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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.