Download Please keep track of any disorders discussed that you would like to

Bell Work
• What markers would you look for to
determine if someone has a learning
disability?
Please keep track of any disorders
discussed that you would like to
learn more about
http://www.4degreez.com/misc/
personality_disorder_test.mv
The following slides is info from
the DSM IV
Cautionary Statement
• “The specified diagnostic criteria for each mental
disorder are offered as guidelines.” (emphasis added)
• “The proper use of these criteria requires specialized
clinical training that provides both a body of
knowledge and clinical skills.”
– Essentially, do not try this at home
• Purpose of DSM is to provide information for clinicians
to diagnose, communicate about, study, and treat
people.
• “Clinical and research purposes” that may not meet
“legal or other non-medical criteria for what
constitutes mental disease, mental disorder, or mental
disability.”
Mental Disorder
• The term “unfortunately implies a distinction between ‘mental’
disorders and ‘physical’ disorders that is a reductionistic
anachronism of mind/body dualism.”
• They don’t have a substitute yet.
• “[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).”
– Cannot be a socially or culturally acceptable response (think about
different response to the death of a loved one)
– Regardless of cause, “it must currently be considered a manifestation
of a behavioral, psychological, or biological dysfunction in the
individual)
– Deviance, whether political/religious/sexual, in and of itself is not a
mental disorder. However, deviance can be a symptom.
Key Concept: The DSM is not classifying
people. It is classifying the disorders
people have.
The DSM “avoids the use of such
expressions as ‘a schizophrenic’ or ‘an
alcoholic’ and instead uses the more
accurate, but admittedly more
cumbersome, ‘an individual with
Schizophrenia’ or ‘an individual with
Alcohol Dependence.’
Limitations of the DSM
• “A categorical approach to classification works best
when all members of a diagnostic class are
homogenous, when there are clear boundaries
between classes” (classes meaning the
categories/labels, not classes of people), “and when
the different classes are mutually exclusive.” But it is
what it is.
– Many of the diagnostic classifications can be a symptom of
another class or can appear to be another class.
– As a result of all of this, it is essential for clinicians to use
clinical judgment and to document all data in case of
incorrect diagnosis.
• This is also why people without the years of medical and clinical
training should not pick up the DSM to try and diagnose
themselves or others.
– Even if you do have this training, it is not considered valid if you
“diagnose” yourself, family, friends—you need another professional and
objective opinion
Severity
• Mild-Few symptoms and only minor, if any,
impairment in social or occupational functioning
• Moderate-Symptoms/functional impairment
between mild and severe
• Severe-”Many symptoms in excess” or “several
symptoms that are particularly severe” or severe
impairment
• In Partial Remission
• In Full Remission
Headings in the DSM
•
•
•
•
•
Diagnostic Features: Clarifications of symptoms and examples
Subtypes and/or Specifiers
Recording Procedures
Associated Features and Disorders
Specific Culture, Age, and Gender Features: General differentiations
and prevalence
• Prevalence: Point and lifetime prevalence/risk
– Not based on above groups
• Course: Typical presentation/evolution; typical age of onset, mode
of onset (e.g., abrupt, insidious); episodic vs. continuous; duration
and progression (including general trend)
• Familial Pattern: Heritability and genetically-linked disorders
• Differential Diagnosis: Which disorders look similar and how to tell
them apart
Classification (Chapters)
• Disorders Usually First
•
Diagnosed in Infancy,
•
Childhood, or Adolescence
• Delirium, Dementia, and
•
Amnestic and Other
•
Cognitive Disorders
• Mental Disorders Due to a •
General Medical Condition
•
Not Elsewhere Classified
• Substance-Related Disorders•
• Schizophrenia and Other
Psychotic Disorders
•
• Mood Disorders
• Anxiety Disorders
• Somatoform Disorders
• Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity
Disorders
Eating Disorders
Sleep Disorders
Impulse-Control Disorders
Not Elsewhere Classified
Adjustment Disorders
Personality Disorders
Other Conditions That May
Be a Focus of Clinical
Attention
Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence
•
•
•
•
•
Mental Retardation
Learning Disorders
Motor Skills Disorders
Communication Disorders
Pervasive Developmental Disorders
– Autism/Asperger’s
• Attention-Deficit and Disruptive Behavior
Disorders
– ADHD/Oppositional Defiant Disorder
Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence
• Feeding and Eating
Disorders of Infancy or
Early Childhood
– Pica (eat all the things!
[that shouldn’t be
eaten])
– Rumination Disorder
(like baby animals… eat,
throw up, eat again)
• Tic Disorders
– Tourette’s
• Elimination Disorders
(Pooping Problems)
• Other Disorders of I/C/A
– Separation Anxiety
Disorder (Early
Onset)/Selective
Mutism
Bell Work
• What is the difference between Pica and
Rumination Disorder?
Multiaxial Assessment
• Axis I (Major Disorders Except Axis II)
– 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
• Axis V (Clinician’s Judgment of Level of Impairment)
– Global Assessment of Functioning
NOS-Not Otherwise Specified
Mental Retardation
• An IQ of approximately 70 or below with onset before
age 18
–
–
–
–
Mild: IQ 50-55 to approx. 70
Moderate: IQ 35-40 to 50-55
Severe: IQ 20-25 to 35-40
Profound: IQ below 20-25
– Why do you believe there is a range within a range for the
degrees of severity?
– “Mild” used to be referred to as “educable” retardation
and “Moderate” used to be referred to as “trainable.”
What is the problem with the outdated labels?
Learning Disorders
• Academic functioning that is substantially below:
– What is expected from person’s chronological age
– Measured intelligence
– Age-appropriate education
• Reading
• Written
Expression
• Mathematics
• NOS
(Not Otherwise
Specified)
Delirium, Dementia, and Amnestic and
Other Cognitive Disorders
• Were once called “Organic Mental Syndromes and
Disorders”
– Suggested that “nonorganic” mental disorders do not have a
biological basis. Also, scientific community has drifted away
from the misuse and overuse of the word “organic”
• Delirium-“characterized by a disturbance of
consciousness and a change in cognition that develop
over a short period of time.”
• Dementia-“characterized by multiple cognitive deficits
that include impairment in memory.”
• Amnestic Disorder-“characterized by memory
impairment in the absence of significant accompanying
cognitive impairments.”
Substance-Related Disorders
•
•
•
•
•
•
•
•
•
•
•
•
•
Alcohol
Amphetamine
Caffeine
Cannabis
Cocaine
Hallucinogen
Inhalant (Volatile Substances)
Nicotine
Opioid
Phencyclidine (PCP)
Sedative, hypnotic, or anxiolytic
Polysubstance
Other or Unknown
What is psychosis?
• Narrowest definition of psychotic: delusions and/or
hallucinations. Hallucinations occur without
awareness that one is hallucinating.
• Broad: Includes those aware they are hallucinating,
includes other positive symptoms of Schizophrenia
(i.e., disorganized speech, grossly disorganized or
catatonic behavior), extreme impairment of normal
functioning, loss of ego boundaries, distance from
reality
Delusions vs. Hallucinations
Schizophrenia and Other Psychotic
Disorders
• Schizophrenia: Lasts at least 6 months, including 1-month of active-phase
symptoms (two or more of: delusions, hallucinations, disorganized speech,
disorganized or catatonic behavior, negative symptoms)
• Schizophreniform: Lasts 1-6 months; doesn’t necessarily result in loss of
functioning
• Schizoaffective: Mood episode and active-phase symptoms of Schizophrenia
occur together and preceded or followed by at least two weeks of delusions
and/or hallucinations (no mood symptoms, except during mood episode—
this is depression or mania)
– Bipolar Type and Depressive Type
• Delusional Disorder: 1 month of non-bizarre delusions and no other activephase Schizophrenia symptoms
– What might constitute “non-bizarre delusions”?
• Brief Psychotic Disorder: Lasts 1 day to 1 month
• Shared Psychotic Disorder: Psychosis influenced by someone else with the
same or similar delusion (this person’s delusion is longer-standing)
– What cases/people might fit this disorder?
Episodic with or without
Interepisode Residual Symptoms
Single Episode
Continuous
Other/Unspecified Pattern
Schizophrenia: Paranoid Type
(Remember, these are generalizations)
• Prominent delusions (persecutory
or grandiose; organized around a
coherent theme) and/or auditory
hallucinations (adhere to theme of
delusion[s])
• Lack of disorganized
speech/behavior, flat/inappropriate
affect, catatonia
• Common Features: Anxiety, anger,
aloofness, and argumentativeness
• Personality: superior, patronizing,
formal, extreme intensity
• Paranoia predisposes individual to
suicide or violence
Schizophrenia: Disorganized Type
• All of the following are prominent:
– Disorganized speech, disorganized behavior, flat or inappropriate affect
• Silliness and laughter that isn’t related to the content of speech
• Behavioral disorganization=lack of goal orientation; disrupts performance of
daily living activities (e.g., showering, dressing, preparing meals)
• Delusions/hallucinations uncommon—if present, fragmented and
no coherent theme
• Features: Grimacing to silliness quickly
• Usually has an early and insidious onset with few to no remissions
Schizophrenia: Catatonic Type
• Psychomotor disturbance: motoric
immobility (catalepsy—waxy flexibility,
or stupor), excessive fine motor activity
(purposeless and uninfluenced by
external stimuli), extreme negativism
(maintenance of rigid posture, resistant
to outside forces), mutism, peculiarities
of voluntary movement (voluntary
assumption of inappropriate or bizarre
postures or facial expressions),
echolalia, echopraxia
• At-risk: Self-harm/harm of others with
movement, malnutrition, exhaustion
• More rare diagnosis, as clinicians are
encouraged to diagnose patient with
different diagnosis if possible
(substance-induced, GMC, Manic or
Major Depressive Episode, etc.)
This Is Your Brain on
Schizophrenia
Note
activity in
frontal lobe
Undifferentiated Type
Residual Type Diagnostic Criteria
• Absence of prominent
delusions, hallucinations,
disorganized speech, and
grossly disorganized or
catatonic behavior
(although may have had an
episode/disturbance of
these things previously)
• There is continuing
evidence of the
disturbance, as indicated
by the presence of
negative symptoms or two
or more positive
symptoms (not extreme
symptoms) (e.g., odd
beliefs, unusual perceptual
experiences)
Good Prognostic Features for SchizoDisorders
• Two or more of the following:
– Onset of prominent psychotic symptoms within 4 weeks of
the first noticeable change in usual behavior or functioning
(rapid development generally means rapid remission)
– Confusion or perplexity at the height of the psychotic
episode (demonstrates some awareness that what is being
experienced is not normal)
– Good premorbid social and occupational functioning (good
social/life skills before onset shows self-discipline and selfcontrol)
– Absence of blunted or flat affect (downward change in
affect generally means decline in brain function—think
about stroke victims that have this change in affect)
Delusional Disorder Subtypes
• Erotomanic Type: Another
person is in love with patient.
– Usually idealized romantic love
and spiritual union, not about sex
– Person is usually of higher status
(e.g., celebrity or boss), but can
be complete stranger
– Phone calls, letters, gifts,
stalking/surveillance—sometimes
just a secret
– Commonly females, males
generally end up conflicting with
law with their delusion (females
sometimes do too)
• “Misguided effort to ‘rescue’ him or
her from some imagined danger”
(e.g., abusive relationship, but really
it’s just their real relationship)
Bell Work
• What is the difference between prognosis and
diagnosis?
Delusional Disorder Subtypes
(What appears to be the central theme
of delusion[s]?)
• Grandiose Type: “Conviction of
having some great (but
unrecognized) talent or insight
or having made some important
discovery.” Less common:
special relationship, nonromantic, with a prominent
person, or being a prominent
person (actual person is an
imposter) May have religious
content.
• Jealous Type: Spouse/romantic
partner is unfaithful
Delusional Disorder Subtypes
• Persecutory Type: “He/she is being conspired against,
cheated, spied on, followed, poisoned or drugged,
maliciously maligned, harassed, or obstructed in the
pursuit of long-term goals.” Small offenses are
exaggerated and may become the focus. Often feel
that injustice must be remedied by legal action.
• Somatic Type: Involves bodily functions/sensations.
Most common: a body part smells really bad; there is
an internal parasite; body dysmorphia; body parts
aren’t functioning
– More extreme
• Mixed Type
• Unspecified Type
Psychotic Stressors
• Loss of a loved one
• Psychological trauma
• Trauma from combat
• Without Marked
Stressor(s)
• Postpartum Onset:
within 4 weeks
Mood Disorders
• Depressive Disorders
• Bipolar Disorders
Specifiers: Catatonia, Melancholia,
Atypical, Postpartum, Seasonal
Pattern, Rapid Cycling
Mood Disorders: Depressive Disorders
• Major Depressive Disorder:
Characterized by one or more
Major Depressive Episodes (i.e.,
at least 2 weeks of depressed
mood or loss of interest
accompanied by at least four
additional symptoms of
depression
• Dysthymic Disorder: 2 years of
depressed mood for more days
than not, accompanied by
additional depressive
symptoms that do not meet
criteria for a Major Depressive
Episode
Criteria for Major Depressive Episode
• A. Five or more of the following within 2-week period (change from
previous functioning) (cannot be due to GMC or a symptom of a psychotic
disorder [e.g., Catatonic Schizophrenia])
– Must Include one of: depressed mood and/or loss of interest or pleasure
– Depressed mood most of the day, nearly every day, indicated by self-report or
observations of others
– Markedly diminished interest or pleasure in (almost) all activities
– Significant weight loss or weight gain not caused by an intentional change in
diet; decrease/increase in appetite
• Children: failure to meet growth milestones
–
–
–
–
Insomnia/hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness, or excessive or inappropriate guilt (may be
delusional)
– Diminished cognitive abilities, indecisiveness
– Recurrent thoughts of death, suicidal ideations with or without a plan, selfharm, suicidal attempts
Criteria for Major Depressive Episode
• B. Do not meet criteria for
Mixed Episode
• Symptoms cause clinically
significant distress or
impairment in life-living
• Not directly due to
physiological effects of a
substance (drugs) or a GMC
(e.g., thyroid)
• Not due to Bereavement
– If the above criteria is met 2
months after the loss of the
loved one, then it may be
considered a Major
Depressive Episode
Criteria for Manic Episode
• A. Abnormally and persistently elevated, expansive, or irritable
mood.
– Lasts at least 1 week
• B. Mood disturbance must be accompanied by at least three
additional symptoms (four if the mood is only irritable)
– Inflated self-esteem or grandiosity (may be delusional)
– Decreased need for sleep (e.g., feels rested after only 3 hours of sleep,
as opposed to insomnia/fatigue)
– More talkative than usual or pressure to keep talking
– Flight of ideas or subjective experience that thoughts are racing
– Distractibility
– Increase in goal-directed activity
– Excessive involvement in pleasurable activities that have a potential for
painful consequences (e.g., buying sprees, sexual indiscretions, foolish
business choices)
• D. Impairment in functioning
Manic vs. Hypomanic Episode
• 1 week vs. 4 days
• Same Criterion B
• Impaired
functioning (social,
occupational, etc.)
vs. No marked
impairment (some
even report that
hypomanic
episodes can be an
asset)
• Hypomanic is mild
or moderate mania
Mood Disorders: Bipolar Disorders
• Bipolar I Disorder: one or
more Manic, Hypomanic, or
Mixed Episodes, accompanied
by Major Depressive Episodes
• Bipolar II Disorder: One or
more Major Depressive
Episodes accompanied by at
least one Hypomanic Episode
• Cyclothymic Disorder: At least
2 years of numerous periods
of hypomanic symptoms that
do not meet the criteria for a
Manic Episode and numerous
periods of depressive
symptoms that do not meet
criteria for a Major Depressive
Episode.
Bipolar I Disorder
• At least one Manic, or Mixed
Episode.
– Hypomanic Episodes may have
occurred in past
• At least one Major Depressive
Episode
• Mood symptoms cause
clinically significant distress, or
impairment in social,
occupational, or other
important areas of functioning
– The distress/impairment is
usually caused by the mania
• Generally about two months
from episode to episode.
Bipolar I Prevalence: .4-1.6%
Bipolar II Prevalence: .5%
Bipolar II Disorder
• A. One or more Major
Depressive Episode
• B. At least one
Hypomanic Episode
• C. There has never been a
Manic or Mixed Episode
• D/E. Mood symptoms
cause clinically significant
distress, or impairment in
social, occupational, or
other important areas of
functioning
– The distress/impairment
is usually caused by the
depression
Anxiety Disorders
• Panic Disorder without
Agoraphobia
• Panic Disorder with
Agoraphobia
• Agoraphobia without History
of Panic Disorder
• Specific Phobia (Type)
• Social Phobia (Generalized
Social Anxiety Disorder)
• OCD
• PTSD
• Acute Stress Disorder
• Generalized Anxiety Disorder
Anxiety Disorder Definitions
• Panic Attack: Sudden onset of intense
apprehension, fearfulness, or terror, often
associated with feelings of impending doom.
Symptoms: shortness of breath, palpitations,
chest pain or discomfort, choking or
smothering sensations, and fear of “going
crazy” or losing control
• Agoraphobia: Anxiety about, or avoidance of,
places or situations from which escape might
be difficult (or embarrassing) or in which help
may not be available in the even of having a
Panic Attack or panic-like symptoms
• Phobia: significant anxiety provoked by
exposure to a feared object or situation,
often leading to avoidance behavior.
• Obsessive-Compulsive Disorder: Obsessions
(which cause anxiety or distress) and/or by
compulsions (which serve to neutralize
anxiety)
• Generalized Anxiety Disorder: At least 6
months of persistent and excessive anxiety
and worry
PTSD Specifiers
• Acute: Duration
of symptoms is
less than 3
months
• Chronic:
Symptoms last 3
months or
longer
• With Delayed
Onset: At least 6
months have
passed between
the traumatic
event and the
onset of the
symptoms
Specific Phobia Subtypes
• Animal Type: Animals or insects. Generally has a childhood onset
• Natural Environment Type: For example, storms, heights, or water. Things that
occur in the natural environment. Generally has a childhood onset.
• Blood-Injection-Injury Type: Seeing blood or injury or by receiving an injection or
other invasive medical procedure. Highly familial and often characterized by a
strong vasovagal response (fainting).
• Situational Type: Cued by a specific situation such as public transportation, tunnels,
bridges, elevators, flying, driving, or enclosed places. (Manmade things unlike
Natural Environment)
• Other Type: For example, fear of choking, vomiting, or contracting an illness;
“space” phobia (the individual is afraid of falling down if away from walls or other
means of physical support); and children’s fears of loud sounds or costumed
characters (clowns)
• Having one phobia increases likelihood of having another phobia in the same
subtype.
Obsessions
• Persistent ideas, thoughts, impulses, or
images that are experienced as intrusive
and inappropriate and that cause marked
anxiety or distress.
– Note the difference between obsessions and
delusions
– Ego-dystonic: individual’s sense that the
content of the obsession is alien, not within
his/her own control, and not the kind of
thought that he/she would expect to have
– They are not simply excessive worries about
real-life problems and are unlikely related to
a real-life problem
• Most common obsessions:
–
–
–
–
Contamination
Repeated doubts (Is the door locked?)
A need to have things in a particular order
Aggressive or horrific impulses (e.g., to hurt
one’s child or to shout an obscenity in
church)
– Sexual imagery (e.g., a recurrent
pornographic image)
Compulsions
• Repetitive behaviors (e.g., hand
washing, ordering, checking) or
mental acts (e.g., praying, counting,
repeating words silently) the goal of
which is to prevent or reduce anxiety
or distress, not to provide pleasure or
gratification.
• By definition, compulsions are either
clearly excessive or are not
connected in a realistic way with
what they are designed to naturalize
or prevent. By definition, adults have
recognized these are excessive or
unreasonable (kids may lack
sufficient cognitive awareness).
• Common Compulsions: washing and
cleaning, counting, checking,
requesting or demanding assurances,
repeating actions, and ordering.
Diagnostic Criteria for OCD
• A. Either obsessions and/or compulsions:
– Obsessions as defined by:
• Recurrent and persistent thoughts, impulses, or images that are
experienced as intrusive and inappropriate (at least at some point) and that
cause marked anxiety or distress
• Cannot be excessive worries about real-life problems
• Person attempts to ignore or suppress obsessions or to neutralize them
with some other thought or action
• Person recognizes that the obsessions are a product of his or her own mind
– Compulsions as defined by:
• Repetitive behaviors or mental acts that the person feels driven to perform
in response to an obsession, or according to rules that must be applied
rigidly
• Aimed at preventing or reducing distress or preventing some dreaded event
or situation; however, they are not connected in a realistic way with what
they are designed to neutralize or prevent, or are clearly excessive
Diagnostic Criteria for OCD Cont.
• B. At some point during the
course of the disorder, the person
has recognized that the
obsessions or compulsions are
excessive or unreasonable
– Doesn’t apply to children
– This is key as it differentiates
from some type of psychosis
• C. The obsessions or compulsions
cause marked distress, are time
consuming (in total, take more
than 1 hour a day), or significantly
interfere with the person’s normal
routine, occupational or academic
functioning, or usual social
activities or relationships.
• D/E. Obsessions or compulsions
should not be a result of a
different Axis I disorder,
substance use, or GMC.