suitable for children (ages 3 to 12) with no speech or with limited physical capabilities, such as those with cerebral palsy
• psychomotor test . a test that assesses the subject's ability to perceive instructions and perform motor responses, often including measurement of the speed of the reaction.
• psychological test : any test to measure a subject's development, achievement, personality, intelligence, thought processes, etc
• Denver Developmental Screening test: a test for identification of infants and preschool children with developmental delay
• reality testing: objective evaluation of the external world and differentiation between it and the ego or self. Impaired reality testing is seen in psychological defense mechanisms that falsify reality, such as projection and denial, and it is a major criterion for psychosis
• Bender Visual-Motor Gestalt test : a psychological test used for evaluating perceptual-motor coordination, for assessing personality dynamics, as a test of organic brain impairment, and for measuring neurological maturation. The subject is asked to make free-hand copies of 9 simple geometric designs presented separately on cards or sometimes to reproduce the design from memory.
• association test : a test based on associative reaction. It is usually performed by mentioning words to a subject and noting what other words he will give as the ones called up in his mind. The reaction time is also noted
• projective test: any of various tests in which an individual interprets ambiguous stimulus situations, e.g., a series of inkblots (Rorschach t.), according to his own unconscious dispositions, thus yielding information about his personality structure, its underlying dynamics, and possible psychopathology.
• Thematic Apperception Test (TAT) : a projective test in which the subject tells a story based on each of a series of standard ambiguous pictures, so that his responses reflect a projection of some aspect of his personality and current psychological preoccupations and conflicts.

Therapy : psychotherapy
Glossary :

• abulia / aboulia : lack of will or willpower; inability to make decisions
• parabulia : perversion of the will, as when an individual intends to perform a particular action but halts and substitutes either an opposite action or an unrelated alternative; usually seen in schizophrenics.
• alogia :
• paralogia : disturbance of the reasoning faculty; marked by delusional or illogical speech.
• thematic paralogia : that limited to one subject, on which the mind dwells insistently
• evasion : in psychiatry, suppression of an idea that would come next in a thought sequence and substitution of a closely related idea; a form of paralogia.
• paralogism : the use of fallacious, meaningless, or illogical thought or language, primarily characteristic of schizophrenia
• pseudologia fantastica : a tendency to tell extravagant and fantastic falsehoods centered about the storyteller, who often comes to believe in and may act on them.
• echolalia / echophrasia : stereotyped repetition of another person's words or phrases, seen in catatonic schizophrenia, Gilles de la Tourette's syndrome
  , and neurological disorders such as transcortical aphasia
• echopraxia : stereotyped imitation of the movements of another person; seen sometimes in catatonic schizophrenia and Gilles de la Tourette's syndrome
• disorientation
• distraibility
• flash-back
• grandiosity : the condition of being grandiose; an exaggerated belief of one's importance or identity.
• idea : an impression, thought, or conception resulting from mental activity.
• autochthonous idea : a persistent idea originating within the mind, usually from the unconscious, but seeming to have come from an outside source and often therefore felt to be of malevolent origin.
• dominant idea : one that controls or colors every action and thought.
• fixed idea / idée fixe : a morbid impression or belief which stays in the mind and cannot be changed by reason
• overvalued idea : a false or exaggerated belief sustained beyond reason or logic but with less rigidity than a delusion, also often being less patently unbelievable.
• idea of reference / referential idea : the assumption by a patient that the words and actions of others refer to himself or the projection of the causes of his own imaginary difficulties upon someone else; if frequent or intense, or if organized and systematized, called delusion of reference.
• ego ideal : the component of the superego comprising the internalized image of what one desires to become and toward the attainment of which the ego strives, formed through conscious or unconscious identification with or emulation of one who plays a significant role or has a place of esteem in the life of the developing child.
• idealization : a conscious or unconscious mental mechanism in which the individual overestimates an admired aspect or attribute of another person.
• ideation : the formation of a mental concept, image, or thought.
• paranoid ideation : the persistent idea, not of delusional intensity, that one is being persecuted, harassed, or otherwise unfairly treated.
• identification : a largely unconscious process by which a person patterns himself after one or more other people, associating closely with them and assuming their viewpoints; sometimes used as a defense mechanism.
• cosmic identification : identification of one's self with the universe, as in schizophrenic delusions of omnipotence.
• projective identification : an unconscious defense mechanism in which unacceptable aspects of the self are falsely attributed to others; it differs from projection in that the target is transformed, unconsciously identifying and responding, and the aspects that are projected are not completely disavowed but rather are perceived as justifiable reactions to the other person's induced responses.
• identity : the aggregate of characteristics by which an individual is recognized by himself and others.
• ego identity : a sense of unity and continuity of oneself.
• core gender identity : a person's concept of himself as being male and masculine or female and feminine, or ambivalent, usually based on physical characteristics, parental attitudes and expectations, and psychological and social pressures. It is the private experience of gender role
• gender role : the public expression of gender; the image projected by a person that identifies their maleness or femaleness, which need not correspond to their gender identity
• identity crisis : a period in the psychosocial development of an individual, generally occurring during adolescence, usually manifested by a loss of the sense of the sameness and historical continuity of one's self, confusion over values, or an inability to accept the role the individual perceives as being expected of him by society.
• suggestion : 1. the act of offering an idea for action or for consideration of action.  2. an idea so offered.  3. in psychiatry, the process of causing uncritical acceptance of an idea.
• hypnotic suggestion : a suggestion imparted to a person in the hypnotic state, by which he is induced to alter perceptions or memory or to perform actions.
• posthypnotic suggestion : implantation in the mind of a subject during hypnosis of a suggestion to be acted upon after recovery from the hypnotic state.
• heterosuggestion : suggestion received from another person
• autosuggestion : self-suggestion; the process by which a person induces in himself an uncritical acceptance of an idea, belief, or opinion, such as by self-hypnosis
• paranormal : beyond the normal or natural
• extrasensory perception (ESP) / parapsychology : the study of psychical effects and experiences which appear to fall outside the scope of physical law, e.g. :
• telepathy : extrasensory perception of the mental activity of another person
• clairvoyance : a form of extrasensory perception in which knowledge of objective events is acquired without the use of the senses
• telekinesis : the power claimed by certain persons of moving objects without contact with the object moved; also motion produced without contact with a moving body
• telemnemonike : the gaining of consciousness of things in the memory of another person
• studies showing that transcranial magnetic stimulation (TMS)
  induces mystical/spiritual experiences are being queried by researchers who cannot reproduce key results. If the traditional theory is wrong, scientists will be left struggling to explain how such thoughts and sensations are generated. In the past, scientists have claimed that religious or out-of-body experiences result from excessive bursts of electrical activity in the brain. In the 1980s, Michael Persinger, a neuroscientist at the Laurentian University in Ontario, Canada, began exploring this idea through a series of experiments. Participants wore helmets that targeted their temporal lobes with weak magnetic fields, of roughly the same strength as those generated by a computer monitor. This caused 80% of the people he tested to feel an unexplained presence in the room. Magnetism causes bursts of electrical activity in the temporal lobes of the brain, and he linked this to the spiritual experiences. A group of Swedish researchers has now repeated the work, but they say their study involves one crucial difference. They ensured that neither the participants nor the experimenters interacting with them had any idea who was being exposed to the magnetic fields, a 'double-blind' protocol. Without such a safeguard, "people in the experimental group who are highly suggestible would pick up on cues from the experimenter and they would be more likely to have these types of experiences. Beyond the double-blind aspect, the nuts and bolts of the experiment mirrored those conducted in the past. He and his colleagues tested 43 undergraduate students by exposing them to magnetic fields that ranged from 3 to 7 mT and were aimed just above and in front of the ears, to target the temporal lobes. They also tested a control group of 46 volunteers who wore the helmet but were not exposed to the magnetic field. The volunteers were then asked to complete questionnaires about what they experienced during each session. In contrast to the results from Persinger and others, the team found that the magnetism had no discernable effects. 2 out of the 3 participants in the Swedish study that reported strong spiritual experiences during the study belonged to the control group, as did 11 out of the 22 who reported subtle experiences. This seems to be quite a high level of spiritual experiences overall, but it matches the level that Persinger saw in his control groups. The researchers say they do not know what neurological mechanism could be generating the experiences. However, using personality tests they did find that people with an orientation toward unorthodox spirituality were more likely to feel a supernatural presence, as were those who were, in general, more suggestible. Persinger, however, argues that the Swedish group did not expose the subjects to magnetic fields for long enough to produce an effect and stresses that some of his studies were double blindedref
• hyphedonia : pathologic diminution of the feeling of pleasure in acts that normally give pleasure.
• animism : 1. the obsolete doctrine that the soul is the source of all organic development.  2. the belief that nonliving objects and phenomena (such as clouds) are inhabited and motivated by a nonphysical agent; it is a characteristic of the thinking of early childhood.  3. the theory that behavior is controlled by an immaterial mind or soul.
• animus : ill will or hostility; animosity. In jungian psychology, the masculine aspect of a woman's soul or inner being; see anima.
• soul / anima :
• anima : in jungian psychology, the soul or inner being of a person, as opposed to the persona, the social role or facade presented to the world; because the inner and outer facades are often opposing, Jung also used the term to refer to the feminine aspect of a man's soul, the analogous masculine aspect of a woman's soul being termed the animus.
• persona [L. �mask�] : in jungian psychology, the personality mask or facade presented by a person to the world, as opposed to the anima, the inner being
• perseveration : the inappropriate persistence or repetition of a thought or act after the causative stimulus has ceased or in response to different stimuli, e.g., answering a question correctly and then inappropriately repeating that answer to succeeding questions; most often associated with brain lesions but also seen in schizophrenia.
• disposition / animus : a tendency, physical or mental, toward a disease.  2. the prevailing temperament or character, giving a degree of predictability to the response to a situation or other stimulus.
• libido : 1. sexual desire.  2. the psychic energy derived from instinctive biological drives; in early freudian theory it was restricted to the sexual drive, then expanded to include all expressions of love and pleasure, but the concept has evolved to include also the death instinct. The mere thought of beer or wine can influence your sex drive, according to a study of 82 male undergraduate students. Alcohol has long been known to have a number of effects on dating behaviour: some good, some bad. Enough booze can wipe away inhibitions and act as an aphrodisiac, or it can dampen sexual performance. It can even produce what are jokingly called 'beer goggles', which mean you judge people as more attractive when you are drunk. But whatever effect someone expects from alcohol can be produced by simple exposure to flashes of alcohol-related words on a computer screen. The researchers first questioned the men about how they felt alcohol affected their libido, and then presented them with rapidly flashing words and jumbled letters on a computer screen. One group was exposed to cue words that suggested alcohol, including beer, whisky, martini and malt; the other, control group was exposed to words such as smoothie, espresso and ice. The men then rated 21 female high-school graduation photos on a scale of 1 to 9 in terms of attractiveness. The men who expected alcohol to boost their libido rated photos more favourably after subconsciously viewing alcohol cue words. Those who expected alcohol to reduce their performance actually rated the girls as less attractive after boozy words. What is most surprising is that mere expectancy can influence perception. The men were also asked to rate the girls' intelligence based on their pictures. In this case the flashing words had no impact on the results, so at least beer goggles may not make the world seem smarter than it really is. The findings shed some worrying light on our vulnerability to subconscious cuesref. These expectations about drugs or alcohol can be activated without your awareness. Friedman stresses that other studies have shown how simple words can sway our behaviour. One notable study found that after undergraduate students were subconsciously exposed to phrases such as 'old age' and 'bingo' they walked more slowly down hallwaysref. Assessing the power of these veiled cues is important, agrees Jack Darkes, a clinical psychologist at the University of South Florida in Tampa who has studied assumptions about alcohol. It's another link in the chain that supports what a lot of us have been saying for a while : appreciating the difference between psychological and chemical effects may help those with alcohol addictions to face up to their problem
• lapsus : an error, or slip, thought to be revealing of an unconscious wish or association
• lapsus calami : an unconsciously motivated slip of the pen.
• lapsus linguae : an unconsciously motivated slip of the tongue.
• lapsus memoriae : an unconsciously motivated lapse of memory.
• skepticism :
• nihilism : an attitude of skepticism regarding traditional values and beliefs or their frank rejection.  2. a delusion of nonexistence of part or all of the self or the world.
• therapeutic nihilism : skepticism regarding the therapeutic value of drugs or treatment procedures.

In UK 23% of current and recent mental health patients had been in mixed-sex accommodation, despite Government reassurances in 2002 that such wards would be eliminated : those patients in mixed-sex wards had greater concerns about their safety and said it compromised their privacy and dignity. 27% rarely felt safe while in hospital, and only 20% felt they were treated with respect and dignity by staff. 23% had been physically or verbally threatened during their stay in hospital, with 20% reporting a physical assault. And 7% of patients had been harassed or assaulted by staff. > 50% of patients said the hospital surroundings had not helped them recover, and 33% thought they had made their health worse.

Among elderly people hospitalization of a spouse is associated with an increased risk of death, and the effect of the illness of a spouse varies among diagnoses. Such interpersonal health effects have clinical and policy implications for the care of patients and their families. Overall, 383,480 husbands (74%) and 347,269 wives (67%) were hospitalized at least once, and 252,557 husbands (49%) and 156,004 wives (30%) died. Mortality after the hospitalization of a spouse varied according to the spouse's diagnosis. Among men, 6.4% died within 1 year after a spouse's hospitalization for colon cancer

, 6.9% after a spouse's hospitalization for stroke, 7.5% after a spouse's hospitalization for psychiatric disease, and 8.6% after a spouse's hospitalization for dementia. Among women, 3.0% died within 1 year after a spouse's hospitalization for colon cancer, 3.7% after a spouse's hospitalization for stroke, 5.7% after a spouse's hospitalization for psychiatric disease, and 5.0% after a spouse's hospitalization for dementia. After adjustment for measured covariates, the risk of death for men was not significantly higher after a spouse's hospitalization for colon cancer (hazard ratio, 1.02; 95% confidence interval, 0.95 to 1.09) but was higher after hospitalization for stroke (hazard ratio, 1.06; 95% confidence interval, 1.03 to 1.09), congestive heart failure (hazard ratio, 1.12; 95% confidence interval, 1.07 to 1.16), hip fracture (hazard ratio, 1.15; 95% confidence interval, 1.11 to 1.18), psychiatric disease (hazard ratio, 1.19; 95% confidence interval, 1.12 to 1.26), or dementia (hazard ratio, 1.22; 95% confidence interval, 1.12 to 1.32). For women, the various risks of death after a spouse's hospitalization were similar. Overall, for men, the risk of death associated with a spouse's hospitalization was 22% of that associated with a spouse's death (95% confidence interval, 17 to 27%); for women, the risk was 16% of that associated with death (95% confidence interval, 8 to 24%)ref.
According to the National Crime Victimization Survey for 1993 to 1999, conducted by the Department of Justice, the annual rate of nonfatal, job-related, violent crime was 12.6 per 1000 workers in all occupations. Among physicians, the rate was 16.2 per 1000, and among nurses, 21.9 per 1000. But for psychiatrists and mental health professionals, the rate was 68.2 per 1000, and for mental health custodial workers, 69.0 per 1000. For Tim Exworthy, a forensic psychiatrist at Redford Lodge Hospital in London who was recently assaulted by a patient, the risk of job-related violence is no longer a dry statistic. He was beaten unconscious by a 19-year-old psychotic man whom he had been treating in the hospital for 5 months. I was talking with him in a room and telling him why he couldn't leave, when I was suddenly aware of a few blows to my head. The next thing I knew, I was at the nursing station wiping the blood off my face. I never saw this coming and hadn't anticipated that he would react like that. Such attacks by psychotic patients highlight a larger question: Are people with mental illness really more likely than others to engage in violent behavior? If so, which psychiatric illnesses are associated with violence, and what is the magnitude of the increase in risk? Posing these questions is itself not without risk: being perceived as dangerous can have a devastating effect on a person's prospects for relationships, employment, housing, and social functioning. People with mental illness already bear the burden of much social stigma, and I am loath to add to it. But without a realistic understanding of this risk, medical practitioners can neither provide the best care for their patients nor ensure their own safety when the clinical situation warrants it. Until recently, most studies have focused on the rates of violence among inpatients with mental illness or, conversely, the rates of mental illness among people who have been arrested, convicted, or incarcerated for violent crimesref. For example, one national survey showed that the lifetime risk of schizophrenia was 5% among people convicted of homicide � a prevalence that is much higher than any published rate of schizophrenia in the general population � suggesting an association between schizophrenia and homicide convictionref.2 These studies, however, tend to be limited by selection bias: subjects who are arrested, incarcerated, or hospitalized are by definition more likely to be violent or very ill and thus are not representative of psychiatric patients in the general population. A more accurate and less biased assessment of the risk of violence perpetrated by the mentally ill comes from epidemiologic studies of community samples. The best known is the NIMH's Epidemiologic Catchment Area (ECA) study, which examined the rates of various psychiatric disorders in a representative sample of 17,803 subjects in five U.S. communities. Although this study was not initially designed to assess the prevalence of violent behavior, data on violence were collected for about 7000 of the subjects. "Violence" was defined as having used a weapon such as a knife or gun in a fight and having become involved, with a person other than a partner or spouse, in more than one fight that came to blows � behavior that is likely to frighten most people.

Lifetime Prevalence of Violent Behavior among Persons with or without Major Psychiatric Disorders and Substance Abuse.
The criteria for violent behavior were use of a weapon in a fight and engaging, with someone other than one's partner or spouse, in a fight that came to blows. Persons were considered to have a relevant psychiatric disorder if they met the lifetime criteria delineated in the Diagnostic and Statistical Manual of Mental Disorders (third edition) for schizophrenia, bipolar disorder, or major depression and had had active symptoms of that disorder within the previous 12 months (Swanson JW. Mental disorder, substance abuse, and community violence: an epidemiological approach. In: Monahan J, Steadman HJ, eds. Violence and mental disorder: developments in risk assessment. Chicago: University of Chicago Press, 1994:101-36)
The study showed that patients with serious mental illness � those with schizophrenia, major depression, or bipolar disorder � were two to three times as likely as people without such an illness to be assaultive. In absolute terms, the lifetime prevalence of violence among people with serious mental illness was 16%, as compared with 7% among people without mental illness. Although not all types of psychiatric illness are associated with violence � anxiety disorders, for example, do not seem to increase the risk � and although most people with schizophrenia, major depression, or bipolar disorder do not commit assaultive acts, the presence of such a disorder is significantly associated with an increased risk of violence. Of course, because serious mental illness is quite rare, it actually contributes very little to the overall rate of violence in the general population; the attributable risk has been estimated to be 3 to 5% � much lower than that associated with substance abuse, for example. (People with no mental disorder who abuse alcohol or drugs are nearly seven times as likely as those without substance abuse to report violent behavior.) But substance abuse among the mentally ill compounds the increased risk of violence: one study involving 802 adults with a psychotic or major mood disorder showed that violence was independently correlated with several risk factors, including substance abuse, a history of having been a victim of violence, homelessness, and poor medical healthref. The 1-year rate of violent behavior for subjects with none or only one of these risk factors was 2% � a prevalence close to the ECA study's estimate for the general population. Thus, violence in people with serious mental illness probably results from multiple risk factors in several domains. Much can be done to diminish the risk of violence among the mentally ill. A study that compared the prevalence of violence in a group of psychiatric patients during the year after hospital discharge with the rate in the community in which the patients lived showed no difference in the risk of violence between treated patients and people without a psychiatric disorderref. Thus, symptoms of psychiatric illness, rather than the diagnosis itself, appear to confer the risk of violent behavior. So patients with schizophrenia who are free of the acute psychotic symptoms that increase this risk, such as having paranoid thoughts or hearing voices that command them to hurt others (called command auditory hallucinations), may be no more likely to be violent than people without a mental disorder. The study did not specifically monitor the treatments, but it seems possible that treating psychiatric illness does not just make patients feel better; it may also drastically reduce the risk of violent behavior. In the wake of Fenton's killing, there may be renewed efforts to expand the criteria or lower the clinical threshold for mandatory treatment of patients with psychosis � a movement that is sure to be controversial. We know that most such patients are not violent, but we also know that a patient with acute psychosis who is paranoid and has command auditory hallucinations or a history of being violent, being a victim of violence, or abusing alcohol or drugs is at high risk for violent behavior. Currently, in order to protect civil liberties, most states mandate treatment (whether hospitalization or medication) only if there is unambiguous evidence of an immediate danger to others, which is generally interpreted as overt threats or violent actions. Perhaps it makes sense to reset the threshold at the presence of known clinical risk factors � psychotic thoughts that are influencing behavior, a history of violence, and significant concurrent substance abuse. But expanding the criteria would require further substantiation that these factors can be accurately identified by clinicians and that their use in mandating treatment is warranted. The possibility that expanding the criteria might also discourage people with psychotic illnesses and substance abuse problems from voluntarily seeking treatment would also need to be considered. It is natural for psychiatrists and other medical professionals who treat psychiatric patients to deny, to some extent, the possible danger. After all, it is hard to have a therapeutic relationship with a patient we fear. Still, we need to remind ourselves that the risk of violence, though small, is real, and we must take necessary precautions. As Exworthy put it, "I guess I let down my guard and paid for it." Keeping up our guard means paying attention to our fear and anxiety about a patient; no physician should ever treat a patient whom he or she fears. It also means seeing patients with acute psychosis in locations where there is adequate assistance and security, such as hospitals and clinics, rather than in a private office setting. The challenge for medical practitioners is to remain aware that some of their psychiatric patients do in fact pose a small risk of violence, while not losing sight of the larger perspective � that most people who are violent are not mentally ill, and most people who are mentally ill are not violent.

Web resources :

• National Institute for Mental Health (NIMH)
• Mental health / mental illness
• Mental health at CDC
• Complete DSM-IV Criteria for Mental Disorders by James Morrison
• Institute of Psychiatry at the Maudsley
• Associations (see also Italian associations
  ) :

Bibliography :

• Diagnostic and Statistical Manual (DSM) of Mental Disorders, Fourth Edition (DSM-IV), 1994, by American Psychiatric Association and DSM-IV-text revision (TR))

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What is the term for a sleep like state marked by reduced sensitivity to stimuli loss or alteration of knowledge and the substitution of automatic for voluntary motor activity?

What is the diminishing sensitivity to an unchanging stimulus called?

Is called the lowest level at which an individual can experience a sensation?

Which part of the brain according to M Persinger is closely associated with so called God experiences?