Disorders
Personality Disorders
Cluster A = Odd, Eccentric
Cluster B = Dramatic, Emotional
Cluster C = Anxious, Fearful
Histrionic Personality Disorder [Cluster B – dramatic, emotional ]
Characterized by:
A pervasive pattern of excessive emotionality and attention-seeking behavior beginning in early
adulthood.
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Demonstrate excessively labile emotions attention seeking behavior
Often use their physical appearance to draw attention
May behave in a sexual provocative manner
They tend to exaggerate and dramatize their emotions, which otherwise lack depth
Dependent Personality Disorder [Cluster C – anxious, fearful]
Characterized by:
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Excessive need to be cared for or protected
Tend to be clingy and submissive with loved ones
Indecisive
Avoid taking initiative because of feelings of inadequate
Have difficulty expressing disagreement with others for fear of losing support
Dread being left alone to fend for themselves
Borderline Personality Disorder [Cluster B – dramatic emotional]
Characterized by:
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Identity disturbance
Impulsivity (marked)
Recklessness
Show a pattern of instability in relationships
They swing wildly between scoring and idealizing people (splitting)
May demonstrate suicidality or self-mutilating behavior
Common feelings are anger and chronic emptiness
Schizotypal Personality Disorder [Cluster A?]
Characterized by:
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Eccentric behavior
Reduced capacity for close relationships
Usually exhibit “magical thinking” inconsistent with cultural norms
They may have bizarre fantasies or believe in telepathy, clairvoyance, or the concept of
a sixth sense
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Often have paranoid ideation
Often have unusual perceptual experiences
Schizoid Personality Disorder
Characterized by:
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Lifelong pattern of social detachment
Restricted range of emotions
Solitary lives, aloof, isolated
No interest in socialization
Do not enjoy close relationships with others
Rarely indulge in any pleasurable activities
Appear indifferent to praise or criticism
No psychosis or bizarre cognition
Schizoaffective Disorder
Characterized by:
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Multiple psychotic episodes with concurrent major depressive or manic episodes
> 2 weeks period free of mood symptoms with paranoia, delusions, or hallucinations
present
Mood symptoms present for majority of total illness
Not due to substances or another medical condition
Must distinguish from:
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Major Depressive Disorder or Bipolar Disorder with psychotic features
 Mood symptoms co-exist with psychosis
Schizophrenia associated mood symptoms
 These are absent or present for only brief periods
2 subtypes: Bipolar or Depressive
Avoidant Personality Disorder [Cluster C]
Characterized by:
 Shyness, social inhibition
 Feelings of inferiority/inadequacy
 Desire to make friends that is overridden by an intense fear of embarrassment or rejection
 Afraid to have intimate relationships
 Fear of judgment
 Perceive themselves as inferior
 Low self-esteem
 Hypersensitive to criticism
Paranoid Personality Disorder [Cluster A – odd, eccentric]
Characterized by:
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Distrust
Fear
Frequently have unfounded suspicion and mistrust of the motives of others
May find it difficult to confide in or forgive people.
Pervasive pattern of suspiciousness or odd beliefs (no clear delusions, not to level of
delusion)
Often read too much into things
Bear grudges
Accuse others of trying to harm them in some way
Antisocial personality disorder [Cluster B = Dramatic, emotional]
Characterized by:
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> 18 years old
Disregard for and violation of rights of others.
Illegal activities (eg drug use, assault, theft)
Endanger the well-being of others
Frequently lie
Tend to be aggressive, impulsive and have difficulty maintaining employment
Frequently display a superficial charm that allows for the manipulation of others.
History of conduct disorder during adolescence (common)
DDX of Conduct Disorder:
- < 18 years old
Requires at least 3 symptoms from the following categories:
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Aggression towards people or animals
Destruction of property
Deceitfulness or theft
Serious violation of rules
Serious violation of the rules
Narcissistic Personality Disorder [Cluster B - dramatic, emotional]
Characterized by:
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Exaggerated sense of self importance
Feelings of entitlement
Lack of empathy for others
Willingness to exploit others
Crave constant admiration
May be preoccupied with thoughts of unlimited power or success
Obsessive compulsive personality disorder
Characterized by:
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Preoccupations with orderliness or precision.
Perfectionism that negatively impacts their functioning
Typically stubborn and inflexible
Believe there is only one way to do things
Overly devoted to their work
Can have difficulty throwing out worn items
Often have trouble in their relationships because of their need for perfection
Often even need to play games by following rules precisely
Often don’t see their behavior as problematic
Eating Disorders
Anorexia
Compulsive disorders
Obsessive Compulsive Disorder (OCD)
Is characterized by:
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Recurrent intrusive obsessive thoughts
 Cause marked distress and anxiety
Repetitive + compulsive behaviors are preformed
 In an effort to relieve the anxiety
Patients usually recognize absurdity of behavior but feel helpless to control it
Often perform multiple time-wasting rituals
Theroized that altered levels of serotonin contribute to OCD
Treatment:
SSRIs are 1st line
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Fluvoamine (Luvox)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Second line with FDA approval of OCD
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Clomipramine (Anafranil) – a TCA
Trichotillomania (Hair Pulling Disorder)
DSM-5 classifies as an obsessive compulsive related disorder
Is characterized by:
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Recurrent hair pulling resulting in hair loss
Repeated attempts to decrease/stop hair pulling
Significant distress or impairment
Not due to medical / dermatological condition (eg Alopecia acreata)
Not due to another mental disorder (eg Body Dysmorphic Disorder)
Patients don’t have intrusive thoughts
Commonly affected sites:
 Scalp
 Eyebrows
 Eyelids
Note: In contrast to alopecia areata, patches of missing hair have broken shafts of varying
lengths
Treatment:
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Cognitive behavioral therapy (habit reversal training)
Trichophagia
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swallowing of hair
Can lead to bowel obstruction
Hoarding Disorder
DSM-5 classifies as an obsessive compulsive related disorder
Is characterized by:
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Difficulty discarding possessions regardless of their actual value
Due to perceived need to save items or distress related to discarding them
Accumulation of items congests and/or clutters living areas and compromises daily life
Distress of functional impairment including safety issues occurs
Stress may intensify symptoms
Disorder is considered chronic
Onset typically occurs during adolescences or young adulthood, or it may begin after brain
damage (eg strokes, surgery, injuries, infections)
Generally significant lag time (years) between onset of symptoms and seeking treatment
Treatment:
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SSRIs
Cognitive therapy
Body Dysmorphic Disorder
DSM-5 classifies as an obsessive compulsive related disorder
Is characterized by: Persistent subjective feelings of ugliness
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Preoccupation of > 1 Perceived (slight) physical defects
Defects are not observable or appear slight to others
Repetitive behavior or mental acts performed in response to the preoccupation
Significant distress or impairment
Specify insight (good, poor, absent/delusional beliefs)
Typically patients will have symptoms after surgical intervention
 Often seek out “Serial Surgeries”
Treatment:
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Appropriate 1st response would be to establish a therapeutic alliance with the patient
 Requires a measured sensitive empathetic approach that take into account
the patient’s level of insight
 Gently explore the patient’s thoughts
 Educate about non-surgical treatment options that may exist
 Minimize invasive interventions
Psychotherapy
Referral to psychiatrist
Medication (SSRIs)
Anorexia Nervosa vs Bulimia
Anorexia Nervosa
BMI: < 18.5
Characterized by:
Two subtypes
 Restriction subtype
 Excess exercise and/or calorie
restriction
 Binge – eating / purging subtype
On PE:
 Emaciation
 Lanugo – Downy hairs
 Calluses on hand “Russell’s sign”
 From purging, also can be found in
bulimia
Treatment:
 Cognitive - behavioral therapy
 Nutritional Rehabilitation
 Olanzapine (if no response)
Anorexia Nervosa
Bulimia
BMI: Maintains normal weight [18.5-30]
Characterized by:
Binge eating followed by compensatory behavior
 Recurrent episodes of uncontrolled binge
eating followed by feelings of extreme
disgust or guilt
 Compensatory behavior to prevent weight
gain after binging (eg induced vomiting,
laxative abuse, diuretic abuse, fasting,
excessive exercise)
Treatment:
 Cognitive - behavioral therapy
 Nutritional Rehabilitation
 SSRI (in addition)
Characterized by:
Two subtypes
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Restriction subtype
 Excess exercise and/or calorie restriction
Binge – eating / purging subtype
On PE:
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Emaciation
 BMI = <18.5
Lanugo – Downy hairs
Calluses on hand “Russell’s sign”
 From purging, also can be found in bulimia
Common Findings:
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Osteoporosis
Elevated cholesterol and carotene levels
Cardiac arrhythmias (prolonged QT intervals)
Euthyroid sick syndrome
Hypothalamic-pituitary axis dysfunction
 Resulting in anovulation, amenorrhea, and estrogen deficiency
Hyponatremia secondary to excess water drinking
 Presence of other electrolyte abnormalities indicates purging behavior
Most common in:
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Adolescent girls
Affluent families
Perfectionist personalities
Other risk factors:
Gymnastics
Ballet
Beauty pageants
Etc… pressure to maintain slim habitus
Possible complications include:
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Bradycardia
Electrolyte imbalance
 Hypokalemia
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Hypophosphatemia
Note: Do not give bupropion to patients with eating disorders!
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Refeeding syndrome
 Electrolyte depletion
 Arrhythmias
 Heart failure
Euthyroid hypothyroxinemia
Due to:
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 Decreased albumin
 Decreased thyroxin binding globulin
Amenorrhea
Hospitalize if:
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Unstable vital signs
 Severe bradycardia or cardiac dysrhythmias
Electrolyte derangements
Goals of treatment include:
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Nutritional rehabilitation
Weight gain
Note: Patients should be monitored closely for refeeding syndrome
Pregnancy in patients with Anorexia Nervosa (past/current)
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Diminished fertility
Risk of complications:
 Miscarriage
 Intrauterine growth retardation
 Hyperemesis gravidarum
 Premature birth
 Cesarean delivery
 Postpartum depression
Osteoporosis is a common finding in anorexic patients (pregnant or not)
Bulimia
Is characterized by:
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Recurrent episodes of uncontrolled binge eating followed by feelings of extreme disgust or guilt
Compensatory behavior to prevent weight gain after binging (eg induced vomiting, laxative
abuse, diuretic abuse, fasting, excessive exercise)
Binging episodes that occur at least twice per week over a three month period
Normal or slightly above normal BMI
dissatisfaction with body weight/shape
Precipitating factors for binge-purge episode includes:
 High levels of anxiety
 Emotional tension
 Boredom
 Exhaustion
 Poor self esteem
 Environmental cues about food and eating, alcohol use, substance abuse, mood disorders
Treatment:
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Cognitive - behavioral therapy
Nutritional Rehabilitation
SSRI (in addition)
Note: Borderline Personality Disorder is frequently diagnosed in patients suffering from bulimia
nervosa
Note: Binge eating disorder is similar but has no compensatory behavior, it is still treated with SSRIs
and cognitive therapy etc…
Tourette Disorder
DSM-5:
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Both multiple motor and > 1 vocal tics (not necessarily concurrent) tics may wax and wane,
>1 year
Motor:
 Facial grimacing
 Nose twitching
 Blinking
 Head/Neck jerking
 Shoulder shrugging
 Tongue protrusion
 Sniffing
Vocal:
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Grunts
Squeaking
Snorts
Throat clearing
Coughing
Barking
Yelling
Coprolalia (obscenities)
Onset before age 18
Tics are usually:
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Preceded by:
 Irresistible urges
Followed by:
 Feelings of relief
Exacerbated by:
 Stress and Fatigue
Symptoms tend to subside:
 During sleep
Occur many times a day (frequently in bouts)
Nearly every day or at regular intervals for at least one year
Treatment:
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Pharmacotherapy when sypmtoms interfew with socal, academic, or occupational
functioning
Antipsychotics
 First generation antipsychotics:
 Pimozide* FDA approved [SE: prolongs QT interval]
 Haloperidol* FDA approved
 Fluphenazine
 Second generation antipsychotics:
 Risperidone and others
 Although these are not FDA approved for treatment they are generally
preferred
Alpha adrenergic receptor agonist
 Clonidine
 Guanfacine
Behavioral therapy (habit reversal training)
Common Comorbidities:
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OCD (27%)
 Usually develops within 3-6 years after the tics first appear
 May peak in late adolescence or in early adulthood at a time when the tics are
waning
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ADHD (60%)
Less common:
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Anxiety
Depression
Impulse control disorders
Also increase incidence of conduct disorder, oppositional defiant disorder, antisocial
personality disorder
Adjustment Disorder (with…)
Characterized by:
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Emotional or behavioral symptoms develop that develop following an identifiable
stressor
Increased anxiety, depression, or disturbed behavior that develops in response to a
stressor
Within 3 months of event/stressor symptoms cause marked distress in excess of that
expected from exposure to the stressor
Rarely lasts more than 6 months
Functional impairment is present
By convention if the patient’s symptoms meet the full criteria for a major depressive
episode the diagnosis of adjustment disorder is not applicable.
Cannot be diagnosed if patient meets criteria for another disorder.
Treatment:
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Cognitive or psychodynamic psychotherapy (1st line)
SSRIs may be used adjunt if patient is suffering from depressive symptoms
Post Traumatic Stress Disorder
Characterized by:
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Intrusive memories thoughts, nightmares, and/or flashbacks about a traumatic event
Hypervigilance
Avoidance behavior
Symptoms last at least 1 month and can last for many years
Known triggers include:
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Military combat
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Natural Disasters
Serious Motor Vehicles
Violent Assault
Sexual Abuse
Kiddnapping
Treatment:
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Eye movement desensitization and reprocessing treatment
Acute stress disorder
DDX requires exposure to an actual or threatened death, injury, or sexual violation
Symptoms develop within 4 weeks of trauma and last no more than 8 weeks total (from event)
Symptoms are identical to PTSD:
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Flashbacks (related to the trauma)
Nightmares (related to the trauma)
Intrusive memories (related to the trauma)
Social detachment
Poor sleep
Dissociation
Hyperarrousal
Avoidance
Negative mood
Cyclothymic disorder [Not considered a true mood disorder any more]
Characterized by:
 At least 2 years of fluctuating mild hypomanic and depressive symptoms.
 Episodes do not meet criteria for hypomanic episodes or major depressive episodes
Delusional Disorder
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Subtypes:
Erotomanic
Grandiose
Jealous
Persecutory
Somatic
Characterized by:
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Non-bizarre delusions (logically, possible)
Fixed and persistent
> 1 month
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Otherwise (high) functioning, otherwise not impaired
Other psychotic symptoms absent
Behavior is not obviously bizarre or odd
Not due to substances or medial conditions
Dissociative Disorders
The dissociative disorders are characterized by forgetfulness and dissociation.
Dissociative Identity Disorder
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Formerly known as Multiple Personality Disorder
Characterized by:
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Presence of two or more distinct personalities that alternately assume control of the
person’s behavior
Amnesia about important personal information about some of the identity is observed
Dissociative Amnesia
Characterized by:
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Presence of one of more episodes of inability to recall important personal information
Memory disturbance is usually related to a traumatic or stressful event
Disturbance is too extensive to be considered ordinary forgetfulness
Depersonalization Disorder
Characterized by:
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Persistent or recurrent feelings of detachment from one’s own physical or mental
processes
In the context of an intact sense of reality
They tend to feel that they are observing their body and thoughts from afar, as if they
are living in a dream
Condition usually results in significant occupational and functional impairment
Derealization Disorder
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Describes the state of experiencing familiar persons + surroundings as if they were
strange or unreal
Dissociative Fugue
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Evidence in support of this diagnosis includes:
 Sudden and unexpected travel
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Inability to remember their past
Confusion about their personal identity
At times these patients assume new identities all together
Pathologic Gambling
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Defined as a persistent and maladaptive gambling behavior that usually results in a
preoccupation with gambling and arranging for the means to indulge in it.
More common in men
Chronic history of gambling
Inability to stop
Common consequences of this behavior
 Significant financial losses
 Damage to relationships
When confronted about the issue pathologic gamblers are usually dishonest and evasive
Gambling may be uses to escape problems or relieve unhappiness
Kleptomania
Clincial Features:
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Rare impulse control disorder
Typical onset in adolescence
Repeatative failure to resist impulses to steal
Stolen objects have little value and are not needed for personal use
Increasing tension prior to theft; pleasure or relief when committing theft
Stolen objects given away, discarded, or returned
Guilt and remorse are common
Differential Diagnosis:
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Shoplifting
 Theft for personal gain; much more common
Antisocial personality disorder
 General pattern of antisocial behavior
Bipolar disorder, manic episode
 Impulsivity, impaired judgment
Psychotic disorder
 Stealing in response to delusions, hallucinations
Treatment:
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Cognitive behavioral psychotherapy is treatment of choice
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Barriers to obtaining care may be fear of moral judgment and legal repercussions
Doesn’t generally respond well to medication
Pyromania
DSM-5 diagnosis:
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Deliberate fire setting on more than 1 occation
Tension, arousal prior to act
Fascination with fire and its consequences
Pleasure or relief when setting / witnessing fires
No obvious motive
 No external gain
 No revenge
 No political motivation
 Not done to attract attention
Not better explained by:
 Conduct disorder
 Manic episode
 Psychosis
 Antisocial personality disorder
 Impaired judgment (eg neurocognitive disorder, substance intoxication)
Genito-Pelvic Pain / Penetration Disorder
Is characterized by:
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Ongoing difficulties with at least one:
 Vaginal penetration during intercourse
 Vaginal or pelvic pain during intercourse or attempted penetration (or fear or anxiety in
anticipation of, during, or after)
 Tenseness of pelvic floor muscles during attempted vaginal penetration
At least 6 months in duration
Significant distress
Not accounted for by other: medical, mental, substance, relationship issues
Female Orgasmic Disorder
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Consists of a persistent delay in of absence of orgasm on all or nearly all occasions of sexual
activity
Female sexual interest / Arousal Disorder
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Lacking or having significantly less interest in sexual activity
Gender Dysphoria
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Considered to be an incongruence between a patient’s expressed gender and assigned
gender for at least 6 months
Patients with this condition may wish to be treated as the other gender or to be rise of their
sexual characteristics
Anxiety
Generalized Anxiety Disorder (GAD)
Is characterized by:
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Chronic multiple worries, anxiety, tension about many events/situations
Multiple aspects of one’s life (eg work, family, finances health etc…)
Patients have a hard time keeping these worries out of their mind and find them very
distressing
> 6 months duration
Plus 3 or more of the following symptoms:
 Impaired Sleep
 Poor Concentration
 Easy Fatigability
 Irritability
 Muscle Tension
 Restlessness
Treatment:
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First line:
 Cognitive behavior therapy
 SSRIs or SNRIs
Second Line:
 Benzodiazepines
 adjunct to manage acute anxiety, while waiting for SSRI or SNRI to kick in
 Buspirone
 Only in GAD without comorbid depression or panic symptoms
Others
 Ziprasidone
 Sometimes used in refractory cases
 Phenelzine (an MAOI)
 Is effective but not 1st line
Social Anxiety Disorder (Social Phobia)
Is characterized by:
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Fear of one or more social situations
Excessive fear of embarrassment and humiliation in social situations
Fear of scrutiny of others
Marked anxiety about > 1 social situations for > 6 months
Socail situations avoided or endured with intense distress
Marked impairment (eg social, academic, occupational
Generalized:
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Anxiety about meeting new people
Anxiety about initiating and maintaining conversations
Anxiety about being observed by others
Anxiety about going to a party (or other social gathering)
Treatment:
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Cognitive Behavioral Therapy
SSRIs/SNRIs
 Example: paroxetine
Performance-Only:
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Anxiety about public speaking, presentations, or performances
Patients do not fear non-performance situations
Treatment:
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Cognitive behavior therapy
It is inappropriate to prescribe a daily medication in a patient who only has performance
anxiety and no comorbid depression
Benzodiazepine or beta-blocker (eg propranolol)
 30-60 minutes prior to the anxiety-provoking situation
Avoid Benzodiazepines if substance abuse is present or sedation is not desired
 Lorazepam – is a bad choice in an academic performance situation
Specific Phobia
History and Clinical Features:
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Marked anxiety about specific object or situation
> 6 months
Types/examples:
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 Flying
 Heights
 Animals
 Injections
 Blood
Avoidance behavior
 Bridges
 Elevators
 Refusing work requiring travel
Common – 10% of population
Usually develops in childhood can develop after trauma
Do not have unexpected panic attacks (as in panic disorder)
Treatment:
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Behavioral Therapy is first line
 Systematic desensitization
 Habituation
Short acting benzodiazepine for acute anxiety relief
Note: Simple phobia is restricted to a fear of a single event
Panic Disorder:
Is characterized by:
1. Recurrent and unexpected panic attacks with > 4 of the following:
 Palpitations
 Sweating
 Trembling or shaking
 SOB or smoothing sensation
 Choking sensation
 Nausea or abdominal distress
 Dizziness or light headedness
 Chills or heat sensation
 Paresthesias
 Derealization or depersonalization
 Fear of losing control of “going crazy”
 Fear of dying
2. At least 1 attack followed by 1 or both of the following for > 1 month:
 Worry about additional panic attacks or consequences
 Changes in behavior related to attacks (ie avoidance)
3. Panic attacks not attributable to another mental illness or substance abuse
Treatment:
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Immediate: Benzodiazepines
Long-term: SSRI/SNRI
 +/- cognitive behavioral therapy
Common Comorbidities:
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Major Depression
Bipolar Disorder
Agoraphobia (fear of public places)
Substance abuse
Also linked to a higher rate of suicide attempts or suicidal ideation
Anxiety Disorder due to a Generalize Medical Condition
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Diagnosed when there is evidence that the anxiety is the direct pathophysiological
consequence of another medical condition
Examples:
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Thyrotoxicosis
Pheochromocytoma/Paraganglioma
Illness Anxiety Disorder (Hypochondriasis)
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Misinterpretation of bodily symptoms and persistent fear of fatal illness, despite negative
medical work ups
Is characterized by:
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Excessive anxiety and preoccupation with the possibility of having some serious
undiagnosed disease
Minimal or no symptoms
Anxiety persists despite negative evaluations and attempts at reassurance
 Gentle reassurances are generally not very effective
Usually develops during period of stress
 Inquire about stressors
Treatment:
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Refer for brief psychotherapy
Somatic Symptom Disorder:
Characterized by:
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Excessive anxiety and preoccupation with > 1 unexplained symptoms
 Minor symptoms: pain, heartburn, fatigue
1 or more Physical symptoms that are distressing or result in significant disruption of
daily life
Excessive thoughts, feelings, or behaviors relating to those symptoms
 Unwarranted and persistent thoughts about the seriousness of the condition
 Persistent anxiety about health or symptoms
 Too much time dedicated to symptoms
Persistent symptoms for > 6 month
These symptoms may represent normal body sensations or minor discomfort that does
not signify serious disease
They may or may not be associated with another medical conditions and concurrent
medical (mental?) illness is not mutually exclusive
If another medical condtion or high risk for developing one is present (eg Family History)
The preoccupation is typically excessive
These patients use medical services frequently
Treatment:
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These patients benefit from regularly scheduled visits to provide reassurance and focus
on psychological distress
Malingering
Characterized by:
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Grossly exaggerated physical or psychological complaints
Often accompanied by the intentional production of false physical symptoms
A marked disparity between the patient’s disability and the objective findings is usually
present
Always associated with secondary gain (eg financial compensation, leave from work,
narcotics)
Factitious Disorder
Characterized by:
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The intentional production of false physical or psychological symptoms
Or actual induction of disease
 To generate signs of disease patients may:
 Manipulate laboratory tests
 Surreptitiously use insulin
 Inject themselves with harmful substances (eg fecal matter)
In order to assume the sick role
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Patients may undergo numerous surgeries and invasive procedures (
 Can result in scarring and adhesions
No secondary gain
Note: Severe Factitious di order in which patients seek invasive potentially life-threatening
procedures is often referred to as Munchausen syndrome
Note: Patients are often knowledgeable about which diagnoses / symptoms warrant admission
Conversion Disorder (aka Functional Neurologic Symptom Disorder)
Characterized by:
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Development of unexplained serious neurological symptoms preceded by an obvious
emotional trigger (eg a tragic event or an argument)
Symptoms are not artificially produced (or faked), not intentionally produced
Symptoms are unexplained by any medical condition
 Neurologic symptoms are inconsistent with any neurologic disease
Symptoms can be severe enough to cause social and functional impairment
Often acute onset
Patients may appear indifferent to symptoms (or they can be hysterical)
 “la belle indifference”
Common Presenting Symptoms:
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Weakness and/or paralysis
Non-epileptic seizures
Movement disorders
Speech or visual impairment
Swallowing difficulties
Ataxia
Aphonia
Sensory disturbances
Cognitive symptoms
Treatment:
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First line – Education and self-help techniques
Second line – Cognitive Behavioral Therapy
Physical therapy for motor symptoms
Folie à deux (Shared Psychotic Disorder)
Characterized by:
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Development of delusions in a person in a close relationship with someone with a
delusional disorder
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Often resolves upon separation
Substance-Induced Mood Disorder

Is diagnosed when
o A drug of abuse
o A medication
Or
o A toxin
Appears to be etiologically related to the mood symptoms