First Aid for the Pediatrics Clerkship, 3 Ed.

Psychiatric Disease



Image Consult multiple sources:

Image Child: Young children usually report information in concrete terms but give accurate details about their emotional states.

Image Parents.

Image Teachers.

Image Child welfare/justice.

Image Methods of gathering information:

Image Play, stories, drawing.

Image Kaufman Assessment Battery for Children (K-ABC): Intelligence test for ages 2½ to 12.

Image Wechsler Intelligence Scale for Children–Revised (WISC-R): Intelligence quotient (IQ) for ages 6–16.

Image Peabody Individual Achievement Test (PIAT): Tests academic achievement.


See Neurologic Disease chapter.


See Neurologic Disease chapter.



Behavioral disorders include oppositional defiant disorder and conduct disorder.

Oppositional Defiant Disorder (ODD)


A 9-year-old boy’s mother has been called to school because her son is defiant toward the teacher and does not comply with her requests to follow the rules. His parents reports similar scenarios at home, and he often becomes argumentative with them. Think: Oppositional defiant disorder.

ODD is a common mental health condition in children. It is more common in boys. A certain degree of oppositional behavior may be normal in childhood. However, normal defiance should not impair significant social relationship or academic performance. Children with this condition have substantially impaired relationships with parents, teachers, and peers. They might not show oppositional behavior in the pediatrician office. The diagnosis is therefore based on reports from the parents or teachers. Attention deficit/hyperactivity disorder (ADHD) and other mood disorders may coexist.


Image Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSMIV) definition: Recurrent pattern of negativistic, defiant, disobedient, and hostile behavior for 6 months.

Image Consistent pattern of disobedience toward parent or teacher

Image Four or more of the following criteria are usually present:

Image Loses temper.

Image Argues with adults.

Image Refuses to follow rules.

Image Deliberately annoys others.

Image Does not take responsibility for mistakes or behavior.

Image Sensitive, touchy, easily annoyed.

Image Angry, resentful.

Image Spiteful, vindictive.

Image Behavior causes impairment in social and academic functioning.

Image Rule out other causes of clinical presentation.


Temper tantrums and breath holding are manipulative behaviors.


Low self-esteem, low frustration tolerance, precocious use of substances.


Image Prevalence: 2–16%.

Image May be a precursor of a conduct disorder.

Image ↑ incidence of substance abuse, mood disorders, disorder (ADHD).


ODD can be a developmental antecedent to conduct disorder. The former does not involve violation of the basic rights of others.


Image Behavioral therapy, problem-solving skills.

Image Early intervention is more effective than waiting for a child to grow out of it.

Image Parental management training.

Conduct Disorder


A 9-year-old boy’s mother has been called to school because her son has been hitting other children and stealing pens. She reports that he often pokes their family cat with sharp objects. Think: Conduct disorder.

This disorder involves a variety of problematic behaviors, including oppositional and defiant behaviors and antisocial activities such as lying, stealing, running away, and physical violence. It is a pattern of behavior that violates the basic rights of others. The basic problem is a chronic conflict with parents, teachers, and peers. It is two to three times more common in boys. Conduct disorder is difficult to treat, and these behaviors are more likely to persist into adulthood.


Image Chronic conflict with parents, teachers, or peers.

Image A repetitive and persistent pattern of behavior that involves violation of the basic rights of others or of social norms and rules, with at least three of the following in 1 year:

Image Aggression toward people and animals.

Image Destruction of property.

Image Deceitfulness or theft.

Image Serious violation of rules.

Image The change in behavior causes significant impairment in social, academic, or occupational functioning.

Image A closely linked behavior is juvenile delinquency, which is a tendency to break the law or engage in illicit behavior.


Image Lack of empathy is an important risk factor.

Image Involves genetic and psychosocial factors.


Image Prevalence: 6–16% in boys, 2–9% in girls.

Image Up to 40% risk of developing antisocial personality disorder in adulthood.

Image ↑ incidence of ADHD, learning disorders, mood disorders, substance abuse, and criminal behavior in adulthood.


Conduct disorder is one of the most difficult mental health problems during adolescence.



Image Structured environment, firm rules, consistent enforcement.

Image Psychotherapy: Behavior modification, problem-solving skills.

Image Adjunctive pharmacotherapy may help: Antipsychotics, lithium, selective serotonin reuptake inhibitors (SSRIs).


Conduct disorder is the most common diagnosis in outpatient psychiatry clinics.



A 9-year-old boy’s mother has been called to school because her son has not done his homework. He claims that he did not know about the assignments. He interrupts other kids and is always getting up during class. His parents report that he cannot sit still at the dinner table. Think: ADHD.

ADHD is a common psychiatric disorder present in up to 10% of school-age children. Onset of symptoms occurs before age 7 yr. Inattention and distractibility is the hallmark. Classic triad: impaired attention, impulsivity, and excessive motor activity. Symptoms must be present in two or more situations, such as school and home. The diagnosis of ADHD is clinical.


Three types predominantly:

Image Inattentive.

Image Hyperactive-impulsive

Image Combined: Most children have the combined type.


Image Six or more of the following for 6 months:

Image Inattention: Problems listening, concentrating, paying attention to details, organizing tasks, easily distracted, forgetful.

Image Hyperactivity-impulsivity: Unable to inhibit impulses in social behavior, → blurting out, interrupting, fidgeting, leaving seat, talking excessively.

Image Combined subtype: Six or more symptoms of inattention and hyper-activity-impulsivity.

Image Onset before age 7 yr.

Image Behavior inconsistent with age and development.

Image Impairment in two or more social settings.

Image Evidence of impairment in functioning.

Image The above may →:

Image Difficulty getting along with peers and family.

Image School underachievement secondary to poor organizational skills.

Image Poor sequential memory, deficits in fine motor skills.

Image Medical conditions and sleep conditions must be ruled out before a diagnosis of ADHD is made.

Image Important to rule out other situations that can trigger ADHD-type behaviors, such as death in the family, divorce, inner ear infection that causes temporary hearing problems, anxiety or depression, learning disability, child abuse.


The diagnosis of ADHD is clinical.


Onset of ADHD occurs no later than age 7 yr.


The three cardinal signs of ADHD:

Image Inattention

Image Hyperactivity

Image Impulsivity

Symptoms must be present in two or more situations for a diagnosis of ADHD.


Image Genetic predisposition.

Image Environmental factors.

Image Perinatal complications, maternal nutrition and substance abuse, obstetric complications, viral infections.

Image Neurochemical/neurophysiologic factors.

Image Psychosocial factors, including emotional deprivation and parental anxiety and inexperience.

Image Family dysfunction.


Image Catecholamine hypothesis, ↓ in norepinephrine metabolites.

Image Hypodopaminergic function, low levels of homovanillic acid.


Up to 15–20% continue to have ADHD in adulthood.


Image Prevalence: 3–10% among young and school-age children.

Image Male-to-female ratio: 3:1.

Image ↑ incidence of mood disorders, personality disorders, conduct disorder, and ODD.

Image Most cases improve in adolescence; 20% have symptoms into adulthood.


Stimulants used appropriately for ADHD do not cause addiction.


ADHD is the most common significant behavioral syndrome in childhood.


Image Pharmacotherapy:

Image Psychostimulants (first-line drugs): Methylphenidate (Ritalin), dextro-amphetamine, pemoline.

Image Atomoxetine (second-line drug).

Image Atypical antipsychotics: On the rise; work by blocking dopamine.

Image Clonidine: Caution when using in combination with methylphenidate.

Image Psychotherapy:

Image Behavior modification, cognitive behavioral therapy.

Image Parental counseling: Positive reinforcement, firm nonpunitive limit setting, reduce external stimulation.

Image Group therapy: Social skills, self-esteem.


Two-thirds of children with ADHD also have conduct disorder or ODD.



Image Group of conditions that involve problems with social skills, language, and behaviors.

Image Apparent early in life with developmental delay involving multiple areas of development.

Image Include autistic disorder, Asperger syndrome, Rett syndrome, and childhood disintegrative disorder.

Image Pervasive developmental disorder not otherwise specified (PDD-NOS; atypical autism): Diagnosed when criteria are not met for any of the above.


The most efficacious pharmacotherapeutic agents for ADHD are psychostimulants, though behavioral modification and firm limit setting should also be used. Seventy-five percent of patients have significant improvement on Ritalin.


Image There is no cure, but goal of treatment is to manage symptoms and improve social skills.

Image Remedial education.

Image Behavioral therapy.

Image Neuroleptics such as haloperidol to control self-injurious and aggressive behavior and mood lability.

Image SSRIs to help control stereotyped and repetitive behaviors.

Autistic Disorder


A 3-year-old boy is brought in by his parents because they think he is deaf. He shows no interest in them or anyone around him and speaks only when spoken to directly. He often lines his toys up in a straight line. Hearing tests are normal. Think: Autism.

Autism is a spectrum of behaviors that include abnormalities in social interactions, aberrant communication, and restricted repetitive and stereotyped behaviors. The onset is usually before age 3 yr. Speech is typically delayed or may regress. It is often associated with mental retardation.

Spectrum of pervasive developmental disorders characterized by various degrees of impaired social interaction and communication and repetitive, stereotyped patterns of behavior.


Seventy percent of children with autistic disorder are mentally retarded, though a few have narrow remarkable abilities (savants). Only 1–2% can function completely independently as adults.


Autism is not caused by thimerosal-containing vaccines.


Image Diagnosis made within the first 3 yr and other causes of the clinical presentation ruled out.

Image It is based on behavior, not cause.

Image Parents usually notice signs in the first 2 yr of the child’s life.

Image Characteristic triad: Impairments in social interaction, impairments in communication, and restricted interests and repetitive behaviors.

Image At least six of the following (with at least two from qualitative impairment in social interaction, one from qualitative impairments in communication, and one from patterns of behavior):

Image Qualitative impairment in social interaction (at least two):

Image Marked impairment in the use of multiple nonverbal behaviors, including poor eye contact.

Image Failure to develop peer relationships and attachments.

Image Lack of spontaneous seeking to share enjoyment, interests, achievements.

Image Lack of emotional or social reciprocity.

Image Qualitative impairments in communication (at least one):

Image Delay or lack of spoken language (expressive language deficit).

Image Marked impairment in the ability to initiate or sustain a conversation with others.

Image Stereotyped and repetitive use of language or idiosyncratic language.

Image Lack of spontaneous make-believe play or social initiative.

Image Repetitive and stereotyped patterns of behavior and activities (at least one):

Image Inflexible rituals: Unvarying pattern of daily activities.

Image Preoccupations.

Image Highly responsive to intimate environment, stimulus overselectivity, unable to cope with change in routine.


Standard developmental screening tests have poor sensitivity for autism.


Two areas are particularly affected in autistic disorder:

Image Communication

Image Social interactions


Computed tomography (CT) and magnetic resonance imaging (MRI) in autistic disorder show ventricular enlargement; polymicrogyria; and small, densely packed, immature cells in the limbic system and cerebellum.


Image Genetic predisposition (36% concordance rate in monozygotic twins, 0% in dizygotic twins).

Image Prenatal neurologic insult.

Image Immunologic and biochemical factors.


Image Neuroanatomic structural abnormalities.

Image Abnormalities in dopamine and serotonin system: ↑ in serotonin.


Half of children with autistic disorder never speak.


Image Prevalence: 10–15:10,000.

Image Male-to-female ratio: 4:1.

Image Diagnosis first year (25%), second year (50%), after 2 years (25%).

Image Significant comorbidity with fragile X syndrome, tuberous sclerosis, mental retardation, and seizures.


Image No effective treatment.

Image Depends on presence or absence of underlying disorder and speech.


Those with autistic disorder who do speak exhibit echolalia, pronoun reversal, inappropriate cadence or intonation, impaired semantics, and failure to use language for social interaction.

Asperger Syndrome


Image Impaired social interaction (at least two, similar to autistic disorder).

Image Restricted or stereotyped behaviors, interests, or activities.

Image No substantial delay in language development (unlike autistic disorders).


Male > female.

Rett Syndrome


A 4-year-old girl with prior history of severe mental retardation is brought in for evaluation. She has been developing normally until 18 months of age, when she acquired dementia and her head circumference plateaued. She wrings her hands and has ataxia and marked loss of gross motor skills. Think: Rett syndrome.

Rett syndrome is a pervasive developmental disorder. It is a genetic disorder in which developmental arrest typically occurs between 6 and 18 months. Parents may report gross motor development delay, disinterest in play, and loss of eye contact. Hand wringing is a hallmark of this condition. Rapid deterioration may occur. This diagnosis should be considered in a previously healthy child with normal development who develops deceleration of head growth.


Unlike those with autistic disorder, children with Asperger syndrome have normal language and cognitive development.


Image Normal pre-and perinatal development until between 6 and 18 months of age.

Image Normal head circumference at birth, but ↓ rate of growth between the ages of 6 and 18 months.

Image Loss of previously learned purposeful hand skills between the ages of 6 and 30 months, followed by the development of stereotyped hand movements.

Image Early loss of social interaction, usually followed by subsequent improvement.

Image Problems with gait or trunk movements: 50% of females are not ambulatory.

Image Severely impaired language and psychomotor development.

Image The diagnosis is also supported by a positive mutational analysis of MECP2.

Image Prone to seizure disorders and gastrointestinal complaints (constipation).


Generally, autistic disorders more common in boys except Rett syndrome (more common in girls).


Image Classically restricted to females; males are beginning to be recognized due to genetic testing.

Image The gene for Rett syndrome is located on the X chromosome.


Image Females can live up to 40 years of age.

Image Currently, there is no cure.

Childhood Disintegrative Disorder


Image Normal development in the first 2 years of life.

Image Loss of previously acquired skills in at least two of the following:

Image Language.

Image Social and self-care skills.

Image Bowel or bladder control.

Image Play skills.

Image Motor skills.

Image At least two of the following:

Image Impaired social interaction.

Image Impaired use of language.

Image Restricted, repetitive, and stereotyped behaviors and interests.

Image Regression can be very sudden.


Image Onset ages 2–10 yr.

Image Four to eight times higher incidence in boys.

Image Rare.


Image No permanent cure.

Image Behavior therapy: Aims to teach child how to relearn skills that are lost.



Image Sudden, repetitive, stereotyped movements (motor tics) and utterances (phonic tics).

Image Most common motor tics involve the face and head (eg, blinking of eyes).

Image Examples of vocal tics include coprolalia (repetitive speaking of obscene words) and echolalia (exact repetition of words).

Tourette Syndrome


A 13-year-old boy has had uncontrollable blinking since he was 9 years old. Recently, he has noticed that he often involuntarily makes a barking noise that is embarrassing. Think: Tourette syndrome.

It is characterized by motor and phonic (or vocal) tics. Tics are defined as involuntary, sudden, intermittent, repetitive movements (motor tics) or sounds (phonic tics). Comorbidities, such as ADHD and obsessive-compulsive disorder, are common. The age of onset is before 18 yr but most children shows readily identifiable symptoms by age 7 yr.


Image Multiple motor and vocal tics occurring multiple times per day, almost daily for > 1 yr (no tic-free period for > 3 months).

Image Onset before age 18.

Image Distress or impairment in social functioning.


Image Three times more common in boys.

Image Onset usually between the ages of 7 and 8 yr.

Image High comorbidity with obsessive-compulsive disorder (OCD) and ADHD.


Tics in Tourette syndrome may be consciously repressed for short periods of time.


Image Genetic: 50% concordance rate in monozygotic twins, 8% in dizygotic.

Image Neurochemical: Impaired regulation of dopamine in the caudate nucleus.


Image Most cases are mild and do not require drug therapy.

Image Supportive psychobehavioral therapy, education, and reassurance.

Image Pharmacotherapy when symptoms interfere with functioning: Haloperidol or pimozide.




Image Lack of involuntary urinary continence beyond age 4 for diurnal enuresis and age 6 for nocturnal enuresis.

Image Occurs at least twice per week for at least 3 consecutive months.

Image Types:

Image Primary: Child never established continence.

Image Secondary: Most commonly occurs between ages 5 and 8 yr.

Image Rule out the influence of a medical condition (eg, urethritis, diabetes, seizures).


Image Genetic predisposition.

Image Physical factors: Small bladder, low nocturnal levels of antidiuretic hormone (ADH).

Image Delayed or stringent toilet training.

Image Psychosocial stressors.


Prevalence: 7% male and 3% female at age 5 yr; 3% male and 2% female prevalence at age 10 yr.


Image Urination during the day, night, or both on the individual.

Image Nocturnal (nighttime only) is the most common subtype.

Image Diurnal (daytime only) is more common in females.


Image According to specific causative factors suggested by an adequate psychosocial evaluation.

Image Enlist child in cure, offer positive reinforcement, do not punish; older children participate in cleaning up.

Image No liquids after dinner; urinate before going to bed.

Image Behavior modification therapy (eg, buzzer to wake up child when wetness is detected).

Image Pharmacotherapy: Antidiuretics (desmopressin [DDAVP]) or tricyclic antidepressants (imipramine).


Most cases of enuresis spontaneously remit by age 7.



Image Repeated passage of feces into inappropriate places (eg, clothing or floor) whether involuntary or intentional.

Image Behavior must occur once a month for 3 months.

Image Individual must be at least 4 years old.

Image Rule out the influence of a medication or a general medical condition (eg, hypothyroidism, lower gastrointestinal [GI] problems, dietary factors).


Image Anxiety about defecating in a particular place.

Image A more generalized anxiety in response to stressful environmental factors.

Image Oppositional behavior.

Image Physiologic conditions: Lack of sphincter control, constipation with overflow incontinence.


Image Prevalence: 1% in 5-year-old children (less common than enuresis).

Image Incidenc ↓ with age.

Image More common in males than females.

Image Associated with other conditions such as conduct disorder and ADHD.


Encopresis in a 7-year-old child likely indicates a more serious disturbance than thumb-sucking in a 4-year-old, which is more serious than a nightmare in a 5-year-old, breath-holding spells in a 2-year-old, and nocturnal enuresis in a 6-year-old.


Image According to the specific causative factors suggested by an adequate psychosocial evaluation.

Image Enlist child in cure, positive reinforcement; do not punish.

Image Older children participate in cleaning up.

Image Choose a specific time every day to attempt bowel movement.

Image Stool softeners: Majority of encopresis cases involve constipation.

Image Psychotherapy, family therapy, and behavioral therapy.


Image Depressive disorders can be classified into three types:

Image Major depressive disorder (MDD).

Image Dysthymic disorder (DD).

Image Depressive disorder not otherwise specified (NOS).

Image Dysthymic disorder: Symptoms are less intense but last longer than major depressive disorder. Characterized by chronically depressed or irritable mood (at least 1 year) and must have two of the following symptoms: appetite disturbance, sleep disturbance, fatigue, low self-esteem, poor concentration, difficulty making decisions, or feelings of hopelessness.

Image Depressive disorder NOS: Clinically significant depressive symptoms but does not meet criteria for any specific mood disorder or adjustment disorder with depressed mood.


Fifty to sixty percent of individuals with a single depressive episode can be expected to have a second episode.

Major Depressive Disorder (MDD)


Image Pathologic sadness or despondency not explained as a normal response to stress and causing an impairment in function.

Image Recurrent condition that generally continues into adulthood.


Electroencephalography (EEG) in depression shows ↓ slow-wave (delta) sleep, shortened time before onset of rapid eye movement (REM), and longer duration of REM.


Image Genetic predisposition.

Image Catecholamine hypothesis: Depression is caused by a deficit of norepinephrine at nerve terminals throughout the brain.

Image Cortisol hypothesis: Larger quantities of cortisol metabolites in blood and urine, abnormal diurnal variation.


In suspected cases of depression, be sure to look for other signs or risk factors such as school failure or family history of mental health disorders.


Image Prevalence: 2% of children; 4–8% of adolescents.

Image Twenty-eight percent of child psychiatry clinic patients.

Image Fifteen to twenty percent incidence in adolescents.

Image Two to three times higher in postpubertal girls than boys.

Image Other mental disorders frequently co-occur with major depressive episode including anxiety/panic disorders, OCD, eating disorders, substance abuse, borderline personality disorder, ADHD, and ODD.


A combination of treatments for depression may be necessary. Childhood depression should be treated with behavior modification before medication.


Image Depressed mood with at least five of the following signs lasting more than 2 weeks:

Image Depressed mood.

Image Loss of interest in activities.

Image Plus, four or more of the following for 2 weeks or longer:

Image Sleep disturbance.

Image Weight change or appetite disturbance.

Image ↓ concentration.

Image Suicidal ideation.

Image Psychomotor agitation or retardation.

Image Fatigue or loss of energy.

Image Feelings of worthlessness or inappropriate guilt.

Image Always rule out other causes of the clinical presentation (eg, hypothyroidism, nutritional deficiency, chronic infection/systemic disease, substance abuse).


Use of antidepressant medications in adolescents may ↑ risk of suicidal thoughts and behaviors during initial weeks due to disinhabition.


Image Can persist into adulthood.

Image Up to 15% of patients with depression commit suicide each year.


Image If suicidal or homicidal, admit to the hospital.

Image Biopsychosocial approach.

Image Cognitive behavior therapy (CBT).

Image Individual and/or group therapy.

Image Family intervention.

Image TCAs, SSRIs. TCAs have risk of lethal overdose—look for convulsions, coma, and cardiac arrythmias in toxicity.

Image Electric shock therapy: Catatonic syndrome or intractable depression.

Image For adolescents, CBT and SSRIs appear to be most effective.


One percent of suicide gestures are lethal.



Image Suicide is a complex human behavior with biologic, sociologic, and psychological roots that results in a self-inflicted death that is intentional rather than accidental.

Image Suicide ideation, with or without a plan.

Image Suicide gesture—for attention, without intent for death.

Image Suicide attempt.


Seventy-five percent of those who go on to attempt suicide convey their suicidal intentions directly or indirectly.


Image Genetic predisposition.

Image Psychiatric disorders: Correlations of suicidal behavior and mood or disruptive disorders, substance abuse.

Image Environmental factors: Stressful life events; family disruption due to death or separation, illness, birth, or siblings; peer pressure; physical or sexual abuse.

Image Parental influence: Psychiatric illness, substance abuse, violence, physical or sexual abuse.


Girls attempt suicide more but boys are more successful.


Thirty to seventy percent of suicides occur with significant alcohol or drug abuse. Substance abuse disinhibits the individual to complete the act.


Image Attempted suicides account for 6% of deaths in 10- to 14-year-olds, 11% of deaths in 15- to 19-year-olds.

Image Third leading cause of death for young adults aged 10–19.

Image In the United States, there are about 50–100 attempts for each complete suicide; 8–9% of U.S. adolescents attempt suicide.

Image Boys more frequently complete suicide, but girls attempt more often. (Girls tend to choose less lethal methods like overdose, cutting; boys will choose firearms, hanging).

Image The rate of suicide is higher in Alaskan, Asian-American, and Native American youth.

Image Of the 1–2% of those who attempt suicide, 10% will eventually complete the act.

Image Risk factors: Look for psychiatric disorders, prior attempts, family clustering of suicides, substance use/abuse, history of sexual abuse, or serotonin abnormalities.


Image Even though risk factors for suicide are known, it is not possible to predict who will commit suicide.

Image Assess signs and symptoms, correlate with other clinical variables such as psychiatric and substance abuse history, gender, age, race, prior history of suicide attempts, and recent traumatic life events.

Image Key questions: Are you having any thoughts about harming yourself or taking your life? Have you developed a plan? What is your plan?


Suicidal ideation, when accompanied by a specific plan, must be taken seriously, and these patients need to be hospitalized for assistance and suicide precautions.


Image Immediate hospitalization; remove all potentially lethal items.

Image Psychotherapeutic intervention, trustful atmosphere, coping strategies; remove motivation for suicide; involve parents and relatives, guidance counselor.

Image Pharmacotherapy depends on the accompanying diagnosis.


Suicide completers: Male, older, history of depression, alcoholism, schizophrenia, careful planning, high lethality, firearms.



Image Homicide is the second leading cause of death among 15- to 19-year-olds and the leading cause of death in African-American adolescents.

Image Rates of homicide are higher in males than in females.

Image Death by firearm homicide is highest in the 15- to 24-year-old age group.


Suicide attempters: Female, younger, history of depression, alcoholism, personality disorder, impulsive, no planning, low lethality, drug overdose.


Image Look for clinical entities associated with violent behavior such as mental retardation, moderate to severe language disorder, learning disorder, ADHD, mood disorders, anxiety disorders, personality disorders, conduct disorders, and ODD.

Image Other risk factors: Substance abuse, gang involvement, history/exposure to domestic/child abuse, and access to firearms.


Ask about recent involvement in physical fights, carrying a weapon, firearms in household, concerns that an adolescent has about his/her safety, past episodes of trauma, and social problems in school or neighborhood.



Image Alcohol and cigarettes are the most prevalent drugs among school-age young adults.

Image Marijuana is the most commonly reported illicit drug used.

Image The prevalence of substance abuse varies according to age, gender, geographic region, race, and other demographic factors.


See Table 21-1 for signs and symptoms of intoxication and withdrawal due to substances of abuse.


Image Group therapy.

Image Narcotics Anonymous.

Image Hospitalizations may be necessary for acute withdrawal.

Image Alcohol abuse: Rule out medical complications, start benzodiazepine for withdrawal symptoms, and give thiamine before glucose to prevent Wernicke’s encephalopathy.

TABLE 21-1. Substances of Abuse—Intoxication and Withdrawal





Separation Anxiety


Image Excessive anxiety beyond that expected for the child’s developmental level related to separation or impending separation from the attachment figure.

Image Separation anxiety is normal until age 3–4 yr.


Image Prevalence: 4% of school-age children.

Image Males and females are affected equally.


Contribution by parental anxiety/excessive concern expressed.


Image May refuse to sleep alone or go to school.

Image May complain of physical symptoms in order to avoid anxiety-provoking activities.

Image Become extremely distressed when forced to separate, and may worry excessively about losing their parents forever.


Image Family therapy.

Image Supportive psychotherapy.

Image Low-dose antidepressants.

School Phobia


Image A child who develops emotional upset at the prospect of going to school in the absence of severe antisocial behavior.

Image Related to separation anxiety.


Image Environmental, hostile, or dependent relationship between a parent and child; stressful events at home or school.

Image Concurrent psychiatric disorders, depression, separation anxiety, generalized anxiety, posttraumatic stress, somatoform disorder, avoidant personality disorder.


Image More common in lower socioeconomic classes, younger children in the family, early teenage years, lack of parental interest or education.

Image Equal in both males and females.

Image Most frequent among younger children.

Image Prevalence: 5% of elementary school children, 2% of junior high school children.


Image Avoidance behavior in relation to school; seeks situations that provide comfort and security; once in school, comfortable and productive, fear of school recurs the next day despite positive experience the day before.

Image Physical complaints secondary to anxiety: Anorexia, headache, abdominal pain.


Image Marked and persistent fear that is excessive and unreasonable, instigated by the anticipation of the school situation.

Image Exposure to school provokes an immediate anxiety response.

Image School is avoided.

Image School phobia interferes with academic and social functioning.

Image Duration of at least 6 months.

Image Other mental disorders ruled out.


Image Mainstay of treatment is returning the child to regular school attendance.

Image Behavioral therapy, recognize and control anxiety symptoms.

Image Anxiolytics or antidepressants for a short period of time when the symptoms are most severe.

Obsessive-Compulsive Disorder (OCD)


Image Obsessions: Persistent, intrusive thoughts, images, impulses involuntarily intruding into consciousness, causing distress and functional impairment. Common themes are contamination and fear of harm to self or others.

Image Compulsions: Actions that are responses to a perceived internal obligation to follow certain rituals and rules, which may be motivated directly by obsessions or efforts to ward off certain thoughts or fears.


Impaired social, academic, or vocational functioning with four or more of the following:

Image Preoccupied with details, rules, lists, order, organization, or schedules, resulting in loss of the goal of activity.

Image Perfectionism that prohibits task completion.

Image Social impairment secondary to preoccupation with work and level of productivity.

Image Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values.

Image Unable to discard objects of no worth or sentimental value.

Image Preference to work as an individual and not in a group.

Image Miserly spending in order to save for future catastrophes.

Image Inflexible, rigid, stubborn.

Image Characteristics must be ego-dystonic and functionally disruptive versus ego-syntonic and functionally adaptive in OCD.


Genetic predisposition, higher concordance among monozygotic versus dizygotic twins.


High comorbidity with ADHD and tic disorders.


Image Unproductive because of preoccupation with details, rules, lists, schedules, organization, order.

Image Uncompleted tasks secondary to perfectionist tendencies.

Image Work habits interfere with social interactions.

Image Impossible standards of morals, ethics, or values.

Image Inflexible, stubborn, cheap; prefers to work as an individual and not in a group.


Image Long-term therapy is required.

Image Maintain a professional distance from the patient.

Image Establish ground rules for therapy.

Image Behavioral therapy such as self-observation, extinction, operant conditioning, and modeling.

Image Pharmacotherapy:

Image First-line agents are SSRIs (ie, fluoxetine, fluvoxamine, paroxetine, sertraline).

Image Clomipramine is a second-line agent.



Repetitive patterns of movement used to discharge tension.


Image A stressful environment at home or school.

Image Concurrent psychiatric disorders including anxiety or depression.


Purposeful movement loses original meaning and becomes repetitive and a means to discharge anxiety or provide comfort.


Image Highest prevalence among 7- to 11-year-olds.

Image Males: 1–13%.

Image Females: 1–11%.


Image Bruxism (teeth grinding or clenching).

Image Tics, repetitive movement, gesture or utterance that mimics some aspect of normal behavior.

Image Stuttering, impairment in speech fluency characterized by frequent repetitions or prolongations of sounds or syllables.

Image Thumb-sucking, self-nurturing, and comforting behavior.


Individual is often unaware of habitual behavior.


Behavior therapy: Identify habit, under what circumstances it most often occurs, work on habit reversal.


Habit reversal: Substituting another, more benign behavior for the previous habit.

Selective Mutism


Not speaking in certain situations (eg, school).


Image Onset usually around age 5 or 6.

Image Girls > boys.

Image May be preceded by a stressful life event.


Supportive psychotherapy, behavior therapy, family therapy.



Image Intense, persistent, and pervasive preoccupation with becoming a member of the opposite sex.

Image Patients exhibit a strong and persistent cross-gender identification and a sense of inappropriateness about their assigned sex.


Image Prevalence: 1 in 30,000 males, 1 in 100,000 females.

Image Coexisting separation and/or generalized anxiety disorder or depression is common.

Image ↑ risk of suicide.

Image Onset for boys is usually between ages 2 and 4; less clear for girls because cross-gender behaviors are more often tolerated in girls.


For genetic men: Overidentification with the mother, overtly feminine behavior, little interest in usual male pursuits, peer relationships primarily with girls.


Image Persistent discomfort with his or her sex.

Image Four or more of the following:

Image Stated desire to be or that he or she is the other sex.

Image Wearing clothes appropriate to the opposite sex.

Image Persistent role-playing or fantasies of being the opposite sex.

Image Interest in the habits of the opposite sex.

Image Preference for playmates of the opposite sex.


Psychotherapy aimed at helping individual to accept his or her anatomic sex, adjustment in social and occupational areas, increasing self-esteem, and building social skills with peers.


Social and occupational adjustment is usually no better after surgery for gender identity disorder.



Two subtypes:

Image Restricting

Image Binge eating/purging

Anorexia Nervosa


A 16-year-old girl has a 6-month history of amenorrhea and a 25-lb weight loss. She is thin, with Tanner stage 4 development of breasts and pubic hair. She also reports constipation and feeling of bloating. When you ask her about the weight loss, she states that she is “overweight.” She had no menstruation in last 6 months. Think: Anorexia nervosa.

Anorexia nervosa is an eating disorder that is characterized by a triad of amenorrhea, weight loss, and psychiatric disturbance. Common presenting symptoms include constipation, intolerance to cold, dry skin, and hair loss. It predominantly affects females. Anorexia nervosa is associated with multiple hormonal abnormalities resulting in amenorrhea. Electrolyte abnormalities such as hyponatremia, hypokalemia, hypophosphatemia, and hypoglycemia may be present.


Image Refusal to maintain body weight at or above 85% of ideal weight for age and height.

Image Even though underweight, an intense fear of gaining weight.

Image Disturbance in self-perception of body weight and lack of insight into the seriousness of physical condition.

Image The absence of at least three consecutive menstrual cycles in women.


Image Genetic predisposition (6–10% of female relatives of anorexic patients have the condition, twin studies confirm).

Image Psychological need to control, perfectionism.

Image Conforming to society’s ideal of beauty.

Image Stressful life events such as leaving home for college or death in the family.


The most common cause of death in anorexia nervosa is cardiac arrhythmias due to electrolyte disturbances, particularly hypokalemia.


Image A primary hypothalamic disturbance secondary to ↑ corticotropin-releasing factor.

Image Central neurotransmitter dysregulation affecting dopamine, serotonin, and norepinephrine.

Image Reduced norepinephrine activity and turnover.

Image Endocrine abnormalities, ↑ growth hormone levels, loss of cortisol diurnal variation, reduced luteinizing hormone (LH), follicle-stimulating hormone (FSH), impaired response to luteinizing hormone–releasing hormone (LHRH), abnormal glucose tolerance test.


Electrocardiography (ECG) in anorexia nervosa may show low-voltage T-wave inversion and flattening, ST depression, supraventricular or ventricular arrhythmias, and/or prolonged QT intervals.


Image Predominance in females (female-to-male ratio 10:1).

Image One percent prevalence among women.

Image Bimodal onset at 14 and 18 yr.

Image More common in industrialized countries.

Image Incidence has ↑ over the past two decades.

Image More common in activities such as ballet, gymnastics, and modeling.


The long-term mortality of anorexia nervosa is 10%.


Image Extreme dieting, special diets such as vegetarianism.

Image Refusal to eat meals with family members or in public.

Image Rituals surrounding meals.

Image Preoccupation with food and its preparation.

Image Intense fear of becoming obese, which does not diminish as weight loss progresses.

Image Disturbance in the way in which one’s body, weight, size, and/or shape is experienced, such as “feeling fat” although one may be emaciated.

Image Denial of hunger.

Image Obsessive interest in physical exercise.

Image Abuse laxatives, diuretics, or stimulants in an effort to enhance weight loss.

Image Studiousness and academic success.

Image Multiorgan involvement:

Image Amenorrhea.

Image Hypothermia.

Image Constipation.

Image Low blood pressure, bradycardia.

Image Lanugo, hair loss.

Image Petechiae.

Image Pedal edema, dry skin.

Image Osteopenia.

Image Electrolyte abnormalities: Alkalosis, hypokalemia.

Image Lab abnormalities: Leukopenia, elevated liver function tests (LFTs), elevated triglycerides, carotenemia.


Image Anorexic patients deny health risks associated with their behavior, making them resistant to treatment.

Image Individual and family psychotherapy: Target abnormal and destructive thought processes.

Image Behavior modification techniques to restore normal eating behavior, set specific weight goals.

Image Nutritional rehabilitation: Restore nutritional state and weight.

Image Pharmacologic therapy (SSRIs have been used successfully).


Beware of complications occurring during rehabilitation for anorexia nervosa, including congestive heart failure (CHF), cardiac arrhythmias, and overcorrection of electrolyte abnormalities.

Bulimia Nervosa


A 15-year-old girl has bilateral parotid gland swelling and erosion of the posterior aspect of the dental enamel of her upper incisors. She reports frequent vomiting after her meal. Think: Bulimia nervosa.

Bulimia nervosa is characterized by recurrent episodes of binge eating defined as the rapid consumption of a large amount of food in a reasonably short period of time. The hallmark of bulimia is a fear of not being able to stop eating when the binge is in progress. Self-induced vomiting and excessive exercise are the compensatory behaviors. Parotid enlargement, dental problems, and abrasions of knuckles are due to biting down on them during self-induced vomiting. The typical age of presentation is during the teenage year.


Image Recurrent episodes of eating within a 2-hr period of larger-than-normal proportions accompanied by a sense of lack of control over actions (binge eating).

Image Unlike anorexia, these patients are at or above their expected weight.

Image Recurrent compensatory behavior in order to prevent weight gain—self-induced vomiting, laxatives, diuretics, enemas, excessive exercise.

Image Episodes occur at least twice a week for 3 months.

Image Body shape and weight is the basis of self-evaluation.

Image Does not occur exclusively during episodes of anorexia nervosa.




Image A primary hypothalamic disturbance secondary to ↑ corticotropin-releasing factor.

Image Central neurotransmitter dysregulation affecting dopamine, serotonin, and norepinephrine.

Image Reduced norepinephrine activity and turnover.

Image Endocrine abnormalities, low triiodothyronine (T3), high T3 receptor uptake (T3RU), impaired thyrotropin-releasing hormone (TRH) responsiveness, abnormal dexamethasone suppression test.


Image Predominantly found in women (4% prevalence).

Image Predominant in whites.

Image More common in industrialized countries.

Image Culturally dependent.


Image Secretive binge-eating and purging behaviors.

Image Abuse laxatives, diuretics, or stimulants in an effort to enhance weight loss.

Image Obsessive interest in physical activity.

Image Physical manifestations include parotid gland enlargement, dental caries, scars on dorsum of fingers (due to teeth scraping during self-induced vomiting).

Image Laboratory abnormalities include dehydration, hypokalemia, hypochloremia, hypomagnesemia, elevated blood urea nitrogen (BUN), and amylase.


Group therapy is the most effective treatment.

Eating Disorder Not Otherwise Specified (NOS)


Abnormal eating behaviors or exhibits characteristics of other eating disorders without meeting all criteria. Examples include:

Image Meets all criteria for anorexia nervosa except weight falls within normal range or does not have amenorrhea.

Image Meets all criteria for bulimia nervosa but binge eating does not meet duration/frequency criteria.

Image Binge eating in the absence of purging activities.



Image Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning.

Image Onset is between 3 and 12 months in normal infant; later in the mentally retarded.

Image Other medical and psychiatric conditions have been ruled out.


Rumination comes from the Greek root, ruminare, meaning “to chew the cud.”


Image Adverse psychosocial environment.

Image Mental retardation.


Image Unsatisfactory mother-infant relationship that causes the infant to seek an internal source of gratification.

Image Positive reinforcement when attention follows rumination.

Image Negative reinforcement when rumination reduces anxiety.


Highest prevalence in normal infants and mentally retarded adults.


Image Presents with “spitting up” or frequent vomiting.

Image Effortless regurgitation, does not involve retching.

Image Infants are irritable and hungry between episodes of regurgitation.

Image Malnutrition, weight loss, failure to thrive.

Image Up to 25% mortality rate.


Image Counseling to improve parent-child dynamics.

Image Behavioral intervention.

Image Aversive techniques, noxious stimulus is paired with rumination.

Image Nonaversive techniques, differential reinforcement or other incompatible responses.

Image In infants, the disorder frequently remits spontaneously.



Image Persistent eating of nonnutritive substances for a period of at least 1 month (eg, clay, dirt, etc.).

Image The eating of nonnutritive substances is inappropriate to the level of development.

Image Behavior is not culturally sanctioned.

Image Rule out other psychiatric disorders.


Image Mental retardation.

Image Vitamin or mineral deficiencies (eg, iron deficiency anemia, particularly in pregnancy).

Image Poverty, neglect, lack of parental supervision, developmental delays.

Image Cultural belief.


Pica is found commonly in PDD and schizophrenia.


Image In children aged 18 months to 2 yr, the ingestion and mouthing of nonnutritive substances is normal behavior.

Image Most common during the second and third years.

Image The prevalence ↑ with the severity of mental retardation.


Image Presenting complaint—“puts everything in his or her mouth.”

Image Direct observation of pica.

Image Complications:

Image Ingestion of paint chips can → lead poisoning.

Image Hair or large objects can cause bowel obstruction.

Image Sharp objects such as pins or nails can cause intestinal perforation.

Image Ingestion of feces or dirt can result in parasitic infections.


Image Often remits spontaneously.

Image Treat underlying vitamin deficiency, if present.

Image Psychotherapy—assess why pica is occurring.

Image Behavior modification.

Image Direct observation and removal of potential pica.


See Table 21-2 comparing somatoform disorders, factitious disorders, and malingering.


Image Symptoms without physical cause.

Image Symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

Image Includes somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder NOS.

TABLE 21-2. Somatoform Disorders versus Factitious Disorders versus Malingering



Image Psychodynamic therapy: Gain insight into unconscious conflicts and understand how psychological factors have influenced maintenance of the symptoms.

Image Identify and eliminate sources of secondary gain in order to avoid reinforcing the symptoms.

Image Improve self-esteem, promoting assertiveness, and teach nonsomatic ways to express distress.

Image Group therapy: Learn better coping strategies and improved social skills.

Somatization Disorder

History of many physical complaints, including at least:

Image Pain symptoms at more than four sites that are not intentionally produced.

Image Two nonpain GI symptoms.

Image One sexual or reproductive complaint.

Image One pseudoneurologic complaint.

Image Age of onset < 30 years old.

Conversion Disorder


Image Sensory symptoms, motor deficits, or pseudoseizures that are not intentionally produced.

Image Cannot be explained by an organic etiology.

Image Initiation of the symptom or deficit preceded by a psychological stressor.

Image Unintentional and involuntary.

Image Appropriate investigation leaves no medical explanation of symptoms.

Image Symptoms cause impairment in social functioning.

Image Other etiologies for the clinical presentation are ruled out.


Favorable prognosis for conversion disorder is associated with acute onset, definite precipitation by a stressful event, good premorbid health, and the absence of previous psychiatric illness.


Conversion disorder may be associated in some cases with history of a traumatic brain injury.


Image Psychodynamic theory: Certain developmental predispositions respond to particular types of stress with conversion symptoms.

Image Behaviorists: A learned excess or deficit that follows a particular event or psychological state and is reinforced by a particular event or set of conditions.

Image Sociocultural: Predisposition of various ethnic and social groups to respond to stress with conversion symptoms.


A proportion of patients diagnosed with conversion disorder go on to develop demonstrable organic pathology (eg, multiple sclerosis or seizure nidus).


Image More common in women, rural areas, and lower socioeconomic classes.

Image Rare in children < 10 years.

Image Incidence ↑ in children who have experienced physical or sexual abuse and in those whose parents are seriously ill or have chronic pain.


Image Paralysis, abnormal movements, inability to speak, see, hear; pseudoseizures.

Image Usually occurs within the context of a primary illness such as major depression, schizophrenia, or somatization disorder.

Image La belle indifference, the lack of interest in potentially life-altering symptoms, is common in adults, but rarely occurs in children.



A 17-year-old girl becomes very concerned that a small lump in her left breast is “malignant cancer.” Her histopathology report showed it to be entirely benign. Despite reassurance by her physician she remains excessively worried. What is the cause of her excessive fear and what is the best possible treatment?

She has hypochondriasis, which is defined as a preoccupation with fears of having, or the belief that one has, a serious disease based on misinterpretation of bodily symptoms. The key feature in this condition is an abnormal concern that one is developing or has a serious illness. Psychotherapy that includes exploration of current life problems often result in symptom resolution.


Image Preoccupation over > 6 months with fear of having a disease based on the individual’s misinterpretation of normal bodily sensations.

Image Persistent preoccupation despite adequate medical evaluation and assurance.

Image Causes impairment in social functioning.

Image Other psychiatric diseases ruled out.


Image Associated with anxiety, depression, and narcissistic traits.

Image Past experience with serious illness as a child or of a family member.


Image There is a 1–9% prevalence in young adults.

Image Affects males and females equally.

Image The most common age of onset is early adulthood.


Hypochondriasis can → strained social relationships because of preoccupation with perceived condition and the patient’s expectation of receiving special treatment.


Image Complaints involving most organ systems.

Image Multiple visits to different doctors and deterioration of doctor-patient relationships.

Image Individuals often believe that they are not receiving proper care so they pursue more opinions.

Image Receive many evaluations and unnecessary surgeries.

Image May become addicted to drugs as a result of their chronic ongoing physical complaints.


Image The primary aim of therapy is to help the patient identify and manage the fear of serious illness.

Image In addition to techniques helpful for somatoform disorders:

Image Behavior modification techniques: Earn points to participate in daily routine despite feeling sick.

Image Educate about physiologic mechanisms.

Body Dysmorphic Disorder

Image Preoccupation with imagined defect in appearance or excessive concern about a slight physical anomaly (eg, large nose, small muscles).

Image Multiple visits to plastic surgeons or dermatologists are common.

Pain Disorder


Image Pain in one or more anatomic sites of sufficient severity to warrant medical attention but with no physical findings to account for the pain or its intensity.

Image Pain causes impairment in social functioning.

Image Psychological factors are directly related to the onset, severity, exacerbation, or maintenance of the pain.

Image Pain is not intentionally produced or feigned.

Image Rule out other causes of the clinical presentation.


Psychiatric—common in conditions such as schizophrenia, somatization disorder, anxiety, dissociation, conversion, and depression.


Image A defect in ego function underlying the experience and expression of feelings.

Image Psychologically stressful events are converted into somatic symptoms rather than the development and appropriate expression of emotions.


Affects males and females equally.


Alexithymia is the inability to express emotion.


Munchausen Syndrome


Intentional production or feigning of symptoms (eg, thermometer manipulation, self-injury, ingestion, injection) for primary gain (eg, relief of anxiety, assuming the sick role).


Image Children who make themselves sick may have been victims of Munchausen by proxy.

Image Experience of misuse of illness to get attention and reinforcement of these actions.


Image Younger children are more likely than older children/adolescents to admit to deception if approached in a direct and concerned (not accusatory) way.

Image Family therapy: Recognize how family communicates through illness and identify more effective ways of communication and getting what they need from family members.

Image Involvement of primary care doctor/pediatrician in confrontation.

Munchausen Syndrome by Proxy (MBP)


Image Intentional fabrication or actual production of symptoms in a child by a caregiver (usually the mother) in order to gain attention for themselves.

Image A form of child abuse.


Image Adults who commit MBP may have a history of factitious disorders themselves.

Image Ninety-eight percent of perpetrators are women.

Image Mortality rate is 9%.

Image Up to 75% of the morbidity involved relates to physicians trying to treat the unknown conditions.


Image Conditions that do not respond to treatment or whose courses are puzzling and persistent, often:

Image Vomiting/diarrhea (ingestion, syrup of ipecac).

Image Rashes (due to scrubbing with solvents).

Image Failure to thrive.

Image Seizures.

Image Infections.

Image Adding blood or other substances to urine specimens.

Image Physical or laboratory findings that are unusual, discrepant, or clinically impossible or do not occur in the absence of the parent.

Image Medically knowledgeable/fascinated mother who appears to enjoy the hospital setting, who is reluctant to leave child, and herself is dramatic and desires attention.

Image Family history of similar problems or unexplained death in sibling.

Image Signs or history of factitious disorder in mother.


Image Appropriate physician suspicion, good medical records, and reporting of abuse (often multiple doctors have been visited, with little continuity).

Image Caregiver requires psychiatric therapy, such as for other factitious disorders.



Intentional creation of symptoms for secondary gain (eg, getting out of going to school or doing chores).



Image Adoption: Acquiring legal guardianship of an individual.

Image Foster care: Temporary placement of an individual who has been removed from an unsafe environment.

Image Kinship: Placement with relatives.


Image Questions of who the other parents are and why they left him or her and the subsequent impact of the perceived abandonment.

Image Parental assumptions of the behavior and personalities of the people whose union produced the child causes them to be hypervigilant.


Image A narcissistic injury resulting in the assumption that they were unlovable, dirty, bad, or unrewarding to the biological parents.

Image Some blame the biological parents, assuming they were bad, alcoholic, or mentally ill.

Image Assume abandonment could happen again.

Image Unconscious rage at having been abandoned.


Image Adoption is common among individuals who are unable to have children and want a family.

Image Two percent of population is adopted.

Image Foster care is common among children who have been abandoned by their parents or were removed from a dysfunctional environment.


Image Adolescent curious about his or her origins and early life creates conflict within the individual.

Image Continually search strangers’ faces for resemblances.

Image Expression of feelings of abandonment and the desire to find biological parents.

Image Foster child relationships may have been disrupted several times before, so the child is ambivalent toward the parents.

Image Rage, stemming from initial abandonment, causes aggressive and antagonist behavior.


Child could be coached to say, “I am adopted—so what! So was President Ford!”


Image Individual and family therapy.

Image Address disruptive behavior and the etiology.

Image Address issues of abandonment.

Image Enhance communication between child and parents.

Image When to tell the child he or she is adopted?

Image Controversial.

Image Sooner is better (age 3–4 or earlier).

Image How to tell the child he or she is adopted? According to development level.


Patterns of behavior that deviate from cultural standards, can begin in adolescence or early adulthood.

Image Cluster A: “Weird”

Image Paranoid: Distrustful and suspicious.

Image Schizoid: Isolated, a “loner” type with limited emotional expression.

Image Cluster B: “Wild”

Image Borderline: Unstable mood, impulsive.

Image Histrionic: Sexually provocative, attention seeking.

Image Narcissistic: Needs to be admired, has sense of entitlement.

Image Antisocial: Lacks remorse, violates laws of society, breaks the law.

Image Cluster C: “Worried”

Image Obsessive-compulsive: See above.

Image Avoidant: Socially inhibited, intense fear of ridicule and being disliked.

Image Dependent: Submissive, needs to be taken care of, cannot be on their own.

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