Download DSM-IV Workshop Outline

3/20/99
DSM-IV Workshop Outline
Kenneth P. Drude, Ph.D.
Dale Bertram, Ph.D.
Bill Dvorak, LISW
March 18 & 19, 1999 Schedule
9:00 a.m.
Begin
10:30 a.m. to 10:45 a.m. Break
12:00 p.m. to 1:00 p.m.
Lunch
2:30 p.m. to 2:45 p.m.
Break
4:00 p.m.
End
1. Introduction to the DSM-IV
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Purposes of the workshop – an introduction to the DSM-IV manual and the DSM-IV classification system
Purposes (goals) of the DSM-IV, serve as a common language, settings where used – clinical (outpatient,
inpatient), educational, research; administrative, third party payers, funding for services– is a major money
source for the American Psychiatric Association who publishes it
The DSM-IV is the most widely used classification system for describing mental health problems.
• Required use by national accrediting organizational standards such as JCAHO, Council on Accreditation
for Services to Families and Children
• Giving a client a diagnosis is uncomfortable for some clinicians for a variety of reasons; however they are
often faced with either assigning a diagnosis or using a diagnosis someone else may have given.
• Functions of diagnoses
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Regulating client flow- diagnoses are used to define who gets what services. For example many
publicly funded mental health services now require that a person be severely or chronically
mentally ill which includes having a specific diagnosis from a list of diagnoses such as
Schizophrenia or Mood Disorders. This list of diagnoses can change as well as which diagnosis
someone is given which effects eligibility for services that they may need.
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Protecting clients from harm – an ethical issue that not uncommon is weighting the potential
harm that a diagnosis may cause someone. This results in some clinicians “underdiagnosing”
clients in order to minimize the possible negative effects a diagnosis may have on their client. On
the other hand given inaccurate diagnoses can also cause problems.
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Acquiring Fiscal Resources – 3rd party payers (insurance companies, Medicare, Medicaid) restrict
payment for services based upon diagnosis. Some problems such relationship problems are often
not covered by 3rd party payers. This in turn may lead to “overdiagnosing” by giving someone a
diagnosis that will be reimbursible. When seeing families or couples this may lead to the
diagnosing one individual even when the primary problem is the family system.
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Rationalizing Decision-Making – Even though diagnoses are generally expected to be made prior
to the decision about treatment and guide treatment there are times when a diagnosis may be
made after treatment. An example of this is that if someone is successfully treated with Lithium
they may be more likely to be given a diagnosis of Bipolar I Disorder.
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Advancing a Political Agenda - Increasing what problems are defined as mental disorders gives
mental health providers the means to include more problems and people for services. For
instance Vietnam veterans are credited with successfully advocating that Post Traumatic Stress
Disorder (PTSD) be recognized as a disorder in the DSM III. Some therapist would like to see
marital and family problems recognized in the DSM in order for treatment to be covered under
health insurance plans.
Background about how the DSM-IV evolved from it’s predecessors
• Brief history of previous classification systems and efforts
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The classification of mental illness has a long history. In the United States one impetus for the
development of classifying mental illness was for purposes of doing the census in the 19th
century.
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Overview of the process, politics and controversies since the DSM-II
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Names and dates of DSM with approximate number of diagnoses for each
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DSM I 1952 106 diagnoses
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DSM II 1968 182 diagnoses
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DSM III 1980 265 diagnoses
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DSM III-R 1987 292 diagnoses
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DSM IV 1994 340 diagnoses
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An “evolving” process of changes
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These relatively frequent revisions cause problems in that there is insufficient time to
collect and analyze data that would be relevant to the studying the diagnoses.
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Nature of changes since DSM-III – explicit more specific criteria, multiaxial approach,
atheoretical (previously influenced by psychoanalytic theory about assumed causes or etiology of
disorders)
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DSM-IV had 13 work groups and a Task Force (listed in Appendix J)
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Questions regarding reliability and validity, “field trials”
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One of the major criticisms of the DSM diagnoses is that there is weak validity and
reliability for the categories that have been created. Remember that these were based on a
voting process within relatively small work groups.
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Standardized structured interview instruments have been developed as a way of defining
what information to ask or obtain in order to increase rater reliability in making
diagnoses. Different therapists or clinicians ask different questions and based upon
different information may come to different conclusions about diagnosis.
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Some diagnostic categories have been effected by politics as much as efforts to be based
upon scientific findings. Examples include homosexuality being dropped as a diagnosis.
Another example is the controversy about a diagnosis of Prementrual Dysphoric Disorder
given to women with premenstral syndrome. Decisions about what is included or not
included is not based upon empirical data to justify the decision.
• Relationship to the WHO ICD-9 CM and ICD-10
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The DSM-IV was developed to be consistent with the World Health Organization’s International
Classification of Diseases, Version 10 that is used all over the world since 1992.
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However, the United States is continuing to use an earlier version of the ICD, version 9.
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This means that 3rd party payers typically expect to have insurance claims with DSM-IV
diagnoses translated into ICD-9 numerical codes rather than using the numerical codes that are in
the DSM-IV manual.
• DSM-IV Sourcebook – 5 volume set published by APA
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1-3 are literature reviews, 4 includes reports of data reanalysis of available data, 5 reports on field
trials and has an executive summary regarding work group decisions
Some assumptions underlying the use of the DSM-IV
• Definition of “mental disorder” – there is no discussion or definition of what is “normal”
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The DSM (pp. xxi-xxii) defines a “mental disorder’ as “ a clinically significant behavioral or
psychological syndrome or pattern that occurs in an individual and that is associated with present
distress (e.g. , a painful symptom) or disability (i.e., impairment in one or more important areas of
functioning) or with a significantly increased risk of suffering death, pain, disability, or an
important loss of freedom. In addition, this syndrome or pattern must not be merely an
expectable and culturally sanctioned response to a particular event, for example, the death of a
loved one. Whatever its original cause, it must currently be considered a manifestation of a
behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior
(e.g. political, religious, or sexual) nor conflicts that are primarily between the individual and
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society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the
individual, as described above.”
The use of the word “disorder” focuses the problem in the individual rather the person’s social
context.
Labeling behavior as mental illness or psychiatric often focuses only on the individual with the
label and pathologizes him or her
It is easy to overlook individual strengths when the primary focus of making a diagnosis is a
focus on psychopathology or weaknesses or deficits.
Also by focusing upon an individual it is easy to lose sight of the importance of seeing that
individual in the context of other people and environments
Increasingly as health information about individuals is computerized and more accessible
diagnostic labels given to people will have greater implications for future insurance, job
possibilities.
There is no good agreement about what “normal” is so that there is considerable subjectivity in
how it and “abnormality” is defined.
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Because of this subjectivity it means that a therapist or clinician must make subjective
judgements to what degree or severity of dysfunctioning or how much a person’s
functioning is impaired and how much distress exits compared to other people.
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These types of judgements can vary significantly across therapists or clinicians with the
same client
There are a lot of factors that affect diagnostic labeling: belief systems of the client and clinician,
personal and cultural stereotypes, socioeconomic class of the client and clinician, cultural
backgrounds of the client and clinician, the training of the clinician, gender of the client and
clinician, and personal biases of the clinician
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Cautions in the use of the manual – manual states not a “cook book” for applying labels, need for training
and supervision, legal and ethical issues, use of diagnostic categories when all criteria not met (disclaimer
statement on pg xxiii “The specific diagnostic criteria for each mental disorder are offered as guidelines
for making diagnoses…”. “The proper use of these criteria requires specialized clinical training that
provides both a body of knowledge and clinical skills.” In other words it is left to the clinician to judge
how to apply the criteria in making a diagnosis.
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The DSM has a disclaimer that the developers of the manual make “no assumption that each
category of mental disorder is a completely discrete entity with absolute boundaries dividing it
from other mental disorders or from no mental disorder.”
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The specific criteria, the minimum number of criteria that have to be met or the time frames
required are not based upon empirical findings for the diagnoses
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The DSM manual acknowledges that there can be considerable heterogeneity within a diagnostic
category since a variety of different criteria can lead to the same diagnosis. This also means that
there can be significant overlap between diagnoses since there are common patterns of behaviors
that are in multiple diagnoses
Assessment or data gathering process
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The DSM states that information for purposes of formulating a diagnosis is not sufficient for
developing and individualized treatment plan.
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Sources of information: client interview, test results, other informants, records from other
sources
Relationship to treatment planning process
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The DSM has only four lines of text about treatment (p. xxv) acknowledging that considerable
more information about the person being evaluated beyond what is needed for a diagnosis will be
needed to develop an “adequate treatment plan.”
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If one of the goals of formulating a diagnosis is to guide you in the development of a treatment
plan it is unfortunate that the DSM diagnoses do not easily translate into an individualized
treatment plan for a client.
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To be effective in providing counseling we need to focus on the individual’s problems and the
contexts (external situations) that they live in rather than treating a diagnosis.
Lack of relationship between diagnosis and “a specific level of impairment or disability”
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Cultural and ethnic influences on manual content- those acknowledged in the manual and those not
acknowledged
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Many references are made in the manual that an individual’s cultural context should be
considered in making a specific diagnosis.
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There is a separate appendix for listing and describing syndromes that are considered to be unique
to particular cultures
2. Basics of the DSM-IV
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Manual “chapters” (not numbered in book) and 10 appendices
17 groupings of diagnostic categories in the main body of the manual
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Groupings are usually based upon “shared phenomenological features”; Exceptions include
Adjustment Disorders, Substance-related Disorders which are grouped based upon a shared
etiology.
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Mnemonic tool for remembering DSM categories (Gorton, 1998)
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DSM –F-SCOPE SAM IS SAD
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D – Delirium, dementia, and amnestic and other cognitive disorders
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S – Substance-related disorders
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M – Mood disorders
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F – Factitious disorders
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S – Schizophrenia and other psychotic disorders
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C – Childhood, infancy, and adolescence disorders
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O – Other disorders that may be a focus of clinical attention
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P – Personality disorders
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E – Eating disorders
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S – Somatoform disorders
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A – Anxiety disorders
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M – Mental disorders due to general medical condition
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I – Impulse control disorders not otherwise classified
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S – Sleep disorders
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S – Sexual and gender identity disorders
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A – Adjustment disorders
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D – Dissociative disorders
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Appendix listings in manual alphabetically, numerically, and clustered by relationship
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Appendix A, Decision Tree for Differential Diagnoses
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For 6 groups of diagnoses: Mental Disorder due to General Medical Condition,
Substance-Related Disorders, Psychotic Disorders, Mood Disorders, Anxiety Disorders,
Somatoform Disorders
Appendix B, “Criteria Sets and Axes Provided for Further Study”
These “proposed” 24 diagnoses and 3 scales although described in the DSM as having
“insufficient information to warrant inclusion” as official categories or axes they are presented to
be used as “research criteria sets”
Appendix C, Glossary of Technical Terms
Appendix D, Annotated Listing of Changes in DSM-IV
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Summary of changes from DSM-III-R to DSM-IV
Appendix E, Alphabetical Listing of DSM-IV Diagnoses and Codes
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Appendix F, Numerical Listing of DSM-IV Diagnoses and Codes
Appendix G, ICD-9CM Codes for Selected General Medical Conditions and Medication-Induced
Disorders
Appendix H, DSM-IV Classification with ICD-10 Codes
Appendix I, Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes
Appendix J, DSM-IV Contributors
When making a DSM-IV diagnosis the frequency, intensity , and duration of symptoms and functioning
before and after symptoms need to be considered. This can sometimes means getting information not only the
client but also others such as family members.
Each diagnosis has both a descriptive label and a 3 to 5 digit numerical code or number
• Usually 3 and sometimes 4 or 5 digits to uniquely identify a specific diagnosis and subtypes or descriptors
Severity and course specifiers
• Severity - mild, moderate, severe (used with Mental Retardation, Conduct Disorder, Manic episode,
Major Depressive episode)
• Course Specifiers - in Partial Remission, in Full Remission, Prior History (used with Manic Episode,
Major Depressive Episode, Substance Dependence)
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Partial Remission – all criteria previously met but currently only some being met
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Full Remission – no symptoms present
Principle Diagnosis (inpatient) or Reason for Visit (outpatient)
• Multiple diagnoses on an axis, listing by priority for focus of services, default Axis I priority over Axis II
Provisional Diagnosis
• This specifier or designation is given to a diagnosis “when there is a strong presumption that the full
criteria will ultimately be met for a disorder, but not enough information is available to make a firm
diagnosis.”
Use of “Not Otherwise Specified” category – lower criteria generally, catch-all categories
Indicating diagnostic uncertainty
• V codes
• Diagnosis Deferred on Axis I and Axis II
• Unspecified Mental Disorder diagnosis
• Psychotic Disorder Not Otherwise Specified
• {class of disorder} Not Otherwise Specified
• {specific diagnosis} (Provisional)
Types of criteria
• Remember that the individual criteria included in each of the diagnoses are based upon what the DSM-IV
work groups believed were useful for inclusion and not based upon empirical findings.
• Exclusion Criteria Used to Exclude Other Diagnoses and to Suggest Differential Diagnoses
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“Criteria have never been met for…” e.g. a Manic Episode for a diagnosis of Major Depressive
Disorder
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“Criteria are not met for…” establishes a hierarchy between diagnostic categories or subtypes
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“does not occur exclusively during the course of…” used to exclude a diagnosis for when
symptoms of a diagnosis occur “during the course of another disorder”
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“not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a
general medical condition.” - to rule out symptoms from drugs or medial conditions
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“not better accounted for by…” clinical judgement to consider another related type diagnosis
using the “Differential Diagnosis” section in the description of the diagnostic category
• Criteria for Substance-Induced Disorders
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General guidelines for deciding if drugs (use, intoxication, withdrawal, toxic effects) are the
etiology of symptoms
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“There is evidence from history, physical examination, or laboratory findings of either…”
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symptoms developed during or within a month of Substance Intoxication or Withdrawal
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medication use is etiologically related to the disturbance
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“The disturbance is not better accounted for by a disorder that is not substance induced.”
Criteria for a Mental Disorder Due to a General Medical Condition
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“There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct physiological consequences of a general medical condition.”
Criteria for Clinical Significance
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Usually worded as “…causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.” Clinical (subjective) judgement when this threshold is
exceeded, issue of third party information as well as self report
Types of information in the descriptive text sections for diagnostic categories
• The descriptive text section each diagnostic category or group of categories include as many as 9 sections
• Diagnostic Features “…clarifies the diagnostic criteria and often provides illustrative examples.”
• Subtypes and /or Specifiers ‘provides definitions and brief discussions concerning applicable subtypes
and /or specifiers.”
• Recording Procedures “provides guidelines for reporting the name of the disorder and for selecting and
recording the appropriate ICD-9-CM diagnostic code” and applying a subtype or specifier to a diagnosis
• Associated Features and Disorders
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Associated descriptive features and mental disorders
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Associated laboratory findings
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Associated physical examination findings and general medical conditions
• Specific Culture, Age, and Gender Features - information about the variation of what a diagnosis
looks like due to culture, developmental or chronological age or gender
• Prevalence information by treatment setting “data on point, lifetime prevalence, incidence, and lifetime
risk
• Course “describes the typical lifetime patterns of presentation and evolution of the disorder”
information about typical age of onset, mode of onset, episodic versus continuous course, single episode
versus recurrent, duration, and progression over time
• Familial Pattern “describes data on the frequency of the disorder among first-degree biological family
relatives of those with the disorder compared with the frequency in the general population.”
• Differential Diagnosis distinguishing between diagnoses
3. The Five “Axes” of the Multiaxial DSM-IV (25-35)
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Axes I and II are given the major attention of the DSM-IV with little to Axis IV which takes into
consideration cultural and social aspects that could be relevant to a person’s functioning.
Axis I Clinical Disorders, Other Conditions that May Be a Focus of Clinical Attention
Axis II Personality Disorders, Mental Retardation
Axis III General Medical Conditions
Axis IV Psychosocial and Environmental Problems (list of 8 problem groups)
• Problems with primary support group - e.g., death of a family member; health problems in family;
disruption of family by separation, divorce, or estrangement; removal from home; remarriage of parent;
sexual or physical abuse; parental overprotection; neglect of child; inadequate discipline; discord with
siblings; birth of a sibling
• Problems related to the social environment – e.g., death or loss of friend; inadequate social support;
living alone; difficulty with acculturation; discrimination; adjustment to life-cycle transition (such as
retirement)
• Educational problems – e.g., illiteracy; academic problems; discord with teachers or classmates;
inadequate school environment
• Occupational problems – e.g., unemployment; threat of job loss; stressful work schedule; difficult work
conditions; job dissatisfaction; job change; discord with boss or co-workers
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• Housing problems – e.g., homelessness; inadequate housing; unsafe neighborhood; discord with
neighbors or landlord
• Problems with access to health care services – e.g., inadequate health care services; transportation to
health care facilities unavailable; inadequate health insurance
• Problems related to interaction with the legal system/crime - e.g., arrest; incarceration; litigation;
victim of crime
• Other psychosocial and environmental problems – e.g., exposure to disasters, war, or other hostilities;
discord with nonfamily caregivers such as counselor, social worker, or physician; unavailability of social
service agencies
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Axis V Global Assessment of Functioning (copy of scale) – current, highest in past year
4. Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence (37-121)
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Grouped by usual age of presentation or when diagnosis is usually given
Mental Retardation
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Diagnostic criteria: A- “significantly subaverage intellectual functioning” (clinical judgement or
IQ testing); B- impairments in adaptive functioning in at least 2 out of 11 areas (e.g.
communications, self-care, social/interpersonal skills, self-direction, work); onset is before age 18
years
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Subtypes (5): based upon severity of intellectual impairment: Mild (85%), Moderate (10%),
Severe (3-4%), Profound (1-2%), Unspecified (includes when no testing results but poor
adaptive functioning)
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• Learning Disorders
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Diagnostic criteria “significantly below”[usually 2 standard deviations from mean average]
achievement on individualized, standardized tests in reading, mathematics, or written expression
for age, schooling, and level of intelligence that interferes with academic achievement or
activities of daily living that require the particular skill
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Subtypes (4): Reading (dyslexia), Mathematics, Written Expression, Not Otherwise
Specified
• Motor Skills Disorder
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Developmental Coordination Disorder
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Diagnostic criteria: marked impairment in the development of motor coordination that interferes
with academic achievement or activities of daily living
• Communication Disorders
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Diagnostic criteria: communication problems that “interfere with academic or occupational
achievement or with social communication”
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Subtypes (5): Expressive Language, Mixed Receptive-Expressive Language, Phonological,
Stuttering, Not Otherwise Specified
• Pervasive Developmental Disorders
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Diagnostic criteria: “severe and pervasive impairment in several areas of development: reciprocal
social interaction skills, communication skills, or the presence of stereotyped behavior, interests,
and activities.”
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Subtypes (5): Autistic, Rett’s, Childhood Disintegrative, Asperger’s, Not Otherwise Specified
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Autistic Disorder
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Onset prior to 3 years in at least one of these areas: social interaction, language as used
in social communication, symbolic or imaginary play
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Usually no apparent normal development prior to symptoms
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Gross impairment in social interactions, marked delayed or no language development,
stereotyped movements, abnormal posture
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Rett’s Disorder
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Limited to females
Normal development then between 5 and 48 months head growth decreases.
Decreased social interactions, stereotyped hand movements, severe expressive and
receptive language difficulties, associated with severe and profound MR
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Childhood Disintegrative Disorder
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Marked regression after at least 2 years of apparently normal development
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Loss of at least 2 areas of previously developed skills (e.g. language, social, adaptive,
bladder or bowel control, play or motor skills)
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Similar social, language, and behavior deficits as with Autistic Disorder diagnosis
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Asperger’s Disorder
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Severe and sustained impairment in social interactions and development of restrictive,
repetitive patterns of behavior, interests and activities
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No delays in language, cognitive, or adaptive behavior development
Attention-Deficit and Disruptive Behavior Disorders
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Attention-Deficit/Hyperactivity Disorder (ADHD)
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Diagnostic criteria: “a persistent pattern of inattention and/or hyperactivity-impulsivity”
for at least 6 months to a degree that is maladaptive and inconsistent with developmental
level, some symptoms prior to age 7 years, some impairment in at least two settings and
“clear evidence of interference with developmentally appropriate social, academic or
occupational functioning.” Must meet at least 6 out of 9 symptoms in either of two sets
of 9 symptoms (inattention, hyperactivity-impulsivity)
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Subtypes: based upon predominance of inattention or hyperactivity-impulsivity pattern
for the past 6 months. Combined Type, Predominantly Inattention Type,
Predominantly Hyperactive-Impulsive Type, Not Otherwise Specified.
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Conduct Disorder
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Diagnostic criteria – “a repetitive and persistent pattern of behavior in which the basic
rights of others or major age-appropriate societal norms or rules are violated” by
exhibiting at least 3 out of 15 criterion (e.g. aggression to people and animals, destruction
of property, deceitfulness or theft, serious violations of rules) in the last 12 months and at
least one in the past 6 months.
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Type Specifieres: Childhood-Onset Type, Adolescent-Onset Type
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Severity Specifiers: Mild, Moderate, Severe
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Oppositional Defiant Disorder – review vignette and small group exercise
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Diagnostic criteria – “a pattern of negativistic, hostile, and defiant behavior lasting at
least 6 months, during which four (or more)” of 8 criteria are met (i.e. often loses temper,
often argues with adults, often actively defies or reuses to comply with adults’ requests or
rules, often deliberately annoys people, often blames others for own mistakes or
misbehavior, often irritable, often angry or resentful, often spiteful or vindictive)
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Less severe disruptive behaviors than Conduct Disorder and usually no aggression
toward people or animals, destruction of property or theft or lying
Feeding and Eating Disorders of Infancy or Early Childhood
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Pica – eating non-nutritive substances for at least 1 month
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Rumination Disorder – regurgitating and rechewing food for at least 1 month
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Feeding Disorder of Infancy or Early Childhood (“failure to thrive”)
Tic Disorders
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“A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.”
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Tourette’s Disorder –tics nearly every day for more than 1 year with no tic free periods during
that time longer than 3 consecutive months
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Chronic Motor or Vocal Tic Disorder –tics nearly every day for more than 1 year
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Transient Tic Disorder – tics nearly every day for more than 4 weeks but less than 1 year
Elimination Disorders
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Encopresis – “repeated passage of feces into inappropriate places for at least once a month for at
least 3 months – usually involuntary but occasionally intentional, child must be at least 4
years
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Enuresis (Not Due to a General Medical Condition) urinary incontinence at least 2 x’s a week
for at least 3 months or “cause clinically significant distress or impairment” in a major
area of functioning. Child must be at least 5 years old
• Other Disorders of Infancy, Childhood or Adolescence
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Separation Anxiety Disorder
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Diagnostic criteria – “inappropriate or excessive anxiety concerning separation from
home or from those to whom the individual is attached” Meets 3 or more of 8 criteria:
excessive distress in leaving, worry regarding losing or harm to attachment source,
reluctance or refusal to go to school, fear of being alone, nightmares regarding separation,
somatic complaints when separation occurs
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At least 4 weeks duration. Onset before age 18 years.
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Specifer – Early Onset if before age 6 years
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Selective Mutism - voluntary not speaking in specific social situations (e.g. school) although
does speak in other situations
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Reactive Attachment Disorder of Infancy or Early Childhood
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Diagnostic criteria – “markedly disturbed and developmentally inappropriate social
relatedness in most contexts before age 5 years…”. “Pathogenic care” believed to be
responsible for the disturbed behavior.
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Stereotypic Movement Disorder
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Diagnostic criteria – repetitive and nonfunctional behavior such as body rocking, head
banging, self biting, picking at one’s own body, hitting self that persists for at least 4
weeks.
5. Delirium, Dementia, and Amnestic and Other Cognitive Disorders (123-163)
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Cognitive disorders are abnormalities in thinking and memory that are associated with temporary or
permanent brain dysfunction.
General criteria: main symptoms are problems in memory, orientation, language, information processing
and attention to task. The cause is assumed to be either a general medical condition, a substance or a
combination of both.
Delirium – review vignette and small group exercise
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“ a disturbance in consciousness” that develops over a short period characterized by a reduction
in “clarity of awareness of the environment” and at least one of the following problems: memory
impairment, disorientation to time, place and language disturbance (e.g. unable to name familiar
objects, rambling or incoherent speech), perceptual disturbances (e.g. illusions, delusions,
hallucinations) that may fluctuate during the day. Inattention is usually one of the first symptoms
seen. Other symptoms may be a disturbance in sleep-wake cycle.
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Subtypes: Due to a General Medical Condition, Substance-Induced, Substance-Withdrawal, etc.
Dementia
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Multiple cognitive deficits including memory impairment and at least one of the following
cognitive disturbances: aphasia (expressive and receptive speech), apraxia (motor task), agnosia
(inability to identify and name objects) or a disturbance in executive functioning (think
abstractly, plan, initiate, sequence, monitor and stop complex behavior). All dementias include
memory loss
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Usually progressive with decrease in daily life functioning
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The course depends upon the cause, it is usually slow for Alzheimer’s type and step-wise fashion
for Vascular Dementia
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Numerous potential diseases may affect the central nervous system
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Dementia of the Alzheimer’s Type (50-60% of dementias) (vignette )
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Most prominent symptoms: agnosia, aphasia, apraxia
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With Early Onset (at 65 years or earlier), With Late Onset (onset after 65 years)
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With Delirium, With Delusions, With Depressed Mood, uncomplicated
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Specifier: With Behavioral Disturbance
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Vascular Dementia (about 20% of dementias)
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Must be evidence of cerebrovascular disease believed related to dementia
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Subtypes: With Delirium, With Delusions, With Depressed Mood, Uncomplicated
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Specifier: With Behavioral Disturbance
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Dementia Due to Other General Medical Conditions
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HIV, Head Trauma, Parkinson’s Disease, Huntington’s Disease, Pick’s Disease,
Creutzfeldt-Jakob Disease, Dementia Due to {name of medical condition}
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Substance-Induced Persisting Dementia
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Name of specific substance is given first that is presumed to cause the dementia,
often alcohol. Problems may appear after discontinuing use after several days or
weeks.
Amnestic Disorders
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“impairment in the ability to learn new information or the inability to recall previously learned
information” due to a physiological consequence of a medical condition – primary memory
problem
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although not a diagnostic criterion, person may confabulate or make up events to fill in memory
gaps
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Amnestic Disorder Due to {name of medical condition, e.g. head trauma, stoke}
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Specifiers: Transient (last for 1 month or less), Chronic (lasts more than 1 month)
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Substance-Induced Persisting Amnestic Disorder (e.g. from chronic alcohol use)
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Name of specific substance is given first that is presumed to cause the memory
disturbance
6. Mental Disorders Due to a General Medical Condition (165-174)
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Disorders characterized by mental symptoms considered to be “the direct physiological consequence of a
general medical condition.” The “general medical condition” is specified using the ICD and also coded on
Axis III.
Some of these disorders are listed in other DSM-IV classes such as Cognitive disorders, Mood, Anxiety,
Psychotic disorders, Sleep disorders. Three are listed separately in this section of the manual
• Catatonic Disorder Due to a General Medical Condition
• Personality Change Due to a General Medical Condition
• Mental Disorder Not Otherwise Specified Due to a General Medical Condition
7. Substance-Related Disorders (175-272)
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Four major categories of disorders: Substance Dependence, Substance Abuse, Intoxication, and Withdrawal
About 120 “disorders related to the taking of drugs of abuse(including alcohol), to the side effects of
medication, and to toxin exposure”
Substances are grouped into 11 classes: alcohol, amphetamines or similar drugs, caffeine, cannabis, cocaine,
hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP) or similar drugs, sedatives, hypnotics or
anxiolytics
Diagnosis must include: specific substance(s) responsible, type of problem (dependence, abuse, intoxication,
withdrawl), and in some cases time relationships between drug use and onset of problem behavior
Substance Use Disorders
• Substance Dependence (vignette of Substance Dependence, Alcohol) [small group exercise]
•
Diagnostic criteria: Cluster of 3 or more of 7 symptoms occurring during the same 12 months
related to repeated self administration resulting usually in tolerance, withdrawal, taking substance
in larger amounts over time or over longer period than intended, unsuccessful efforts to cut down
10
•
on use, giving up important life activities due to substance use, and continued use even knowing
the negative consequences
•
Applied to every drug class except caffeine
•
Specifiers: With Physiological Dependence, Without Physiological Dependence
• Course specifiers: Early Full Remission, Early Partial Remission, Sustained
Full Remission, Sustained Full Remission, On Agonist Therapy, In a
Controlled Environment
• Substance Abuse
•
Similar criteria as substance dependence but fewer criteria are met, applied to all drugs except
caffeine. Focus is on individual not following through on responsibilities, does not have
symptoms for intoxication or withdrawal
•
Diagnostic criteria: pattern of substance use during a 12 month period leading to “significant
impairment and distress” indicated by 1 of 4 criteria: failure to meet major role obligations
(work, family, school), repeated use in hazardous situations, resulting in legal problems,
continued use after having ‘persistent or recurrent social or interpersonal problems” from use
Substance-Induced Disorders
• Substance Intoxication
•
Diagnostic criteria: “the development of a reversible substance specific syndrome due to the
recent ingestion of (or exposure to) a substance.” And “clinically significant maladaptive
behavioral or psychological changes that are due to the effect of the substance on the central
nervous system” developed during or shortly after use of the substance.
•
All drugs but nicotine have a specific syndrome of intoxication.
• Substance Withdrawal
•
Diagnostic criteria: “the development of a substance-specific syndrome due the cessation of (or
reduction in) substance use that has been heavy and prolonged.”
•
Types of symptoms: mood (anxiety, irritability, depression), motor behavior (restless,
immobility), sleep (too little or too much), other physical problems (fatigue, changes in appetite)
•
Used for all drugs except: caffeine, cannabis, PCP, hallucinogens, and inhalants
• Substance-Induced {name of mental disorder]
•
Listed in each of the major class of disorders as a diagnosis
8. Schizophrenia and Other Psychotic Disorders (273-315)
•
Psychotic symptoms – hallucinations, delusions, disorganized speech, impairment of reality testing
• Schizophrenia (Schizophrenia video and small group exercise]
•
Diagnostic criteria: Two or more of the following 5 symptoms, “each present for a significant
portion of time during a 1-month period (or less if successfully treated).”: delusions,
hallucinations, disorganized speech (e.g. incoherent, derailment), grossly disorganized or catatonic
behavior, negative symptoms (i.e. flat affect, alogia (decreased thinking), or avolition (decreased
goal directed activity)). “Continuous signs of the disturbance persist for at least 6 months.”
•
Delusions and hallucinations are the most common symptoms
•
Delusions are defined as “erroneous beliefs that usually involve a misinterpretation of
perceptions or experiences.”
•
Types of delusions: persecutory, referential, somatic, religious, grandiose
•
Hallucinations are “false” sensory perceptions not based upon external stimulation
•
Types of hallucinations: auditory, visual, smell, tactile, taste
•
Positive and Negative Symptoms
•
Positive Symptoms are “an excess or distortion of normal functions” and include:
delusions, hallucinations, disorganized language and communications, and grossly
disorganized or catatonic behavior
11
•
•
•
•
•
•
•
•
Negative Symptoms include such symptoms as decreased capacity to express emotions
(affect flattening), decrease in the amount of speech and thinking, and doing goaldirected behavior.
5 Subtypes
•
Paranoid Type
•
“Preoccupation with one or more delusions or frequent auditory hallucinations
•
Disorganized Type
•
Has disorganized speech, disorganized behavior, and flat or inappropriate affect
•
Catatonic Type
•
Diagnostic criteria “marked psychomotor disturbance that may involve motoric
immobility, excessive activity, extreme negativism, mutism, peculiarities of
voluntary movement, echoalia, echopraxia.”
•
Undiffereniated Type
•
An “other” category for Schizophrenia
•
Residual Type
•
Diagnostic criteria Has had at least one episode of Schizophrenia, has no
prominent “positive” symptoms (i.e. delusions, hallucinations, disorganized
speech, grossly disorganized, or catatonic behavior.) Does have some “negative
symptoms” and “two or more attenuated positive symptoms”.
Schizophreniform Disorder
•
Has at least 2 out of 5 Schizophrenia symptoms for at least 1 month but less than 6
months
Schizoaffective Disorder
•
Diagnostic criteria Meets criteria for Major Depressive Episode, Manic Episode, or a
Mixed Episode and has at least 2 out of 5 symptoms for Schizophrenia. There have
been delusions or hallucinations for at least 2 weeks without “prominent mood
symptoms”. Mood episode symptoms are “present for a substantial portion” of the time.
•
Specifiers: Bipolar Type, Depressive Type
Delusional Disorder
•
Diagnostic criteria “one or more nonbizarre delusions that persist for at least 1 month”
and never had met Schizophrenia criteria. Functioning in nondelusional areas may not be
affected and behavior is not bizarre.
•
Specifiers: Erotmanic Type, Grandiose Type, Jealous Type, Persecutory Type,
Somatic Type, Mixed Type, Unspecified Type
Brief Psychotic Disorder
•
Diagnostic criteria Sudden onset of at least one of the following positive psychotic
symptoms: delusions, hallucinations, disorganized speech or grossly disorganized
behavior. Must last “at least 1 day but less than 1 month, with eventual full return to
premorbid level of functioning.”
•
Specifiers: With Marked Stressor(s), Without Marked Stressor(s), With Postpartum
Onset
Shared Psychotic Disorder(Folie a Deux)
•
The formation of a shared or similar delusion by someone with whom they have a close
relationship and “who already has a Psychotic disorder with prominent delusions.”
Psychotic Disorder Due to…{name of general medical condition}
•
Prominent delusions or hallucinations and evidence that this is due to the consequences
of a medical condition
9. Mood Disorders (317-391)
•
Mood Episodes (not separate diagnoses but describe types of mood descriptions used in diagnoses)
• Major Depressive Episode
12
•
•
•
Diagnostic criteria: “a period of at least 2 weeks during which there is either depressed mood or
the loss of interest or pleasure in nearly all activities” most of the day nearly every day. 5 or
more of 9 symptoms: “changes in appetite, weight, sleep (e.g. insomnia), and psychomotor
activity; decreased energy, feelings of worthlessness or guilt, difficulty thinking, concentrating or
making decisions; or recurrent thoughts of death or suicide ideation, plans or attempts.”
• Manic Episode
•
Diagnostic criteria “an abnormally and persistently elevated, expansive, or irritable mood” lasting
at least 1 week (or less if hospitalization is required). 3 or more of 7 symptoms: inflated self
esteem or grandiosity, decreased need for sleep, pressured, loud and rapid speech, flight of ideas,
distractibility, increased goal-directed activities or psychomotor activity, and “excessive
involvement in pleasurable activities with a high potential for painful consequences.”
• Mixed Episode
•
Diagnostic criteria: has met criteria for both Manic Episode and Major Depressive Episode nearly
every day for at least 1 week. Rapid mood changes.
• Hypomanic Episode
•
Diagnostic criteria: “an abnormally and persistently elevated, expansive, or irritable mood that
lasts at least 4 days” “that is clearly different from the usual nondepressed mood” 3 or more of
the 7 symptoms listed for Manic Episode. Or 4 of 7 if mood is “irritable rather than elevated or
expansive”
•
Delusions or hallucinations which may be present with Manic Episode are not present. Does not
cause marked impairment in social or occupational functioning.
Depressive Disorders
• Major Depressive (vignette of Major Depressive Disorder) [small group exercise ]
•
Diagnostic criteria: one or more Major Depressive Episodes without a history of Manic, Mixed or
Hypomanic Episodes.
•
Specifiers:
•
For Current or Most Recent Major Depressive Episode: Mild, Moderate, Severe
Without Psychotic Features, Severe With Psychotic Features, In Partial Remission,
In Full Remission, Chronic, With Catatonic Features, With Melancholic Features,
With Atypical Features, With Postpartum Onset, With Full Interepisode Recovery,
Without Full Interepisode Recovery, With Seasonal Pattern
• Dysthymic
•
Diagnostic criteria: “chronically depressed mood that occurs for most of the day more days than
not for at least 2 years” (for children irritable mood and 1 year). When depressed has 2 or more
out of 6 symptoms: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue,
low self esteem, poor concentration or difficulty making decisions, feelings of hopelessness. Not
symptom free for more than 2 months. No Depressive Episodes during the 2 years. (1 year for
children) Never met criteria for Manic Episode, Mixed Episode, Hypomanic Episode,
Cyclothymic Disorder.
•
Specifiers: Early Onset (before age 21 years), Late Onset (at age 21 or older), With Atypical
Features
Bipolar Disorders
• Bipolar disorders are mood disorders characterized by Manic Episodes and Depressed Episodes. Most
attention is given to differentiating between various categories of Bipolar I Disorders.
• Bipolar I Disorder
•
Diagnostic criteria: characterized by one or more Manic Episodes or Mixed Episodes as well as
often one or more Major Depressive Episodes
•
Specifiers: Similar to Major Depressive Disorder. For current or recent episodes: Mild,
Moderate, Severe Without Psychotic Features, Severe With Psychotic Features, In Partial
Remission, In Full Remission; For current or recent Major Depressive Episode: Chronic, With
Catatonic Features, With Melancholic Features, With Atypical Features; For patterns of
episodes: With Full Interepisode Recovery, Without Full Interepisode Recovery, With
Seasonal Pattern, With Rapid Cycling
13
•
•
Bipolar II Disorder (Recurrent Major Depressive Episodes with Hypomanic Episodes)
•
Diagnostic criteria: characterized by one or more Major Depressive Episodes with at least one
Hypomanic Episode. Never had a Manic Episode or Mixed Episode
•
Specifiers: For Current or recent episode: Hypomanic, Depressed; For the current or most recent
Major Depressive Episode: : Mild, Moderate, Severe Without Psychotic Features, Severe
With Psychotic Features, In Partial Remission, In Full Remission, Chronic, With Catatonic
Features, With Melancholic Features, With Atypical Features, With Postpartum Onset
• Cyclothymic Disorder
•
Diagnostic criteria: For at least 2 years (1 year for children and adolescents), the presence of
numerous periods with hypomanic symptoms and numerous periods with depressive symptoms
that do not meet criteria for a Major Depressive Episode.” No more than 2 months without
preceding symptoms. No Major Depressive Episode, Manic Episode, or Mixed Episode during
the same period.
• Mood Disorder Due to…(name of general medical condition)
•
Diagnostic criteria: “a prominent and persistent disturbance in mood (depressed or manic) that is
judged to be due to the direct physiological effects of a general medical condition.” The full
criteria for a Major Depressive, Manic, Mixed, or Hypomanic Episode are not met.
•
Subtypes: With Depressive Features, With Major Depressive-Like Episode, With Manic
Features, With Mixed Features
• Substance-Induced Mood Disorder
•
Diagnostic criteria: “a prominent and persistent disturbance in mood (depressed or manic) that is
judged to be due to the direct physiological effects of a substance.”
•
Subtypes: With Depressive Features, With Major Depressive-Like Episode, With Manic
Features, With Mixed Features
•
Specifiers: With Onset During Intoxication, With Onset During Withdrawal
•
Used “only when the mood symptoms are in excess of those usually associated with the
intoxication or withdrawal syndrome and when the symptoms are sufficiently sever to warrant
independent clinical attention”
Mood Disorder Specifiers
• For Describing Most Recent Episode
•
Severity/Psychotic/Remission, Chronic, With Catatonic Features, With Melancholic
Features, With Atypical Features, and With Postpartum Onset
•
Only the specifiers that indicate severity, remission and psychotic features can be coded.using a
fifth digit for the diagnosis
• For Describing Course of Recurrent Episodes
•
With/Without Interepisode Recovery, Seasonal Pattern, Rapid Cycling
10. Mood Disorders - continued
11. Anxiety Disorders (393-444)
•
•
Panic Attack (not a codable disorder)
• “A discrete period of intense fear or discomfort, in which 4 or more of 13 somatic or cognitive symptoms
developed abruptly, and reached a peak within 10 minutes.”
Pounding heart or increased heart rate,
sweating, shaking or trembling, sensations of shortness of breath, feeling of choking, chest pain or
discomfort, nausea or abdominal distress, feeling of dizzy or lightheaded, feelings of unreality or being
detached from oneself, fear of going crazy or losing control, fear of dying, numbness or tingling
sensations, chills or hot flashes
• Types of panic attacks: unexpected Panic Attacks, situationally bound Panic Attacks, situationally
predisposed Panic Attacks
Agoraphobia (not a codable disorder)
• “anxiety about being places or situations from which escape might be difficult (or embarrassing) or in
which help may not be available in the event of having an unexpected or situationally predisposed Panic
14
•
•
•
•
•
•
•
•
•
•
Attack or panic-like symptoms” Avoidance of situations are common or experience dread in those
situations.
Panic Disorder
• Diagnostic criteria “presence of recurrent, unexpected Panic Attacks followed by at least 1 month of
persistent concern about having another Panic Attack, worry about the possible implications or
consequences of the Panic Attacks, or a significant behavioral change related to the Panic Attacks.”
• Without Agoraphobia, With Agoraphobia
Agoraphobia Without History of Panic Disorder
Specific Phobia
• Diagnostic criteria “marked and persistent fear that is excessive or unreasonable, cued by the presence or
anticipation of a specific object or situation” The person recognizes the fear is excessive. Exposure to the
object or situation causes an immediate anxiety response.
• Specifier Types: Animal Type, Nautral Environmental, Blood-Injection-Injury Type, Situational
Type, Other Type
Social Phobia (Social Anxiety Disorder)
• Diagnostic criteria: “a marked and persistent fear of social or performance situations in which
embarrassment may occur.” Exposure to the feared situation usually results in a Panic Attack. The person
recognizes the fear is excessive. In individuals over age 18 years, the duration is at least 6 months.
Obsessive-Compulsive Disorder
• “Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and
inappropriate and that cause marked anxiety or distress.”
• “Compulsions are repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g.
praying, counting, repeating world silently) the goal of which is to prevent or reduce anxiety or distress,
not to provide pleasure or gratification.”
• Diagnostic criteria: “recurrent obsessions or compulsions that are severe enough to be time consumeing
(i.e. they take more than 1 hour a day) or cause marked distress or significant impairment.” The person if
an adult recognizes the obsessions or compulsions are excessive or unreasonable.
Posttraumatic Stress Disorder (PTSD)
• Diagnostic criteria: following exposure to “an extreme traumatic stressor” that involved or threatened
serious injury or death to self or others resulting in ”intense fear, helplessness or horror” persistently
reexperiences the traumatic event. “Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness. Persistent symptoms of increased arousal. Symptoms must occur for
more than 1 month.
• Specifiers: Acute (symptoms are from 1 to less that 3 months , Chronic (symptoms are 3 or more
months), With Delayed Onset (symptoms at least 6 months after stressor)
Acute Stress Disorder
• Diagnostic criteria: similar to PTSD but are within 1 month of the extreme stressor. Lasts at least 2 days
and a maximum of 4 weeks.
Generalized Anxiety Disorder (Includes Overanxious Disorder of Childhood)
• Diagnostic criteria: “excessive anxiety and worry, occurring more days than not for a period of at least 6
month, about a number of events or activities (such as work or school performance). The person finds it
difficult to control the worry.” At least 3 out of 6 other symptoms must have been present for “more days
than not during the past 6 months (restlessness, easily fatigued, poor concentration, irritability, muscle
tension, sleep disturbance)
Anxiety Disorder Due to… (name of general medical condition)
• Diagnostic criteria: “clinically significant anxiety that is judged to be due to the direct physiological
effects of a general medical condition.” Symptoms include “prominent anxiety, Panic Attacks, or
obsessions or compulsions”
• Specifiers: With Generalized Anxiety, With Panic Attacks, With Obsessive-Compulsive Symptoms
Substance-Induced Anxiety Disorder
• Diagnostic criteria: similar to due to a medical condition but considered to be the result of a substance
(medication or drug of abuse or toxin exposure)
15
•
Sepecifiers: With Generalized Anxiety, With Panic Attacks, With Obsessive-Compulsive Symptoms,
With Phobic Symptoms, With Onset During Intoxication, With Onset During Withdrawal
12. Somatoform Disorders (445-469)
•
•
•
•
•
•
•
•
Diagnostic criteria: “presence of physical symptoms that suggest a general medical condition and are not fully
explained by a general medical condition, by the direct effects of a substance , or by another mental disorder.”
Symptoms are not under voluntary control.
Somatization Disorder
• Diagnostic criteria: “a pattern of recurring, multiple, clinically significant (i.e. results in medical
treatment or “significant impairment” in an important area of functioning) somatic complaints” prior to
age 30 years occurring “over a period of several years”. At least 8 symptoms from 4 different types of
symptoms are required: pain symptoms (4), gastrointestinal symptoms (2), sexual symptoms (1),
pseudoneurological symptom (1). Symptoms are not intentionally produced or feigned.
Undifferentiated Somatoform Disorder
• Diagnostic criteria: “one or more physical complaints that persist for 6 months or longer.” For
somatoform presentations that do not meet criteria for full criteria for another Somatoform Disorder.
Conversion Disorder
• Diagnostic criteria: “presence of symptoms or deficits affecting voluntary motor or sensory function that
suggest neurological or other general medical condition.” Psychological factor assumed to be related to
the symptom. Symptoms not intentionally produced or feigned.
• “pseudoneurological” Includes a wide variety of medical symptoms. Medical evaluation recommended
Symptoms may not be consistent or conform to known anatomical pathways and physiological
mechanisms.
• Specifiers: With Motor Symptoms or Deficit, With Sensory Symptom or Deficit, With Seizures or
Convulsions, With Mixed Presentation
Pain Disorder
• Diagnostic criteria: “pain in one or more anatomical sites is the predominant focus of the clinical
presentation and is of sufficient severity to warrant clinical attention.” “Psychological factors are judged
to have an important role in the onset, severity, exacerbation or maintenance of the pain.”
• Subtypes: Pain Disorder Associated with Psychological Factors, Pain Disorder Associated with
Both Psychological Factors and a General Medial Condition
• Specifiers: Acute (less than 6 months duration), Chronic (duration of 6 or more months)
Hypochondriasis
• Diagnostic criteria: “preoccupation with fears of having, or the idea that one has a serious disease based
on the person’s misinterpretation of bodily symptoms” that persists even after medical evaluation and
assurance. Must last at least 6 months.
• Specifier: With Poor Insight
Body Dysmorphic Disorder
• Diagnostic criteria: “preoccupation with an imagined defect in appearance.” “ If a slight physical
anomaly is present, the person’s concern is markedly excessive.” Is excessively time consuming and
associated with significant distress or impairment in social, occupational or other areas of functioning.”
13. Factitious Disorders (471-475)
•
•
•
Factitious Disorder
Diagnostic criteria: “intentional production of feigning or physical or psychological signs or symptoms” in
order to assume a sick role. “External incentives for the behavior (such as economic gain, avoiding legal
responsibility, or improving physical well-being, as in Malingering are absent.”
Subtypes: With Predominatly Psychological Signs and Symptoms, With Predominantly Phsycial Signs
and Symptoms, With Combined Psychological and Physical Signs and Symptoms
16
14. Dissociative Disorders (477-491)
•
•
•
•
•
Disassociative Disorders are characterized by “a disruption in the usually integrated functions of
consciousness, memory, identity, or perception of the environment.”
Dissociative Amnesia
• Diagnostic criteria: one or more episodes of “an inability to recall important personal information, usually
of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness.”
• Usually presents as a gap or series of gaps in a person’s ability to remember their past. The extent of the
past effected can vary considerably from minutes to years. May resolve after removal from traumatic
situation or circumstances, gradually resolve or persist from long time.
• Repressed Memory Syndrome
Dissociative Fugue
• Diagnostic criteria: “the predominant disturbance is sudden, unexpected travel away from home or one’s
customary place of work, with inability to recall one’s past.” Confusion about personal identity or less
frequently assumption of a new identity.
• Usually related to traumatic or stressful life events. Single episodes are most common and may last from
a few hours to months. May be difficult to distinguish at times from Malingering.
Dissociative Identity Disorder (formerly Multiple Personality Disorder)
• Diagnostic criteria: “the presence of two or more distinct identities or personality states (each with its
own relatively enduring pattern of perceiving, relating to and thinking about the environment and self).”
“At least two of these identities or personality states recurrently take control of the person’s behavior.”
“Inability to recall important information that is too extensive to be explained by ordinary forgetfulness.”
• Each identity may be experienced as having a separate history and unique identity including a different
name. Amnesia usually more effects the passive identities, Stress can precipitate transitions between
identities. Usually associated with reported traumatic childhood with physical and or sexual abuse.
Depersonalization Disorder
• Diagnostic criteria: “persistent or recurrent experiences of feeling detached from, and as if one is an
outside observer of, one’s mental processes or body (e.g. feeling like one is in a dream).” “During the
depersonalization experience, reality testing remains intact.”
15. Sexual and Gender Identity Disorders (493-538)
•
Sexual Dysfunctions are disturbances “in sexual desire or in the physiological changes that characterize the
sexual response cycle and cause marked distress and interpersonal difficulty.”
•
Sexual response cycle: desire, arousal, orgasm, resolution
• Paraphilias include diagnostic categories that “are characterized by recurrent, intense sexual urges, fantasies,
or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or
impairment in” an important life area of functioning.
• Gender Identity Disorder is “characterized by strong and persistent cross-gender identification accompanied
by persistent discomfort with one’s assigned sex.”
• Sexual Dysfunctions
• Sexual Desire Disorders
•
Hypoactive Sexual Desire Disorder
•
Diagnostic criteria: deficient or absent sexual fantasies and desire for sexual activity
•
Sexual Aversion Disorder
•
Diagnostic criteria: the persistent aversion to and active avoidance of genital sexual
contact with a sexual partner
• Sexual Arousal Disorders
•
Female Sexual Arousal Disorder
•
Diagnostic criteria: persistent or inability “to attain, or to maintain until completion of
the sexual activity, an adequate lubrication-swelling response of sexual excitement”
17
•
•
•
•
Male Erectile Disorder
•
Diagnostic criteria: persistent inability “to attain, or to maintain until completion of the
sexual activity, an adequate erection
• Orgasmic Disorders
•
Female Orgasmic Disorder
•
Diagnostic criteria: “persistent or recurrent delay in or absence of, orgasm following a
normal sexual excitement phase”
•
Male Orgasmic Disorder
•
Diagnostic criteria: “persistent or recurrent delay in or absence of, orgasm following a
normal sexual excitement phase”
•
Premature Ejaculation
•
Diagnostic criteria: “persistent or recurrent ejaculation with minimal sexual stimulation
before, on or shortly after penetration and before the person wishes it”
• Sexual Pain Disorders
•
Dyspareunia
•
Diagnostic criteria: experiencing of genital pain during sexual intercourse (male or
female)
•
Vaginismus
•
Diagnostic criteria: “persistent or recurrent involuntary spasm of the musculatrue of the
outer third of the vagina that interferes with sexual intercourse.”
Paraphillias
The DSM-IV manual defines paraphillias as having “recurrent, intense sexually arousing fantasies, sexual
urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or
one’s partner, or 3) children or other nonconsenting persons, that occur over a period of 6 months.”
• Exhibitionism
•
Diagnostic criteria: exposure of one’s genitals to a stranger
• Fetishism
•
Diagnostic criteria: use of nonliving objects to achieve sexual arousal (e.g. women’s underwear)
• Frotteurism
•
Diagnostic criteria: “intense sexually arousing fantasies, sexual urges, or behaviors involving
touching and rubbing against a nonconsenting person.”
• Pedophilia
•
Diagnostic criteria: sexual activity with “a prepubescent child (generally age 13 years or
younger)”
• Sexual Masochism
•
Diagnostic criteria: involves the real or simulated act “of being humiliated, beaten, bound, or
otherwise made to suffer.”
• Sexual Sadism
•
Diagnostic criteria: obtaining sexual excitement from the real or simulated psychological or
physical (including humiliation) suffering of another person
• Transvestic Fetishism
•
Diagnostic criteria: “in a heterosexual male, recurrent intense sexually arousing fantasies, sexual
urges, or behaviors involving cross-dressing.”
• Voyeurism
•
Diagnostic criteria: achieving sexual excitement from the looking at unsuspecting individuals
who are naked or in the process of undressing or engaging in sexual activity
Gender Identity Disorders
• Gender Identity Disorder
•
Diagnostic criteria: “a strong and persistent cross-gender identification, which is the desire to be,
or the insistence that one is, of the other sex” and “ persistent discomfort with one’s assigned sex
or inappropriateness in the gender of that sex.”
18
•
•
Children
Adolescents or Adults
16. Eating Disorders (539-550)
•
•
Anorexia Nervosa (video tape)
• Diagnostic criteria: “Refusal to maintain body weight at or above a minimally normal weight for age and
height” (weight less than 85% of expected). “Intense fear of gaining weight or becoming fat, even though
underweight.” Significant disturbance in the perception of the shape and size of his or her body. In
postmenarchael females, the absence of at least 3 consecutive menstrual cycles.
• Subtypes: Restricting Type, Binge-Eating/Purging Type
Bulimia Nervosa
• Diagnostic criteria: recurrent episodes of binge eating and “inappropriate compensatory behavior” (e.g.
vomiting, misuse of laxatives, enemas, excessive exercising, fasting) to prevent weight gain. ‘…both
occur on average, at least twice a week for 3 months.”
• In contrast to Anorexia Nervosa, weight is maintained at or above minimum expectation.
• Subtypes: Purging Type, Nonpurging Type
17. Sleep Disorders (551-607)
•
•
•
•
•
Four subcategories based upon presumed etiology
• Primary Sleep Disorders
• Sleep Disorders Due to Another Mental Disorder
• Sleep Disorders Due to a General Medical Condition
• Substance-Induced Sleep Disorders
Dyssomnias
Dyssomnias are sleep disorders characterized by “abnormalities in the amount, quality, or timing of sleep”
• Primary Insomnia
•
Diagnostic criteria: difficulty initiating or maintaining sleep or nonrestorative sleep for at least 1
month
• Primary Hypersomnia
•
Diagnostic criteria: “excessive sleepiness” for at least 1 month, may include extended nocturnal
sleeping and long daytime naps
• Narcolepsy
•
Diagnostic criteria: “irresistible attacks of refreshing sleep that occur daily over at least 3
months”
• Breathing-Related Sleep Disorder
•
Diagnostic criteria: “sleep disruption, leading to excessive sleepiness or insomnia, that is judged
to be a sleep-related breathing condition”
• Circadian Rhythm Sleep Disorder
•
Diagnostic criteria: a mismatch between a person’s sleep-wake schedule and the person’s
environment.
•
Subtypes: Delayed Sleep Phase Type, Jet Lag Type, Shift Work Type
Parasomnias
• Characterized by “abnormal behavioral or physiological events occurring in association with sleep,
specific sleep stages, or sleep-wake transitions.” This disorders activate “the autonomic nervous system,
motor system or cognitive processes during sleep or sleep-wake transitions.”
• Nightmare Disorder
•
Diagnostic criteria: repeatedly awakened by frightening dreams
19
•
•
Sleep Terror Disorder
•
Diagnostic criteria: repeated pattern of abrupt awakenings in which the person may scream or yell
out in fear and show autonomic signs such as sweating, increased heart rate and breathing and
amnesia regarding the incidents
•
Children
Sleepwalking Disorder
•
Diagnostic criteria: repeated episodes of getting out of bed and walking around with no memory
after the episode
18. Impulse-Control Disorders Not Otherwise Classified (609-621)
•
General Diagnostic criteria: “the failure to resist an impulse, drive, or temptation to perform an act that is
harmful to the person or to others.” Prior to the act the person feels a sensation of increasing tension and a
sense of relief or pleasure on completion of the act. There may or may not be feelings of guilt or regret after
the act.
• Intermittent Explosive Disorder
• Diagnostic criteria: several different episodes of failure to resist aggressive impulses leading to “serious
assaultive acts or destruction of property.” “The degree of aggressiveness expressed during the episodes is
grossly out of proportion to any precipitating psychosocial stressors.”
• Rule out aggressive behavior related to other mental disorders (e.g. Antisocial Personality Disorder,
Conduct Disorder, Oppositional Defiant Disorder)
• Kelptomania
• Diagnostic criteria: “recurrent failure to resist impulses to steal objects that are not needed for personal
use or for their monetary value.” Increasing sense of tension prior to the theft and relief/gratification after
the theft. Stealing is not in response to anger, revenge or a delusion or hallucination.
• Person often is concerned about being caught stealing and feels depressed or guilty about stealing. Thefts
are usually done without preplanning and without assistance of others.
• Pyromania
• Diagnostic criteria: “Deliberate and purposeful fire setting on more than one occasion. Tension or
affective arounsal before the act. Fascination with, interest in curiosity about, or attraction to fire, and its
situational contexts (e.g. paraphernalia, uses, consequences.). Pleasure, gratification, or relief when
setting fires, or when witnessing or participating in their aftermath.” Fire setting is not done for personal
gain, to conceal a criminal act or express anger, a political ideology or as a result of impaired judgement.
• Pathological Gambling
• Diagnostic criteria: “Persistent and recurrent maladaptive gambling behavior as indicated by” 4 or more
of 10 criteria: preoccupation with gambling, needs to gamble with increasing amounts of money to get the
desired excitement, has repeatedly attempted to stop or reduce gambling, is restless or irritable when
trying to stop or reduce gambling, gambles to escape from problems or unpleasant moods, after losing
often returns the next day to gamble more, lies to conceal gambling, has committed illegal acts to finance
gambling, has jeopardized or lost relationships, job, educational or career opportunities due to gambling,
and relies on others to rescue him or her to pay for desperate financial debt caused by gambling.
• Trichotillomania
• Diagnostic criteria: “Recurrent pulling out of one’s hair resulting in noticeable hair loss” Sense of tension
before act and relief or pleasure and gratification after the act.
• Hair may be anywhere on body. Usually not done in the presence of others except immediate family
members.
19. Adjustment Disorders (623-627)
•
Diagnostic criteria: The development of emotional or behavioral symptoms in response to an identifiable
stressor(s) occurring with 3 months of the onset of the stressor(s).” Symptoms are not from Bereavement.
“Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an
additional 6 months.”
20
•
•
Subtypes: With Depressed Mood, With Anxiety, With Mixed Anxiety and Depressed Mood, With
Disturbance of Conduct, With Mixed Disturbance of Emotions and Conduct, Unspecified
Diagnosis requires the presence of an identifiable stressor. A “residual category” for diagnosing when criteria
for other Axis I diagnoses are not met.
20. Personality Disorders (629-673)
•
•
•
•
•
•
•
•
•
•
General Diagnostic criteria: “an enduring pattern of thinking, feeling and behaving” “ that deviates markedly
from the expectations of the individual culture, is pervasive and inflexible, has an onset in adolescence or
early adulthood, is stable over time, and leads to distress or impairment.” Pattern occurs in at least 2 out of 4
areas: cognition (i.e. ways of perceiving and interpreting self, other people and events), affectivity (i.e. the
range, intensity, lability, and appropriateness of emotional response), interpersonal functioning, and impulse
control.
Personality traits are similar to Personality Disorders but are not as inflexible or maladaptive and do not
cause significant functional impairment or personal distress. Traits can be coded on Axis II.
Personality Disorders are coded on Axis II. More than one Personality Disorder may be given if criteria are
met. Although usually personality diagnoses are given to adults they can be applied (except for Antisocial
Personality Disorder) to children and adolescents but “the features must have been present for at least 1
year.”
Three “clusters” of personality disorders: A – odd or eccentric, B – dramatic, emotional or erratic, C –
anxious or fearful
Cluster A
Paranoid Personality
• Diagnostic criteria: “a pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood and present in a variety of contexts,” as indicated
by 4 or more of 7 criteria related to seeing others as a threat to them
• Common characteristics: rigidity, critical of others, combative or hostile in relating to others, highly
suspicious, hypervigilant to potential criticism or perceived attacks from others. May have very brief
psychotic episodes (minutes or hours)
Schizoid Personality
• Diagnostic criteria: “a pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of
contexts, as indicated by” 4 or more of 7 criteria related to their not having a desire for relationships with
other people.
• Common characteristics: poor social skills, appear aloof, seek social isolation, May have very brief
psychotic episodes (minutes or hours)
Schizotypal Personality
• Diagnostic criteria: “a pervasive pattern of social and interpersonal deficits marked by acute discomfort
with and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and
eccentricities of behavior, beginning by early adulthood and present in a variety of contexts.” Meets 5 or
more of 9 criteria (suspiciousness or paranoid thinking, unusual perceptional experiences, odd thinking
and speech, magical thinking or odd beliefs, ideas of reference, inappropriate or constricted affect, odd or
peculiar behavior, lack of close friends, excessive social anxiety)
• May have very brief psychotic episodes (minutes or hours)
Cluster B
Antisocial Personality (video tape)
• Diagnostic criteria: “a pervasive pattern of disrespect for and violation of the rights of others occurring
since age 15 years, as indicated by” 3 or more of 7 criteria: (repeated performing illegal acts,
deceitfulness, impulsivity, irritability and aggressiveness, reckless disregard for safety of self or others,
“consistent irresponsibility”, lack of remorse for personal actions)
21
•
•
•
•
•
•
•
•
Diagnosis not used for persons under age 18 years. The DSM-IV cautions to distinguish this diagnosis
“from criminal behavior undertaken for gain that is not accompanied by the personality features
characteristic of this disorder” Related categories are Adult Antisocial Behavior (a V code category)
and Conduct Disorder
Borderline Personality (vignette and small group exercise)
• Diagnostic criteria: “a pervasive pattern of instability of interpersonal relationships, self-image, and
affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.”
Meets at least 5 out of 9 criteria: frantic effort so avoid abandonment, pattern of intense and unstable
interpersonal relationships characterized by over idealization and devaluation, unstable sense of self,
impulsive behavior in at least 2 areas (e.g. spending, sex, substance abuse, binge eating), recurrent threats
or attempts of suicide, chronic feelings of emptiness, mood instability, intense and poorly controlled
anger, transient, stress-related paranoid ideation or severe dissociative symptoms.
Histrionic Personality
• Diagnostic criteria: “a pervasive pattern of excessive emotionality and attention-seeking” Meets 5 out of 8
other criteria: uncomfortable unless the center of attention, interactions with others may be characterized
by “inappropriate seductive or provocative behavior”, shallow affect, consistently uses physical
appearance to draw attention to self, style of speech tends to lack details, theatrical expression of emotion,
easily influenced by others and environment, considers relationships more intimate than they actually are.
Narcissistic Personality
• Diagnostic criteria: “a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and
lack of empathy” characterized by 5 or more of 9 other criteria: has a grandiose sense of selfimportance; preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
believes self to be “special” and can only be understood with other special or high-status people; requires
excessive admiration; has a sense of entitlement; is interpersonally exploitative; poor empathy, arrogant
attitude or behaviors, envious of others
Cluster C
Avoidant Personality
• Diagnostic criteria: “a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity
to negative evaluation” and meets 4 or more of 7 other criteria: avoidance of jobs that involve significant
interpersonal contact, avoids people unless certain of being liked, “shows restraint in intimate
relationships”, preoccupied with rejection or criticism, “is inhibited in new interpersonal situations
because of feelings of inadequacy”, poor self esteem, avoidance of new activities or to take personal risks
Dependent Personality
• Diagnostic criteria: “a pervasive and excessive need to be taken care of that leads to submissive and
clinging behavior and fears of separation’ and 5 or more of 8 other criteria: dependent on others for
making everyday decisions, depends on others for taking responsibility for most major areas of their lives,
difficulty expressing disagreement for fear of loss of support, difficulty starting or doing things on own
due to lack of confidence, goes to extremes to get support from others such as doing unpleasant tasks,
fearful of being alone, if a close relationship ends, urgently seeks to replace it, “unrealistically”
preoccupied with fears of abandonment
Obsessive-Compulsive Personality
• Diagnostic criteria: “a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and
interpersonal control, at the expense of flexibility, openness, and efficiency” and 4 or more of 8 other
criteria: preoccupied with rules, order, lists; perfectionism that interferes with completion of tasks;
excessively work-focused, highly inflexible regarding morals, ethics or values, unable to throw away old
or useless objects when they have no sentimental value; difficulty delegating things to others; “miserly
spending style”; “shows rigidity and stubbornness”
22
21. Other Conditions That May Be a Focus of Clinical Attention (675-686)
•
•
•
•
•
•
This section of the DSM-IV is a collection of 23 different problem categories not considered “clinical
disorders” that are given “V” a code and other ‘conditions or problems” not diagnosable in the other
diagnostic sections of the manual. These are coded on Axis I.
Psychological Factors Affecting Medical Condition
• Used when one or more “psychological or behavioral factors adversely affect a general medical
condition”. (e.g. the course of the condition, the treatment of the condition, cause greater health risk for
the person, or exacerbate the symptoms of the condition) Includes any Axis I or II diagnosis, symptom or
personality traits that don’t meet any diagnostic disorder criteria, physiological responses to stress, or any
“maladaptive health behaviors”.
• Six different factors: specific Axis I or II disorder, symptoms that do not meet criteria for a disorder,
personality traits or coping style, maladaptive lifestyle, stress related physiological response, other
•
Medication-Induced Movement Disorder
• Seven different categories for muscle movement problems believed to be caused by taking a medication.
Relational Problems
• These are the “V’ code categories for problematic relationship problems for couples, families, parents and
children, and siblings “that are associated with clinically significant impairment in functioning”. If these
are the primary focus of treatment they are coded on Axis I, if not the primary focus they are coded on
Axis IV. These are generally not reimbursed for services by health insurance plans.
•
Parent-Child Relational Problem
•
Partner Relational Problem
•
Sibling Relational Problem
Problems Related to Abuse or Neglect
• These are “V” code categories for the victims or perpetrators of physical or sexual abuse or child neglect
that evaluated or treated. Separately coded depending upon whether focus is on victim or perpetrator.
Additional Conditions That May be a Focus of Clinical Attention
• A miscellaneous group of unrelated “V” code “conditions” that include:
•
Malingering – intentional production of symptoms for external incentive
•
Adult Antisocial Behavior –ex. Behavior of thieves, drug dealers, etc.
•
Child or Adolescent Antisocial Behavior – ex. Isolated antisocial acts
•
Borderline Intellectual Functioning – between Average IQ and Mild Mental Retardation
•
Bereavement – depressed mood after loss, under 2 months
•
Academic Problem – academic problem (e.g. failing grades) not warranting clinical attention
•
Occupational Problem – includes any occupational problem the focus of clinical attention (e.g.
job dissatisfaction, uncertainty about career choices)
22. Summary and Closing
23
DSM-IV Selected Reading List
DSM-IV: Diagnostic & Statistical Manual of Mental Disorders
American Psychiatric Association / Paperback / January 1994
Diagnostic Criteria from DSM-IV
John S. McIntyre / Paperback / January 1994
DSM-IV Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders
Robert L. Spitzer, Miriam Gibbon, Andrew Skodol / Paperback / January 1994
Interview Guide for Evaluating DSM-IV Psychiatric Disorders and the Mental Status Examination
Mark Zimmerman / Paperback / January 1994
DSM-IV Handbook of Differential Diagnosis
Michael B. First, Allen Frances / Paperback / January 1995
Study Guide to DSM-IV
Michael A. Fauman / Paperback / January 1994
DSM-IV Guidebook
Allen Frances, Michael B. First, Harold Alan Pincus / Paperback / January 1995
DSM-IV Training Guide for Diagnosis of Childhood Disorders
Judith L. Rapoport, Deborah R. Ismond / Paperback / January 1996
In Your Face: Flash Cards for the DSM-IV, Vol. 1
Steven M. Cohn, Judd Robbins (Editor) / Paperback / January 1995
The DSM-IV Internet Companion
M. Robert Morrison, Robert F. Stamps / Paperback / January 1998
Using DSM-IV : A Clinician's Guide to Psychiatric Diagnosis
Anthony. L. Labruzza, with Jose M. Mendez-Villarrubia / Paperback / January 1997
The Clinical Interview Using DSM-IV: Volume 1: Fundamentals
Ekkehard Othmer, Sieglinde C. Othmer / Paperback /: January 1994
The Clinical Interview Using DSM-IV: The Difficult Patient, Vol. 2
Ekkehard Othmer, Sieglinde C. Othmer / Hardcover / January 1994
DSM-IV Case Studies: A Clinical Guide to Differential Diagnosis
Allen Frances, Ruth Ross / Paperback / January 1996
Practical Guide to DSM-IV Diagnosis and Treatment (Cole Communications), 2nd Edition
Carol Joy Cole / Paperback / January 1998
Disorders of Personality: DSM-IV and Beyond: Dsm-IV and Beyond
Theodore Millon, With Roger D. Davis / Hardcover / January 1996
Personality Disorders: Clinical and Social Perspectives: Assessment and Treatment Based on DSM IV and
ICD 10
Jan Derksen / Hardcover / January 1995
DSM-IV Diagnosis in the Schools
Alvin E. House / Hardcover / January 1999
24
DSM-IV Training Guide
William H. Reid, Michael G. Wise / Paperback / January 1995
Interviewer's Guide to the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D)
Marlene Steinberg / Other Format / January 1995
DSM-IV SourceBook, Vol. 1
Thomas A. Widiger,Ruth Ross (Editor),Michael B. First (Editor) / Hardcover / January 1994
DSM-IV SourceBook, Vol. 2
American Psychiatric Association Staff, Ruth Ross, Michael B. First, Allen J. Frances, Harold Alan Pincus,Wendy
Wakefield Davis / Hardcover / January 1996
DSM-IV SourceBook, Vol. 3
American Psychiatric Association / Paperback / January 1997
DSM-IV SourceBook, Vol. 4
American Psychiatric Association Tas, Thomas A. Widiger (Editor) / Hardcover / January 1998
Practical Guide to DSM-IV Diagnosis and Treatment
Carol J. Cole, Mike DeRosa / Hardcover / January 1998
DSM-IV Made Easy : The Clinician's Guide to Diagnosis
James Morrison / Hardcover / Published 1995
“New Mnemonic Tool for DSM-IV Diagnosis”, The American Journal of Psychiatry, June 1998, 155:6, p.
856 Gregg E. Gorton
25
Major Depression Disorder
Brian Murphy
Brian Murphy had inherited a small business from his father and built it into a large one. When he sold out a few
years later, he invested most of his money; with the rest, he bought a small almond farm in northern California.
With his tractor, he handled most of the farm chores himself. Most years the farm earned a few hundred dollars,
but as Brian was fond of pointing out, it really didn’t make much difference. If he never made a dime, he felt he
got “full value from keeping busy and fit.”
When Brian was 55, his mood, which had always been normal, slid into depression. Farm chores seemed
increasingly to be a burden; his tractor sat undriven in its shed.
As his mood blackened, Brian’s body functioning seemed to deteriorate. Although he was constantly fatigued,
often falling into bed by 9 p.m., he would invariably awaken at 2 or 3 a.m. then obsessive worrying kept him
awake until sunrise. Mornings were worst for him. The prospect of “another damn day to get through” seemed
overwhelming. In the evenings he usually felt somewhat better, though he’d sit around working out sums on a
magazine cover to see how much money they’d have if he “couldn’t work the farm” and they had to live on their
savings. His appetite deserted him. Although he never weighed himself, he had to buckle his belt two notches
smaller than he had several months before.
“Brian just seemed to lose interest,” his wife reported the day he was admitted to the hospital. “He doesn’t enjoy
anything any more. He spends all his time sitting round and worrying about being in debt.
We owe a few hundred dollars on our credit card, but we pay it off every month!”
During the previous week or two, Brian had begun to ruminate about his health. “At first it was his blood
pressure,” his wife said. “He’d ask me to take it several times a day. I still work part-time as a nurse. Several
times he thought he was having a stroke. Then yesterday he became convinced that his heart was going to stop.
He’d get up, feel his pulse, pace around the room, lie down, put his feet above his head, do everything he could to
‘keep it going.’ That’s when I decided to bring him here.”
“We’ll have to sell the farm.” That was the first thing Brian said to the mental health clinician when they met.
Brian was casually dressed and rather rumpled. He had prominent worry lines on his forehead, and he kept
feeling for his pulse. Several times during the interview, he seemed unable to sit still; he would get up from the
bed where he was sitting and pace over to the window.
His speech was slow but coherent. He talked mostly about his feelings of being poverty-stricken and his fears that
the farm would have to go on the block. He denied having hallucinations, but admitted feeling tired and ‘all
washed up – not good for anything any more.” He was fully oriented, had a full fund of information, and scored a
perfect 30 on the Mini-Mental Status Exam. He admitted that he was depressed, but denied having thoughts
about death. Somewhat reluctantly, he agreed that he needed treatment.
From: DSM-IV Made Easy: The Clinician’s Guide to Diagnosis, James Morrison 1995, pp204-205
26
Borderline Personality Disorder
Josephine Armitage
“I’m cutting myself!” the voice on the telephone was high-pitched and quavering. “I’m cutting myself right now!
Ow! There, I’ve started.” The voice howled with pain and rage.
Twenty minutes later, the clinician had Joesphine’s address and her promise that she would come into the
emergency room right away. Two hours later, her left forearm swathed in bandages, Josephiine Armitage was
sitting in the mental health department. Criss-crossing scares furrowed her right arm from wrist to elbow. She
was 33, a bit overweight, and chewing gum.
“If feel a lot better,” she said with a smile. “I really think you saved my life.”
The clinician glanced at her nonswathed arm. “This isn’t the first time, is it?”
“I should think that would be pretty obvious. Are you going to be terminally dense, just like my last shrink?”
She scowled and turned 90 degrees to look at the wall. “Sheesh!”
her previous therapist had seen Josephine for a reduced fee, but had been unable to give her more time when she
requested it. She had respond by letting the air out of all four tires of the therapist’s new BMW.
Her current trouble was with her boyfriend. One of her girlfriends had been “pretty sure” James had been out
with another woman two nights ago. Yesterday morning, Josephine had called in sick to work and staked out
James’s workplace so she could confront him. He hadn’t appeared, so last evening she had banged on the door of
his apartment until neighbors threatened to call the police. Before leaving, she’d kicked a hole in the wall beside
James’s door. Then she got drunk and drove up and down the main drag, trying to pick up a date.
“Sounds dangerous,” observed the clinician.
“I was looking for Mr. Goodbar, but no one turned up. I decided I’d have to cut myself again. It always seems to
help.” Josephine’s anger had once again evaporated, and she had turned away from the wall. “Life’s a bitch, and
then you die.”
“When you cut yourself, do you every really intend to kill yourself?”
“Well, let’s see.” She chewed her gum thoughtfully. “I get so angry and depressed, I just don’t care what
happens. My last shrink said all my life I’ve felt like a shell of a person, and I guess that’s right. It feels like
there’s no on living inside, so I might as well pour out the blood and finish the job.”
From: DSM-IV Made Easy: The Clinician’s Guide to Diagnosis, James Morrison 1995, pp204-205
27
Schizophrenia, Paranoid Type
Shizotypal Personality Disorder
Lyonel Childs
When he was young, Lyonel Childs had always been somewhat isolated, even from his two brothers and his
sister. During the first few grades in school, he seemed almost suspicious if other children talked to him. He
seldom seemed to feel as ease, even with those he had known since kindergarten. He never smiled or showed
much emotion, so that by the time he was 10, even his siblings thought he was peculiar. Adults said he was
“nervous.” For a few months during his early teens, he was interested in magic and the occult; he read extensively
about witchcraft and casting spells. Later he decided he would like to become a minister. He spent hours in his
room learning Bible passages by hear.
Lyonel had never been much interested in sex, but at age 24, still attending college, he was attracted to girl in his
poetry class. He noticed that his heart skipped a beat when he first saw her. She always said “Hello” and smiled
when they met. He didn’t want to betray too great an interest, so he waited until an evening several weeks later to
ask her to a New Year’s Eve party. She refused him, politely but firmly.
As Lyonel mentioned to an interviewer months later, he thought that this seemed strange. During the day Mary
was friendly and open with him, but when he ran into her at night, she was reserved. He knew there was a
message in this that eluded him, and it made feel shy and indecisive. He also noticed that his thoughts had
speeded up so that he couldn’t sort them out.
“I noticed that my mental energy had lessened,” he told the interviewer, “so I went to see the doctor. I told him I
had gas forming on my intestines, and I thought it was giving me erections. And my muscles seemed all flabby.
He asked me if I used drugs or was feeling depressed. I told him neither one. He gave me a prescription for some
tranquilizers, but I just threw them away.”
Lyonel’s skin was pasty white and he was abnormally thin, even for someone so slightly built. He sat quietly
without fidgeting during the interview, and his casual clothing seemed quite ordinary. His speech was entirely
ordinary; one thought flowed normally into the next, and there were no made-up words.
By summer, he had become convinced that Mary was thinking about him. He decided that something must be
keeping them apart. Whenever he had this feeling, his thoughts became so “loud” that he felt sure other people
must know what he was thinking. He neglected to look for a summer job that year and moved back into his
parents’ house, where he kept to his room, brooding. He wrote long letters to Mary, most of which he destroyed.
In the fall, Lyonel realized that his relatives were trying to help him. Although they would wink an eye or tap a
finger to let him know when she was near, it did no good. She continued to elude him, sometimes only by
minutes. Sometimes there was a ringing in his right ear, which caused him to wonder whether he was becoming
deaf. His suspicion seemed confirmed by what he privately called “a clear sign.” One day while driving he
noticed, as if for the first time, the control button for his rear window defroster. It was labeled REAR DEF, which
to him meant “right-ear deafness.”
When winter deepened and the holidays approached, Lyonel knew that he would have to take action. He drove
off to Mary’s house to have it out with her. As he crossed town, people he passed nodded and winked at him to
signal that they understood and approved. A woman’s voice, speaking clearly to him from just behind him in the
back seat, said, “Turn right” and “Atta boy!”
From: DSM-IV Made Easy: The Clinician’s Guide to Diagnosis, James Morrison, 1995, pp. 145-147
28
Substance Dependence, Alcohol
Quentin McCarthy
“I can get off it, but I can’t stay off it.” Quentin McCarthy was 43, and he was talking about alcohol. He liked to
say that throughout his adult life he had been successful at two things – drinking and selling insurance. Now he
was having trouble with both.
Quentin was the second of three sons born to parents who were both attorneys. Both of his brothers had been
excellent students. Quentin was bright, but he had been hyperactive and the class clown. In school, he had never
been able to focus his attention well enough to excel at anything but physical education.
To please his parents, after high school Quentin tried a semester of junior college. It was worse than high school
– the only thing that kept him going was guilt. Whereas his older brother was admitted to law school (with
honors at entrance) and his younger brother mopped up the prizes at the state science fair, Quentin felt almost
joyful when his birthday was that year’s number four pick in the national draft lottery. The following day he
enlisted in the Army.
Somewhere in his schooling Quentin had learned to type, so he was assigned to his battalion’s administrative
section. Throughout four years in the military, he never fired his weapon in anger. By comparison with some of
the older men, his drinking was moderate. Although he had about the usual number of fights, he managed to
avoid serious trouble. When he left the service at the age of 22, he had held onto his sergeant’s stripes through
two tours of duty in Vietnam.
After that, life suddenly became serious. Working part-time after hours in the post exchange, Quentin had
discovered that he was a natural salesman. So it seemed a logical move to take a job selling life insurance. It also
seemed sensible to marry the boss’s daughter. When his father-in-law died suddenly two years later, Quentin
became sole proprietor of the agency.
“The business made me and it ruined me,” he said. “I made a lot of money having lunch with people and selling
them large policies. I told myself that I had to drink with them in order to make a sale, but I suppose that was just
rationalization.”
As time went on, Quentin’s two martini lunches turned into four martini lunches. By the time he was 31, he was
skipping lunch completely and nipping throughout the afternoon to “keep the glow on.” At the end of the day, he
was sometimes surprised to see how much had disappeared from the bottle he kept in his desk drawer.
The past year had brought Quentin two unpleasant surprises. The first came when his doctor informed him that
the nagging pain just above his navel was an ulcer; for the sake of his health, he would have to stop drinking. The
second, which in a way seemed worse because it injured his pride, occurred one afternoon over lunch. A longtime client of the agency apologetically said that he would be taking his substantial business elsewhere; his wife
didn’t feel comfortable that he was “doing business with a lush.” Thinking back, Quentin realized that there had
been several other, less blatant instances of customers departing the fold.
The result had been his resolve to quit, or at least to reduce the amount of his drinking. (“Quitting is easy,” he
remarked ruefully. “I did it twice in one month.”) At first he promised himself he would not drink before 5 p.m.;
that proved impractical, and he later amended it to “around lunch time.” With the level in his desk drawer bottle
receding as fast as ever, Quentin decided he would try Alcoholics Anonymous. “That was worse than useless,” he
explained. “The stories I heard from some of those people made me feel like a teetotaler.”
A comment made by his wife, herself no stranger to alcohol, eventually brought him in for evaluation. “You used
to drink to have a good time,” she told him. “Now you drink because you need it.”
From: DSM-IV Made Easy: The Clinician’s Guide to Diagnosis, James Morrison, 1995 p. 70-71
29
Alzheimer Dementia, with late onset
Sarah Neal
After her husband died, Sarah Neal had made the rounds of her three children and had finally settled in with Jason
(who provided the details of her history). She had now lived with him for four years. Even when she was 74, she
had managed the gardening, the marketing, and most of the cooking. The arrangement had worked out well for
both of them – Jason had remained single after a stormy divorce decades before. But for nearly a year, problems
had been evident.
Around Christmas, Sarah had spent two days searching the house for the presents she had hidden. She and Jason
finally found them in the storage shed, but this was only the beginning of her forgetfulness. She had always
prided herself on her ability to remember telephone numbers, but in February, when Jason was assigned a new
extension number at work, she could never seem to recall what it was or where she had written it down. After
several days of frustration, he finally pasted the new number to both of their telephones. She began to avoid her
circle of friends from the mobile home park where they lived.
Late that spring, they suffered the first of several kitchen fires. These all started because Sarah had forgotten
about food left bubbling on the stove. Although the last one caused $1,500 worth of damage to their kitchen,
Sarah had seemed strangely unaffected. “She’s always been so careful about money,” Jason mused, “but when I
got home to find the fire department there and water soaking everything, she didn’t turn a hair. It’s as if a
stranger had moved inside my mother’s head”. A physical examination by her internist had revealed no evidence
of medical illness.
Sarah looked a good 10 years younger than her stated age. She was clean and neatly dressed, though her silk
blouse was missing a button from one sleeve and she wore two sweaters. Throughout the 45 minutes, she gave
good eye contact and seemed to pay attention to the conversation. She smiled continually while asserting (several
times) that she had been “just fine.” When the interviewer pointed out that her son said she had almost burned
down the house, she replied, “Stuff and nonsense. He’s a little poop!”
“It sounds like you’re upset,” remarked the interviewer.
“Stuff and nonsense. I couldn’t feel happier.”
The interviewer asked how an apple and an orange were alike, and learned that she “had them in my ‘fridge.” A
child and a dwarf were different because “that’s just the way they are.”
When asked to elaborate, she said, “A child’s a child and a dwarf’s a dwarf.”
When asked to name the president of the United States, she said, “That’s what you should know for yourself. I
don’t feel like helping you any more.”
Later in the interview she was asked to identify a ballpoint pen. “It’s a whatis for writing, of course! Stuff and
nonsense.”
From: DSM-IV Made Easy: The Clinician’s Guide to Diagnosis, James Morrison, 1995 p. 34
30
Oppositional Defiant Disorder
Charles Smith
Charles is an eight year old boy who is described by his mother as almost daily having temper tantrums and
getting into physical and verbal fights with his two younger siblings, a brother age 7 and a sister age 5. Charles’s
fighting often is a result of his teasing brother or sister or if they are playing a game, his becoming upset if he is
not winning. He frequently blames his brother or sister whenever he is confronted by his parents about provoking
his siblings.
Temper tantrums have become increasingly disruptive to the family and now his mother expresses concern that
Charles’s brother is starting to have them as well. Examples of tantrums include yelling at his parents (e.g. “I hate
you”), cursing, crying and occasionally hitting his head on the wall. These usually occur when he does not get
what he wants (e.g. his favorite food at meals, to watch the television program he wants to watch, is requested to
pick up his toys). Mr. Smith says that he does not tolerate this behavior and has yelled at Charles and spanked
him when he has had tantrums. Mrs. Smith on the other hand says that she is not as harsh as her husband in
dealing with these incidents and usually only yells at Charles to stop. She acknowledges that she has let Charles
have what he wants just to “shut him up”.
His mother reports that this pattern has gone on for the past year during which time it has become more severe.
Recently Charles has been refusing to get up in the morning to get ready for school. When he does get up he is
slow in getting dressed, plays with his breakfast. This has lead to his missing the school bus because he is not
dressed and his mother taking him to school
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