Abnormal Psych

bipolar II disorder

in which the person does not experience full-blown manic (or mixed) episodes but has experienced clear-cut hypomanic episodes as well as major depressive episodes

PTSD

1. Intrusion: Recurrent reexperiencing of the traumatic event through nightmares, intrusive images, and physiological reactivity to reminders of the trauma. (In DSM-IV ruminative thoughts about the trauma were also considered to reflect intrusion. This is not the case in DSM-5.) 2. Avoidance: Efforts to avoid thoughts, feelings, or reminders of the trauma. 3. Negative alterations in cognitions and mood: This includes such symptoms as feelings of detachment as well as negative emotional states such as shame or anger, or distorted blame of oneself or others. 4. Arousal and reactivity: Hypervigilance, excessive response when startled, aggression, and reckless behavior.

psychopathy

1a. The interpersonal dimension reflects a personality style that is characterized by glibness/superficial charm, a grandiose sense of self-worth, pathological lying, and the conning manipulation of others. 1b. The affective dimension reflects traits such as lack of remorse or guilt, callousness/lack of empathy, shallow affect, and a failure to accept responsibility for one's behavior. 2a. The lifestyle dimension reflects a need for stimulation, a tendency to be easily bored, impulsivity, irresponsibility, a lack of reasonable long-term goals, as well as a parasitic lifestyle. 2b. Finally, the antisocial dimension reflects the aspects of psychopathy that involve poor behavior controls, early behavior problems, delinquency, and criminality.

Dependent Personality Disorder

A. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. 2. Needs others to assume responsibility for most major areas of his or her life. 3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.) 4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). 5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. 7. Urgently seeks another relationship as a source of care and support when a close relationship ends. 9. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Paranoid Personality Disorder (Cluster A)

A. 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 four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. 4. Reads hidden demeaning or threatening meanings into benign remarks or events. 5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Schizoid Personality Disorder

A. 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 four (or more) of the following: 1. Neither desires nor enjoys close relationships, including being part of a family. 2. Almost always chooses solitary activities. 3. Has little, if any, interest in having sexual experiences with another person. 4. Takes pleasure in few, if any, activities. 5. Lacks close friends or confidants other than first-degree relatives. 6. Appears indifferent to the praise or criticism of others. 7. Shows emotional coldness, detachment, or flattened affectivity. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

Antisocial Personality Disorder

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others. 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. The individual is at least age 18 years. C. There is evidence of conduct disorder with onset before age 15 years. D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Histrionic Personality Disorder

A. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the center of attention. 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. 3. Displays rapidly shifting and shallow expression of emotions. 4. Consistently uses physical appearance to draw attention to self. 5. Has a style of speech that is excessively impressionistic and lacking in detail. 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion. 7. Is suggestible (i.e., easily influenced by others or circumstances). 8. Considers relationships to be more intimate than they actually are.

Narcissistic Personality Disorder

A. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. 3. Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). 4. Requires excessive admiration. 5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations). 6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends). 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. 8. Is often envious of others or believes that others are envious of him or her. 9. Shows arrogant, haughty behaviors or attitudes.

Borderline Personality Disorder

A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Obsessive-Compulsive Personality Disorder

A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value. 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8. Shows rigidity and stubbornness.

Schizotypal Personality Disorder

A. 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, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference). 2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations). 3. Unusual perceptual experiences, including bodily illusions. 4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). 5. Suspiciousness or paranoid ideation. 6. Inappropriate or constricted affect. 7. Behavior or appearance that is odd, eccentric, or peculiar. 8. Lack of close friends or confidants other than first-degree relatives. 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Avoidant Personality Disorder

A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. 2. Is unwilling to get involved with people unless certain of being liked. 3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. 4. Is preoccupied with being criticized or rejected in social situations. 5. Is inhibited in new interpersonal situations because of feelings of inadequacy. 6. Views self as socially inept, personally unappealing, or inferior to others. 7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Body Dysmorphic Disorder

A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

Alcohol Use Disorder

A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499-500). b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Schizoaffective Disorder

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. 1. Note: The major depressive episode must include Criterion A1: Depressed mood. B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness. C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Persistent Depressive Disorder

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.Note: In children and adolescents, mood can be irritable and duration must be at least 1 year. B. Presence, while depressed, of two (or more) of the following:1. Poor appetite or overeating.2. Insomnia or hypersomnia.3. Low energy or fatigue.4. Low self-esteem.5. Poor concentration or difficulty making decisions.6. Feelings of hopelessness. C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time. D. Criteria for a major depressive disorder may be continuously present for 2 years. E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder. F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.

Dissociative Identity Disorder

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual. B. Recurrent gaps in the recall of everyday events, important personal information, and/ or traumatic events that are inconsistent with ordinary forgetting. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.

Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): ​Note:​ Only one item is required in children. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Posttraumatic Stress Disorder

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). a. Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). a. Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). b. Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) c. Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined"). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Factitious Disorder Imposed on Self

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. B. The individual presents himself or herself to others as ill, impaired, or injured. C. The deceptive behavior is evident even in the absence of obvious external rewards. D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Major Depressive Disorder

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.Note: ​Do not include symptoms that are clearly attributable to another medical condition.​1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)4. Insomnia or hypersomnia nearly every day.5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).6. Fatigue or loss of energy nearly every day.7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition.Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode.Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.

Specific Phobia

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). 1. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

Agoraphobia

A. Marked fear or anxiety about two (or more) of the following five situations: 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes). 2. Being in open spaces (e.g., parking lots, marketplaces, bridges). 3. Being in enclosed places (e.g., shops, theaters, cinemas). 4. Standing in line or being in a crowd. 5. Being outside of the home alone. B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence). C. The agoraphobic situations almost always provoke fear or anxiety. D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. If another medical condition (e.g., inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety, or avoidance is clearly excessive. I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder); and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).

Somatic Symptom Disorder

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life. B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: 1. Disproportionate and persistent thoughts about the seriousness of one's symptoms. 2. Persistently high level of anxiety about health or symptoms. 3. Excessive time and energy devoted to these symptoms or health concerns. C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Illness Anxiety Disorder

A. Preoccupation with having or acquiring a serious illness. B. Somatic symptoms are not present or, if present, are only mild in intensity; If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate. D. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals). E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time. F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

Obsessive-Compulsive Disorder

A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Brief Psychotic Disorder

A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. *Note: Do not include a symptom if it is a culturally sanctioned response. B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Binge-Eating Disorder

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1.Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. The binge-eating episodes are associated with three (or more) of the following: 1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full. 3. Eating large amounts of food when not feeling physically hungry. 4. Eating alone because of feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very guilty afterward. C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Panic Disorder

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: ​Note: ​The abrupt surge can occur from a calm state or an anxious state.​ 1.​ Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations. 10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself). 12. Fear of losing control or "going crazy." 13. Fear of dying. a. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy").2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Anorexia Nervosa

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Delusional Disorder

A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. 1. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation). C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.

Depersonalization/Derealization Disorder

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both: 1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one's thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). 2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). B. During the depersonalization or derealization experiences, reality testing remains intact. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures). E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

Schizophreniform Disorder

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition). B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as "provisional." C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Schizophrenia

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition). B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Suggested Revised Diagnostic Criteria for Somatic Symptom Disorder

A:One or more prominent physical symptoms. B:Excessive and maladaptive thoughts, feelings, and behaviors related to the physical symptoms. All three of the following must be present: (a) clearly disproportionate and intrusive worries about the seriousness of the symptoms, (b) extreme anxiety about the symptoms, and (c) excessive time and energy devoted to the symptoms or health concerns. C:The excessive concerns have persisted at a clearly problematic level for at least 6 months. D:The excessive concerns about physical symptoms are pervasive and cause significant disruption and impairment in daily life. E:If a diagnosed medical condition is present, the thoughts, feelings, and behaviors are grossly in excess of what would be expected, given the nature of the medical condition. F:If no medical diagnosis has been made, a thorough medical workup has been performed to rule out possible causes and is repeated at suitable intervals to uncover medical conditions that may declare themselves with the passage of time. G:The physical symptom or concern is not better accounted for by another mental disorder (e.g., anxiety, depressive, or psychotic disorder).

In Physical and Emotional Pain

Anna G., a 38-year-old married woman, the mother of five children, reports to a mental health clinic with the chief complaint of depression, meeting diagnostic criteria for major depressive disorder. Her marriage has been a chronically unhappy one. Anna describes her husband as an alcoholic with an unstable work history, and there have been frequent arguments revolving around finances, her sexual indifference, and her complaints of pain during intercourse. Anna describes herself as having been nervous since childhood and also as having been continuously sick from an early age. She experiences chest pain and says she has been told by doctors that she has a "nervous heart." Anna sees physicians frequently for abdominal pain, having been diagnosed on one occasion as having a "spastic colon." In addition to physicians, Anna has consulted chiropractors and osteopaths for backaches, pains in her extremities, and a feeling of anesthesia in her fingertips. She was recently admitted to a hospital following complaints of abdominal and chest pain and of vomiting. During this admission she received a hysterectomy. Since the surgery she has been troubled by spells of anxiety, fainting, vomiting, food intolerance, weakness, and fatigue. So far, physical examinations have failed to reveal any explanations for her symptoms.

Schizoid Personality Disorder: The Introverted Computer Analyst

Bill, a highly intelligent but quite introverted and withdrawn 33-year-old computer analyst, was referred for psychological evaluation by his physician, who was concerned that Bill might be depressed and unhappy. Bill had virtually no contact with other people. He lived alone in his apartment, worked in a small office by himself, and usually saw no one at work except his supervisor, who occasionally visited to give him new work and pick up completed projects. He ate lunch by himself, and about once a week, on nice days, went to the zoo for his lunch break. Bill was a lifelong loner; as a child he had had few friends and had always preferred solitary activities over family outings (he was the oldest of five children). In high school he had never dated and in college had gone out with a woman only once—and that was with a group of students after a game. He had been active in sports, however, and had played varsity football in both high school and college. In college he had spent a lot of time with one relatively close friend—mostly drinking. However, this friend now lived in another city. Bill reported rather matter-of-factly that he had a hard time making friends; he never knew what to say in a conversation. On a number of occasions he had thought of becoming friends with other people but simply couldn't think of the right words, so "the conversation just died." He reported that he had given some thought lately to changing his life in an attempt to be more "positive," but it had never seemed worth the trouble. It was easier for him not to make the effort because he became embarrassed when someone tried to talk with him. He was happiest when he was alone.

Alcohol Amnestic Disorder

Brendan was brought into the detoxification unit of a local county hospital by the police after an incident at a crowded city park. He was arrested because of his assaultive behavior toward others (he was walking through the crowded groups of sunbathers muttering to himself, kicking at people). At admission to the hospital, Brendan was disoriented (did not know where he was), incoherent, and confused. When asked his name, he paused a moment, scratched his head, and said, "George Washington." When asked about what he was doing at the park, he indicated that he was "marching in a parade in his honor."

Bulimia Nervosa Catherine: Distressed by Her Weight

Catherine is 20 years old. Catherine has been concerned about her weight and shape for several years. As a teenager she felt plump and was frequently on a diet, even though she was within the normal weight range for her age and height. As she became older, these concerns became more serious. She severely restricted her food intake and started punishing exercise regimens. At one stage she became significantly underweight. Medical help led to weight gain, which was quickly followed by more dieting and, for the first time, she started binge eating. Distressed by the increase in her weight and by increasingly frequent binge eating, Catherine began vomiting in a desperate attempt to lose weight. Over the past 6 months Catherine has skipped breakfast and lunch, eaten a normal evening meal with her family, but gone on to binge eat in the late evening, usually two or three times a week. She binge eats in response to feeling upset and worried. In a recent typical binge-eating episode she ate four slices of toast with butter and jam, six packets of potato chips, three large bars of chocolate, half a box of cereal, and a large bowl of ice cream. She had been feeling rejected by a friend. Catherine drinks large quantities of water to help her induce vomiting after binging. More recently she has started to take 30 to 40 laxatives, as well as vomiting. She has a strenuous exercise regime, including 500 daily sit-ups and an aerobic workout. Food is divided rigidly into good and bad categories; food in the bad category (such as cookies, chocolate, and cheese) is not allowed. Catherine has become increasingly self-conscious. She refuses to weigh herself, has given up swimming (she used to swim on her school team), and if she goes shopping she will not try on clothes unless she has privacy. Catherine dislikes her body. She is preoccupied with her shape and reports that a little voice in her head constantly says, "You're fat and ugly, I can't stand the way you look." Catherine worries that her friends will think less of her if she does not lose weight (when out with friends she avoids eating and sucks her tummy in to the point of pain in order to appear thinner). She feels very bad about herself if she thinks she has gained weight.

Yes. The person has a somatic symptom (gut pain) that is distressing and that creates a high level of anxiety. A lot of time is spent consulting medical professionals or reading about health topics. The anxiety is disproportionate to the seriousness of the symptom, as evidenced by the fact that all medical tests have been negative and doctors have been reassuring.

Clinical Vignette Interviewer: Now I would like to ask you some questions about your physical health. Do you worry a lot about your physical health? Patient: I have a pain on the right side of my gut. I worry about that a lot. Interviewer: Tell me more about that. Patient: Well I have been to see my doctor about it a few times. She has done some tests and they never find anything. I think it might be the early stages of stomach cancer or something like that. Interviewer: What does your doctor say? Patient: She tells me not to worry. But I've had this for almost a year now. Sometimes it goes away for a short while. But it obviously means something. You don't have gut pain for no reason. I get a lot of medical newsletters and read about things online. But my doctor doesn't seem to take me very seriously.

A Psychopath in Action

Donald, 30 years old, has just completed a 3-year prison term for fraud, bigamy, false pretenses, and escaping lawful custody. The circumstances leading up to these offenses are interesting and consistent with his past behavior. With less than a month left to serve on an earlier 18-month term for fraud, he faked illness and escaped from the prison hospital. During the 10 months of freedom that followed, he engaged in a variety of illegal enterprises; the activity that resulted in his recapture was typical of his method of operation. By passing himself off as the "field executive" of an international philanthropic foundation, he was able to enlist the aid of several religious organizations in a fund-raising campaign. The campaign moved slowly at first, and in an attempt to speed things up, he arranged an interview with the local TV station. His performance during the interview was so impressive that funds started to pour in. However, unfortunately for Donald, the interview was also carried on a national news network. He was recognized and quickly arrested. During the ensuing trial it became evident that he experienced no sense of wrongdoing for his activities. . . . At the same time, he stated that most donations to charity are made by those who feel guilty about something and who therefore deserve to be bilked. While in prison he was used as a subject in some of the author's research. On his release he applied for admission to a university and, by way of reference, told the registrar that he had been one of the author's research colleagues! Several months later the author received a letter from him requesting a letter of recommendation on behalf of Donald's application for a job. Background. Donald was the youngest of three boys born to middle-class parents. Both of his brothers led normal, productive lives. His father spent a great deal of time with his business; when he was home he tended to be moody and to drink heavily when things were not going right. Donald's mother was a gentle, timid woman who tried to please her husband and to maintain a semblance of family harmony. . . . However, . . . on some occasions [the father] would fly into a rage and beat the children, and on others he would administer a verbal reprimand, sometimes mild and sometimes severe. By all accounts Donald was considered a willful and difficult child. When his desire for candy or toys was frustrated he would begin with a show of affection, and if this failed he would throw a temper tantrum; the latter was seldom necessary because his angelic appearance and artful ways usually got him what he wanted. . . . Although he was obviously very intelligent, his school years were academically undistinguished. He was restless, easily bored, and frequently truant . . . when he was on his own he generally got himself or others into trouble. Although he was often suspected of being the culprit, he was adept at talking his way out of difficulty. Donald's misbehavior as a child took many forms including lying, cheating, petty theft, and the bullying of smaller children. As he grew older he became more and more interested in sex, gambling, and alcohol. When he was 14 he made crude sexual advances toward a younger girl, and when she threatened to tell her parents he locked her in a shed. It was about 16 hours before she was found. Donald at first denied knowledge of the incident, later stating that she had seduced him and that the door must have locked itself. . . . His parents were able to prevent charges being brought against him. . . . When he was 17, Donald . . . forged his father's name to a large check and spent about a year traveling around the world. He apparently lived well, using a combination of charm, physical attractiveness, and false pretenses to finance his way. During subsequent years he held a succession of jobs, never . . . for more than a few months. Throughout this period he was charged with a variety of crimes, including theft, drunkenness in a public place, assault, and many traffic violations. In most cases he was either fined or given a light sentence. A Ladies' Man. His sexual experiences were frequent, casual, and callous. When he was 22, he married a 41-year-old woman whom he had met in a bar. Several other marriages followed, all bigamous. . . . The pattern was the same: He would marry someone on impulse, let her support him for several months, and then leave. One marriage was particularly interesting. After being charged with fraud Donald was sent to a psychiatric institution for a period of observation. While there he came to the attention of a female member of the professional staff. His charm, physical attractiveness, and convincing promises to reform led her to intervene on his behalf. He was given a suspended sentence, and they were married a week later. At first things went reasonably well, but when she refused to pay some of his gambling debts he forged her name to a check and left. He was soon caught and given an 18-month prison term. . . . He escaped with less than a month left to serve. It is interesting to note that Donald sees nothing particularly wrong with his behavior, nor does he express remorse or guilt for using others and causing them grief. Although his behavior is self-defeating in the long run, he considers it to be practical and possessed of good sense. Periodic punishments do nothing to decrease his egotism and confidence in his own abilities. . . . His behavior is entirely egocentric, and his needs are satisfied without any concern for the feelings and welfare of others.

Anorexia Nervosa

Eisha was 22 years old and in her fourth year of graduate study at a university in the United States when she first sought treatment. Her eating disorder, however, had begun many years earlier. When she was 14 and at school in her home country of India, she reported being bullied by her classmates who told her she looked fat in her new school dress. After this incident, she started to feel that she had become fat and she began to starve herself to lose weight. By the time she was 18 she was in a physically weak state. She ate only once a day. The rest of the time she exercised, and refused all other requests to eat food. Occasionally, her restraint would break down and she would binge eat. After each binge-eating episode she would starve herself for 3 or 4 days to compensate. Eventually she began to purge routinely after eating any food to make sure she did not gain any weight. She believed that "to be beautiful you need to be thin" and that eating was bad. After eating, she would tell herself "you are good for nothing." (Based on Roy, 2014.)

Clinical Interview: Alcohol Use Disorder Yes. This person's pattern of alcohol use is leading to ongoing problems at work and school - and potentially in family relationships - and he is continuing to drink despite these problems.

Interviewer: Has your drinking ever caused problems in your relationships, like with friends, family members, or romantic partners? Patient: A little, but not in any way that I couldn't handle. Interviewer: Tell me more about that. Patient: Well, I mean, all of my friends like to party. And I certainly am not the one in my group that drinks the most. And, of course, everyone has times where they miss class or work or something because they were partying too much, you know? I'm sure you had times when you were in college where you partied, right? Interviewer: I'd like to keep us focused on you for the moment. And in response to your question, yes, I think most people like to go to parties and to spend time with their friends. Tell me about the time when your partying or drinking alcohol led to the biggest problem for you. Patient: Biggest problem? I don't know. Maybe last month. You know, it's finally nice weather after this long winter we've had and so my friends and I partied pretty hard for several days in a row. It was super fun and things got kind of crazy. The problem, though, is that because we were having so much fun, I just said "forget get about it" to my job and classes, you know? I didn't think it was going to be a big deal, but my boss over-reacted and fired me. Then my parents found out and now they are telling me that they are no longer paying my tuition, rent, or anything. This is crazy. It's just a little partying, and now things are kind of spiraling out of control. Interviewer: Are there other times this past year in which your drinking has caused problems with your job, school work, or relationships? Patient: Well, yeah. Like I said, we like to party. And so maybe 1 or 2 days a week I stay home from classes because I'm hung over, and maybe 1 night a week I skip my shift at work to go out drinking with my friends. Whatever, you know? It's college and we're supposed to be having fun.

Hallucinations Yes. The person reports smelling angels and smells them in a wide range of places. No one else smells them and there is no tangible evidence that an angel is present when the smell is experienced.

Interviewer: Now I would like to ask you about some unusual experiences that people sometimes have. Have you ever had a time when you smelled some smell that other people couldn't smell like decaying food or something like that? Patient: I smell angels when they are present. Is that what you mean? Interviewer: Tell me more about that. Patient: Sometimes I smell angels. They smell nice. Like talcum powder. Interviewer: Does anyone else smell them like that? Patient: No. I have asked people, but I think it is just me that can detect them when they are there. Sometimes they have a kind of lavender smell. Interviewer: And where do you smell the angels? Patient: Oh, it could be anywhere. In church, in my kitchen, in the street. They get around a lot. They go where I go.

No. This person has a medical condition. But there is no evidence of a high level of anxiety about this, or excessive energy being devoted to health-related concerns. The person receives medical attention, follows recommendations, and appears to have a realistic sense of what having this illness involves.

Interviewer: Now I would like to ask you some questions about your physical health. Do you worry a lot about your physical health? Patient: Well I have rheumatoid arthritis so I have to pay attention to that. Interviewer: Tell me more about that. Patient: I was diagnosed a few years ago. I take medication and see my doctor regularly. So I take care of things as best I can. Interviewer: Do you worry a lot about your condition? Patient: Not really. Worrying about it doesn't help. I get a lot of pain in my joints and it's worse if I rest for too long. So I try and avoid doing that if I can. But it's just something I have to deal with. And I have a lot of faith in my doctors.

Yes. The person meets criteria for illness anxiety disorder. Although there are no real symptoms, there is a preoccupation with having heart disease and dying from a heart attack. Activities that might stress the heart are avoided and any normal heart-related events (fluttering feeling) are a cause for alarm.

Interviewer: Now I would like to ask you some questions about your physical health. Do you worry a lot about your physical health? Patient: Yes. I hate to admit it but I do. Interviewer: Tell me more about that. Patient: I didn't used to. But ever since a colleague dropped dead of a heart attack two years ago, I have been terrified of the same thing happening to me. There's no history of heart disease in my family. But I still worry a lot about just dropping dead like my co-worker did. Interviewer: What does your doctor say? Patient: My blood pressure is fine. Apparently. And everything looks normal when I go for a physical. But doctors don't know everything. Something could be wrong. They don't call heart disease the silent killer for nothing do they? So I try and avoid doing anything that could put stress on my heart. Interviewer: Like what? Patient: Exercising, lifting heavy things. That kind of thing. So far so good. But anytime I get a fluttering type of feeling in my heart, I freak out. That's probably not good for me either. But I can't help it. Maybe it's a sign of things to come, you know.

A Student's Struggle with Panic

Jackson is a 21-year-old college student who came to his university's mental health clinic complaining of unexplainable panic attacks. He reports experiencing these attacks for about a year, and is coming for treatment now because they have been increasing in frequency and have gotten to the point of interfering significantly with his ability to pay attention in class and to interact with his friends socially. Jackson describes his panic attacks as coming on completely out of the blue. They are typically characterized by feelings of derealization, extreme panic, and a strong desire to leave whatever situation he is in, and physical symptoms of racing heart, dizziness, sweating, chest pains, and shortness of breath. Jackson has these panic attacks at seemingly random times, but they occur most often in the shower, during his morning classes, and in the dining hall. Because of the distress experienced during these attacks and out of fear of having more attacks, Jackson has been showering less frequently, leaving class whenever he thinks a panic attack may be coming, and he no longer eats in the dining hall. He also has begun drinking alcohol earlier and earlier each evening because he has noticed that alcohol calms his anxiety and seems to decrease the amount of panic he experiences during the evening.

Binge-Eating Disorder

Jenna is a 33-year-old single woman who lives alone. She works as a therapist in a school for children with learning difficulties. She came to the clinic for help with chronic feelings of depression. She also acknowledged a history of obesity and binge eating dating back to her adolescent years. By the time of her initial consultation she weighed 260 pounds and had a BMI of 39.5. She was afraid that her weight would continue to increase unless she found ways to control her eating. Jenna told the therapist that she had "always been fat." She was extremely reluctant to talk about her eating habits because to do so made her feel embarrassed and ashamed. She said that, in addition to eating three substantial meals every day, she snacked constantly because there were always cookies and cakes available in the teachers' room at school. She also had eating binges. These occurred approximately twice a week and were invariably triggered by anything that made her feel sad, disappointed, or upset. If she had a difficult day at work, she would stop at a convenience store on her way home, buy candy and cookies, and eat quickly in the car. She would then feel disgusted with herself, setting the stage for another binge eating episode when she was alone at home. She would prepare large amounts of food for herself and eat as rapidly as she could until she was so full she was uncomfortable. Jenna longed to be able to "eat normally" but also acknowledged how reliant she was on food to help her cope with all the sadness in her life. There was no evidence of any purging, fasting, or misuse of laxatives. Occasionally, Jenna did try to exercise, although she regarded herself as "too fat to go to the gym."

MDD Jennifer

Jennifer is a 35-year-old graphic designer who is married and has three young children at home. She has been running a successful, and growing, business out of her home office, which she has really enjoyed because working from home allows her the time and flexibility to be with her children when they are not in school. Jennifer experienced a major life stressor 6 months ago when her husband of 15 years, Michael, told her that he was leaving her for a younger woman he met at his job. Jennifer was totally blindsided by this news. After an initial period of trying to work things out, Michael moved out of the house. Jennifer continued on with her business and managing of her household for several weeks, but then things started to change. She felt increasingly sad and would have long periods of crying throughout the day several times per week. Whereas she used to enjoy work, time with her children, and going out with her girlfriends, none of that seemed fun anymore. Even "movie nights" at home with the kids, which was one of her favorite times of the week, just wasn't enjoyable to her anymore. Her body felt heavier and heavier and she lacked the energy to keep up appointments, leading her business to decline-she began losing even her most loyal clients. Jennifer also had difficulties managing her household, on several occasions forgetting to pick up her children from school and not remembering to make dinner for the family. Her eating and sleeping both declined drastically, and she spent hours lying in bed feeling like she had let down her husband, her children, and her friends. In addition to her extreme sadness, Jennifer began to experience extreme anxiety and worry in multiple domains. How would her business succeed? If she lost her business, wouldn't she lose her house? Would she lose her children as well? Who would take care of them? She wanted to address all of these things but felt paralyzed and unable to take action. This led her to feel even more like a failure. She believed she was completely worthless and began contemplating whether everyone wouldn't be better off if she was dead, which increased to explicit and frequent thoughts of suicide.

A Cyclothymic Chef

Kevin is a 35-year-old chef who is seeking treatment at the suggestion of both his employer and girlfriend. His presenting problem is that "for the past 10 or so years I have been having extreme ups and downs ... pretty serious mood swings." Kevin says that he knows that some of his employees refer to him as "Dr. Jekyll and Mr. Hyde" behind his back, and his employer and girlfriend have said that they never know "which Kevin" they are going to see. He describes his mood swings as periods of ups and downs. The "ups" last 3 to 5 days during which he is happy, full of energy and creativity, often expanding his menu, creating new dishes, and experiencing "a deep love of life and everything in it." The "downs" last a little bit longer, maybe 5 to 7 days, and during those periods he feels down, lacks energy, has to really push himself to get into work and prepare his menu, and is often agitated-yelling at his cooks, occasionally so loud that customers can hear him. This pattern of ups and downs has started to have a negative impact on his work, and is putting a significant strain on his relationship.

Histrionic Personality Disorder

Lulu, a 24-year-old housewife, was seen in an inpatient unit several days after she had been picked up for "vagrancy" after her husband had left her at the bus station to return her to her own family because he was tired of her behavior and of taking care of her. Lulu showed up for the interview all made-up and in a very feminine robe, with her hair done in a very special way. Throughout the interview with a male psychiatrist, she showed flirtatious and somewhat childlike seductive gestures and talked in a rather vague way about her problems and her life. Her chief complaints were that her husband had deserted her and that she couldn't return to her family because two of her brothers had abused her. Moreover, she had no friends to turn to and wasn't sure how she was going to get along. Indeed, she complained that she had never had female friends, whom she felt just didn't like her, although she wasn't quite sure why, assuring the interviewer that she was a very nice and kind person. Recently she and her husband had been out driving with a couple who were friends of her husband's. The wife had accused Lulu of being overly seductive toward the wife's husband, and Lulu had been hurt, thinking her behavior was perfectly innocent and not at all out of line. This incident led to a big argument with her own husband, one in a long series during the past 6 months in which he complained about her inappropriate behavior around other men and about how vain and needing of attention she was. These arguments and her failure to change her behavior had ultimately led her husband to desert her.

Obsessions about Confessing and Compulsive Checking

Mark was a 28-year-old single male who, at the time he entered treatment, suffered from severe obsessive thoughts and images about causing harm to others such as running over pedestrians while he was driving. He also had severe obsessions that he would commit a crime such as robbing a store of a large amount of money or poisoning family members or friends. These obsessions were accompanied by lengthy and excessive checking rituals. For example, one day when he drove, he began obsessing that he had caused an accident and hit a pedestrian at an intersection, and he felt compelled to spend several hours driving and walking around all parts of that intersection to find evidence of the accident. At the time Mark went to an anxiety disorder clinic, he was no longer able to live by himself after having lived alone for several years since college. He was a very bright young man with considerable artistic talent. He had finished college at a prestigious school for the arts and had launched a successful career as a young artist when the obsessions began in his early 20s. At first, they were focused on the possibility that he would be implicated in some crime that he had not committed; later, they evolved to the point where he was afraid that he might actually commit a crime and confess to it. The checking rituals and avoidance of all places where such confessions might occur eventually led to his having to give up his career and his own apartment and move back in with his family. At the time he presented for treatment, Mark's obsessions about harming others and confessing to crimes (whether or not he had committed them) were so severe that he had virtually confined himself to his room at his parents' house. Indeed, he could leave his room only if he had a tape recorder with him so that he would have a record of any crimes he confessed to out loud because he did not trust his own memory. The clinic was several hours' drive from his home; his mother usually had to drive because of his obsessions about causing accidents with pedestrians or moving vehicles and because the associated checking rituals could punctuate any trip with several very long stops. He also could not speak at all on the phone for fear of confessing some crime that he had (or had not) committed, and he could not mail a letter for the same reason. He also could not go into a store alone or into public bathrooms, where he feared he might write a confession on the wall and be caught and punished.

A Thief with Antisocial Personality Disorder

Mark, a 22-year-old, was awaiting trial for car theft and armed robbery. His case records included a long history of arrests beginning at age 9, when he had been picked up for vandalism. He had been expelled from high school for truancy and disruptive behavior. On a number of occasions he had run away from home for days or weeks at a time—always returning in a disheveled and "rundown" condition. To date he had not held a job for more than a few days at a time even though his generally charming manner enabled him to obtain work readily. He was described as a loner with few friends. Although initially charming, Mark usually soon antagonized those he met with his aggressive, self-oriented behavior. Shortly after his first therapy session, he skipped bail and presumably left town to avoid his trial. His therapist never saw him again.

Social Anxiety Disorder (Social Phobia)

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. The social situations are avoided or endured with intense fear or anxiety. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specific Phobia Mary's Treatment

Mary participated in 13 sessions of graduated exposure exercises in which her clinician accompanied Mary first into mildly fear-provoking situations and then gradually into more and more fear-provoking situations. Mary also engaged in homework, doing these exposure exercises by herself. The prolonged in vivo ("real-life") exposure sessions lasted as long as necessary for her anxiety to subside. Initial sessions focused on Mary's claustrophobia and on getting her to be able to ride for a few floors in an elevator, first with the therapist and then alone. Later she took longer elevator rides in taller buildings. Exposure for the acrophobia consisted of walking around the periphery of the inner atrium on the top floor of a tall hotel and, later, spending time at a mountain vista overlook spot. The top step of Mary's claustrophobia hierarchy consisted of taking a tour of an underground cave. After 13 sessions, Mary successfully took a flight with her husband to Europe and climbed to the top of many tall tourist attractions there.

A Mother's Fears-Specific Phobia

Mary, a married mother of three, was 47 at the time she first sought treatment for anxiety. She reported being intensely afraid of enclosed spaces (claustrophobia) and of heights (acrophobia) since her teens. She said that as a child, her older siblings used to lock her in closets and hold her down under blankets while saying things to scare her. She traced the onset of her claustrophobia to those traumatic incidents, but she had no idea why she was afraid of heights. While her children had been growing up, she had been a housewife and had managed to live a fairly normal life in spite of her two specific phobias. However, her children were now grown, and she wanted to find a job outside her home. This was proving to be very difficult because she could not take elevators and was terrified of being any higher than the first floor of an office building. Moreover, her husband had for some years been working for an airline, which entitled him to free airline tickets. The fact that Mary could not fly (due to her phobias) had become a sore point in her marriage because they both wanted to be able to take advantage of these free tickets to travel to distant places. Thus, although she had had these phobias for many years, they had become truly disabling only in recent years as her life circumstances had changed and she could no longer easily avoid heights or enclosed spaces.

Abducted and Terrorized-PTSD

Mr. A. was a married accountant, the father of two, in his early 30s. One night, while out running an errand, he was attacked by a group of young men. They forced him into their car and took him to a deserted country road. There they pulled him from the car and began beating and kicking him. They took his wallet, began taunting him about its contents (they had learned his name, his occupation, and the names of his wife and children), and threatened to go to his home and harm his family. Finally, after brutalizing him for several hours, they tied him to a tree. One man held a gun to his head. Mr. A. begged and pleaded for his life; then the armed assailant pulled the trigger. The gun was empty, but at the moment the trigger was pulled, Mr. A. defecated and urinated in his pants. Then the men untied him and left him on the road. Mr. A. slowly made his way to a gas station and called the police. [One of the authors] was called to examine him and did so at intervals for the next 2 years. The diagnosis was PTSD. Mr. A. had clearly experienced an event outside the range of normal human experience and was reexperiencing the event in various ways: intrusive recollections, nightmares, flashbacks, and extreme fear upon seeing groups of tough-looking young men. He was initially remarkably numb in other respects: He felt estranged and detached. He withdrew from his family, lost interest in his job, and expected to die in the near future. Mr. A. also showed symptoms of increased physiological arousal. His sleep was poor, he had difficulty concentrating, and he was easily startled. When Mr. A. first spoke about his abduction in detail he actually soiled himself at the moment he described doing so during the original traumatic experience. Mr. A. received treatment from a psychiatrist for the next 2 years. This consisted of twice-weekly individual psychotherapy as well as antidepressant medications. A focus of the therapy was the sense of shame and guilt Mr. A. felt over his behavior during his abduction. He wished he had been more stoic and had not pleaded for his life. With the help of his therapist, Mr. A. came to see that his murderous rage at his abductors was understandable, as was his desire for revenge. He was also able to accept that his response to his experience was likely similar to how others might have responded if faced with the same circumstances. By the end of treatment Mr. A. was almost without symptoms, although he still became somewhat anxious when he saw some groups of young men. Most important, his relationship with his wife and children was warm and close, and he was again interested in his work.

Borderline Personality Disorder

Ms. R. is 19 years old. Although she has no formal history of psychiatric treatment, she reports a long history of mood instability, suicidal gestures, and skin cutting. She also has had many stormy relationships, including a history of physical abuse, as well as three abortions. She was admitted to the hospital for the first time after she threatened to kill herself following a physical fight with her boyfriend and crashing the family car. The patient says that she recently moved out of her family home and went to live with her boyfriend. After a fight with her boyfriend that left her with a bloody lip, she was feeling "depressed." She returned home and began to fight with her mother. She then stole the family car and crashed into a pole. When a neighbor found her, she stated she was going to kill herself. Her mother subsequently brought her to the hospital. On admission, Ms. R said she was "depressed" and suicidal. She was described as angry, entitled, manipulative, and "regressed." She was diagnosed with borderline personality. The presence of narcissistic traits was also noted. (From Avery et al., 2012.)

A Surgeon's Social Anxiety

Paul was a single, white male in his mid-30s when he first presented for treatment. He was a surgeon who reported a 13-year history of social anxiety. He had very few social outlets because of his persistent concerns that people would notice how nervous he was in social situations, and he had not dated in many years. Convinced that people would perceive him as foolish or crazy, he particularly worried that people would notice how his jaw tensed up when around other people. Paul frequently chewed gum in public situations, believing that this kept his face from looking distorted. Notably, he had no particular problems talking with people in professional situations. For example, he was quite calm talking with patients before and after surgery. During surgery, when his face was covered with a mask, he also had no trouble carrying out surgical tasks or interacting with the other surgeons and nurses in the room. The trouble began when he left the operating room and had to make small talk—and eye contact—with the other doctors and nurses or with the patient's family. He frequently had panic attacks in these social situations. During the panic attacks he experienced heart palpitations, fears of "going crazy," and a sense of his mind "shutting down." Because the panic attacks occurred only in social situations, he was diagnosed as having social anxiety rather than panic disorder. Paul's social anxiety and panic had begun about 13 years earlier when he was under a great deal of stress. His family's business had failed, his parents had divorced, and his mother had had a heart attack. It was in this context of multiple stressors that a personally traumatic incident probably triggered the onset of his social anxiety. One day he had come home from medical school to find his best friend in bed with his fiancée. About a month later he had his first panic attack and started avoiding social situations.

somatic symptom disorder

Richard is a 46-year-old software engineer who reports a long history of many somatic complaints. His problems began in high school when he started to have headaches and pain in his chest. As time has progressed he has developed a broad range of symptoms all over his body including back pain, abdominal pain and discomfort, joint pain, feelings of dizziness, and a general sense of weakness and fatigue. During the past 20 years, Richard has seen many doctors and received numerous medical examinations. Although he has received several descriptive diagnoses that do little more than note his symptoms, no medical explanation for his problems has been found. Richard worries constantly that something is being missed and that, on the days the tests were done, the underlying problem was somehow unable to be detected. Richard subscribes to several health newsletters and frequently uses the Internet to learn more about the possible causes of his symptoms. He realizes his current doctor is getting annoyed with his frequent visits, but he continues to worry constantly about his health.

A Graduate Student with GAD

Rodney was a 26-year-old, single graduate student in the social sciences at a prestigious university. He reported that he had had problems with anxiety nearly all his life, but they had become worse since he had left home and gone to an Ivy League college. During the past year his anxiety had seriously interfered with his functioning, and he worried about several different spheres of his life such as his own and his parents' health. During one incident a few months earlier, he had thought that his heart was beating more slowly than usual, and he had experienced some tingling sensations; this led him to worry that he might die. In another incident he had heard his name spoken over a loudspeaker in an airport and had worried that someone at home must be dying. He was also very worried about his future because his anxiety had kept him from completing his master's thesis on time. Rodney also worried excessively about getting a bad grade even though he had never had one either in college or in graduate school. In classes he worried excessively about what the professor and other students thought of him. Although he had a number of friends, he had never had a girlfriend because of his shyness about dating. He had no problem talking or socializing with women as long as it was not defined as a dating situation. He worried that he should date a woman only if he was quite sure, from the outset, that it could be a serious relationship. He also worried excessively that if a woman did not want to date him, it meant that he was boring. In addition to his worries, which he perceived as uncontrollable, Rodney reported muscle tension and becoming easily fatigued. He also reported great difficulty concentrating and a considerable amount of restlessness and pacing. At times he had difficulty falling asleep if he was particularly anxious, but at other times he slept excessively, in part to escape from his worries. He frequently experienced dizziness and palpitations, and in the past he had had full-blown panic attacks. Rodney's mother was also quite anxious and had been treated for panic disorder. Rodney was obviously extremely bright and had managed to do very well in school in spite of his lifelong problems with anxiety. But as the pressures of finishing graduate school and starting his career loomed before him, and as he got older and had still never dated, the anxiety became so severe that he sought treatment.

Four Days of Symptoms and Rapid Recovery

Ronald was 32 years old and had worked successfully as a lawyer for 6 years. He was married with two young children and he had many close friends. One day he returned home early from work and was shocked to find his wife in bed with his best friend. His initial reaction was anger, followed by depression. However, within 2 days he began to hear voices that called his name and that said, "Love, love, love." Ronald began to express odd ideas, speaking of fusing with God and dispensing peace on Earth. He also talked about needing to fight what he called the "giant conspiracy." During this time his affect was flat and he spoke in a slow and distinct manner. Ronald was admitted to hospital and was given medication. He and his wife also began marital therapy. Ronald showed rapid improvement of his symptoms and within 5 days of the onset of his initial symptoms he was back at work again. (Based on Janowsky et al., 1987.)

A Persistently Depressed Student

Rosa, a 20-year-old college student, came into the university clinic for an evaluation at the encouragement of her roommate. She reports that "ever since high school" she has "felt sad, like, all of the time ... it doesn't seem normal and I don't know why." Rosa notes that there was no major stressor that she can remember that triggered her feelings of sadness, "just the normal high school stuff." But her feelings of sadness have persisted for nearly 4 years now. When asked about what her sadness is like, she tells the psychologist that she just feels like she is not as good as everyone else-not as smart as the other students, not as attractive as the other girls, and can't seem to have fun and enjoy college like everyone else seems to be doing. Rosa was very active and popular early in high school: She was a member of the track team, in honors classes and an A student, and had a wonderful and supportive network of friends. However, during her junior and senior years, she lost interest in track and school, and just didn't feel close to her friends anymore and so over time stopped hanging out with them. No one seemed to care or try to change things, which really affected Rosa's self-esteem and to this day causes her to think that no one "really" cares about her. In addition to her feelings of sadness, Rosa has been having trouble sleeping several nights per week, tossing and turning throughout the night. She also weighs about 20 pounds less than she did in high school, not because of diet or exercise but because she "doesn't really enjoy food much anymore." All of this has led to problems with Rosa's ability to care about school or to be motivated to apply herself in class, and so this once A student is now barely passing her classes. Rosa's roommate has been asking her to come in to talk with someone about all of this for months, and Rosa's declining attendance at school and decreasing contact with her family and friends led her roommate to walk her to the clinic for an evaluation today-to make sure she came in for help.

Avoidant Personality Disorder

Sally, a 35-year-old librarian, lived a relatively isolated life and had few acquaintances and no close personal friends. From childhood on, she had been very shy and had withdrawn from close ties with others to keep from being hurt or criticized. Two years before she entered therapy, she had had a date to go to a party with an acquaintance she had met at the library. The moment they had arrived at the party, Sally had felt extremely uncomfortable because she had not been "dressed properly." She left in a hurry and refused to see her acquaintance again. In the early treatment sessions, she sat silently much of the time, finding it too difficult to talk about herself. After several sessions, she grew to trust the therapist, and she related numerous incidents in her early years in which she had been "devastated" by her alcoholic father's obnoxious behavior in public. Although she had tried to keep her school friends from knowing about her family problems, when this had become impossible, she instead had limited her friendships, thus protecting herself from possible embarrassment or criticism. When Sally first began therapy, she avoided meeting people unless she could be assured that they would "like her." With therapy that focused on enhancing her assertiveness and social skills, she made some progress in her ability to approach people and talk with them.

Dependent Personality Disorder

Sarah, a 32-year-old mother of two and a part-time tax accountant, came to a crisis center late one evening after Michael, her husband of a year and a half, had abused her physically and then left home. Although he never physically harmed the children, he frequently threatened to do so when he was drunk. Sarah appeared acutely anxious and worried about the future and "needed to be told what to do." She wanted her husband to come back and seemed rather unconcerned about his regular pattern of physical abuse. At the time, Michael was an unemployed resident in a day treatment program at a halfway house for paroled drug abusers. He was almost always in a surly mood and "ready to explode." Although Sarah had a well-paying job, she voiced great concern about being able to make it on her own. She realized that it was foolish to be "dependent" on her husband, whom she referred to as a "real loser." (She had had a similar relationship with her first husband, who had left her and her oldest child when she was 18.) Several times in the past few months, Sarah had made up her mind to get out of the marriage but couldn't bring herself to break away. She would threaten to leave, but when the time came to do so, she would "freeze in the door" with a numbness in her body and a sinking feeling in her stomach at the thought of "not being with Michael."

Psychoactive Drugs Commonly Involved in Drug Abuse

Sedatives Stimulants Opiates Hallucinogens Antianxiety drugs (minor tranquilizers)

Seeing Spots

Steve is a 24-year-old engineer who presented for treatment at the request of his wife. He was recently fired from his job after refusing to go into work for a 2-week period because of his extreme concerns about his appearance. He explains that he could no longer tolerate the enormous birth marks that cover his face, and so he has begun trying to pluck them off his face with nail clippers. This led to noticeable cuts and scabs on his face, which embarrassed him further and prevented him from going to work. Steve's wife reports that although he does have a few very small and hardly noticeable freckles on his face, Steve has never had any significant birth marks or detectable skin discoloration. Steve explained that ever since he can remember he has "not been thrilled" with the beauty marks on his face, but in the past year they have really bothered him to the point of thinking about them constantly and wishing they were gone. His wife said that Steve spends at least an hour in the mirror each morning and evening looking at the marks, asking her if she really loves him despite their presence, and researching ways to eliminate them via facial plastic surgery, bleaching, or some other cosmetic procedure. His job loss and facial lacerations were enough to push Steve's wife to insist that he see a psychologist for treatment, and Steve has agreed to do so.

Sybil: Did She Really Have Multiple Personality Disorder?

Sybil (whose real name was Shirley Mason) was a troubled woman from Minnesota with a history of traumatic abuse. Over the course of therapy with Dr. Cornelia Wilbur she went on to develop 16 alter personalities. However, there is no evidence that Shirley had any alters or even any symptoms of dissociative identity disorder prior to starting therapy with Dr. Wilbur. There was also no evidence that Shirley was ever mistreated in childhood. Yet under Wilbur's questioning and through Wilbur's suggestive prompts, Shirley began to "recall" many instances of sadistic abuse from her mother. Numerous alters also began to emerge. The idea that these were developed in an effort to please Wilbur is suggested by another aspect to the story. When a colleague was covering Shirley's treatment while Dr. Wilbur was away at a professional meeting, Shirley asked the new psychiatrist, "Well, do you want me to be Helen?", meaning one of her other personalities. The new psychiatrist was understandably rather confused. When he asked Shirley what she meant, she told him, "Well, when I'm with Dr. Wilbur, she wants me to be Helen" (Nathan, 2011, p. 131). And when Shirley later confessed to Dr. Wilbur that she had been essentially lying and did not have any multiple personalities, Wilbur interpreted this as a sign of resistance in the therapy. The therapy continued in the same manner and Shirley soon took back her confession.

Psychopathy

Table 10.4 Cleckley's Criteria for Superficial charm and good "intelligence" Absence of delusions and other signs of irrational thinking Absence of nervousness or psychoneurotic manifestations Unreliability Untruthfulness and insincerity Lack of remorse or shame Inadequately motivated antisocial behavior Poor judgement and failure to learn from experience Pathological egocentricity and incapacity for love General poverty in major affective reactions Specific loss of insight Unresponsiveness in general interpersonal relations Fantastic and uninviting behavior with drink and sometimes without Suicide rarely carried out Sex life impersonal, trivial, and poorly integrated Failure to follow any life plan

Living in a Dream

The patient, a 22-year-old man employed as a mail carrier in India, came to the outpatient clinic reporting feelings of unreality, heaviness in his head, and a sense that his surroundings had changed. He told the doctors that his problems had begun suddenly, 6 months earlier when he was with his friends. According to the patient, he felt that his friends had changed-that they were no longer his friends but more like ghosts or devils. Scared, the patient hurried home, but when he got home and saw his mother, he felt that she, too, had changed. These feelings continued and it became hard for the patient to tell the difference between the real and the unreal. Although he continued to work in his job, he no longer had any interest in social activities. When he went into a crowded place, he felt as if he was in a dream or somehow roaming in a different kind of a world. He realized that these feelings were his own and he sometimes pinched himself to feel the pain and try and get rid of the feelings of unreality. (Based on Ghosh et al., 2007.)

Paranoid Personality Disorder

The patient, a 46-year-old male who worked in a blue collar job, was admitted to the psychiatric hospital after he made a suicide attempt. In his teenage years, he had been involved in a car accident and was hospitalized for head trauma and brain concussion. He also had a long history of abusing alcohol. Those who knew him described him as hyper-sensitive, touchy, suspicious, and mistrustful. His most prominent feature, however, was concern about his wife's fidelity. He repeatedly accused her of being unfaithful and "interrogated" her frequently about a wide range of matters. When he drank, his paranoia became even more marked.

Sped Up and Out of Control-Bipolar

Tim is a 25-year-old student and aspiring poet, rapper, and musician. He was just admitted to a psychiatric hospital in an apparent manic episode. Although he has had a fairly stable life in which he lives with his girlfriend, Tessa, takes classes at the local community college, and works at a coffee shop in town, his behavior has become increasingly erratic. More specifically, his girlfriend reports that Tim has appeared to be "really sped up" the past month, talking faster than usual, expressing some pretty grandiose ideas (e.g., "I'm going to start and finish a PhD in poetry this year," "I set up a meeting with Kanye West to discuss signing with him," and "I am Tupac reincarnated!"). Tessa reports that things have gotten much worse during the past 2 weeks, during which Tim sleeps just 1 to 2 hours per night and spends the rest of his time in the evenings making music, smoking marijuana, and buying expensive items online (he has maxed out their credit cards buying multiple guitars, turntables, a new refrigerator, and a five-star trip to Paris). She also reports that Tim disappeared for the past 4 days (skipping school and work as well), only to return home this morning saying that he "has been living with another woman he just met." Tessa says that this is all very out of character for Tim. Since she has known him he has had periods of pretty severe depression during which he becomes extremely sad, stops playing or making music, sleeps most of the day, and barely leaves the house. However, she has never seen him so sped up and out of control and he has become a completely different person these past few weeks.

Obsessive-Compulsive Personality Disorder

Tom appeared to be well suited to his work as a train dispatcher. He was conscientious, perfectionistic, and attended to minute details. However, he was not close to his coworkers, and they reportedly thought him "off." He would get quite upset if even minor variations to his daily routine occurred. For example, he would become tense and irritable if coworkers did not follow exactly his elaborately constructed schedules and plans. Tom also had difficulty when his coworkers suggested other ways to accomplish work-related tasks. He was unable to acknowledge that there might be other equally good ways to do things, and he quickly dismissed all suggestions and ideas from his colleagues and coworkers. In short, Tom got little pleasure out of life and worried constantly about minor problems. His rigid routines were impossible to maintain, and he often developed tension headaches or stomachaches when he couldn't keep his complicated plans in order. His physician, noting the frequency of his physical complaints and his generally perfectionistic approach to life, referred him for a psychological evaluation. Psychotherapy was recommended, but he did not follow up on the treatment recommendations because he felt that he could not afford the time away from work.

Bipolar I disorder

is distinguished from MDD by the presence of mania.