General Behavioral Health Course Objectives, Diagnosis: Behavioral Health PA 604

obsessive-compulsive disorder

•Obsessions: recurrent or persistent thoughts/images. These thoughts are inappropriate, intrusive, & unwanted. The patient tries to ignore or suppress the obsessions. They are usually ego-dystonic (inconsistent with one's own personal beliefs). •Compulsions: repetitive behaviors (rituals) the person feels driven to perform to reduce or prevent stress from the obsession. These compulsions cause distress, impairment, or are time consuming (eg, > 1 hour a day). •Men = women but men often present earlier in their teens. Genetic component. •Mean age of onset 20y with symptoms often present in adolescence (onset rare after 50y). •Theorized due to abnormal communication between the basal ganglia, orbitofrontal cortex, and the anterior cingulate gyrus. •Serotonin thought to be primary neurotransmitter involved. •May be associated with the triad of "uncontrollable urges" OCD, ADHD, & tic disorders (Tourette). CLINICAL MANIFESTATIONS 4 major patterns: •1. Contamination - compulsion may include cleaning or hand washing. •2. Pathologic doubt eg, forgetting to unplug iron to avoid potential danger. •3. Symmetry/precision eg, ordering or counting. •4. Intrusive obsessive thoughts without compulsion. SPECIFIERS •Good/fair insight: recognizes OCD beliefs are not true or may not be true. •Poor insight: thinks the OCD beliefs are probably true. •Absent insight/delusional beliefs: completely convinced that the OCD beliefs are true. MANAGEMENT •Combination of cognitive behavioral therapy and pharmacotherapy. •Cognitive behavioral therapy: first-line therapy exposure & response prevention psychoeducation. •Pharmacotherapy - SSRIs first-line medical therapy (eg, Fluoxetine, Sertraline, Paroxetine) - higher doses needed compared to depressive disorders; Tricyclic antidepressants (Clomipramine because it is the most serotonin specific), SNRis (eg, Venlafaxine). Augmentation therapy with antipsychotics. •Severely debilitating or resistant: psychosurgery (cingulotomy) or electroconvulsive therapy.

Specifiers for bipolar and related disorders

149-154 in DSM-5

Specifiers for Depressive Disorders

184-188 DSM

Panic attacks

214-217

Intoxication and withdrawal symptoms chart

605

Stimulant Use Disorder (DSM)

A. A pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. The stimulant 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 stimulant use. 3. A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant, or recover from its effects. 4. Craving, or a strong desire or urge to use the stimulant. 5. Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the stimulant. 7. Important social, occupational, or recreational activities are given up or reduced because of stimulant use. 8. Recurrent stimulant use in situations in which it is physically hazardous. 9. Stimulant 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 the stimulant. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the stimulant to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of the stimulant. Note: This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the stimulant (refer to Criteria A and B of the criteria set for stimulant withdrawal, p. 569). b. The stimulant (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. Specifiers "In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these and locked hospital units. environments are closely supervised and substance-free jails, therapeutic communities, And locked hospital units Diagnostic Features The amphetamine and amphetamine-type stimulants include substances with a substi- tuted-phenylethylamine structure, such as amphetamine, dextroamphetamine, and meth- amphetamine. Also included are those substances that are structurally different but have similar effects, such as methylphenidate. These substances are usually taken orally or in- travenously, although methamphetamine is also taken by the nasal route. In addition to the synthetic amphetamine-type compounds, there are naturally occurring, plant-derived stimulants such as khât. Amphetamines and other stimulants may be obtained by prescrip- ton for the treatment of obesity, attention-deficit /hyperactivity disorder, and narcolepsy. Consequently, prescribed stimulants may be diverted into the illegal market. The effects of amphetamines and amphetamine-like drugs are similar to those of cocaine, such that the criteria for stimulant use disorder are presented here as a single disorder with the ability to specify the particular stimulant used by the individual. Cocaine may be consumed in sev- eral preparations (e.g., coca leaves, coca paste, cocaine hydrochloride, and cocaine alka- loids such as freebase and crack) that differ in potency because of varying levels of purity and speed of onset. However, in all forms of the substance, cocaine is the active ingredient. Cocaine hydrochloride powder is usually "snorted" through the nostrils or dissolved in water and injected intravenously. Individuals exposed to amphetamine-type stimulants or cocaine can develop stimu- lant use disorder as rapidly as 1 week, although the onset is not always this rapid. Re- gardless of the route of administration, tolerance occurs with repeated use. Withdrawal symptoms, particularly hypersomnia, increased appetite, and dysphoria, can occur and can enhance craving. Most individuals with stimulant use disorder have experienced tol- erance or withdrawal. Use patterns and course are similar for disorders involving amphetamine-type stimu- lants and cocaine, as both substances are potent central nervous system stimulants with similar psychoactive and sympathomimetic effects. Amphetamine-type stimulants are longer acting than cocaine and thus are used fewer times per day. Usage may be chronic or episodic, with binges punctuated by brief non-use periods. Aggressive or violent behavior is common when high doses are smoked, ingested, or administered intravenously. Intense temporary anxiety resembling panic disorder or generalized anxiety disorder, as well as paranoid ideation and psychotic episodes that resemble schizophrenia, is seen with high- dose use. Withdrawal states are associated with temporary but intense depressive symptoms that can resemble a major depressive episode; the depressive symptoms usually resolve within 1 week. Tolerance to amphetamine-type stimulants develops and leads to escalation of the dose. Conversely, some users of amphetamine-type stimulants develop sensitization, characterized by enhanced effects. Associated Features Supporting Diagnosis When injected or smoked, stimulants typically produce an instant feeling of well-being, confidence, and euphoria. Dramatic behavioral changes can rapidly develop with stimu- lant use disorder. Chaotic behavior, social isolation, aggressive behavior, and sexual dys- function can result from long-term stimulant use disorder. Individuals with acute intoxication may present with rambling speech, headache, tran- sient ideas of reference, and tinnitus. There may be paranoid ideation, auditory halluci- nations in a clear sensorium, and tactile hallucinations, which the individual usually recognizes as drug effects. Threats or acting out of aggressive behavior may occur. Depres- sion, suicidal ideation, irritability, anhedonia, emotional lability, or disturbances in atten- tion and concentration commonly occur during withdrawal. Mental disturbances associated with cocaine use usually resolve hours to days after cessation of use but can persist for 1 month. Physiological changes during stimulant withdrawal are opposite to those of the intoxication phase, sometimes including bradycardia. Temporary depressive symptoms may meet symptomatic and duration criteria for major depressive episode. Histories con- sistent with repeated panic attacks, social anxiety disorder (social phobia)-like behavior, and generalized anxiety-like syndromes are common, as are eating disorders. One ex- treme instance of stimulant toxicity is stimulant-induced psychotic disorder, a disorder that resembles schizophrenia, with delusions and hallucinations. Individuals with stimulant use disorder often develop conditioned responses to drug- related stimuli (e.g., craving on seeing any white powderlike substance). These responses contribute to relapse, are difficult to extinguish, and persist after detoxification. Depressive symptoms with suicidal ideation or behavior can occur and are generally the most serious problems seen during stimulant withdrawal. Prevalence Stimulant use disorder: amphetamine-type stimulants. Estimated 12-month prevalence of amphetamine-type stimulant use disorder in the United States is 0.2% among 12- to 17- year-olds and 0.2% among individuals 18 years and older. Rates are similar among adult males and females (0.2%), but among 12- to 17-year-olds, the rate for females (0.3%) is greater than that for males (0.1%). Intravenous stimulant use has a male-to-female ratio of 3:1 or 4:1, but rates are more balanced among non-injecting users, with males representing 54% of primary treatment admissions. Twelve-month prevalence is greater among 18-to 29-year-olds (0.4%) compared with 45- to 64-year-olds (0.1%). For 12- to 17-year-olds, rates are highest among whites and African Americans (0.3%) compared with Hispanics (0.1%) and Asian Americans and Pacific Islanders (0.01%), with amphetamine-type stimulant use disorder virtually absent among Native Americans. Among adults, rates are highest among Native Americans and Alaska Natives (0.6%) compared with whites (0.2%) and Hispanics (0.2%), with amphetamine-type stimulant use disorder virtually absent among African Americans and Asian Americans and Pacific Islanders. Past-year nonprescribed use of prescription stimulants occurred among 5%-9% of children through high school, with 5%-35% of college-age persons reporting past-year use. Stimulant use disorder: cocaine. Estimated 12-month prevalence of cocaine use disorder in the United States is 0.2% among 12- to 17-year-olds and 0.3% among individuals 18 years and older. Rates are higher among males (0.4%) than among females (0.1%). Rates are highest among 18-to 29-year-olds (0.6%) and lowest among 45-to 64-year-olds (0.1%). Among adults, rates are greater among Native Americans (0.8%) compared with African Ameri- cans (0.4%), Hispanics (0.3%), whites (0.2%), and Asian Americans and Pacific Islanders (0.1%). In contrast, for 12- to 17-year-olds, rates are similar among Hispanics (0.2%), whites (0.2%), and Asian Americans and Pacific Islanders (0.2%); and lower among African Amer- icans (0.02%); with cocaine use disorder virtually absent among Native Americans and Alaska Natives. Development and Course Stimulant use disorders occur throughout all levels of society and are more common among individuals ages 12-25 years compared with individuals 26 years and older. First regular use among individuals in treatment occurs, on average, at approximately age 23 years. For pri- mary methamphetamine-primary treatment admissions, the average age is 31 years. Some individuals begin stimulant use to control weight or to improve performance in school, work, or athletics. This includes obtaining medications such as methylphenidate or amphetamine salts prescribed to others for the treatment of attention-deficit/hyperac- tivity disorder. Stimulant use disorder can develop rapidly with intravenous or smoked administration; among primary admissions for amphetamine-type stimulant use, 66% re- ported smoking, 18% reported injecting, and 10% reported snorting. Patterns of stimulant administration include episodic or daily (or almost daily) use. Episodic use tends to be separated by 2 or more days of non-use (e.g., intense use over a weekend or on one or more weekdays). "Binges" involve continuous high-dose use over hours or days and are often associated with physical dependence. Binges usually termi- nate only when stimulant supplies are depleted or exhaustion ensues. Chronic daily use may involve high or low doses, often with an increase in dose over time. Stimulant smoking and intravenous use are associated with rapid progression to se- vere-level stimulant use disorder, often occurring over weeks to months. Intranasal use of cocaine and oral use of amphetamine-type stimulants result in more gradual progression occurring over months to years. With continuing use, there is a diminution of pleasurable effects due to tolerance and an increase in dysphoric effects. Risk and Prognostic Factors Temperamental. Comorbid bipolar disorder, schizophrenia, antisocial personality disor- der, and other substance use disorders are risk factors for developing stimulant use disorder and for relapse to cocaine use in treatment samples. Also, impulsivity and similar personality traits may affect treatment outcomes. Childhood conduct disorder and adult antisocial per- sonality disorder are associated with the later development of stimulant-related disorders. Environmental. Predictors of cocaine use among teenagers include prenatal cocaine ex- posure, postnatal cocaine use by parents, and exposure to community violence during childhood. For youths, especially females, risk factors include living in an unstable home environment, having a psychiatric condition, and associating with dealers and users. Culture-Related Diagnostic Issues Stimulant use-attendant disorders affect all racial/ ethnic, socioeconomic, age, and gender groups. Diagnostic issues may be related to societal consequences (e.g., arrest, school sus- pensions, employment suspension). Despite small variations, cocaine and other stimulant use disorder diagnostic criteria perform equally across gender and race/ ethnicity groups. Chronic use of cocaine impairs cardiac left ventricular function in African Americans. Approximately 66% of individuals admitted for primary methamphetamine/amphet- amine-related disorders are non-Hispanic white, followed by 21% of Hispanic origin, 3% Asian and Pacific Islander, and 3% non-Hispanic black. Diagnostic Markers Benzoylecgonine, a metabolite of cocaine, typically remains in the urine for 1-3 days after a single dose and may be present for 7-12 days in individuals using repeated high doses. Mildly elevated liver function tests can be present in cocaine injectors or users with con- comitant alcohol use. There are no neurobiological markers of diagnostic utility. Discon- tinuation of chronic cocaine use may be associated with electroencephalographic changes, suggesting persistent abnormalities; alterations in secretion patterns of prolactin; and downregulation of dopamine receptors. Short-half-life amphetamine-type stimulants (MDMA [3,4-methylenedioxy-N-methyl- amphetamine], methamphetamine) can be detected for 1-3 days, and possibly up to 4 days depending on dosage and metabolism. Hair samples can be used to detect presence of am- phetamine-type stimulants for up to 90 days. Other laboratory findings, as well as physical findings and other medical conditions (e.g., weight loss, malnutrition; poor hygiene), are similar for both cocaine and amphetamine-type stimulant use disorder. Functional Consequences of Stimulant Use Disorder Various medical conditions may occur depending on the route of administration. Intrana- sal users often develop sinusitis, irritation, bleeding of the nasal mucosa, and a perforated nasal septum. Individuals who smoke the drugs are at increased risk for respiratory prob- lems (e.g., coughing, bronchitis, and pneumonitis). Injectors have puncture marks and "tracks." " most commonly on their forearms. Risk of HIV infection increases with frequent intravenous injections and unsafe sexual activity. Other sexually transmitted diseases, hepatitis, and tuberculosis and other lung infections are also seen. Weight loss and mal- nutrition are common. Chest pain may be a common symptom during stimulant intoxication. Myocardial in- faction, palpitations and arrhythmias, sudden death from respiratory or cardiac arrest, and stroke have been associated with stimulant use among young and otherwise healthy individuals. Seizures can occur with stimulant use. Pneumothorax can result from per- forming Valsalva-like maneuvers done to better absorb inhaled smoke. Traumatic injuries due to violent behavior are common among individuals trafficking drugs. Cocaine use is associated with irregularities in placental blood flow, abruptio placenta, premature labor and delivery, and an increased prevalence of infants with very low birth weights. Individuals with stimulant use disorder may become involved in theft, prostitution, or drug dealing in order to acquire drugs or money for drugs. Neurocognitive impairment is common among methamphetamine users. Oral health problems include "meth mouth" with gum disease, tooth decay, and mouth sores related to the toxic effects of smoking the drug and to bruxism while intoxicated. Adverse pulmo- nary effects appear to be less common for amphetamine-type stimulants because they are smoked fewer times per day. Emergency department visits are common for stimulant-re- lated mental disorder symptoms, injury, skin infections, and dental pathology. Differential Diagnosis Primary mental disorders. Stimulant-induced disorders may resemble primary mental disorders (e.g., major depressive disorder) (for discussion of this differential diagnosis, see "Stimulant Withdrawal"). The mental disturbances resulting from the effects of stimulants should be distinguished from the symptoms of schizophrenia; depressive and bipolar dis- orders; generalized anxiety disorder; and panic disorder. Phencyclidine intoxication. Intoxication with phencyclidine ("PCP" or "angel dust") or synthetic "designer drugs' " such as mephedrone (known by different names, including "bath salts") may cause a similar clinical picture and can only be distinguished from stim- ulant intoxication by the presence of cocaine or amphetamine-type substance metabolites in a urine or plasma sample. Stimulant intoxication and withdrawal. Stimulant intoxication and withdrawal are dis- tinguished from the other stimulant-induced disorders (e.g., anxiety disorder, with onset during intoxication) because the symptoms in the latter disorders predominate the clinical presentation and are severe enough to warrant independent clinical attention. Comorbidity Stimulant-related disorders often co-occur with other substance use disorders, especially those involving substances with sedative properties, which are often taken to reduce insomnia nervousness, and other unpleasant side effects. Cocaine users often use alcohol, while amphetamine-type stimulant users often use cannabis. Stimulant use disorder may be associated with posttraumatic stress disorder, antisocial personality disorder, atten- tion-deficit/hyperactivity disorder, and gambling disorder. Cardiopulmonary problems are often present in individuals seeking treatment for cocaine-related problems, with chest pain being the most common. Medical problems occur in response to adulterants used as "cutting" " agents. Cocaine users who ingest cocaine cut with levamisole, an antimicrobial and veterinary medication, may experience agranulocytosis and febrile neutropenia.

Oppositional Defiant Disorder (ODD) (DSM)

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling. Angry/Irritable Mood 1. Often loses temper. 2. Is often touchy or easily annoyed. 3. Is often angry and resentful. Argumentative/Defiant Behavior 4. Often argues with authority figures or, for children and adolescents, with adults. 5. Often actively defies or refuses to comply with requests from authority figures or with rules. 6. Often deliberately annoys others. 7. Often blames others for his or her mistakes or misbehavior. Vindictiveness 8. Has been spiteful or vindictive at least twice within the past 6 months. Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8). While these frequency criteria provide guidance on a minimal lev- el of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is nor- mative for the individual's developmental level, gender, and culture. B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts neg- atively on social, educational, occupational, or other important areas of functioning. C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder. Specify current severity: Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers). Moderate: Some symptoms are present in at least two settings. Severe: Some symptoms are present in three or more settings. Specifiers It is not uncommon for individuals with oppositional defiant disorder to show symptoms only at home and only with family members. However, the pervasiveness of the symp- toms is an indicator of the severity of the disorder. Diagnostic Features The essential feature of oppositional defiant disorder is a frequent and persistent pattern of angry /irritable mood, argumentative/ defiant behavior, or vindictiveness (Criterion A). It is not unusual for individuals with oppositional defiant disorder to show the behav- oral features of the disorder without problems of negative mood. However, individuals with the disorder who show the angry/irritable mood symptoms typically show the be- havioral features as well. The symptoms of oppositional defiant disorder may be confined to only one setting, and this is most frequently the home. Individuals who show enough symptoms to meet the diagnostic threshold, even if it is only at home, may be significantly impaired in their social functioning. However, in more severe cases, the symptoms of the disorder are pres- ent in multiple settings. Given that the pervasiveness of symptoms is an indicator of the severity of the disorder, it is critical that the individual's behavior be assessed across mul- tiple settings and relationships. Because these behaviors are common among siblings, they must be observed during interactions with persons other than siblings. Also, because symptoms of the disorder are typically more evident in interactions with adults or peers whom the individual knows well, they may not be apparent during a clinical examination. The symptoms of oppositional defiant disorder can occur to some degree in individu- als without this disorder. There are several key considerations for determining if the be- haviors are symptomatic of oppositional defiant disorder. First, the diagnostic threshold of four or more symptoms within the preceding 6 months must be met. Second, the per- sistence and frequency of the symptoms should exceed what is normative for an individ- ual's age, gender, and culture. For example, it is not unusual for preschool children to show temper tantrums on a weekly basis. Temper outbursts for a preschool child would be considered a symptom of oppositional defiant disorder only if they occurred on most days for the preceding 6 months, if they occurred with at least three other symptoms of the dis- order, and if the temper outbursts contributed to the significant impairment associated with the disorder (e.g., led to destruction of property during outbursts, resulted in the child being asked to leave a preschool). The symptoms of the disorder often are part of a pattern of problematic interactions with others. Furthermore, individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances. Thus, it can be difficult to disentangle the rela- tive contribution of the individual with the disorder to the problematic interactions he or she experiences. For example, children with oppositional defiant disorder may have ex- perienced a history of hostile parenting, and it is often impossible to determine if the child's behavior caused the parents to act in a more hostile manner toward the child, if the Parents' hostility led to the child's problematic behavior, or if there was some combination of both. Whether or not the clinician can separate the relative contributions of potential Causal factors should not influence whether or not the diagnosis is made. In the event that the child may be living in particularly poor conditions where neglect or mistreatment may occur (e.g., in institutional settings), clinical attention to reducing the contribution of the environment may be helpful. Associated Features Supporting Diagnosis in children and adolescents, oppositional defiant disorder is more Prevalent in families in Which child care is disrupted by a succession of different caregivers or in families in which harsh, inconsistent, or negleciful child-rearing practices are common. Two of the most common co occurring conditions with oppositional defiant disorder are attention-deficit hyperactivity disorder (ADHD) and conduct disorder (see the section "Comorbidity" for this disorder). Oppositional defiant disorder has been associated with increased risk for suicide attempts, even after comorbid disorders are controlled for. Prevalence The prevalence of oppositional defiant disorder ranges from 1% to 11%, with an average prevalence estimate of around 3.3%. The rate of oppositional defiant disorder may vary depending on the age and gender of the child. The disorder appears to be somewhat more prevalent in males than in females (1.4:1) prior to adolescence. This male predominance is not consistently found in samples of adolescents or adults. Development and Course The first symptoms of oppositional defiant disorder usually appear during the preschool years and rarely later than early adolescence. Oppositional defiant disorder often precedes the development of conduct disorder, especially for those with the childhood-onset type of conduct disorder. However, many children and adolescents with oppositional defiant disorder do not subsequently develop conduct disorder. Oppositional defiant disorder also conveys risk for the development of anxiety disorders and major depressive disorder, even in the absence of conduct disorder. The defiant, argumentative, and vindictive symp- toms carry most of the risk for conduct disorder, whereas the angry-irritable mood symp- toms carry most of the risk for emotional disorders. Manifestations of the disorder across development appear consistent. Children and adolescents with oppositional defiant disorder are at increased risk for a number of prob- lems in adjustment as adults, including antisocial behavior, impulse-control problems, substance abuse, anxiety, and depression. Many of the behaviors associated with oppositional defiant disorder increase in fre- quency during the preschool period and in adolescence. Thus, it is especially critical dur- ing these development periods that the frequency and intensity of these behaviors be evaluated against normative levels before it is decided that they are symptoms of opposi- tonal defiant disorder. Risk and Prognostic Features Temperamental. Temperamental factors related to problems in emotional regulation (e.g., high levels of emotional reactivity, poor frustration tolerance) have been predictive of the disorder. Environmental. Harsh, inconsistent, or neglectful child-rearing practices are common in families of children and adolescents with oppositional defiant disorder, and these parent- ing practices play an important role in many causal theories of the disorder. Genetic and physiological. A number of neurobiological markers (e.g., lower heart rate and skin conductance reactivity; reduced basal cortisol reactivity; abnormalities in the pre- frontal cortex and amygdala) have been associated with oppositional defiant disorder. However, the vast majority of studies have not separated children with oppositional de- fiant disorder from those with conduct disorder. Thus, it is unclear whether there are markers specific to oppositional defiant disorder. Culture-Related Diagnostic Issues The prevalence of the disorder in children and adolescents is relatively consistent across countries that differ in race and ethnicity. Functional Consequences of Oppositional Defiant Disorder When oppositional defiant disorder is persistent throughout development, individuals with the disorder experience frequent conflicts with parents, teachers, supervisors, peers, and romantic partners. Such problems often result in significant impairments in the indi- vidual's emotional, social, academic, and occupational adjustment. Differential Diagnosis Conduct disorder. Conduct disorder and oppositional defiant disorder are both related to conduct problems that bring the individual in conflict with adults and other authority figures (e.g., teachers, work supervisors). The behaviors of oppositional defiant disorder are typically of a less severe nature than those of conduct disorder and do not include ag- gression toward people or animals, destruction of property, or a pattern of theft or deceit. Furthermore, oppositional defiant disorder includes problems of emotional dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct disorder. Attention-deficit/hyperactivity disorder. ADHD is often comorbid with oppositional de- fiant disorder. To make the additional diagnosis of oppositional defiant disorder, it is impor- tant to determine that the individual's failure to conform to requests of others is not solely in situations that demand sustained effort and attention or demand that the individual sit still. Depressive and bipolar disorders. Depressive and bipolar disorders often involve neg- ative affect and irritability. As a result, a diagnosis of oppositional defiant disorder should not be made if the symptoms occur exclusively during the course of a mood disorder. Disruptive mood dysregulation disorder. Oppositional defiant disorder shares with dis- ruptive mood dysregulation disorder the symptoms of chronic negative mood and temper outbursts. However, the severity, frequency, and chronicity of temper outbursts are more severe in individuals with disruptive mood dysregulation disorder than in those with oppositional defiant disorder. Thus, only a minority of children and adolescents whose symptoms meet criteria for oppositional defiant disorder would also be diagnosed with dis- ruptive mood dysregulation disorder. When the mood disturbance is severe enough to meet criteria for disruptive mood dysregulation disorder, a diagnosis of oppositional defiant dis- order is not given, even if all criteria for oppositional defiant disorder are met. Intermittent explosive disorder. Intermittent explosive disorder also involves high rates of anger. However, individuals with this disorder show serious aggression toward others that is not part of the definition of oppositional defiant disorder. Intellectual disability (intellectual developmental disorder). In individuals with intel- lectual disability, a diagnosis of oppositional defiant disorder is given only if the opposi- tonal behavior is markedly greater than is commonly observed among individuals of comparable mental age and with comparable severity of intellectual disability. Language disorder and SAD Comorbidity Rates of oppositional defiant disorder are much higher in samples of children, adoles- cents, and adults with ADHD, and this may be the result of shared temperamental risk fac- tors. Also, oppositional defiant disorder often precedes conduct disorder, although this appears to be most common in children with the childhood-onset subtype. Individuals with oppositional defiant disorder are also at increased risk for anxiety disorders and ma- jor depressive disorder, and this seems largely attributable to the presence of the angry- irritable mood symptoms. Adolescents and adults with oppositional defiant disorder also show a higher rate of substance use disorders, although it is unclear if this association is in- dependent of the comorbidity with conduct disorder.

Course specifiers for MDD

1. SEASONAL AFFECTIVE DISORDER/SEASONAL PATTERN: the presence of depressive symptoms at the same time each year (ex. most common in the winter - "winter blues" - due to reduction of sunlight & cold weather). Management: SSRIs, light therapy, Bupropion. 2. ATYPICAL DEPRESSION: shares many of the typical symptoms of major depression but patients experience mood reactivity (improved mood in response to positive events). Symptoms include significant weight gain/appetite increase, hypersomnia, heavy/leaden feelings in arms or legs & oversensitivity to interpersonal rejection. Management: MAO inhibitors. 3. MELANCHOLIA: characterized by anhedonia (inability to find pleasure in things), lack of mood reactivity, depression, severe weight loss/loss of appetite, excessive guilt, psychomotor agitation or retardation & sleep disturbance (increased REM time & reduced sleep). Sleep disturbances may lead to early morning awakening or mood that is worse in the morning. 4 CATATONIC DEPRESSION: motor immobility, stupor & extreme withdrawal.

acute stress disorder - DSM diagnostic criteria

A. Exposure to actual or threatened death, serious injury, or sexual violation 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 event(s) occurred to a close family member or close friend. Note: 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). Note: This does not apply to exposure through electronic media, television, mov- ies, or pictures, unless this exposure is work related. B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or wors- ening after the traumatic event(s) occurred: Intrusion Symptoms 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, 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 event(s). 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 it 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.) Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress or marked physiological reactions in re- sponse to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Negative Mood 5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Dissociative Symptoms from another's perspective, being in a daze, time slowing). 7. 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). Avoidance Symptoms 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely asso- cited with the traumatic event(s). 9. Efforts to avoid external reminders (people, places, conversations, activities, ob- jects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Arousal Symptoms 10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). 11. Irritable behavior and angry outbursts (with little or no provocation), typically ex- pressed as verbal or physical aggression toward people or objects. 12. Hypervigilance. 13. Problems with concentration. 14. Exaggerated startle response. C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria. D. The disturbance causes clinically significant distress or impairment in social, occupa- tonal, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

Agoraphobia (DSM)

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 toms or other incapacitating or embarrassing symptoms (e.g., tear of falling in the fl. derly; 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. The fear, anxiety, or avoidance is not better explained by the symptoms of another men- tal 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 re- lated 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). Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual's presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned. The essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis re quires endorsement of symptoms occurring in at least two of the following five situations: 1) using public transporation, such as automobiles, buses, trains, ships, or planes; 2) being in open spaces, such as parking lots, marketplaces, or bridges; 3) being in enclosed spaces, such as shops, theaters, or cinemas; 4) standing in line or being in a crowd; or 5) being out- side of the home alone. The examples for each situation are not exhaustive; other situations may be feared. When experiencing fear and anxiety cued by such situations, individuals typically experience thoughts that something terrible might happen (Criterion B). Individ- uals frequently believe that escape from such situations might be difficult (e.g., "can't get out of here") or that help might be unavailable (e.g., "there is nobody to help me") when panic-like symptoms or other incapacitating or embarrassing symptoms occur. "Panic-like symptoms" refer to any of the 13 symptoms included in the criteria for panic attack, such as dizziness, faintness, and fear of dying. "Other incapacitating or embarrassing symptoms" include symptoms such as vomiting and inflammatory bowel symptoms, as well as, in older adults, a fear of falling or, in children, a sense of disorientation and getting lost. The amount of fear experienced may vary with proximity to the feared situation and may occur in anticipation of or in the actual presence of the agoraphobic situation. Also, the fear or anxiety may take the form of a full- or limited-symptom panic attack (i.e., an ex- pected panic attack). Fear or anxiety is evoked nearly every time the individual comes into contact with the feared situation (Criterion C). Thus, an individual who becomes anxious only occasionally in an agoraphobic situation (e.g., becomes anxious when standing in line on only one out of every five occasions) would not be diagnosed with agoraphobia. The in- dividual actively avoids the situation or, if he or she either is unable or decides not to avoid it, the situation evokes intense fear or anxiety (Criterion D). Active avoidance means the in- dividual is currently behaving in ways that are intentionally designed to prevent or min imize contact with agoraphobic situations. Avoidance can be behavioral (e.g., changing daily routines, choosing a job nearby to avoid using public transportation, arranging for food delivery to avoid entering shops and supermarkets) as well as cognitive (e.g., using distraction to get through agoraphobic situations) in nature. The avoidance can become so severe that the person is completely homebound. Often, an individual is better able to con- front a feared situation when accompanied by a companion, such as a partner, friend, or health professional. The fear, anxiety, or avoidance must be out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context (Criterion E). Differentiating clinically significant agoraphobic fears from reasonable fears (e.g., leaving the house dur- ing a bad storm) or from situations that are deemed dangerous (e.g, walking in a parking lot or using public transportation in a high-crime area) is important for a number of reasons. First, what constitutes avoidance may be difficult to judge across cultures and sociocultural contexts (e.g., it is socioculturally appropriate for orthodox Muslim women in certain parts of the world to avoid leaving the house alone, and thus such avoidance would not be con- sidered indicative of agoraphobia). Second, older adults are likely to overattribute their fears to age-related constraints and are less likely to judge their fears as being out of pro- portion to the actual risk. Third, individuals with agoraphobia are likely to overestimate danger in relation to panic-like or other bodily symptoms. Agoraphobia should be diag- nosed only if the fear, anxiety, or avoidance persists (Criterion F) and if it causes clinically significant distress or impairment in social, occupational, or other important areas of func- toning (Criterion G). The duration of "typically lasting for 6 months or more' ." is meant to exclude individuals with short-lived, transient problems. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility. Associated Features Supporting Diagnosis In its most severe forms, agoraphobia can cause individuals to become completely home- bound, unable to leave their home and dependent on others for services or assistance to pro- vide even for basic needs. Demoralization and depressive symptoms, as well as abuse of alcohol and sedative medication as inappropriate self-medication strategies, are common. Prevalence Every year approximately 1.7% of adolescents and adults have a diagnosis of agoraphobia. Females are twice as likely as males to experience agoraphobia. Agoraphobia may occur in Childhood, but incidence peaks in late adolescence and early adulthood. Twelve-month prevalence in individuals older than 65 years is 0.4%. Prevalence rates do not appear to vary systematically across cultural/racial groups. Development and Course The percentage of individuals with agoraphobia reporting panic attacks or panic disorder preceding the onset of agoraphobia ranges from 30% in community samples to more than 50% in clinic samples. The majority of individuals with panic disorder show signs of anx- iety and agoraphobia before the onset of panic disorder. In two-thirds of all cases of agoraphobia, initial onset is before age 35 years. There is a substantial incidence risk in late adolescence and early adulthood, with indications for a second high incidence risk phase after age 40 years. First onset in childhood is rare. The overall mean age at onset for agoraphobia is 17 years, although the age at onset without preceding panic attacks or panic disorder is 25-29 years. The course of agoraphobia is typically persistent and chronic. Complete remission is rare (10%), unless the agoraphobia is treated. With more severe agoraphobia, rates of full remission decrease, whereas rates of relapse and chronicity increase. A range of other dis- orders, in particular other anxiety disorders, depressive disorders, substance use disor- ders, and personality disorders, may complicate the course of agoraphobia. The long-term course and outcome of agoraphobia are associated with substantially elevated risk of sec. Ondary major depressive disorder, persistent depressive disorder (dysthymia), and sul stance use disorders. "The clinical features of agoraphobia are relatively consistent across the lifespan, although the type of agoraphobic situations triggering fear, anxiety, or avoidance, as well as the type or cognitions, may vary. For example, in children, being outside of the home alone is the most fre quent situation feared, whereas in older adults, being in shops, standing in line, and being in open spaces are most often feared. Also, cognitions often pertain to becoming lost (in children), to experiencing panic-like symptoms (in adults), to falling (in older adults). The low prevalence of agoraphobia in children could reflect difficulties in symptomre- porting, and thus assessments in young children may require solicitation of information from multiple sources, including parents or teachers. Adolescents, particularly males, may be less willing than adults to openly discuss agoraphobic fears and avoidance; how- ever, agoraphobia can occur prior to adulthood and should be assessed in children and adolescents. In older adults, comorbid somatic symptom disorders, as well as motor dis- turbances (e.g., sense of falling or having medical complications), are frequently men- tioned by individuals as the reason for their fear and avoidance. In these instances, care is to be taken in evaluating whether the fear and avoidance are out of proportion to the real danger involved. Risk and Prognostic Factors Temperamental. Behavioral inhibition and neurotic disposition lie, negative affectivity (neuroticism) and anxiety sensitivity) are closely associated with agoraphobia but are te!. evant to most anxiety disorders (phobic disorders, panic disorder, generalized anxiety dis order). Anxiety sensitivity (the disposition to believe that symptoms of anxiety are harmful) is also characteristic of individuals with agoraphobia. Environmental. Negative events in childhood (e.g., separation, death of parent) and other stressful events, such as being attacked or mugged, are associated with the onset of agorapho- bia. Furthermore, individuals with agoraphobia describe the family climate and child-rearing behavior as being characterized by reduced warmth and increased overprotection. Genetic and physiological. Heritability for agoraphobia is 61%. Of the various phobias, agoraphobia has the strongest and most specific association with the genetic factor that represents proneness to phobias. Gender-Related Diagnostic Issues Females have different patterns of comorbid disorders than males. Consistent with gender differences in the prevalence of mental disorders, males have higher rates of comorbid substance use disorders. Functional Consequences of Agoraphobia Agoraphobia is associated with considerable impairment and disability in terms of role functioning, work productivity, and disability days. Agoraphobia severity is a strong de- terminant of the degree of disability, irrespective of the presence of comorbid panic disor- der, panic attacks, and other comorbid conditions. More than one-third of individuals with agoraphobia are completely homebound and unable to work. Differential Diagnosis Specific phobia, situational type. Differentiating agoraphobia from situational specific phobia can be challenging in some cases, because these conditions share several symptom characteristics and criteria. Specific phobia, situational type, should be diagnosed versus ago- raphobia if the fear, anxiety, or avoidance is limited to one of the agoraphobic situations. Requiring fears from two or more of the agoraphobic situations is a robust means for differen- tiating agoraphobia from specific phobias, particularly the situational subtype. Additional dif- ferentiating features include the cognitive ideation. Thus, if the situation is feared for reasons other than panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fears of being directly harmed by the situation itself, such as fear of the plane crashing for individ- uals who fear flying), then a diagnosis of specific phobia may be more appropriate. Separation anxiety disorder. Separation anxiety disorder can be best differentiated from agoraphobia by examining cognitive ideation. In separation anxiety disorder, the thoughts are about detachment from significant others and the home environment (i.e., parents or other attachment figures), whereas in agoraphobia the focus is on panic-like symptoms or other incapacitating or embarrassing symptoms in the feared situations. Social anxiety disorder (social phobia). Agoraphobia should be differentiated from so- cial anxiety disorder based primarily on the situational clusters that trigger fear, anxiety, or avoidance and the cognitive ideation. In social anxiety disorder, the focus is on fear of being negatively evaluated. Panic disorder. When criteria for panic disorder are met, agoraphobia should not be di- agnosed if the avoidance behaviors associated with the panic attacks do not extend to avoid- ance of two or more agoraphobic situations. Acute stress disorder and posttraumatic stress disorder. Acute stress disorder and posttraumatic stress disorder (PTSD) can be differentiated from agoraphobia by examin- ing whether the fear, anxiety, or avoidance is related only to situations that remind the individual of a traumatic event. If the fear, anxiety, or avoidance is restricted to trauma re- minders, and if the avoidance behavior does not extend to two or more agoraphobic situ- ations, then a diagnosis of agoraphobia is not warranted. Major depressive disorder. In major depressive disorder, the individual may avoid leav- ing home because of apathy, loss of energy, low self-esteem, and anhedonia. If the avoid- ance is unrelated to fears of panic-like or other incapacitating or embarrassing symptoms, then agoraphobia should not be diagnosed. Other medical conditions. Agoraphobia is not diagnosed if the avoidance of situations is judged to be a physiological consequence of a medical condition. This determination is based on history, laboratory findings, and a physical examination. Other relevant medical conditions may include neurodegenerative disorders with associated motor disturbances (e.g., Parkinson's disease, multiple sclerosis), as well as cardiovascular disorders. Individ- uals with certain medical conditions may avoid situations because of realistic concerns about being incapacitated (e.g., fainting in an individual with transient ischemic attacks) or being embarrassed (e.g., diarrhea in an individual with Crohn's disease). The diagnosis of agoraphobia should be given only when the fear or avoidance is clearly in excess of that usually associated with these medical conditions. Comorbidity The majority of individuals with agoraphobia also have other mental disorders. The most frequent additional diagnoses are other anxiety disorders (e.g., specific phobias, panic dis- order, social anxiety disorder), depressive disorders (major depressive disorder), PTSD, and alcohol use disorder. Whereas other anxiety disorders (e.g., separation anxiety disor- der, specific phobias, panic disorder) frequently precede onset of agoraphobia, depressive disorders and substance use disorders typically occur secondary to agoraphobia.

Voyeurisitc disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from observing unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors. B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age. Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in voyeuristic behavior are restricted. Specifiers The in full remission' specifictioes not address the continued presence or absence of Voyeurism per se, which may still be present after behaviors and distress have remitted Diagnostic Features The diagnostic criteria for voyeuristic disorder can apply both to individuals who more or less reely disclose this paraphilic interest and to those who categorically deny any sexual arousal from observing an unsuspecting person who is naked, disrobing, or engaged in sexual activity despite substantial objective evidence to the contrary. If disclosing individuals also report dis- less or psychosocial problems because of their voyeuristic sexual preferences, they could be diagnosed with voyeuristic disorder. On the other hand, if they declare no distress, demon- stated by lack of anxiety, obsessions, guilt, or shame, about these paraphilic impulses and are not impaired in other important areas of functioning because of this sexual interest, and their psychiatric or legal histories indicate that they do not act on it, they could be ascertained as having voyeuristic sexual interest but should not be diagnosed with voyeuristic disorder. #_Nondisclosing individuals include, for example, individuals known to have been spy- ing repeatedly on unsuspecting persons who are naked or engaging in sexual activity on separate occasions but who deny any urges or fantasies concerning such sexual behavior, and who may report that known episodes of watching unsuspecting naked or sexually ac- tive persons were all accidental and nonsexual. Others may disclose past episodes of ob- serving unsuspecting naked or sexually active persons but contest any significant or sustained sexual interest in this behavior. Since these individuals deny having fantasies or impulses about watching others nude or involved in sexual activity, it follows that they would also reject feeling subjectively distressed or socially impaired by such impulses. De- spite their nondisclosing stance, such individuals may be diagnosed with voyeuristic dis- order. Recurrent voyeuristic behavior constitutes sufficient support for voyeurism (by fulfilling Criterion A) and simultaneously demonstrates that this paraphilically motivated behavior is causing harm to others (by fulfilling Criterion B). "Recurrent" spying on unsuspecting persons who are naked or engaging in sexual ac- tivity (i.e., multiple victims, each on a separate occasion) may, as a general rule, be inter- preted as three or more victims on separate occasions. Fewer victims can be interpreted as satisfying this criterion if there were multiple occasions of watching the same victim or if there is corroborating evidence of a distinct or preferential interest in secret watching of naked or sexually active unsuspecting persons. Note that multiple victims, as sussested earlier, are a sufficient but not a necessary condition for diagnosis; the criteria may also be met if the individual acknowledges intense voyeuristic sexual interest. The Criterion A time frame, indicating that signs or symptoms of voyeurism must have persisted for at least 6 months, should also be understood as a general guideline, not a strict threshold, to ensure that the sexual interest in secretly watching unsuspecting naked or sexually active others is not merely transient. Adolescence and puberty generally increase sexual curiosity and activity. To alleviate the risk of pathologizing normative sexual interest and behavior during pubertal adoles- cence, the minimum age for the diagnosis of voyeuristic disorder is 18 years (Criterion C). . Prevalence Voyeuristic acts are the most common of potentially law-breaking sexual behaviors. The population prevalence of voyeuristic disorder is unknown. However, based on voyeuristic tic sexual acts in nonclinical samples, the highest possible lifetime prevalence for voyeuris- tic disorder is approximately 12% in males and 4% in females. Development and Course Adult males with voyeuristic disorder often first become aware of their sexual interest in secretly watching unsuspecting persons during adolescence. However, the minimum age for a diagnosis of voyeuristic disorder is 18 years because there is substantial difficulty in differentiating it from age-appropriate puberty-related sexual curiosity and activity. The persistence of voyeurism over time is unclear. Voyeuristic disorder, however, per defini- tion requires one or more contributing factors that may change over time with or without treatment: subjective distress (e.g., guilt, shame, intense sexual frustration, loneliness), psychiatric morbidity, hypersexuality, and sexual impulsivity; psychosocial impairment; and/or the propensity to act out sexually by spying on unsuspecting naked or sexually ac- tive persons. Therefore, the course of voyeuristic disorder is likely to vary with age. Risk and Prognostic Factors Temperamental. Voyeurism is a necessary precondition for voyeuristic disorder; hence, risk factors for voyeurism should also increase the rate of voyeuristic disorder. Environmental. Childhood sexual abuse, substance misuse, and sexual preoccupation / hypersexuality have been suggested as risk factors, although the causal relationship to voyeurism is uncertain and the specificity unclear. Gender-Related Diagnostic Issues Voyeuristic disorder is very uncommon among females in clinical settings, while the male- to-female ratio for single sexually arousing voyeuristic acts might be 3:1. Differential Diagnosis Conduct disorder and antisocial personality disorder. Conduct disorder in adolescents and antisocial personality disorder would be characterized by additional norm-breaking and antisocial behaviors, and the specific sexual interest in secretly watching unsuspect- ing others who are naked or engaging in sexual activity should be lacking. Substance use disorders. Substance use disorders might involve single voyeuristic ep- isodes by intoxicated individuals but should not involve the typical sexual interest in se- cretly watching unsuspecting persons being naked or engaging in sexual activity. Hence, recurrent voyeuristic sexual fantasies, urges, or behaviors that occur also when the indi- vidual is not intoxicated suggest that voyeuristic disorder might be present. Comorbidity Known comorbidities in voyeuristic disorder are largely based on research with males suspected of or convicted for acts involving the secret watching of unsuspecting nude or sexually active persons. Hence, these comorbidities might not apply to all individuals with voyeuristic disorder. Conditions that occur comorbidly with voyeuristic disorder include hypersexuality and other paraphilic disorders, particularly exhibitionistic disorder. De- pressive, bipolar, anxiety, and substance use disorders; attention-deficit/hyperactivity disorder; and conduct disorder and antisocial personality disorder are also frequent co- morbid conditions,

kleptomania

A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value. B. Increasing sense of tension immediately before committing the theft. C. Pleasure, gratification, or relief at the time of committing the theft. D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination. E. The stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Anorexia nervosa (DSM)

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.. Specify whether: (F50.01) Restricting type: During the last 3 months, the individual has not engaged in re- current episodes of binge eating or purging behavior (i.e., self-induced vomiting or the mis- use of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. (F50.02) Binge-eating/purging type: During the last 3 months, the individual has en- gaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Specify if: In partial remission: After full criteria for anorexia nervosa were previously met, Cri- terion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met. In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adoles- cents, corresponding BMI percentiles should be used. The level of severity may be in- creased to reflect clinical symptoms, the degree of functional disability, and the need for supervision. Mild: BMI ≥ 17 kg/m? Moderate: BMI 16-16.99 kg/m? Severe: BMI 15-15.99 kg/m? Extreme: BMI < 15 kg/m? Subtypes Most individuals with the binge-eating/ purging type of anorexia nervosa who binge eat also purge through self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Some individuals with this subtype of anorexia nervosa do not binge eat but do regularly purge after the of small amounts of food. Crossover between the subtypes over the of the disorder is not uncommon; therefore, subtype description should be used to describe current symptoms rather than longitudinal course. Diagnostic Features There are three essential features of anorexia nervosa: persistent energy intake restriction; intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain; and a disturbance in self-perceived weight or shape. The individual main- tains a body weight that is below a minimally normal level for age, sex, developmental tra- jectory, and physical health (Criterion A). Individuals' body weights frequently meet this criterion following a significant weight loss, but among children and adolescents, there may alternatively be failure to make expected weight gain or to maintain a normal devel- opmental trajectory (i.e., while growing in height) instead of weight loss. Criterion A requires that the individual's weight be significantly low (i.e., less than minimally normal or, for children and adolescents, less than that minimally expected). Weight assessment can be challenging because normal weight range differs among indi- viduals, and different thresholds have been published defining thinness or underweight status. Body mass index (BMI; calculated as weight in kilograms/height in meters? is a useful measure to assess body weight for height. For adults, a BMI of 18.5 kg/m? has been employed by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) as the lower limit of normal body weight. Therefore, most adults with a BMI greater than or equal to 18.5 kg/m? would not be considered to have a significantly low body weight. On the other hand, a BMI of lower than 17.0 kg/m? has been considered by the WHO to indiçate moderate or severe thinness; therefore, an individual with a BMI less than 17.0 kg/m? would likely be considered to have a significantly low weight. An adult with a BMI between 17.0 and 18.5 kg/m?, or even above 18.5 kg/m?, might be consid- ered to have a significantly low weight if clinical history or other physiological informa- tion supports this judgment. For children and adolescents, determining a BMI-for-age percentile is useful (see, e.g., the CDC BMI percentile calculator for children and teenagers. As for adults, it is not pos- sible to provide definitive standards for judging whether a child's or an adolescent's weight is significantly low, and variations in developmental trajectories among youth limit the utility of simple numerical guidelines. The CDC has used a BMI-for-age below the 5th per- centile as suggesting underweight; however, children and adolescents with a BMI above this benchmark may be judged to be significantly underweight in light of failure to main- tain their expected growth trajectory. In summary, in determining whether Criterion A is met, the clinician should consider available numerical guidelines, as well as the individual's body build, weight history, and any physiological disturbances. Individuals with this disorder typically display an intense fear of gaining weight or of becoming fat (Criterion B). This intense fear of becoming fat is usually not alleviated by weight loss. In fact, concern about weight gain may increase even as weight falls. Younger individuals with anorexia nervosa, as well as some adults, may not recognize or acknowl- edge a fear of weight gain. In the absence of another explanation for the significantly low weight, clinician inference drawn from collateral history, observational data, physical and laboratory findings, or longitudinal course either indicating a fear of weight gain or sup- porting persistent behaviors that prevent it may be used to establish Criterion B. The experience and significance of body weight and shape are distorted in these indi- viduals (Criterion C). Some individuals feel globally overweight. Others realize that they are thin but are still concerned that certain body parts, particularly the abdomen, buttocks, and thighs, are "too fat." They may employ a variety of techniques to evaluate their body size or weight, including frequent weighing, obsessive measuring of body parts, and per- sistent use of a mirror to check for perceived areas of "fat." The self-esteem of individuals with anorexia nervosa is highly dependent on their perceptions of body shape and weight. Weight loss is often viewed as an impressive achievement and a sign of extraordinary self- discipline, whereas weight gain is perceived as an unacceptable failure of self-control. Al- though some individuals with this disorder may acknowledge being thin, they often do not recognize the serious medical implications of their malnourished state. Often, the individual is brought to professional attention by family members after marked weight loss (or failure to make expected weight gains) has occurred. If individuals seek help on their own, it is usually because of distress over the somatic and psychological sequelae of starvation. It is rare for an individual with anorexia nervosa to complain of weight loss per se. In fact, individuals with anorexia nervosa frequently either lack insight into or deny the problem. It is therefore often important to obtain information from family members or other sources to evaluate the history of weight loss and other features of the illness. Associated Features Supporting Diagnosis The semi-starvation of anorexia nervosa, and the purging behaviors sometimes associated with it, can result in significant and potentially life-threatening medical conditions. The nutritional compromise associated with this disorder affects most major organ systems and can produce a variety of disturbances. Physiological disturbances, including amenor- rhea and vital sign abnormalities, are common. While most of the physiological distur- bances associated with malnutrition are reversible with nutritional rehabilitation, some, including loss of bone mineral density, are often not completely reversible. Behaviors such as self-induced vomiting and misuse of laxatives, diuretics, and enemas may cause a num- ber of disturbances that lead to abnormal laboratory findings; however, some individuals with anorexia nervosa exhibit no laboratory abnormalities. When seriously underweight, many individuals with anorexia nervosa have depressive signs and symptoms such as depressed mood, social withdrawal, irritability, insomnia, and diminished interest in sex. Because these features are also observed in individuals without anorexia nervosa who are significantly undernourished, many of the depressive features may be secondary to the physiological sequelae of semi-starvation, although they may also be sufficiently severe to warrant an additional diagnosis of major depressive disorder. Obsessive-compulsive features, both related and unrelated to food, are often prominent. Most individuals with anorexia nervosa are preoccupied with thoughts of food. Some col- lect recipes or hoard food. Observations of behaviors associated with other forms of star- vation suggest that obsessions and compulsions related to food may be exacerbated by undernutrition. When individuals with anorexia nervosa exhibit obsessions and compul- sions that are not related to food, body shape, or weight, an additional diagnosis of obses- sive-compulsive disorder (OCD) may be warranted. Other features sometimes associated with anorexia nervosa include concerns about eating in public, feelings of ineffectiveness, a strong desire to control one's environment, inflexible thinking, limited social spontaneity, and overly restrained emotional ex- pression. Compared with individuals with anorexia nervosa, restricting type, those with binge-eating/purging type have higher rates of impulsivity and are more likely to abuse alcohol and other drugs. A subgroup of individuals with anorexia nervosa show excessive levels of physical ac- tivity. Increases in physical activity often precede onset of the disorder, and over the course of the disorder increased activity accelerates weight loss. During treatment, exces- sive activity may be difficult to control, thereby jeopardizing weight recovery. Individuals with anorexia nervosa may misuse medications, such as by manipulating dosage, in order to achieve weight loss or avoid weight gain. Individuals with diabetes mellitus may omit or reduce insulin doses in order to minimize carbohydrate metabolism. Prevalence The 12-month prevalence of anorexia nervosa among young females is approximately 0.4%. Less is known about prevalence among males, but anorexia nervosa is far less com- mon in males than in females, with clinical populations generally reflecting approximately a 10:1 female-to-male ratio. Development and Course Anorexia nervosa commonly begins during adolescence or young adulthood. It rarely be- gins before puberty or after age 40, but cases of both early and late onset have been de- scribed. The onset of this disorder is often associated with a stressful life event, such as leaving home for college. The course and outcome of anorexia nervosa are highly variable. Younger individuals may manifest atypical features, including denying * "fear of fat." Older individuals more likely have a longer duration of illness, and their clinical presentation may include more signs and symptoms of long-standing disorder. Clinicians should not exclude anorexia nervosa from the differential diagnosis solely on the basis of older age. Many individuals have a period of changed eating behavior prior to full criteria for the disorder being met. Some individuals with anorexia nervosa recover fully after a single episode, with some exhibiting a fluctuating pattern of weight gain followed by relapse, and others experiencing a chronic course over many years. Hospitalization may be re- quired to restore weight and to address medical complications. Most individuals with an- orexia nervosa experience remission within 5 years of presentation. Among individuals admitted to hospitals, overall remission rates may be lower. The crude mortality rate (CMR) for anorexia nervosa is approximately 5% per decade. Death most commonly results from medical complications associated with the disorder itself or from suicide. Risk and Prognostic Factors Temperamental. Individuals who develop anxiety disorders or display obsessional traits in childhood are at increased risk of developing anorexia nervosa. Environmental. Historical and cross-cultural in the prevalence of anorexia nervosa supports its association with cultures and settings in which thinness is valued. Oc- cupations and avocations that encourage thinness, such as modeling and elite athletics, are also associated with increased risk. Genetic and physiological. There is an increased risk of anorexia nervosa and bulimia nervosa among first-degree biological relatives of individuals with the disorder. An in- creased risk of bipolar and depressive disorders has also been found among first-degree relatives of individuals with anorexia nervosa, particularly relatives of individuals with the binge-eating/purging type. Concordance rates for anorexia nervosa in monozygotic twins are significantly higher than those for dizygotic twins. A range of brain abnormali- ties has been described in anorexia nervosa using functional imaging technologies (func- tional magnetic resonance imaging, positron emission tomography). The degree to which these findings reflect changes associated with malnutrition versus primary abnormalities associated with the disorder is unclear. Culture-Related Diagnostic Issues Anorexia nervosa occurs across culturally and socially diverse populations, although available evidence suggests cross-cultural variation in its occurrence and presentation. Anorexia ner- vosa is probably most prevalent in post-industrialized, high-income countries such as in the United States, many European countries, Australia, New Zealand, and Japan, but its incidence in most low- and middle-income countries is uncertain. Whereas the prevalence of anorexia nervosa appears comparatively low among Latinos, African Americans, and Asians in the United States, clinicians should be aware that mental health service utilization among individ- uals with an eating disorder is significantly lower in these ethnic groups and that the low rates may reflect an ascertainment bias. The presentation of weight concerns among individuals with eating and feeding disorders varies substantially across cultural contexts. The absence of an expressed intense fear of weight gain, sometimes referred to as "fat phobia, " appears to be relatively more common in populations in Asia, where the rationale for dietary restriction is commonly related to a more culturally sanctioned complaint such as gastrointestinal discom- fort. Within the United States, presentations without a stated intense fear of weight gain may be comparatively more common among Latino groups. Diagnostic Markers The following laboratory abnormalities may be observed in anorexia nervosa; their pres- ence may serve to increase diagnostic confidence. Hematology. Leukopenia is common, with the loss of all cell types but usually with ap- parent lymphocytosis. Mild anemia can occur, as well as thrombocytopenia and, rarely, bleeding problems. Serum chemistry. Dehydration may be reflected by an elevated blood urea nitrogen level. Hypercholesterolemia is common. Hepatic enzyme levels may be elevated. Hypo- magnesemia, hypozincemia, hypophosphatemia, and hyperamylasemia are occasionally observed. Self-induced vomiting may lead to metabolic alkalosis (elevated serum bicarbon- ate), hypochloremia, and hypokalemia; laxative abuse may cause a mild metabolic acidosis. Endocrine. Serum thyroxine (Ta) levels are usually in the low-normal range; triiodothy- ronine (T3) levels are decreased, while reverse T, levels are elevated. Females have low se- rum estrogen levels, whereas males have low levels of serum testosterone. Electrocardiography. Sinus bradycardia is common, and, rarely, arrhythmias are noted. Significant prolongation of the QT interval is observed in some individuals. Bone mass. Low bone mineral density, with specific areas of osteopenia or osteoporo- sis, is often seen. The risk of fracture is significantly elevated. Electroencephalography. Diffuse abnormalities, reflecting a metabolic encephalopa- thy, may result from significant fluid and electrolyte disturbances. Resting energy expenditure. There is often a significant reduction in resting energy ex- penditure. Physical signs and symptoms. Many of the physical signs and symptoms of anorexia nervosa are attributable to starvation. Amenorrhea is commonly present and appears to be an indicator of physiological dysfunction. If present, amenorrhea is usually a conse- quence of the weight loss, but in a minority of individuals it may actually precede the weight loss. In prepubertal females, menarche may be delayed. In addition to amenorrhea, there may be complaints of constipation, abdominal pain, cold intolerance, lethargy, and excess energy. The most remarkable finding on physical examination is emaciation. Commonly, there is also significant hypotension, hypothermia, and bradycardia. Some individuals develop lanugo, a fine downy body hair. Some develop peripheral edema, especially during weight restoration or upon cessation of laxative and diuretic abuse. Rarely, petechiae or ecchymoses, usually on the extremities, may indicate a bleeding diathesis. Some individ- uals evidence a yellowing of the skin associated with hypercarotenemia. As may be seen in individuals with bulimia nervosa, individuals with anorexia nervosa who self-induce vomiting may have hypertrophy of the salivary glands, particularly the parotid glands, as well as dental enamel erosion. Some individuals may have scars or calluses on the dorsal surface of the hand from repeated contact with the teeth while inducing vomiting. Suicide Risk Suicide risk is elevated in anorexia nervosa, with rates reported as 12 per 100,000 per year. Comprehensive evaluation of individuals with anorexia nervosa should include assess- ment of suicide-related ideation and behaviors as well as other risk factors for suicide, in- cluding a history of suicide attempt(s). Differential Diagnosis Other possible causes of either significantly low body weight or significant weight loss should be considered in the differential diagnosis of anorexia nervosa, especially when the presenting features are atypical (e.g., onset after age 40 years). Medical conditions (e.g., gastrointestinal disease, hyperthyroidism, occult malignan- cies, and acquired immunodeficiency syndrome [AIDS). Serious weight loss may oc- cur in medical conditions, but individuals with these disorders usually do not also mani- fest a disturbance in the way their body weight or shape is experienced or an intense fear of weight gain or persist in behaviors that interfere with appropriate weight gain. Acute weight loss associated with a medical condition can occasionally be followed by the onset of recurrence of anorexia nervosa, which can initially be masked by the comorbid medical condition. Rarely, anorexia nervosa develops after bariatric surgery for obesity. Major depressive disorder. In major depressive disorder, severe weight loss may occur, but most individuals with major depressive disorder do not have either a desire for exces- sive weight loss or an intense fear of gaining weight. Schizophrenia. Individuals with schizophrenia may exhibit odd eating behavior and oc- casionally experience significant weight loss, but they rarely show the fear of gaining weight and the body image disturbance required for a diagnosis of anorexia nervosa. Substance use disorders. Individuals with substance use disorders may experience low weight due to poor nutritional intake but generally do not fear gaining weight and do not manifest body image disturbance. Individuals who abuse substances that reduce appetite (e.g., cocaine, stimulants) and who also endorse fear of weight gain should be carefully evaluated for the possibility of comorbid anorexia nervosa, given that the substance use may represent a persistent behavior that interferes with weight gain (Criterion B). Social anxiety disorder (social phobia), obsessive-compulsive disorder, and body dys- morphic disorder. Some of the features of anorexia nervosa overlap with the criteria for social phobia, OCD, and body dysmorphic disorder. Specifically, individuals may feel hu- miliated or embarrassed to be seen eating in public, as in social phobia; may exhibit obses- sions and compulsions related to food, as in OCD; or may be preoccupied with an imagined defect in bodily appearance, as in body dysmorphic disorder. If the individual with anorexia nervosa has social fears that are limited to eating behavior alone, the diagnosis of social pho- bia should not be made, but social fears unrelated to eating behavior (e.g., excessive fear of speaking in public) may warrant an additional diagnosis of social phobia. Similarly, an ad- ditional diagnosis of OCD should be considered only if the individual exhibits obsessions and compulsions unrelated to food (e.g., an excessive fear of contamination), and an addi- tional diagnosis of body dysmorphic disorder should be considered only if the distortion is unrelated to body shape and size (e.g., preoccupation that one's nose is too big). Bulimia nervosa. Individuals with bulimia nervosa exhibit recurrent episodes of binge eating, engage in inappropriate behavior to avoid weight gain (e.g., self-induced vomit- ing), and are overly concerned with body shape and weight. However, unlike individuals with anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa main- tain body weight at or above a minimally normal level. Avoidant/restrictive food intake disorder. Individuals with this disorder may exhibit significant weight loss or significant nutritional deficiency, but they do not have a fear of gaining weight or of becoming fat, nor do they have a disturbance in the way they expe- rience their body shape and weight. Comorbidity Bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa. Many individuals with anorexia nervosa report the presence of either an anxiety disorder or symptoms prior to onset of their eating disorder. OCD is described in some individuals with anorexia nervosa, especially those with the restricting type. Alcohol use disorder and other substance use disorders may also be comorbid with anorexia nervosa, especially among those with the binge-eating/purging type.

Cluster C disorders

Anxious, fearful, worried

histrionic personality disorder (DSM)

DIAGNOSTIC CRITERIA 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. Diagnostic Features The essential feature of histrionic personality disorder is pervasive and excessive emotion- ality and attention-seeking behavior. This pattern begins by early adulthood and is pres- ent in a variety of contexts. Individuals with histrionic personality disorder are uncomfortable or feel unappreci- ated when they are not the center of attention (Criterion 1). Often lively and dramatic, they tend to draw attention to themselves and may initially charm new acquaintances by their enthusiasm, apparent openness, or flirtatiousness. These qualities wear thin, however, as these individuals continually demand to be the center of attention. They commandeer the role of " the life of the party." If they are not the center of attention, they may do something dramatic (e.g., make up stories, create a scene) to draw the focus of attention to themselves. This need is often apparent in their behavior with a clinician (e.g., being flattering, bring- ing gifts, providing dramatic descriptions of physical and psychological symptoms that are replaced by new symptoms each visit). The appearance and behavior of individuals with this disorder are often inappropri- ately sexually provocative or seductive (Criterion 2). This behavior not only is directed to- ward persons in whom the individual has a sexual or romantic interest but also occurs in a wide variety of social, occupational, and professional relationships beyond what is ap- propriate for the social context. Emotional expression may be shallow and rapidly shifting (Criterion 3). Individuals with this disorder consistently use physical appearance to draw attention to themselves (Criterion 4). They are overly concerned with impressing others by their appearance and expend an excessive amount of time, energy, and money on clothes and grooming. They may "fish for compliments" regarding appearance and may be easily and excessively upset by a critical comment about how they look or by a photograph that they regard as unflattering. These individuals have a style of speech that is excessively impressionistic and lacking in detail (Criterion 5). Strong opinions are expressed with dramatic flair, but underlying reasons are usually vague and diffuse, without supporting facts and details. For example, an individual with histrionic personality disorder may comment that a certain individual is a wonderful human being, yet be unable to provide any specific examples of good qual- ities to support this opinion. Individuals with this disorder are characterized by self- dramatization, theatricality, and an exaggerated expression of emotion (Criterion 6). They may embarrass friends and acquaintances by an excessive public display of emotions (e.g., embracing casual acquaintances with excessive ardor, sobbing uncontrollably on minor sentimental occasions, having temper tantrums). However, their emotions often seem to be turned on and off too quickly to be deeply felt, which may lead others to accuse the in- dividual of faking these feelings. Individuals with histrionic personality disorder have a high degree of suggestibility (Cri- terion 7). Their opinions and feelings are easily influenced by others and by current fads. They may be overly trusting, especially of strong authority figures whom they see as mag- ically solving their problems. They have a tendency to play hunches and to adopt convic- tions quickly. Individuals with this disorder often consider relationships more intimate than they actually are, describing almost every acquaintance as "my dear, dear friend" or referring to physicians met only once or twice under professional circumstances by their first names (Criterion 8). Associated Features Supporting Diagnosis Individuals with histrionic personality disorder may have difficulty achieving emotional in- timacy in romantic or sexual relationships. Without being aware of it, they often act out a role (e.g., "victim" or "princess") in their relationships to others. They may seek to control their partner through emotional manipulation or seductiveness on one level, while display- ing a marked dependency on them at another level. Individuals with this disorder often have impaired relationships with same-sex friends because their sexually provocative inter- personal style may seem a threat to their friends' relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and up- set when they are not the center of attention. They may crave novelty, stimulation, and ex- citement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction. Although they often ini- tiate a job or project with great enthusiasm, their interest may lag quickly. Longer-term re- lationships may be neglected to make way for the excitement of new relationships. The actual risk of suicide is not known, but clinical experience suggests that individu- als with this disorder are at increased risk for suicidal gestures and threats to get attention and coerce better caregiving. Histrionic personality disorder has been associated with higher rates of somatic symptom disorder, conversion disorder (functional neurological symptom disorder), and major depressive disorder. Borderline, narcissistic, antisocial, and dependent personality disorders often co-occur. Prevalence Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of histrionic personality of 1.84%. Culture-Related Diagnostic Issues Norms for interpersonal behavior, personal appearance, and emotional expressiveness vary widely across cultures, genders, and age groups. Before considering the various traits (e.g., emotionality, seductiveness, dramatic interpersonal style, novelty seeking, sociabil- ity, charm, impressionability, a tendency to somatization) to be evidence of histrionic per- sonality disorder, it is important to evaluate whether they cause clinically significant impairment or distress. Gender-Related Diagnostic Issues In clinical settings, this disorder has been diagnosed more frequently in females; however, the sex ratio is not significantly different from the sex ratio of females within the respective clinical setting. In contrast, some studies using structured assessments report similar prevalence rates among males and females. Differential Diagnosis Other personality disorders and personality traits. Other personality disorders may be confused with histrionic personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differ- ences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to histrionic personal- ity disorder, all can be diagnosed. Although borderline personality disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, it is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and identity disturbance. Individuals with antisocial personality disorder and histrionic personality disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with histrionic personality disorder tend to be more exaggerated in their emotions and do not characteristically engage in antisocial behaviors. Individuals with histrionic personality disorder are manipulative to gain nurturance, whereas those with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification. Al- though individuals with narcissistic personality disorder also crave attention from others, they usually want praise for their "superiority, " whereas individuals with histrionic per- sonality disorder are willing to be viewed as fragile or dependent if this is instrumental in getting attention. Individuals with narcissistic personality disorder may exaggerate the intimacy of their relationships with other people, but they are more apt to emphasize the "VIP" status or wealth of their friends. In dependent personality disorder, the individual is excessively dependent on others for praise and guidance, but is without the flamboyant, exaggerated, emotional features of individuals with histrionic personality disorder. Many individuals may display histrionic personality traits. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute histrionic personality disorder. Personality change due to another medical condition. Histrionic personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. The disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

female sexual interest/arousal disorder (DSM)

DIAGNOSTIC CRITERIA A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following: 1. Absent/reduced interest in sexual activity. 2. Absent/reduced sexual/erotic thoughts or fantasies. 3. No/reduced initiation of sexual activity, and typically unreceptive to a partner's at- tempts to initiate. 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts). 5. Absent/reduced sexual interest/arousal in response to any internal or external sex- ual/erotic cues (e.g., written, verbal, visual). 6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational con- texts or, if generalized, in all contexts). B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. Specify whether: Lifelong: The disturbance has been present since the individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function. Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners. Situational: Only occurs with certain types of stimulation, situations, or partners. Specify current severity: Mild: Evidence of mild distress over the symptoms in Criterion A. Moderate: Evidence of moderate distress over the symptoms in Criterion A. Severe: Evidence of severe or extreme distress over the symptoms in Criterion Diagnostic Features In assessing female sexual interest / arousal disorder, interpersonal context must be taken into account. A "desire discrepancy, " in which a woman has lower desire for sexual activ- ity than her partner, is not sufficient to diagnose female sexual interest / arousal disorder. In order for the criteria for the disorder to be met, there must be absence or reduced fre- quency or intensity of at least three of six indicators (Criterion A) for a minimum duration of approximately 6 months (Criterion B). There may be different symptom profiles across women, as well as variability in how sexual interest and arousal are expressed. For exam- ple, in one woman, sexual interest / arousal disorder may be expressed as a lack of interest in sexual activity, an absence of erotic or sexual thoughts, and reluctance to initiate sexual activity and respond to a partner's sexual invitations. In another woman, an inability to be- come sexually excited, to respond to sexual stimuli with sexual desire, and a corresponding lack of signs of physical sexual arousal may be the primary features. Because sexual desire and arousal frequently coexist and are elicited in response to adequate sexual cues, the criteria for female sexual interest / arousal disorder take into account that difficulties in desire and arousal often simultaneously characterize the complaints of women with this disorder. Short-term changes in sexual interest or arousal are common and may be adaptive responses to events in a woman's life and do not represent a sexual dysfunction. Diagnosis of female sexual interest/arousal disorder requires a minimum duration of symptoms of approximately 6 months as a reflection that the symptoms must be a persistent problem. The estimation of persistence may be determined by clinical judgment when a duration of 6 months cannot be ascertained precisely. There may be absent or reduced frequency or intensity of interest in sexual activity (Crite- rion A1), which was previously termed hypoactive sexual desire disorder. The frequency or inten- sity of sexual and erotic thoughts or fantasies may be absent or reduced (Criterion A2). The expression of fantasies varies widely across women and may include memories of past sexual experiences. The normative decline in sexual thoughts with age should be taken into account when this criterion is being assessed. Absence or reduced frequency of initiating sexual activ- ity and of receptivity to a partner's sexual invitations (Criterion A3) is a behaviorally focused criterion. A couple's beliefs and preferences for sexual initiation patterns are highly relevant to the assessment of this criterion. There may be absent or reduced sexual excitement or pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (Cri- terion A4). Lack of pleasure is a common presenting clinical complaint in women with low de- sire. Among women who report low sexual desire, there are fewer sexual or erotic cues that elicit sexual interest or arousal (i.e., there is a lack of "responsive desire"). Assessment of the adequacy of sexual stimuli will assist in determining if there is a difficulty with responsive sex- ual desire (Criterion A5). Frequency or intensity of genital or nongenital sensations during sex- ual activity may be reduced or absent (Criterion A6). This may include reduced vaginal lubrication/ vasocongestion, but because physiological measures of genital sexual response do not differentiate women who report sexual arousal concerns from those who do not, the self- report of reduced or absent genital or nongenital sensations is sufficient. For a diagnosis of female sexual interest / arousal disorder to be made, clinically signif- icant distress must accompany the symptoms in Criterion A. Distress may be experienced as a result of the lack of sexual interest/ arousal or as a result of significant interference in a woman's life and well-being. If a lifelong lack of sexual desire is better explained by one's self-identificationas "asexual, " then a diagnosis of female sexual interest / arousal disor- der would not be made. Associated Features Supporting Diagnosis Female sexual interest /arousal disorder is frequently associated with problems in experi- encing orgasm, pain experienced during sexual activity, infrequent sexual activity, and couple-level discrepancies in desire. Relationship difficulties and mood disorders are also frequently associated features of female sexual interest / arousal disorder. Unrealistic ex- pectations and norms regarding the "appropriate" level of sexual interest or arousal, along with poor sexual techniques and lack of information about sexuality, may also be evident in women diagnosed with female sexual interest / arousal disorder. The latter, as well as normative beliefs about gender roles, are important factors to consider. In addition to the subtypes "lifelong/acquired' and "generalized / situational," the follow- ing five factors must be considered during assessment and diagnosis of female sexual interest / arousal disorder given that they may be relevant to etiology and/ or treatment: 1) partner fac- tors (e.g., partner's sexual problems, partner's health status); 2) relationship factors (e.g., poor communication, discrepancies in desire for sexual activity); 3) individual vulnerability factors (e.g., poor body image, history of sexual or emotional abuse), psychiatric comorbidity (e.g., de- pression, anxiety), or stressors (e.g., job loss, bereavement); 4) cultural/ religious factors (e.g., inhibitions related to prohibitions against sexual activity; attitudes toward sexuality); and 5) medical factors relevant to prognosis, course, or treatment. Note that each of these factors may contribute differently to the presenting symptoms of different women with this disorder. Prevalence The prevalence of female sexual interest / arousal disorder, as defined in this manual, is unknown. The prevalence of low sexual desire and of problems with sexual arousal (with and without associated distress), as defined by DSM-IV or ICD-10, may vary markedly in relation to age, cultural setting, duration of symptoms, and presence of distress. Regard- ing duration of symptoms, there are striking differences in prevalence estimates between short-term and persistent problems related to lack of sexual interest. When distress about sexual functioning is required, prevalence estimates are markedly lower. Some older women report less distress about low sexual desire than younger women, although sexual desire may decrease with age. Development and Course By definition, lifelong female sexual interest / arousal disorder suggests that the lack of sexual interest or arousal has been present for the woman's entire sexual life. For Criteria A3, A4, and A6, which assess functioning during sexual activity, a subtype of lifelong would mean presence of symptoms since the individual's first sexual experiences. The ac- quired subtype would be assigned if the difficulties with sexual interest or arousal de- veloped after a period of nonproblematic sexual functioning. Adaptive and normative changes in sexual functioning may result from partner-related, interpersonal, or personal events and may be transient in nature. However, persistence of symptoms for approxi- mately 6 months or more would constitute a sexual dysfunction. There are normative changes in sexual interest and arousal across the life span. Fur- thermore, women in relationships of longer duration are more likely to report engaging in sex despite no obvious feelings of sexual desire at the outset of a sexual encounter com- pared with women in shorter-duration relationships. Vaginal dryness in older women is related to age and menopausal status. Risk and Prognostic Factors Temperamental. Temperamental factors include negative cognitions and attitudes about sexuality and past history of mental disorders. Differences in propensity for sexual excitation and sexual inhibition may also predict the likelihood of developing sexual problems. Environmental. Environmental factors include relationship difficulties, partner sexual functioning, and developmental history, such as early relationships with caregivers and childhood stressors. Genetic and physiological. Some medical conditions (e.g., diabetes mellitus, thyroid dysfunction) can be risk factors for female sexual interest / arousal disorder. There appears to be a strong influence of genetic factors on vulnerability to sexual problems in women. Psychophysiological research using vaginal photoplethysmography has not found differ- ences between women with and without perceived lack of genital arousal. Culture-Related Diagnostic Issues There is marked variability in prevalence rates of low desire across cultures. Lower rates of sexual desire may be more common among East Asian women compared with Euro- Canadian women. Although the lower levels of sexual desire and arousal found in men and women from East Asian countries compared with Euro-American groups may reflect less interest in sex in those cultures, the possibility remains that such group differences are an artifact of the measures used to quantify desire. A judgment about whether low sexual desire reported by a woman from a certain ethnocultural group, meets criteria for female desult interest/ arousal disorder must take into account the fact that different cultures nay pathologize some behaviors and not others. Gender-Related Diagnostic Issues By definition, the diagnosis of female sexual interest/arousal disorder is only given to women. Distressing difficulties with sexual desire in men would be considered under male hypoactive sexual desire disorder. Functional Consequences of Female Sexual Interest/Arousal Disorder Difficulties in sexual interest/arousal are often associated with decreased relationship sat- isfaction. Differential Diagnosis Nonsexual mental disorders. Nonsexual mental disorders, such as major depressive disorder, in which there is "markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day, "may explain the lack of sexual interest/ arousal. If the lack of interest or arousal is completely attributable to another mental dis- order, then a diagnosis of female sexual interest / arousal disorder would not be made. Substance/medication use. Substance or medication use may explain the lack of inter- est/arousal. Another medical condition. If the sexual symptoms are considered to be almost exclu- sively associated with the effects of another medical condition (e.g., diabetes mellitus, en- dothelial disease, thyroid dysfunction, central nervous system disease), then a diagnosis of female sexual interest / arousal disorder would not be made. Interpersonal factors. If interpersonal or significant contextual factors, such as severe relationship distress, intimate partner violence, or other significant stressors, explain the sexual interest / arousal symptoms, then a diagnosis of female sexual interest / arousal dis- order would not be made. Other sexual dysfunctions. The presence of another sexual dysfunction does not rule out a diagnosis of female sexual interest / arousal disorder. It is common for women to ex- perience more than one sexual dysfunction. For example, the presence of chronic genital pain may lead to a lack of desire for the (painful) sexual activity. Lack of interest and arousal during sexual activity may impair orgasmic ability. For some women, all aspects of the sexual response may be unsatisfying and distressing. Inadequate or absent sexual stimuli. When differential diagnoses are being considered, it is important to assess the adequacy of sexual stimuli within the woman's sexual experi- ence. In cases where inadequate or absent sexual stimuli are contributing to the clinical pic- ture, there may be evidence for clinical care, but a sexual dysfunction diagnosis would not be made. Similarly, transient and adaptive alterations in sexual functioning that are second- ary to a significant life or personal event must be considered in the differential diagnosis. Comorbidity Comorbidity between sexual interest / arousal problems and other sexual difficulties is extremely common. Sexual distress and dissatisfaction with sex life are also highly cor- related in women with low sexual desire. Distressing low desire is associated with depres- sion, thyroid problems, anxiety, urinary incontinence, and other medical factors. Arthritis and inflammatory or irritable bowel disease are also associated with sexual arousal problems. Low desire appears to be comorbid with depression, sexual and physical abuse in adulthood, global mental functioning, and use of alcohol

somatic symptom disorder (DSM)

DIAGNOSTIC CRITERIA 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). Specify if: With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain. Specify if: Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). Specify current severity: Mild: Only one of the symptoms specified in Criterion B is fulfilled. Moderate: Two or more of the symptoms specified in Criterion B are fulfilled. Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom). Diagnostic features Individuals with somatic symptom disorder typically have multiple, current, somatic symp- toms that are distressing or result in significant disruption of daily life (Criterion A), al- though sometimes only one severe symptom, most commonly pain, is present. Symptoms may be specific (e.g., localized pain) or relatively nonspecific (e.g., fatigue). The symptoms sometimes represent normal bodily sensations or discomfort that does not generally sig- nify serious disease. Somatic symptoms without an evident medical explanation are not sufficient to make this diagnosis. The individual's suffering is authentic, whether or not it is medically explained. The symptoms may or may not be associated with another medical condition. The di- agnoses of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together. For example, an individual may become se- riously disabled by symptoms of somatic symptom disorder after an uncomplicated myo- cardial infarction even if the myocardial infarction itself did not result in any disability. If another medical condition or high risk for developing one is present (e.g., strong family history), the thoughts, feelings, and behaviors associated with this condition are excessive (Criterion B). Individuals with somatic symptom disorder tend to have very high levels of worry about illness (Criterion B). They appraise their bodily symptoms as unduly threatening, harmful, or troublesome and often think the worst about their health. Even when there is evidence to the contrary, some patients still fear the medical seriousness of their symp- toms. In severe somatic symptom disorder, health concerns may assume a central role in the individual's life, becoming a feature of his or her identity and dominating interpersonal relationships. Individuals typically experience distress that is principally focused on somatic symp. toms and their significance. When asked directly about their distress, some individuals de scribe it in relation to other aspects of their lives, while others deny any source of distress other than the somatic symptoms. Health-related quality of life is often impaired, both physically and mentally. In severe somatic symptom disorder, the impairment is marked, and when persistent, the disorder can lead to invalidism. There is often a high level of medical care utilization, which rarely alleviates the individ- ual's concerns. Consequently, the patient may seek care from multiple doctors for the same symptoms. These individuals often seem unresponsive to medical interventions, and new interventions may only exacerbate the presenting symptoms. Some individuals with the dis- order seem unusually sensitive to medication side effects. Some feel that their medical as- sessment and treatment have been inadequate. Associated Features Supporting Diagnosis Cognitive features include attention focused on somatic symptoms, attribution of normal bodily sensations to physical illness (possibly with catastrophic interpretations), worry about illness, and fear that any physical activity may damage the body. The relevant as- sociated behavioral features may include repeated bodily checking for abnormalities, re- peated seeking of medical help and reassurance, and avoidance of physical activity. These behavioral features are most pronounced in severe, persistent somatic symptom disorder. These features are usually associated with frequent requests for medical help for different somatic symptoms. This may lead to medical consultations in which individuals are so fo- cused on their concerns about somatic symptom(s) that they cannot be redirected to other matters. Any reassurance by the doctor that the symptoms are not indicative of serious physical illness tends to be short-lived and/ or is experienced by the individuals as the doctor not taking their symptoms with due seriousness. As the focus on somatic symp- toms is a primary feature of the disorder, individuals with somatic symptom disorder typ- ically present to general medical health services rather than mental health services. The suggestion of referral to a mental health specialist may be met with surprise or even frank refusal by individuals with somatic symptom disorder. Since somatic symptom disorder is associated with depressive disorders, there is an in- creased suicide risk. It is not known whether somatic symptom disorder is associated with suicide risk independent of its association with depressive disorders. Prevalence The prevalence of somatic symptom disorder is not known. However, the prevalence of somatic symptom disorder is expected to be higher than that of the more restrictive DSM- IV somatization disorder (<1%) but lower than that of undifferentiated somatoform dis- order (approximately 19%). The prevalence of somatic symptom disorder in the general adult population may be around 5%-7%. Females tend to report more somatic symptoms than do males, and the prevalence of somatic symptom disorder is consequently likely to be higher in females. Development and Course In older individuals, somatic symptoms and concurrent medical illnesses are common, and a focus on Criterion B is crucial for making the diagnosis. Somatic symptom disorder may be underdiagnosed in older adults either because certain somatic symptoms (e.g., pain, fatigue) are considered part of normal aging or because illness worry is considered "understandable" in older adults who have more general medical illnesses and medica- tions than do younger people. Concurrent depressive disorder is common in older people who present with numerous somatic symptoms. In children, the most common symptoms are recurrent abdominal pain, headache, fa- tigue, and nausea. A single prominent symptom is more common in children than in adults. While young children may have somatic complaints, they rarely worry about "ill- ness" " per se prior to adolescence. The parents' response to the symptom is important, as this may determine the level of associated distress. It is the parent who may determine the interpretation of symptoms and the associated time off school and medical help seeking Risk and Prognostic Factors Temperamental. The personality trait of negative affectivity (neuroticism) has been identified as an independent correlate/ risk factor of a high number of somatic symptoms. Comorbid anxiety or depression is common and may exacerbate symptoms and impairment. Environmental. Somatic symptom disorder is more frequent in individuals with few years of education and low socioeconomic status, and in those who have recently experienced stressful life events. Course modifiers. Persistent somatic symptoms are associated with demographic fea- tures (female sex, older age, fewer years of education, lower socioeconomic status, un- employment), a reported history of sexual abuse or other childhood adversity, concurrent chronic physical illness or psychiatric disorder (depression, anxiety, persistent depressive disorder [dysthymia], panic), social stress, and reinforcing social factors such as illness benefits. Cognitive factors that affect clinical course include sensitization to pain, height- ened attention to bodily sensations, and attribution of bodily symptoms to a possible medical illness rather than recognizing them as a normal phenomenon or psychological stress. Culture-Related Diagnostic Issues Somatic symptoms are prominent in various "culture-bound syndromes." High numbers of somatic symptoms are found in population-based and primary care studies around the world, with a similar pattern of the most commonly reported somatic symptoms, impair- ment, and treatment seeking. The relationship between number of somatic symptoms and illness worry is similar in different cultures, and marked illness worry is associated with impairment and greater treatment seeking across cultures. The relationship between nu- merous somatic symptoms and depression appears to be very similar around the world and between different cultures within one country. Despite these similarities, there are differences in somatic symptoms among cultures and ethnic groups. The description of somatic symptoms varies with linguistic and other local cultural factors. These somatic presentations have been described as "idioms of dis- tress" because somatic symptoms may have special meanings and shape patient-clinician interactions in the particular cultural contexts. "Burnout, " the sensation of heaviness or the complaints of "gas"; too much heat in the body; or burning in the head are examples of symptoms that are common in some cultures or ethnic groups but rare in others. Explan- atory models also vary, and somatic symptoms may be attributed variously to particular family, work, or environmental stresses; general medical illness; the suppression of feel- ings of anger and resentment; or certain culture-specific phenomena, such as semen loss. There may also be differences in medical treatment seeking among cultural groups, in ad- dition to differences due to variable access to medical care services. Seeking treatment for multiple somatic symptoms in general medical clinics is a worldwide phenomenon and occurs at similar rates among ethnic groups in the same country. Functional Consequences of Somatic Symptom Disorder The disorder is associated with marked impairment of health status. Many individuals with severe somatic symptom disorder are likely to have impaired health status scores more than 2 standard deviations below population norms. Differential Diagnosis If the somatic symptoms are consistent with another mental disorder (e8, panic disorder) and the diagnostic criteria for that disorder are fulfilled, then that mental disorder should be considefed as an alternative or additional diagnosis. A separate diagnosis of somatic symptom disorder is not made if the somatic symptoms and related thoughts, feelings, or behaviors occur only during major depressive episodes. If, as commonly occurs, the crite ria for both somatic symptom disorder and another mental disorder diagnosis are ful. filled, then both should be coded, as both may require treatment. Other medical conditions. The presence of somatic symptoms of unclear etiology is not in itself sufficient to make the diagnosis of somatic symptom disorder. The symptoms of many individuals with disorders like irritable bowel syndrome or fibromyalgia would not satisfy the criterion necessary to diagnose somatic symptom disorder (Criterion B). Con- versely, the presence of somatic symptoms of an established medical disorder ( g., diabe- tes or heart disease) does not exclude the diagnosis of somatic symptom disorder if the criteria are otherwise met. Panic disorder. In panic disorder, somatic symptoms and anxiety about health tend to occur in acute episodes, whereas in somatic symptom disorder, anxiety and somatic symp- toms are more persistent. Generalized anxiety disorder. Individuals with generalized anxiety disorder worry about multiple events, situations, or activities, only one of which may involve their health. The main focus is not usually somatic symptoms or fear of illness as it is in somatic symptom disorder. Depressive disorders. Depressive disorders are commonly accompanied by somatic symptoms. However, depressive disorders are differentiated from somatic symptom dis- order by the core depressive symptoms of low (dysphoric) mood and anhedonia. Illness anxiety disorder. If the individual has extensive worries about health but no or minimal somatic symptoms, it may be more appropriate to consider illness anxiety disorder. Conversion disorder (functional neurological symptom disorder). In conversion disor- der, the presenting symptom is loss of function (e.g., of a limb), whereas in somatic symp- tom disorder, the focus is on the distress that particular symptoms cause. The features listed under Criterion B of somatic symptom disorder may be helpful in differentiating the two disorders. Delusional disorder. In somatic symptom disorder, the individual's beliefs that somatic symptoms might reflect serious underlying physical illness are not held with delusional intensity. Nonetheless, the individual's beliefs concerning the somatic symptoms can be firmly held. In contrast, in delusional disorder, somatic subtype, the somatic symptom be- liefs and behavior are stronger than those found in somatic symptom disorder. Body dysmorphic disorder. In body dysmorphic disorder, the individual is excessively concerned about, and preoccupied by, a perceived defect in his or her physical features. In contrast, in somatic symptom disorder, the concern about somatic symptoms reflects fear of underlying illness, not of a defect in appearance. Obsessive-compulsive disorder. In somatic symptom disorder, the recurrent ideas about somatic symptoms or illness are less intrusive, and individuals with this disorder do not exhibit the associated repetitive behaviors aimed at reducing anxiety that occur in obses- sive-compulsive disorder. Comorbidity Somatic symptom disorder is associated with high rates of comorbidity with medical disorders as well as anxiety and depressive disorders. When a concurrent medical illness is present, the degree of impairment is more marked than would be expected from the physical illness alone. When an individual's symptoms meet diagnostic criteria for somatic symptom disorder, the disorder should be diagnosed; however, in view of the frequent comorbidity, especially with anxiety and depressive disorders, evidence for these concurrent diagnoses should be sought.

Conversion Disorder (Functional Neurological Symptom Disorder) (DSM)

DIAGNOSTIC CRITERIA A. One or more symptoms of altered voluntary motor or sensory function. B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. C. The symptom or deficit is not better explained by another medical or mental disorder. D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. DIAGNOSTIC FEATURES Many clinicians use the alternative names of "functional" (referring to abnormal central nervous system functioning) or "psychogenic" ' (referring to an assumed etiology) to de- scribe the symptoms of conversion disorder (functional neurological symptom disor- der). In conversion disorder, there may be one or more symptoms of various types. Motor symptoms include weakness or paralysis; abnormal movements, such as tremor or dys- tonic movements; gait abnormalities; and abnormal limb posturing. Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing. Episodes of abnor- mal generalized limb shaking with apparent impaired or loss of consciousness mar resem- ble epileptic seizures (also called psychogenic or non-epileptic seizures). There say ine episodes of unresponsiveness resembling syncope or coma. Other symptoins include re duced or absent speech volume (dysphonia/ aphonia), altered articulation (dysarthria), a sensation of a lump in the throat (globus), and diplopia. Although the diagnosis requires that the symptom is not explained by neurological disease, it should not be made simply because results from investigations are normal or because the symptom is "bizarre. ." There must be clinical findings that show clear evidence of incompatibility with neurological disease. Internal inconsistency at examination is one way to demonstrate incompatibility (i.e., demonstrating that physical signs elicited through one examination method are no longer positive when tested a different way). Ex- amples of such examination findings include -Hoover's sign, in which weakness of hip extension returns to normal strength with con- tralateral hip flexion against resistance. •Marked weakness of ankle plantar-flexion when tested on the bed in an individual who is able to walk on tiptoes; -Positive findings on the tremor entrainment test. On this test, a unilateral tremor may be identified as functional if the tremor changes when the individual is distracted away from it. This may be observed if the individual is asked to copy the examiner in making a rhythmical movement with their unaffected hand and this causes the functional tremor to change such that it copies or "entrains" to the rhythm of the unaffected hand or the functional tremor is suppressed, or no longer makes a simple rhythmical move- ment. -In attacks resembling epilepsy or syncope ("psychogenic" non-epileptic attacks), the occurrence of closed eyes with resistance to opening or a normal simultaneous electro- encephalogram (although this alone does not exclude all forms of epilepsy or syncope). •For visual symptoms, a tubular visual field (i.e., tunnel vision). It is important to note that the diagnosis of conversion disorder should be based on the overall clinical picture and not on a single clinical finding. Prevalence Transient conversion symptoms are common, but the precise prevalence of the disorder is unknown. This is partly because the diagnosis usually requires assessment in secondary care, where it is found in approximately 5% of referrals to neurology clinics. The incidence of individual persistent conversion symptoms is estimated to be 2-5/100,000 per year. Development and Course Onset has been reported throughout the life course. The onset of non-epileptic attacks peaks in the third decade, and motor symptoms have their peak onset in the fourth decade. The symptoms can be transient or persistent. The prognosis may be better in younger chil- dren than in adolescents and adults. Risk and Prognostic Factors Temperamental. Maladaptive personality traits are commonly associated with conver- sion disorder. Environmental. There may be a history of childhood abuse and neglect. Stressful life events are often, but not always, present. Genetic and physiological. The presence of neurological disease that causes similar symp- toms is a risk factor (e.g., non-epileptic seizures are more common in patients who also have epilepsy). Course modifiers. Short duration of symptoms and acceptance of the diagnosis are pos- itive prognostic factors. Maladaptive personality traits, the presence of comorbid physical disease, and the receipt of disability benefits may be negative prognostic factors. Culture-Related Diagnostic Issues Changes resembling conversion (and dissociative) symptoms are common in certain culturally sanctioned rituals. If the symptoms are fully explained within the particular cultural context and do not result in clinically significant distress or disability, then the di- agnosis of conversion disorder is not made. Gender-Related Diagnostic Issues Conversion disorder is two to three times more common in females. Functional Consequences of Conversion Disorder individuals with conversion symptoms may have substantial disability. The severity of dis- ability can be similar to that experienced by individuals with comparable medical diseases. Differential Diagnosis If another mental disorder better explains the symptoms, that diagnosis should be made. However the diagnosis of conversion disorder may be made in the presence of another mental disorder. Neurological disease. The main differential diagnosis is neurological disease that might better explain the symptoms. After a thorough neurological assessment, an unexpected neurological disease cause for the symptoms is rarely found at follow up. However, reas- sessment may be required if the symptoms appear to be progressive. Conversion disorder may coexist with neurological disease. Somatic symptom disorder. Conversion disorder may be diagnosed in addition to so- matic symptom disorder. Most of the somatic symptoms encountered in somatic symptom disorder cannot be demonstrated to be clearly incompatible with pathophysiology (e.g., pain, fatigue), whereas in conversion disorder, such incompatibility is required for the di- agnosis. The excessive thoughts, feelings, and behaviors characterizing somatic symptom disorder are often absent in conversion disorder. Factitious disorder and malingering. The diagnosis of conversion disorder does not require the judgment that the symptoms are not intentionally produced (i.e., not feigned), because assessment of conscious intention is unreliable. However definite evidence of feigning (e.g., clear evidence that loss of function is present during the examination but not at home) would suggest a diagnosis of factitious disorder if the individual's apparent aim is to assume the sick role or malingering if the aim is to obtain an incentive such as money. Dissociative disorders. Dissociative symptoms are common in individuals with con- version disorder. If both conversion disorder and a dissociative disorder are present, both diagnoses should be made. Body dysmorphic disorder. Individuals with body dysmorphic disorder are exces- sively concerned about a perceived defect in their physical features but do not complain of symptoms of sensory or motor functioning in the affected body part. Depressive disorders. In depressive disorders, individuals may report general heavi- ness of their limbs, whereas the weakness of conversion disorder is more focal and prom- inent. Depressive disorders are also differentiated by the presence of core depressive symptoms. Panic disorder. Episodic neurological symptoms (e.g., tremors and paresthesias) can occur in both conversion disorder and panic attacks. In panic attacks, the neurological symptoms are typically transient and acutely episodic with characteristic cardiorespira- tory symptoms. Loss of awareness with amnesia for the attack and violent limb move- ments occur in non-epileptic attacks, but not in panic attacks. Comorbidity Anxiety disorders, especially panic disorder, and depressive disorders commonly co-occur with conversion disorder. Somatic symptom disorder may co-occur as well. Psychosis, sub- stance use disorder, and alcohol misuse are uncommon. Personality disorders are more common in individuals with conversion disorder than in the general population. Neuro- logical or other medical conditions commonly coexist with conversion disorder as well.

fetishistic disorder (DSM)

DIAGNOSTIC CRITERIA A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or devices specifically designed for the purpose of tactile genital stimulation (e.g., vibrator). Specify: Body part(s) Nonliving object(s) Other Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in fetishistic behaviors are restricted. In full remission: There has been no distress or impairment in social, occupational, or other areas of functioning for at least 5 years while in an uncontrolled environment. Specifiers Although individuals with fetishistic disorder may report intense and recurrent sexual arousal to inanimate objects or a specific body part, it is not unusual for non-mutually ex- clusive combinations of fetishes to occur. Thus, an individual may have fetishistic disorder associated with an inanimate object (e.g., female undergarments) or an exclusive focus on an intensely eroticized body part (e.g., feet, hair), or their fetishistic interest may meet cri- teria for various combinations of these specifiers (e.g., socks, shoes and feet). Diagnostic Features The paraphilic focus of fetishistic disorder involves the persistent and repetitive use of or de- pendence on nonliving objects or a highly specific focus on a (typically nongenital) body part as primary elements associated with sexual arousal (Criterion A). A diagnosis of fetishistic dis- order must include clinically significant personal distress or psychosocial role impairment (Criterion B). Common fetish objects include female undergarments, male or female footwear, rubber articles, leather clothing, or other wearing apparel. Highly eroticized body parts asso- cited with fetishistic disorder include feet, toes, and hair. It is not uncommon for sexualized fetishes to include both inanimate objects and body parts (e.g., dirty socks and feet), and for this reason the definition of fetishistic disorder now re-incorporates partialism (i.e., an exclusive focus on a body part) into its boundaries. Partialism, previously considered a paraphilia not otherwise specified disorder, had historically been subsumed in fetishism prior to DSM-III. Many individuals who self-identify as fetishist practitioners do not necessarily report clinical impairment in association with their fetish-associated behaviors. Such individuals could be considered as having a fetish but not fetishistic disorder. A diagnosis of fetishistic disorder requires concurrent fulfillment of both the behaviors in Criterion A and the clin- ically significant distress or impairment in functioning noted in Criterion B. Associated Features Supporting Diagnosis Fetishistic disorder can be a multisensory experience, including holding, tasting, rubbing, inserting, or smelling the fetish object while masturbating, or preferring that a sexual part- ner wear or utilize a fetish object during sexual encounters. Some individuals may acquire extensive collections of highly desired fetish objects. Development and Course Usually paraphilias have an onset during puberty, but fetishes can develop prior to ado- lescence. Once established, fetishistic disorder tends to have a continuous course that fluc- tuates in intensity and frequency of urges or behavior. Culture-Related Diagnostic Issues Knowledge of and appropriate consideration for normative aspects of sexual behavior are important factors to explore to establish a clinical diagnosis of fetishistic disorder and to distinguish a clinical diagnosis from a socially acceptable sexual behavior. Gender-Related Diagnostic Issues Fetishistic disorder has not been systematically reported to occur in females. In clinical samples, fetishistic disorder is nearly exclusively reported in males. Functional Consequences of Fetishistic Disorder Typical impairments associated with fetishistic disorder include sexual dysfunction during romantic reciprocal relationships when the preferred fetish object or body part is unavailable during foreplay or coitus. Some individuals with fetishistic disorder may pre- fer solitary sexual activity associated with their fetishistic preference(s) even while in- volved in a meaningful reciprocal and affectionate relationship. Although fetishistic disorder is relatively uncommon among arrested sexual offenders with paraphilias, males with fetishistic disorder may steal and collect their particular fe- tishistic objects of desire. Such individuals have been arrested and charged for nonsexual antisocial behaviors (e.g., breaking and entering, theft, burglary) that are primarily moti- vated by the fetishistic disorder. Differential Diagnosis Transvestic disorder. The nearest diagnostic neighbor of fetishistic disorder is transves- tic disorder. As noted in the diagnostic criteria, fetishistic disorder is not diagnosed when fetish objects are limited to articles of clothing exclusively worn during cross-dressing (as in transvestic disorder), or when the object is genitally stimulating because it has been de- signed for that purpose (e.g., a vibrator). Sexual masochism disorder or other paraphilic disorders. Fetishes can co-occur with other paraphilic disorders, especially "sadomasochism" and transvestic disorder. When an individual fantasizes about or engages in "forced cross-dressing" and is primarily sex- ally aroused by the domination or humiliation associated with such fantasy or repetitive activity, the diagnosis of sexual masochism disorder should be made. Fetishistic behavior without fetishistic disorder. Use of a fetish object for sexual arousal without any associated distress or psychosocial role impairment or other adverse conse- quence would not meet criteria for fetishistic disorder, as the threshold required by Crite- rion B would not be met. For example, an individual whose sexual partner either shares or can successfully incorporate his interest in caressing, smelling, or licking feet or toes as an important element of foreplay would not be diagnosed with fetishistic disorder; nor would an individual who prefers, and is not distressed or impaired by, solitary sexual be- havior associated with wearing rubber garments or leather boots. Comorbidity Fetishistic disorder may co-occur with other paraphilic disorders as well as hypersexual- ity. Rarely, fetishistic disorder may be associated with neurological conditions.

Trichotillomania (DSM)

DIAGNOSTIC CRITERIA A. Recurrent pulling out of one's hair, resulting in hair loss. B. Repeated attempts to decrease or stop hair pulling. C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition). E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

Cannabis Intoxication (DSM)

DIAGNOSTIC CRITERIA A. Recent use of cannabis. B. Clinically significant problematic behavioral or psychological changes (e.g., impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use. C. Two (or more) of the following signs or symptoms developing within 2 hours of cannabis use: 1. Conjunctival injection. 2. Increased appetite. 3. Dry mouth. 4. Tachycardia. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Specify if: With perceptual disturbances: Hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Specifiers When hallucinations occur in the absence of intact reality testing, a diagnosis of substance/ medication-induced psychotic disorder should be considered. Diagnostic Features The essential feature of cannabis intoxication is the presence of clinically significant prob- lematic behavioral or psychological changes that develop during, or shortly after, canna- bis use (Criterion B). Intoxication typically begins with a "high" feeling followed by symptoms that include euphoria with inappropriate laughter and grandiosity, sedation, lethargy, impairment in short-term memory, difficulty carrying out complex mental pro- cesses, impaired judgment, distorted sensory perceptions, impaired motor performance, and the sensation that time is passing slowly. Occasionally, anxiety (which can be severe), dysphoria, or social withdrawal occurs. These psychoactive effects are accompanied by two or more of the following signs, developing within 2 hours of cannabis use: conjuncti- val injection, increased appetite, dry mouth, and tachycardia (Criterion C). Intoxication develops within minutes if the cannabis is smoked but may take a few hours to develop if the cannabis is ingested orally. The effects usually last 3 4 hours, with the duration being somewhat longer when the substance is ingested orally. The magnitude of the behavioral and physiological changes depends on the dose, the method of adminis- tration, and the characteristics of the individual using the substance, such as rate of absorp- tion, tolerance, and sensitivity to the effects of the substance. Because most cannabinoids, including delta-9-tetrahydrocannabinol (delta-9-THC), are fat soluble, the effects of canna- bis or hashish may occasionally persist or reoccur for 12-24 hours because of the slow re- lease of psychoactive substances from fatty tissue or to enterohepatic circulation. Prevalence The prevalence of actual episodes of cannabis intoxication in the general population is un- known. However, it is probable that most cannabis users would at some time meet criteria for cannabis intoxication. Given this, the prevalence of cannabis users and the prevalence of individuals experiencing cannabis intoxication are likely similar. Functional Consequences of Cannabis Intoxication Impairment from cannabis intoxication may have serious consequences, including dys- function at work or school, social indiscretions, failure to fulfill role obligations, traffic ac- cidents, and having unprotected sex. In rare cases, cannabis intoxication may precipitate a psychosis that may vary in duration. Differential Diagnosis Note that if the clinical presentation includes hallucinations in the absence of intact reality testing, a diagnosis of substance/ medication-induced psychotic disorder should be con- sidered. Other substance intoxication. Cannabis intoxication may resemble intoxication with other types of substances. However, in contrast to cannabis intoxication, alcohol intoxica- tion and sedative, hypnotic, or anxiolytic intoxication frequently decrease appetite, in- crease aggressive behavior, and produce nystagmus or ataxia. Hallucinogens in low doses may cause a clinical picture that resembles cannabis intoxication. Phencyclidine, like can- nabis, can be smoked and also causes perceptual changes, but phencyclidine intoxication is much more likely to cause ataxia and aggressive behavior. Other cannabis-induced disorders. Cannabis intoxication is distinguished from the other cannabis-induced disorders (e.g., cannabis-induced anxiety disorder, with onset during intoxication) because the symptoms in these latter disorders predominate the clinical pre- sentation and are severe enough to warrant independent clinical attention.

Phencyclidine Intoxication (DSM)

DIAGNOSTIC CRITERIA A. Recent use of phencyclidine (or a pharmacologically similar substance). B. Clinically significant problematic behavioral changes (e.g., belligerence, assaultiveness, impulsiveness, unpredictability, psychomotor agitation, impaired judgment) that developed during, or shortly after, phencyclidine use. C. Within 1 hour, two (or more) of the following signs or symptoms: Note: When the drug is smoked, "snorted," or used intravenously, the onset may be particularly rapid. 1. Vertical or horizontal nystagmus. 2. Hypertension or tachycardia. 3. Numbness or diminished responsiveness to pain. 4. Ataxia. 5. Dysarthria. 6. Muscle rigidity. 7. Seizures or coma. 8. Hyperacusis. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Diagnostic Features Phencyclidine intoxication reflects the clinically significant behavioral changes that occur shortly after ingestion of this substance (or a pharmacologically similar substance). The most common clinical presentations of phencyclidine intoxication include disorientation, confusion without hallucinations, hallucinations or delusions, a catatonic-like syndrome, and coma of varying severity. The intoxication typically lasts for several hours but, de- pending on the type of clinical presentation and whether other drugs besides phencycli- dine were consumed, may last for several days or longer. Prevalence Use of phencyclidine or related substances may be taken as an estimate of the prevalence of intoxication. Approximately 2.5% of the population reports having ever used phency- clidine. Among high school students, 2.3% of 12th graders report ever using phencycli- dine, with 57% having used in the past 12 months. This represents an increase from prior to 2011. Past-year use of ketamine, which is assessed separately from other substances, has remained stable over time, with about 1.7% of 12th graders reporting use. Diagnostic Markers Laboratory testing may be useful, as phencyclidine is detectable in urine for up to 8 days following use, although the levels are only weakly associated with an individual's clinical presentation and may therefore not be useful for case management. Creatine phosphoki- nase and aspartate aminotransferase levels may be elevated. Functional Consequences of Phencyclidine Intoxication Phencyclidine intoxication produces extensive cardiovascular and neurological (e.g., sei- zures, dystonias, dyskinesias, catalepsy, hypothermia or hyperthermia) toxicity. Differential Diagnosis In particular, in the absence of intact reality testing (i.e., without insight into any percep- tual abnormalities), an additional diagnosis of phencyclidine-induced psychotic disorder should be considered. Other substance intoxication. Phencyclidine intoxication should be differentiated from intoxication due to other substances, including other hallucinogens; amphetamine, cocaine or other stimulants; and anticholinergics, as well as withdrawal from benzodiaze- pines. Nystagmus and bizarre and violent behavior may distinguish intoxication due to phencyclidine from that due to other substances. Toxicological tests may be useful in mak- ing this distinction, since phencyclidine is detectable in urine for up to 8 days after use. However, there is a weak correlation between quantitative toxicology levels of phencycli- dine and clinical presentation that diminishes the utility of the laboratory findings for pa- tient management. Other conditions. Other conditions to be considered include schizophrenia, depression, withdrawal from other drugs (e.g., sedatives, alcohol), certain metabolic disorders like hy- poglycemia and hyponatremia, central nervous system tumors, seizure disorders, sepsis, neuroleptic malignant syndrome, and vascular insults.

Bulimia nervosa (DSM)

DIAGNOSTIC CRITERIA 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. Specify if: In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time. In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. 10 Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behav- iors per week. Diagnostic features There are three essential features of bulimia nervosa: recurrent episodes of binge eating (Criterion A), recurrent inappropriate compensatory behaviors to prevent weight gain (Criterion B), and self-evaluation that is unduly influenced by body shape and weight (Criterion D). To qualify for the diagnosis, the binge eating and inappropriate compensa- tory behaviors must occur, on average, at least once per week for 3 months (Criterion C). An "episode of binge eating" is defined as eating, in a discrete period of time, an amount of food that is definitely larger than most individuals would eat in a similar period of time under similar circumstances (Criterion A1). The context in which the eating occurs may affect the clinician's estimation of whether the intake is excessive. For example, a quantity of food that might be regarded as excessive for a typical meal might be consid- ered normal during a celebration or holiday meal. A "discrete period of time" refers to a limited period, usually less than 2 hours. A single episode of binge eating need not be re- stricted to one setting. For example, an individual may begin a binge in a restaurant and then continue to eat on returning home. Continual snacking on small amounts of food throughout the day would not be considered an eating binge. An occurrence of excessive food consumption must be accompanied by a sense of lack of control (Criterion A2) to be considered an episode of binge eating. An indicator of loss of control is the inability to refrain from eating or to stop eating once started. Some indi- viduals describe a dissociative quality during, or following, the binge-eating episodes. The impairment in control associated with binge eating may not be absolute; for example, an individual may continue binge eating while the telephone is ringing but will cease if a roommate or spouse unexpectedly enters the room. Some individuals report that their binge-eating episodes are no longer characterized by an acute feeling of loss of control but rather by a more generalized pattern of uncontrolled eating. If individuals report that they have abandoned efforts to control their eating, loss of control should be considered as present. Binge eating can also be planned in some instances. The type of food consumed during binges varies both across individuals and for a given individual. Binge eating appears to be characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient. However, during binges, individuals tend to eat foods they would otherwise avoid. Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms. Binge eating usually occurs in secrecy or as inconspic- uously as possible. The binge eating often continues until the individual is uncomfortably, or even painfully, full. The most common antecedent of binge eating is negative affect. Other triggers include interpersonal stressors; dietary restraint; negative feelings related to body weight, body shape, and food; and boredom. Binge eating may minimize or mit- gate factors that precipitated the episode in the short-term, but negative self-evaluation and dysphoria often are the delayed consequences. Another essential feature of bulimia nervosa is the recurrent use of inappropriate com- pensatory behaviors to prevent weight gain, collectively referred to as purge behaviors or purging (Criterion B). Many individuals with bulimia nervosa employ several methods to compensate for binge eating. Vomiting is the most common inappropriate compensatory behavior. The immediate effects of vomiting include relief from physical discomfort and re- duction of fear of gaining weight. In some cases, vomiting becomes a goal in itself, and the individual will binge eat in order to vomit or will vomit after eating a small amount of food. Individuals with bulimia nervosa may use a variety of methods to induce vomiting, includ- ing the use of fingers or instruments to stimulate the gag reflex. Individuals generally become adept at inducing vomiting and are eventually able to vomit at will. Rarely, indi- viduals consume syrup of ipecac to induce vomiting. Other purging behaviors include the misuse of laxatives and diuretics. A number of other compensatory methods may also be used in rare cases. Individuals with bulimia nervosa may misuse enemas following epi- sodes of binge eating, but this is seldom the sole compensatory method employed. Individ- uals with this disorder may take thyroid hormone in an attempt to avoid weight gain. Individuals with diabetes mellitus and bulimia nervosa may omit or reduce insulin doses in order to reduce the metabolism of food consumed during eating binges. Individuals with bulimia nervosa may fast for a day or more or exercise excessively in an attempt to prevent weight gain. Exercise may be considered excessive when it significantly interferes with im- portant activities, when it occurs at inappropriate times or in inappropriate settings, or when the individual continues to exercise despite injury or other medical complications. Individuals with bulimia nervosa place an excessive emphasis on body shape or weight in their self-evaluation, and these factors are typically extremely important in determining self-esteem (Criterion D). Individuals with this disorder may closely resemble those with anorexia nervosa in their fear of gaining weight, in their desire to lose weight, and in the level of dissatisfaction with their bodies. However, a diagnosis of bulimia nervosa should not be given when the disturbance occurs only during episodes of anorexia nervosa (Cri- terion E). Associated Features Supporting Diagnosis Individuals with bulimia nervosa typically are within the normal weight or overweight range (body mass index [BMI] ≥ 18.5 and < 30 in adults). The disorder occurs but is un- common among obese individuals. Between eating binges, individuals with bulimia ner- vosa typically restrict their total caloric consumption and preferentially select low-calorie ("diet") foods while avoiding foods that they perceive to be fattening or likely to trigger a binge. Menstrual irregularity or amenorrhea often occurs among females with bulimia ner- vosa; it is uncertain whether such disturbances are related to weight fluctuations, to nu- tritional deficiencies, or to emotional distress. The fluid and electrolyte disturbances resulting from the purging behavior are sometimes sufficiently severe to constitute med- ically serious problems. Rare but potentially fatal complications include esophageal tears, gastric rupture, and cardiac arrhythmias. Serious cardiac and skeletal myopathies have been reported among individuals following repeated use of syrup of ipecac to induce vom- iting. Individuals who chronically abuse laxatives may become dependent on their use to stimulate bowel movements. Gastrointestinal symptoms are commonly associated with bulimia nervosa, and rectal prolapse has also been reported among individuals with this disorder. Prevalence Twelve-month prevalence of bulimia nervosa among young females is 1%-1.5%. Point prevalence is highest among young adults since the disorder peaks in older adolescence and young adulthood. Less is known about the point prevalence of bulimia nervosa in males, but bulimia nervosa is far less common in males than it is in females, with an ap- proximately 10:1 female-to-male ratio. Development and Course Bulimia nervosa commonly begins in adolescence or young adulthood. Onset before pu- berty or after age 40 is uncommon. The binge eating frequently begins during or after an episode of dieting to lose weight. Experiencing multiple stressful life events also can pre- cipitate onset of bulimia nervosa. Disturbed eating behavior persists for at least several years in a high percentage of clinic samples. The course may be chronic or intermittent, with periods of remission alternating with recurrences of binge eating. However, over longer-term follow-up, the symptoms of many individuals appear to diminish with or without treatment, although treatment clearly impacts outcome. Periods of remission longer than 1 year are associated with better long-term outcome. Significantly elevated risk for mortality (all-cause and suicide) has been reported for individuals with bulimia nervosa. The CM (crude mortality rate) for bulimia nervosa is nearly 2% per decade. Diagnostic cross-over from initial bulimia nervosa to anorexia nervosa occurs in a mi- nority of cases (10%-15%). Individuals who do experience cross-over to anorexia nervosa commonly will revert back to bulimia nervosa or have multiple occurrences of cross-overs between these disorders. A subset of individuals with bulimia nervosa continue to binge eat but no longer engage in inappropriate compensatory behaviors, and therefore their symptoms meet criteria for binge-eating disorder or other specified eating disorder. Diag- nosis should be based on the current (i.e., past 3 months) clinical presentation. Risk and Prognostic Factors Temperamental. Weight concerns, low self-esteem, depressive symptoms, social anxi- ety disorder, and overanxious disorder of childhood are associated with increased risk for the development of bulimia nervosa. Environmental. Internalization of a thin body ideal has been found to increase risk for developing weight concerns, which in turn increase risk for the development of bulimia nervosa. Individuals who experienced childhood sexual or physical abuse are at increased risk for developing bulimia nervosa. Genetic and physiological. Childhood obesity and early pubertal maturation increase risk for bulimia nervosa. Familial transmission of bulimia nervosa may be present, as well as genetic vulnerabilities for the disorder. Course modifiers. Severity of psychiatric comorbidity predicts worse long-term outcome of bulimia nervosa. Culture-Related Diagnostic Issues Bulimia nervosa has been reported to occur with roughly similar frequencies in most in- dustrialized countries, including the United States, Canada, many European countries, Australia, Japan, New Zealand, and South Africa. In clinical studies of bulimia nervosa in the United States, individuals presenting with this disorder are primarily white. However, the disorder also occurs in other ethnic groups and with prevalence comparable to esti- mated prevalences observed in white samples. Gender-Related Diagnostic Issues Bulimia nervosa is far more common in females than in males. Males are especially under- represented in treatment-seeking samples, for reasons that have not yet been systemati- cally examined. Diagnostic Markers No specific diagnostic test for bulimia nervosa currently exists. However, several labora- tory abnormalities may occur as a consequence of purging and may increase diagnostic certainty. These include fluid and electrolyte abnormalities, such as hypokalemia (which can provoke cardiac arrhythmias), hypochloremia, and hyponatremia. The loss of gastric acid through vomiting may produce a metabolic alkalosis (elevated serum bicarbonate), and the frequent induction of diarrhea or dehydration through laxative and diuretic abuse can cause metabolic acidosis. Some individuals with bulimia nervosa exhibit mildly ele- vated levels of serum amylase, probably reflecting an increase in the salivary isoenzyme. Physical examination usually yields no physical findings. However, inspection of the mouth may reveal significant and permanent loss of dental enamel, especially from lin- gual surfaces of the front teeth due to recurrent vomiting. These teeth may become chipped and appear ragged and "moth-eaten." There may also be an increased frequency of dental caries. In some individuals, the salivary glands, particularly the parotid glands, may become notably enlarged. Individuals who induce vomiting by manually stimulating the gag reflex may develop calluses or scars on the dorsal surface of the hand from re- peated contact with the teeth. Serious cardiac and skeletal myopathies have been reported among individuals following repeated use of syrup of ipecac to induce vomiting. Suicide Risk Suicide risk is elevated in bulimia nervosa. Comprehensive evaluation of individuals with This disorder should include assessment of suicide-related ideation and behaviors as with as other risk factors for suicide, including a history of suicide attempts. Functional Consequences of Bulimia Nervosa Individuals with bulimia nervosa may exhibit a range of functional limitations associated with the disorder. A minority of individuals report severe role impairment, with the so cial-life domain most likely to be adversely affected by bulimia nervosa. Differential Diagnosis Anorexia nervosa, binge-eating/purging type. Individuals whose binge-eating behav- for occurs only during episodes of anorexia nervosa are given the diagnosis anorexia ner- vosa, binge-eating/ purging type, and should not be given the additional diagnosis of bulimia nervosa. For individuals with an initial diagnosis of anorexia nervosa who binge and purge but whose presentation no longer meets the full criteria for anorexia nervosa, binge-eating/ purging type (e.g. when weight is normal), a diagnosis of bulimia ner- vosa should be given only when all criteria for bulimia nervosa have been met for at least 3 months. Binge-eating disorder. Some individuals binge eat but do not engage in regular inap- propriate compensatory behaviors. In these cases, the diagnosis of binge-eating disorder should be considered. Kleine-Levin syndrome. In certain neurological or other medical conditions, such as Kleine-Levin syndrome, there is disturbed eating behavior, but the characteristic psycho- logical features of bulimia nervosa, such as overconcern with body shape and weight, are not present. Major depressive disorder, with atypical features. Overeating is common in major de- pressive disorder, with atypical features, but individuals with this disorder do not engage in inappropriate compensatory behaviors and do not exhibit the excessive concern with body shape and weight characteristic of bulimia nervosa. If criteria for both disorders are met, both diagnoses should be given. Borderline personality disorder. Binge-eating behavior is included in the impulsive be- havior criterion that is part of the definition of borderline personality disorder. If the cri- teria for both borderline personality disorder and bulimia nervosa are met, both diagnoses should be given. Comorbidity Comorbidity with mental disorders is common in individuals with bulimia nervosa, with most experiencing at least one other mental disorder and many experiencing multiple co- morbidities. Comorbidity is not limited to any particular subset but rather occurs across a wide range of mental disorders. There is an increased frequency of depressive symptoms (e.g., low self-esteem) and bipolar and depressive disorders (particularly depressive dis- orders) in individuals with bulimia nervosa. In many individuals, the mood disturbance begins at the same time as or following the development of bulimia nervosa, and individ- uals often ascribe their mood disturbances to the bulimia nervosa. However, in some in- dividuals, the mood disturbance clearly precedes the development of bulimia nervosa. There may also be an increased frequency of anxiety symptoms (.g, fear of social situa- tons) or anxiety disorders. These mood and anxiety disturbances frequently remit follow ing effective treatment of the bulimia nervosa. The lifetime prevalence of substance use, particularly alcohol or stimulant use, is at least 30% among individuals with bulimia ner- vosa. Stimulant use often begins in an attempt to control appetite and weight. A substan- tial percentage of individuals with bulimia nervosa also have personality features that meet criteria for one or more personality disorders, most frequently borderline personality disorder.

Hallucination types

HALLUCINATIONS Sensory perception without physical stimuli Auditory Sound or a voice. Voice often in "3rd person" or can be command (Most common type) hallucinations. Visual Simple (flashing light) or complex (eg, seeing faces). Olfactory Stench or foul smells common. Tactile Insects on skin or being touched. Somatic Sensation arising from within the body. Gustatory Can be a part of persecutory delusions (tasting poison in food).

Major Depressive Disorder (DSM)

Major Depressive Episode 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 subjec- tive 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 delu- sional) 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 with- out 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, occupa- tional, 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 AC constitute a major depressive episode. Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a nat- ural 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 understand- able 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 schizoaf- fective 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 med- ical condition. Diagnostic Features The criterion symptoms for major depressive disorder must be present nearly every day to be considered present, with the exception of weight change and suicidal ideation. De- pressed mood must be present for most of the day, in addition to being present nearly ev- ery day. Often insomnia or fatigue is the presenting complaint, and failure to probe for accompanying depressive symptoms will result in underdiagnosis. Sadness may be de- nied at first but may be elicited through interview or inferred from facial expression and demeanor. With individuals who focus on a somatic complaint, clinicians should de- termine whether the distress from that complaint is associated with specific depressive symptoms. Fatigue and sleep disturbance are present in a high proportion of cases; psy- chomotor disturbances are much less common but are indicative of greater overall sever- ity, as is the presence of delusional or near-delusional guilt. The essential feature of a major depressive episode is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activi- ties (Criterion A). In children and adolescents, the mood may be irritable rather than sad. The individual must also experience at least four additional symptoms drawn from a list that includes changes in appetite or weight, sleep, and psychomotor activity; decreased en- ergy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making deci- sions; or recurrent thoughts of death or suicidal ideation or suicide plans or attempts. To count toward a major depressive episode, a symptom must either be newly present or must have clearly worsened compared with the person's pre-episode status. The symptoms must persist for most of the day, nearly every day, for at least 2 consecutive weeks. The ep- isode must be accompanied by clinically significant distress or impairment in social, occu- pational, or other important areas of functioning. For some individuals with milder episodes, functioning may appear to be normal but requires markedly increased effort. The mood in a major depressive episode is often described by the person as depressed, sad, hopeless, discouraged, or "down in the dumps" (Criterion A1). In some cases, sadness may be denied at first but may subsequently be elicited by interview (e.g., by pointing out that the individual looks as if he or she is about to cry). In some individuals who complain of feeling "blah," having no feelings, or feeling anxious, the presence of a depressed mood can be inferred from the person's facial expression and demeanor. Some individuals em- phasize somatic complaints (e.g., bodily aches and pains) rather than reporting feelings of sadness. Many individuals report or exhibit increased irritability (e.g., persistent anger, a tendency to respond to events with angry outbursts or blaming others, an exaggerated sense of frustration over minor matters). In children and adolescents, an irritable or cranky mood may develop rather than a sad or dejected mood. This presentation should be dif- ferentiated from a pattern of irritability when frustrated. TAR Loss of interest or pleasure is nearly always present, at least to some degree. Individ- uals may report feeling less interested in hobbies, " not caring anymore," or not feeling any enjoyment in activities that were previously considered pleasurable (Criterion A2). Family members often notice social withdrawal or neglect of pleasurable avocations (e.g., a for- merly avid golfer no longer plays, a child who used to enjoy soccer finds excuses not to practice). In some individuals, there is a significant reduction from previous levels of sex- al interest or desire. Appetite change may involve either a reduction or increase. Some depressed individ- uals report that they have to force themselves to eat. Others may eat more and may crave specific foods (e.g., sweets or other carbohydrates). When appetite changes are severe (in either direction), there may be a significant loss or gain in weight, or, in children, a failure to make expected weight gains may be noted (Criterion A3). Sleep disturbance may take the form of either difficulty sleeping or sleeping exces- sively (Criterion A4). When insomnia is present, it typically takes the form of middle in- somnia (i.e., waking up during the night and then having difficulty returning to sleep) or terminal insomnia (i.e., waking too early and being unable to return to sleep). Initial in- somnia (i.e., difficulty falling asleep) may also occur. Individuals who present with over- sleeping (hypersomnia) may experience prolonged sleep episodes at night or increased daytime sleep. Sometimes the reason that the individual seeks treatment is for the dis- turbed sleep. Psychomotor changes include agitation (e.g., the inability to sit still, pacing, hand- wringing; or pulling or rubbing of the skin, clothing, or other objects) or retardation (e.g., slowed speech, thinking, and body movements; increased pauses before answering; speech that is decreased in volume, inflection, amount, or variety of content, or muteness) (Criterion A5). The psychomotor agitation or retardation must be severe enough to be ob- servable by others and not represent merely subjective feelings. Decreased energy, tiredness, and fatigue are common (Criterion A6). A person may re- Port sustained fatigue without physical exertion. Even the smallest tasks seem to require substantial effort. The efficiency with which tasks are accomplished may be reduced. For example, an individual may complain that washing and dressing in the morning are ex hausting and take twice as long as usual. The sense of worthlessness or guilt associated with a major depressive episode may in- clude unrealistic negative evaluations of one's worth or guilty preoccupations or rumina- tions over minor past failings (Criterion A7). Such individuals often misinterpret neutral or trivial day-to-day events as evidence of personal defects and have an exaggerated sense of responsibility for untoward events. The sense of worthlessness or guilt may be of delu- sional proportions (e.g., an individual who is convinced that he or she is personally re- sponsible for world poverty). Blaming oneself for being sick and for failing to meet occupational or interpersonal responsibilities as a result of the depression is very common and, unless delusional, is not considered sufficient to meet this criterion. Many individuals report impaired ability to think, concentrate, or make even minor decisions (Criterion A8). They may appear easily distracted or complain of memory diffi- culties. Those engaged in cognitively demanding pursuits are often unable to function. In children, a precipitous drop in grades may reflect poor concentration. In elderly individ- uals, memory difficulties may be the chief complaint and may be mistaken for early signs of a dementia ("pseudodementia"). When the major depressive episode is successfully treated, the memory problems often fully abate. However, in some individuals, particu- larly elderly persons, a major depressive episode may sometimes be the initial presenta- tion of an irreversible dementia. Thoughts of death, suicidal ideation, or suicide attempts (Criterion A9) are common. They may range from a passive wish not to awaken in the morning or a belief that others would be better off if the individual were dead, to transient but recurrent thoughts of com- mitting suicide, to a specific suicide plan. More severely suicidal individuals may have put their affairs in order (e.g., updated wills, settled debts), acquired needed materials (e.g., a rope or a gun), and chosen a location and time to accomplish the suicide. Motivations for suicide may include a desire to give up in the face of perceived insurmountable obstacles, an intense wish to end what is perceived as an unending and excruciatingly painful emo- tional state, an inability to foresee any enjoyment in life, or the wish to not be a burden to others. The resolution of such thinking may be a more meaningful measure of diminished suicide risk than denial of further plans for suicide. solo Isi The evaluation of the symptoms of a major depressive episode is especially difficult when they occur in an individual who also has a general medical condition (e.g., cancer, stroke, myocardial infarction, diabetes, pregnancy). Some of the criterion signs and symp- toms of a major depressive episode are identical to those of general medical conditions (e.g., weight loss with untreated diabetes; fatigue with cancer; hypersomnia early in preg- nancy; insomnia later in pregnancy or the postpartum). Such symptoms count toward a major depressive diagnosis except when they are clearly and fully attributable to a general medical condition. Nonvegetative symptoms of dysphoria, anhedonia, guilt or worthless- ness, impaired concentration or indecision, and suicidal thoughts should be assessed with particular care in such cases. Definitions of major depressive episodes that have been mod- ified to include only these nonvegetative symptoms appear to identify nearly the same in dividuals as do the full criteria. Associated Features Supporting Diagnosis Major depressive disorder is associated with high mortality, much of which is accounted for by suicide; however, it is not the only cause. For example, depressed individuals ad- mitted to nursing homes have a markedly increased likelihood of death in the first year. In- dividuals frequently present with tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of pain (e.g., head- aches; joint, abdominal, or other pains). In children, separation anxiety may occur. Although an extensive literature exists describing neuroanatomical, neuroendocrino- logical, and neurophysiological correlates of major depressive disorder, no laboratory test has yielded results of sufficient sensitivity and specificity to be used as a diagnostic tool for this disorder. Until recently, hypothalamic-pituitary-adrenal axis hyperactivity had been the most extensively investigated abnormality associated with major depressive episodes, and it appears to be associated with melancholia, psychotic features, and risks for eventual suicide. Molecular studies have also implicated peripheral factors, including genetic vari- ants in neurotrophic factors and pro-inflammatory cytokines. Additionally, functional magnetic resonance imaging studies provide evidence for functional abnormalities in spe- cific neural systems supporting emotion processing, reward seeking, and emotion regula- tion in adults with major depression. Prevalence Twelve-month prevalence of major depressive disorder in the United States is approximately 7%, with marked differences by age group such that the prevalence in 18- to 29-year-old indi- viduals is threefold higher than the prevalence in individuals age 60 years or older. Females ex- perience 1.5- to 3-fold higher rates than males beginning in early adolescence. Development and Course Major depressive disorder may first appear at any age, but the likelihood of onset in- creases markedly with puberty. In the United States, incidence appears to peak in the 20s; however, first onset in late life is not uncommon. The course of major depressive disorder is quite variable, such that some individuals rarely, if ever, experience remission (a period of 2 or more months with no symptoms, or only one or two symptoms to no more than a mild degree), while others experience many years with few or no symptoms between discrete episodes. It is important to distinguish individuals who present for treatment during an exacerbation of a chronic depressive ill- ness from those whose symptoms developed recently. Chronicity of depressive symptoms substantially increases the likelihood of underlying personality, anxiety, and substance use disorders and decreases the likelihood that treatment will be followed by full symp- tom resolution. It is therefore useful to ask individuals presenting with depressive symp- toms to identify the last period of at least 2 months during which they were entirely free of depressive symptoms. Recovery typically begins within 3 months of onset for two in five individuals with ma- jor depression and within 1 year for four in five individuals. Recency of onset is a strong determinant of the likelihood of near-term recovery, and many individuals who have been depressed only for several months can be expected to recover spontaneously. Features as- sociated with lower recovery rates, other than current episode duration, include psychotic features, prominent anxiety, personality disorders, and symptom severity. The risk of recurrence becomes progessively lower over time as the duration of re- mission increases. The risk is higher in individuals whose preceding episode was severe, in younger individuals, and in individuals who have already experienced multiple epi- sodes. The persistence of even mild depressive symptoms during remission is a powerful predictor of recurrence. Many bipolar illnesses begin with one or more depressive episodes, and a substantial proportion of individuals who initially appear to have major depressive disorder will prove, in time, to instead have a bipolar disorder. This is more likely in individuals with onset of the illness in adolescence, those with psychotic features, and those with a family history of bipolar illness. The presence of a "with mixed features" specifier also increases the risk for future manic or hypomanic diagnosis. Major depressive disorder, particularly With psychotic features, may also transition into schizophrenia, a change that is much more frequent than the reverse. Despite consistent differences between genders in prevalence rates for depressive disor- ders, there appear to be no clear differences by gender in phenomenology, course, or treat- ment response. Similarly, there are no clear effects of current age on the course or treatment response of major depressive disorder. Some symptom differences exist, though, such that hypersomnia and hyperphagia are more likely in younger individuals, and melancholic symptoms, particularly psychomotor disturbances, are more common in older individuals. The likelihood of suicide attempts lessens in middle and late life, although the risk of com- pleted suicide does not. Depressions with earlier ages at onset are more familial and more likely to involve personality disturbances. The course of major depressive disorder within individuals does not generally change with aging. Mean times to recovery appear to be sta- ble over long periods, and the likelihood of being in an episode does not generally increase or decrease with time. Risk and Prognostic Factors Temperamental. Neuroticism (negative affectivity) is a well-established risk factor for the onset of major depressive disorder, and high levels appear to render individuals more likely to develop depressive episodes in response to stressful life events. Environmental. Adverse childhood experiences, particularly when there are multiple experiences of diverse types, constitute a set of potent risk factors for major depressive dis- order. Stressful life events are well recognized as precipitants of major depressive epi- sodes, but the presence or absence of adverse life events near the onset of episodes does not appear to provide a useful guide to prognosis or treatment selection. Genetic and physiological. First-degree family members of individuals with major de- pressive disorder have a risk for major depressive disorder two- to fourfold higher than that of the general population. Relative risks appear to be higher for early-onset and re- current forms. Heritability is approximately 40%, and the personality trait neuroticism ac- counts for a substantial portion of this genetic liability. Course modifiers. Essentially all major nonmood disorders increase the risk of an indi- vidual developing depression. Major depressive episodes that develop against the back- ground of another disorder often follow a more refractory course. Substance use, anxiety, and borderline personality disorders are among the most common of these, and the pre- senting depressive symptoms may obscure and delay their recognition. However, sus- tained clinical improvement in depressive symptoms may depend on the appropriate treatment of underlying illnesses. Chronic or disabling medical conditions also increase risks for major depressive episodes. Such prevalent illnesses as diabetes, morbid obesity, and cardiovascular disease are often complicated by depressive episodes Culture-Related Diagnostic Issues Surveys of major depressive disorder across diverse cultures have shown sevenfold dif- ferences in 12-month prevalence rates but much more consistency in female-to-male ratio, mean ages at onset, and the degree to which presence of the disorder raises the likelihood of comorbid substance abuse. While these findings suggest substantial cultural differences in the expression of major depressive disorder, they do not permit simple linkages be- tween particular cultures and the likelihood of specific symptoms. Rather, clinicians should be aware that in most countries the majority of cases of depression go unrecog- nized in primary care settings and that in many cultures, somatic symptoms are very likely to constitute the presenting complaint. Among the Criterion A symptoms, insomnia and loss of energy are the most uniformly reported. Gender-Related Diagnostic Issues Although the most reproducible finding in the epidemiology of major depressive disorder has been a higher prevalence in females, there are no clear differences between genders in symptoms, course, treatment response, or functional consequences. In women, the risk for suicide attempts is higher, and the risk for suicide completion is lower. The disparity in suicide rate by gender is not as great among those with depressive disorders as it is in the population as a whole. Suicide Risk The possibility of suicidal behavior exists at all times during major depressive episodes. The most consistently described risk factor is a past history of suicide attempts or threats, but it should be remembered that most completed suicides are not preceded by unsuccess- ful attempts. Other features associated with an increased risk for completed suicide include male sex, being single or living alone, and having prominent feelings of hopeless- ness. The presence of borderline personality disorder markedly increases risk for future suicide attempts. Functional Consequences of Major Depressive Disorder Many of the functional consequences of major depressive disorder derive from individual symptoms. Impairment can be very mild, such that many of those who interact with the af- fected individual are unaware of depressive symptoms. Impairment may, however, range to complete incapacity such that the depressed individual is unable to attend to basic self- care needs or is mute or catatonic. Among individuals seen in general medical settings, those with major depressive disorder have more pain and physical illness and greater de- creases in physical, social, and role functioning. Differential Diagnosis Manic episodes with irritable mood or mixed episodes. Major depressive episodes with prominent irritable mood may be difficult to distinguish from manic episodes with irritable mood or from mixed episodes. This distinction requires a careful clinical evalua- tion of the presence of manic symptoms. Mood disorder due to another medical condition. A major depressive episode is the appropriate diagnosis if the mood disturbance is not judged, based on individual history, physical examination, and laboratory findings, to be the direct pathophysiological conse- quence of a specific medical condition (e.g., multiple sclerosis, stroke, hypothyroidism). Substance/medication-induced depressive or bipolar disorder. This disorder is distin- guished from major depressive disorder by the fact that a substance (e.g., a drug of abuse, a medication, a toxin) appears to be etiologically related to the mood disturbance. For ex- ample, depressed mood that occurs only in the context of withdrawal from cocaine would be diagnosed as cocaine-induced depressive disorder. Attention-deficit/hyperactivity disorder. Distractibility and low frustration tolerance can occur in both attention-deficit/ hyperactivity disorder and a major depressive epi- sode; if the criteria are met for both, attention-deficit/hyperactivity disorder may be diag- nosed in addition to the mood disorder. However, the clinician must be cautious not to Overdiagnose a major depressive episode in children with attention-deficit/hyperactivity disorder whose disturbance in mood is characterized by irritability rather than by sadness or loss of interest. Adjustment disorder with depressed mood. A major depressive episode that occurs in response to a psychosocial stressor is distinguished from adjustment disorder with de- pressed mood by the fact that the full criteria for a major depressive episode are not met in adjustment disorder. Sadness. Finally, periods of sadness are inherent aspects of the human experience. These periods should not be diagnosed as a major depressive episode unless criteria are met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day, nearly ev- ery day for at least 2 weeks), and clinically significant distress or impairment. The diagno- sis other specified depressive disorder may be appropriate for presentations of depressed mood with clinically significant impairment that do not meet criteria for duration or se- verity. Comorbidity Other disorders with which major depressive disorder frequently co-occurs are substance- related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, buli- mia nervosa, and borderline personality disorder.

PTSD (DSM)

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below. 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 events) as it occurred to others. 3. Learning that the traumatic events) 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). 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). 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). 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 events) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) BUTE 18 ME 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 re- semble 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 feel- ings 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 dis- sociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persisiantand exaggeraled negalive beliets or expila-t' ha wollonsselt. Other, or the world (e.g., "| 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, fershifeothees of the traumath. event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.9, 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 inabily to experience positive emotions (%.9. Inability to experience happiness, satisfaction, or loving feelings). E. Marked alferations in arousal and reactivity associated with the traumatic event(6), be. fining or worsening after the traumatic events) occurred, as evidenced by two for more) of the following: 1. Iritable behavior and angry outbursts (with little or no provocation) typically ex pressed 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, occupa- tional, 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. Specify whether: With dissociative symptoms: The individual's symptoms meet the criteria for post- traumatic stress disorder, and in addition, in response to the stressor, the individual ex- periences persistent or recurrent symptoms of either of the following: 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., or of time moving slowly). feeling as though one were in a dream; feeling a sense of unreality of self or body 2. Derealization: Persistent or recurrent experiences of unreality of surroundings or distorted). le.9, the world around the individual is experienced as unreal, dreamlike, distant, Nole: To use this subtype, the dissociative symptoms must not be attributable to the pils dog/cal effects of a substance (e.g., blackouts, behavior during alcohol intoxica:- tion) or another medical condition (e.g., complex partial seizures). Specify if. With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate) Posttraumatic Stress Disorder for Children 6 Years and Younger A. In children 6 years and younger, 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, especially primary care- givers. Note: Witnessing does not include events that are witnessed only in electronic me- dia, television, movies, or pictures. 3. Learning that the traumatic event(s) occurred to a parent or caregiving figure. 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). Note: Spontaneous and intrusive memories may not necessarily appear distress- ing and may be expressed as play reenactment. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: It may not be possible to ascertain that the frightening content is related to the traumatic event. 3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic events) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present sur- roundings.) Such 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 reminders of the traumatic event(s). C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic events) or negative alterations in cognitions and mood associated with the traumatic events), must be present, beginning after the event(s) or worsening after the event(s): Persistent Avoidance of Stimuli 1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s). Negative Alterations in Cognitions 3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion). 4. Markedly diminished interest or participation in significant activities, including con- striction of play. 5. Socially withdrawn behavior. 6. Persistent reduction in expression of positive emotions. D. 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 ex- pressed as verbal or physical aggression toward people or objects (including ex- treme temper tantrums). 2. Hypervigilance. 3. Exaggerated startle response. 4. Problems with concentration. 5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). E. The duration of the disturbance is more than 1 month. F. The disturbance causes clinically significant distress or impaiment in relationships with parents, siblings, peers, or other caregivers or with school behavior. 6. The Disturbance is not atributable to the physiological effects of a substance (eg. medication or alcohol) or another medical condition. Specify whether: With dissociative symptoms: The individual's symptoms meet the criteria for post. traumatic stress disorder, and the individual experiences persistent or recurrent symp. toms of either of the following: 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures). amera Specify if. With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of symptoms may be immediate) Diagnostic Features The essential feature of postraumatic stress disorder (PTSD) is the development of char. acteristic symptoms following exposure to one or more traumatic events. Emotional re- actions to the traumatic event (eg, fear, helplessness, horror) are no longer a part of Criterion A. The clinical presentation of PTSD varies. In some individuals, fear-based re- experiencing, emotional, and behavioral symptoms may predominate. In others, anhe- donic or dysphoric mood states and negative cognitions may be most distressing. In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in others, dissociative symptoms predominate. Finally, some individuals exhibit combina- tions of these symptom patterns. The directly experienced traumatic events in Criterion A include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault (e.g., physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual violence (e.g., forced sexual penetration, alcohol/ drug-facilitated sexual penetration, abu- sive sexual contact, noncontact sexual abuse, sexual trafficking), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or hu- man-made disasters, and severe motor vehicle accidents. For children, sexually violent events may include developmentally inappropriate sexual experiences without physical violence or injury. A life-threatening illness or debilitating medical condition is not neces- sarily considered a traumatic event. Medical incidents that qualify as traumatic events in- volve sudden, catastrophic events (e.%, waking during surgery, anaphylactic shock) Witnessed events include, but are not limited to, observing threatened or serious injury, unnatural death, physical or sexual abuse of another person due to violent assault, domes- tic violence, accident, war or disaster, or a medical catastrophe in one's child (e.g., a life- threatening hemorrhage), Indirect exposure through learning about an event is limited to experiences affecting close relatives or friends and experiences that are violent or acciden tal (e.%, death due to natural causes does not qualify). Such events include violent personal assault, suicide, serious accident, and serious injury. The disorder may be especially severe or long-lasting when the stressor is interpersonal and intentional (e.g., torture, sex- ual violence). The traumatic event can be reexperienced in various ways. Commonly, the individual has recurrent, involuntary, and intrusive recollections of the event (Criterion B1). Intrusive recollections in PTSD are distinguished from depressive rumination in that they apply only to involuntary and intrusive distressing memories. The emphasis is on recurrent memories of the event that usually include sensory, emotional, or physiological behavioral components. A common reexperiencing symptom is distressing dreams that replay the event itself or that are representative or thematically related to the major threats involved in the traumatic event (Criterion B2). The individual may experience dissociative states that last from a few seconds to several hours or even days, during which components of the event are relived and the individual behaves as if the event were occurring at that mo- ment (Criterion B3). Such events occur on a continuum from brief visual or other sensory intrusions about part of the traumatic event without loss of reality orientation, to complete loss of awareness of present surroundings. These episodes, often referred to as "flash- backs," are typically brief but can be associated with prolonged distress and heightened arousal. For young children, reenactment of events related to trauma may appear in play or in dissociative states. Intense psychological distress (Criterion B4) or physiological re- activity (Criterion B5) often occurs when the individual is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., windy days after a hurricane; seeing someone who resembles one's perpetrator). The triggering cue could be a physical sensation (e.g., dizziness for survivors of head trauma; rapid heartbeat for a previously traumatized child), particularly for individuals with highly somatic presentations. Stimuli associated with the trauma are persistently (e.g., always or almost always) avoided. The individual commonly makes deliberate efforts to avoid thoughts, memories, feelings, or talking about the traumatic event (e.g., utilizing distraction techniques to avoid internal reminders) (Criterion C1) and to avoid activities, objects, situations, or people who arouse recollections of it (Criterion C2). Negative alterations in cognitions or mood associated with the event begin or worsen after exposure to the event. These negative alterations can take various forms, including an inability to remember an important aspect of the traumatic event; such amnesia is typically due to dissociative amnesia and is not due to head injury, alcohol, or drugs (Criterion D1). Another form is persistent (i.e., always or almost always) and exaggerated negative ex- pectations regarding important aspects of life applied to oneself, others, or the future (e.g., "Thave always had bad judgment"; "People in authority can't be trusted") that may man- ifest as a negative change in perceived identity since the trauma (e.g., "I can't trust anyone ever again"; Criterion D2). Individuals with PTSD may have persistent erroneous cogni- tions about the causes of the traumatic event that lead them to blame themselves or others (e.g., "It's all my fault that my uncle abused me") (Criterion D3). A persistent negative mood state (e.g., fear, horror, anger, guilt, shame) either began or worsened after exposure to the event (Criterion D4). The individual may experience markedly diminished interest or participation in previously enjoyed activities (Criterion D5), feeling detached or es- tranged from other people (Criterion D6), or a persistent inability to feel positive emotions (especially happiness, joy, satisfaction, or emotions associated with intimacy, tenderness, and sexuality) (Criterion D7). Individuals with PTSD may be quick tempered and may even engage in aggressive verbal and/or physical behavior with little or no provocation (e.g., yelling at people, get- ting into fights, destroying objects) (Criterion E1). They may also engage in reckless or self- destructive behavior such as dangerous driving, excessive alcohol or drug use, or self- injurious or suicidal behavior (Criterion E2). PTSD is often characterized by a heightened sensitivity to potential threats, including those that are related to the traumatic experience leg, following a motor vehicle accident, being especially sensitive to the threat potentially caused by cars or trucks) and those not related to the traumatic event (e.g., being fearful of suffering a heart attack) (Criterion E3). Individuals with PISD may be very reactive to un. expected stimuli, displaying a heightened startle response, or jumpiness, to loud noises or unexpected movements (e.g., jumping markedly in response to a telephone ringing) (Cri- terion E4). Concentration difficulties, including difficulty remembering daily events (eg, forgetting one's telephone number) or attending to focused tasks (e.g., following a conver. sation for a sustained period of time), are commonly reported (Criterion E5). Problems with sleep onset and maintenance are common and may be associated with nightmares and safety concerns or with generalized elevated arousal that interferes with adequate sleep (Criterion E6). Some individuals also experience persistent dissociative symptoms of de- tachment from their bodies (depersonalization) or the world around them (derealization); this is reflected in the "with dissociative symptoms" specifier. Associated Features Supporting Diagnosis Developmental regression, such as loss of language in young children, may occur. Audi- tory pseudo-hallucinations, such as having the sensory experience of hearing one's thoughts spoken in one or more different voices, as well as paranoid ideation, can be pres- ent. Following prolonged, repeated, and severe traumatic events (e.g., childhood abuse, torture), the individual may additionally experience difficulties in regulating emotions or maintaining stable interpersonal relationships, or dissociative symptoms. When the trau- matic event produces violent death, symptoms of both problematic bereavement and PISD may be present. Prevalence In the United States, projected lifetime risk for PTSD using DSM-1V criteria at age 75 years 353,7%. Twelve-month prevalence among U.S. adults is about 3.5%. Lower estimates are seen in Europe and most Asian, African, and Latin American countries, clustering around 0.5%-1.0%. Although different groups have different levels of exposure to traumatic events, the conditional probability of developing PTSD following a similar level of expo- sure may also vary across cultural groups. Rates of PTSD are higher among veterans and others whose vocation increases the risk of traumatic exposure (e.g. police, firefighters, emergency medical personnel). Highest rates (ranging from one-third to more than one- half of those exposed) are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide. The prevalence of PTSD may vary across development; children and adolescents, including preschool children, generally have displayed lower prevalence following exposure to serious traumatic events; however, this may be because previous criteria were insufficiently developmen- tally informed. The prevalence of full-threshold PTSD also appears to be lower among older adults compared with the general population; there is evidence that subthreshold presentations are more common than full PTSD in later life and that these symptoms are associated with substantial clinical impairment. Compared with U.S. non-Latino whites higher rates of PTSD have been reported among U.S. Latinos, African Americans, and American Indians, and lower rates have been reported among Asian Americans, after at- justment for traumatic exposure and demographic variables. Development and Course PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before criteria for the diagnosis are met. There is abundant evidence for what DSM-IV called "delayed onset" but is now called "delayed expression, with the recognition that some symptoms typically appear immediately and that the delay is in meeting full criteria. Frequently, an individual's reaction to a trauma initially meets criteria for acute stress disorder in the immediate aftermath of the trauma. The symptoms of PTSD and the rela. live predominance of different symptoms may vary over lime. Duration of the symptoms also varies, with complete recovery within 3 months occurring in approximately one-half of adults, while some individuals remain symptomatic for longer than 12 months and sometimes for more than 50 years. Symptom recurrence and intensification may occur in response to reminders of the original trauma, ongoing life stressors, or newly experienced traumatic events. For older individuals, declining health, worsening cognitive function- ing, and social isolation may exacerbate PSD symptoms. 'The clinical expression of reexperiencing can vary across development. Young children may report new onset of frightening dreams without content specific to the traumatic event. Before age 6 years (see criteria for preschool subtype), young children are more likely to ex- press reexperiencing symptoms through play that refers directly or symbolically to the trauma. They may not manifest fearful reactions at the time of the exposure or during reex- periencing. Parents may report a wide range of emotional or behavioral changes in young children. Children may focus on imagined interventions in their play or storytelling. In ad- dition to avoidance, children may become preoccupied with reminders. Because of young children's limitations in expressing thoughts or labeling emotions, negative alterations in mood or cognition tend to involve primarily mood changes. Children may experience co- occurring traumas (e.g., physical abuse, witnessing domestic violence) and in chronic cir- cumstances may not be able to identify onset of symptomatology. Avoidant behavior may be associated with restricted play or exploratory behavior in young children; reduced par- ticipation in new activities in school-age children; or reluctance to pursue developmental op- portunities in adolescents (e.g., dating, driving). Older children and adolescents may judge themselves as cowardly. Adolescents may harbor beliefs of being changed in ways that make them socially undesirable and estrange them from peers (e.g., "Now I'll never fit in") and lose aspirations for the future. Irritable or aggressive behavior in children and adoles- cents can interfere with peer relationships and school behavior. Reckless behavior may lead to accidental injury to self or others, thrill-seeking, or high-risk behaviors. Individuals who continue to experience PTSD into older adulthood may express fewer symptoms of hy- perarousal, avoidance, and negative cognitions and mood compared with younger adults with PTSD, although adults exposed to traumatic events during later life may display more avoidance, hyperarousal, sleep problems, and crying spells than do younger adults exposed to the same traumatic events. In older individuals, the disorder is associated with negative health perceptions, primary care utilization, and suicidal ideation. Risk and Prognostic Factors Risk (and protective) factors are generally divided into pretraumatic, peritraumatic, and posttraumatic factors. Pretraumatic factors Temperamental. These include childhood emotional problems by age 6 years (e.g., prior traumatic exposure, externalizing or anxiety problems) and prior mental disorders (e.g., panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder [OCD]). Environmental. These include lower socioeconomic status; lower education; exposure to prior trauma (especially during childhood); childhood adversity (e.g., economic depriva- tion, family dysfunction, parental separation or death); cultural characteristics (e.g., fatal- istic or self-blaming coping strategies); lower intelligence; minority racial/ethnic status; and a family psychiatric history. Social support prior to event exposure is protective. Genetic and physiological. These include female gender and younger age at the time of trauma exposure (for adults). Certain genotypes may either be protective or increase risk of PTSD after exposure to traumatic events Peritraumatic factors Environmental. These include severity (dose) of the trauma (the greater the magnitude of trauma, the greater the likelihood of PTSD), perceived life threat, personal injury, in- terpersonal violence (particularly trauma perpetrated by a caregiver or involving a wit. nessed threat to a caregiver in children), and, for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy. Finally, dissociation that occurs during the trauma and persists afterward is a risk factor. Posttraumatic factors Temperamental. These include negative appraisals, inappropriate coping strategies, and development of acute stress disorder. Environmental. These include subsequent exposure to repeated upsetting reminders, subse- quent adverse life events, and financial or other trauma-related losses. Social support (includ- ing family stability, for children) is a protective factor that moderates outcome after trauma. Culture-Related Diagnostic Issues The risk of onset and severity of PISD may differ across cultural groups as a result of vari- ation in the type of traumatic exposure (e.g. genocide), the impact on disorder severity of the meaning attributed to the traumatic event (e.g., inability to perform funerary rites after a mass killing), the ongoing sociocultural context (e.g., residing among unpunished per- petrators in postconflict settings), and other cultural factors (e.g., acculturative stress in immigrants). The relative risk for PTSD of particular exposures (e.g., religious persecu- tion) may vary across cultural groups. The clinical expression of the symptoms or symp. tom clusters of PISD may vary culturally, particularly with respect to avoidance and numbing symptoms, distressing dreams, and somatic symptoms (e.g., dizziness, short- ness of breath, heat sensations). Cultural syndromes and idioms of distress influence the expression of PTSD and the range of comorbid disorders in different cultures by providing behavioral and cognitive templates that link traumatic exposures to specific symptoms. For example, panic attack symptoms may be salient in PTSD among Cambodians and Latin Americans because of the association of traumatic exposure with panic-like khyal attacks and ataque de nervios. Comprehensive evaluation of local expressions of PTSD should include assessment of cul- tural concepts of distress (see the chapter "Cultural Formulation" in Section III). Gender-Related Diagnostic Issues PTSD is more prevalent among females than among males across the lifespan. Females in the general population experience PTSD for a longer duration than do males. At least some of the increased risk for PTSD in females appears to be attributable to a greater likelihood of exposure to traumatic events, such as rape, and other forms of interpersonal violence. Within populations exposed specifically to such stressors, gender differences in risk for PTSD are attenuated or nonsignificant. Suicide Risk Traumatic events such as childhood abuse increase a person's suicide risk. PTSD is associated with suicidal ideation and suicide attempts, and presence of the disorder may indicate which individuals with ideation eventually make a suicide plan or actually attempt suicide. Functional Consequences of Posttraumatic Stress Disorder PTSD is associated with high levels of social, occupational, and physical disability, as well as considerable economic costs and high levels of medical utilization. Impaired functioning is exhibited across social, interpersonal, developmental, educational, physical health, and occupational domains. In community and veteran samples, PTSD is associated with poor social and family relationships, absenteeism from work, lower income, and lower ed- ucational and occupational success. Differential Diagnosis Adjustment disorders. In adjustment disorders, the stressor can be of any severity or type rather than that required by PTSD Criterion A. The diagnosis of an adjustment dis- order is used when the response to a stressor that meets PTSD Criterion A does not meet all other PTSD criteria (or criteria for another mental disorder). An adjustment disorder is also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that does not meet PTSD Criterion A (e.g., spouse leaving, being fired). Other posttraumatic disorders and conditions. Not all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed to PTSD. The diagnosis requires that trauma exposure precede the onset or exacerbation of pertinent symptoms. Moreover, if the symptom response pattern to the extreme stressor meets cri- teria for another mental disorder, these diagnoses should be given instead of, or in addi- tion to, PTSD. Other diagnoses and conditions are excluded if they are better explained by PTSD (e.g., symptoms of panic disorder that occur only after exposure to traumatic re- minders). If severe, symptom response patterns to the extreme stressor may warrant a sep- arate diagnosis (e.g., dissociative amnesia). Acute stress disorder. Acute stress disorder is distinguished from PTSD because the symptom pattern in acute stress disorder is restricted to a duration of 3 days to 1 month following exposure to the traumatic event. Anxiety disorders and obsessive-compulsive disorder. In OCD, there are recurrent intrusive thoughts, but these meet the definition of an obsession. In addition, the intrusive thoughts are not related to an experienced traumatic event, compulsions are usually pres- ent, and other symptoms of PTSD or acute stress disorder are typically absent. Neither the arousal and dissociative symptoms of panic disorder nor the avoidance, irritability, and anxiety of generalized anxiety disorder are associated with a specific traumatic event. The symptoms of separation anxiety disorder are clearly related to separation from home or family, rather than to a traumatic event. Major depressive disorder. Major depression may or may not be preceded by a trau- matic event and should be diagnosed if other PTSD symptoms are absent. Specifically, ma- jor depressive disorder does not include any PTSD Criterion B or C symptoms. Nor does it include a number of symptoms from PTSD Criterion D or E. Personality disorders. Interpersonal difficulties that had their onset, or were greatly ex- acerbated, after exposure to a traumatic event may be an indication of PTSD, rather than a personality disorder, in which such difficulties would be expected independently of any traumatic exposure. Dissociative disorders. Dissociative amnesia, dissociative identity disorder, and de- personalization-derealization disorder may or may not be preceded by exposure to a trau- matic event or may or may not have co-occurring PTSD symptoms. When full PTSD criteria are also met, however, the PTSD "with dissociative symptoms" subtype should be considered. Conversion disorder (functional neurological symptom disorder). New onset of somatic symptoms within the context of posttraumatic distress might be an indication of PTSD rather than conversion disorder (functional neurological symptom disorder). Psychotic disorders. Flashbacks in PTSD must be distinguished from illusions, halluci- nations, and other perceptual disturbances that may occur in schizophrenia, brief psy- chotte disorder, and other psychotic disorders; depressive and bipolar disorders with psychotic features; delirium; substance/ medication-induced disorders; and psychotic dis- orders due to another medical condition. Traumatic brain injury. When a brain injury occurs in the context of a traumatic event (eg, traumatic accident, bomb blast, acceleration/ deceleration trauma), symptoms of PISD may appear. An event causing head trauma may also constitute a psychological traumatic event and tramautic brain injury (TBI)-related neurocognitive symptoms are not mutually exclusive and may occur concurrently. Symptoms previously termed postconcussive (e.g., headaches, dizziness, sensitivity to light or sound, irritability, concentration deficits) can occur in brain- injured and non-brain-injured populations, including individuals with PISD. Because symp toms of PTSD and TBI-related neurocognitive symptoms can overlap, a differential diagnosis between PTSD and neurocognitive disorder symptoms attributable to TBI may be possible based on the presence of symptoms that are distinctive to each presentation. Whereas reexpe- riencing and avoidance are characteristic of PTSD and not the effects of TBI, persistent disori- entation and confusion are more specific to TBI (neurocognitive effects) than to PTSD. Comorbidity Individuals with PISD are 80% more likely than those without PTSD to have symptoms that meet diagnostic criteria for at least one other mental disorder (e.g., depressive, bipo- lar, anxiety, or substance use disorders). Comorbid substance use disorder and conduct disorder are more common among males than among females. Among U.S. military per- sonnel and combat veterans who have been deployed to recent wars in Afghanistan and Iraq, co-occurrence of PTSD and mild TBI is 48%. Although most young children with PTSD also have at least one other diagnosis, the patterns of comorbidity are different than in adults, with oppositional defiant disorder and separation anxiety disorder predominat- ing. Finally, there is considerable comorbidity between PTSD and major neurocognitive disorder and some overlapping symptoms between these disorders.

Alcohol withdrawal

Uncomplicated alcohol withdrawal: • Onset: 6 - 36 hours after last drink (time may vary). • Clinical manifestations: increased CNS activity - tremors, anxiety, irritability, diaphoresis, palpitations, hypertension, insomnia, & Gl (nausea, vomiting, diarrhea). • Uncomplicated = no seizures, hallucinosis or delirium tremens. Withdrawal seizures: • Onset: 6 - 48 hours after last drink. Usually generalized tonic-clonic type. • Most commonly occurs as a single brief episode. Alcoholic hallucinosis: • Onset: 12 - 48 hours after last drink. • Clinical manifestations: visual auditory and/or tactile hallucinations. Patient has a clear sensorium & normal vital signs. Delirium tremens: • Onset: 2 - 5 days after last drink. • Clinical manifestations: delirium (altered sensorium), hallucinations, agitation. Abnormal vital signs (eg, tachycardia, hypertension, fever). Patients often diaphoretic. MANAGEMENT • Requires medical treatment & hospitalization. Alcohol withdrawal can be fatal. • IV Benzodiazepines: Diazepam, Lorazepam, Chlordiazepoxide, & Oxazepam. - Mechanism: potentiates GABA-mediated CNS inhibition. Alcohol mimics GABA at the receptor sites (GABA is the most abundant inhibitory neurotransmitter in the CNS) so ETOH withdrawal causes increased CNS activity. Benzodiazepines are titrated until the patient is slightly somnolent & then gradually tapered. • Lorazepam or Oxazepam preferred in patients with advanced cirrhosis or alcoholic hepatitis (Chlordiazepoxide may cause over titration in these patients). • IV fluids, IV thiamine (B1), magnesium, multivitamins (including B12 & folate), & electrolyte repletion.

Cluster A disorders

paranoid, schizoid, schizotypal Social detachment with unusual behaviors; wierd, odd, eccentric behavior

Narcolepsy

• Long-term neurological disorder characterized by decreased ability to regulate sleep-wake cycles. • Elements of sleep interfere with wakefulness and elements of wakefulness interferes with sleep. • Typically presents initially in the teens and early twenties. CLINICAL MANIFESTATIONS • Chronic daytime sleepiness: patients are prone to fall asleep throughout the day and develop sleep attacks (rapid dozing off without warning ), often at inappropriate times. • Cataplexy: emotionally-triggered transient weakness of the muscles (eg, excitement, laughter, anger). The weakness often begins in the face (eg, slack, ptosis, hypotonic face with an open mouth) and often affects the neck and knees. Patients may develop bilateral weakness or paralysis. • Hypnagogic hallucinations: vivid visual, tactile, or auditory hallucinations occurring as the patient is falling asleep. • Sleep paralysis: complete inability to move for 1-2 minutes immediately after waking or before falling asleep. • May also develop other sleeping disorders (eg, fragmented sleep, obstructive sleep apnea, restless leg syndrome, sleepwalking, REM sleep behavior disorder). WORKUP • Thorough medical history, history and physical examination, sleep history, and neurologic examination. Workup usually includes both polysomnography and multiple sleep latency testing. • Polysomnography; excludes alternative and/or coexisting causes of daytime sleepiness. Narcolepsy: spontaneous awakenings, mild reduced sleep efficiency, increased light non-REM sleep, REM sleep within 15 minutes after the onset of sleep (healthy individuals usually experience REM sleep 80-100 minutes after the onset of sleep). • Multiple sleep latency test: identifies the sleep onset rapid eye movements and measure the mean sleep latency. The patient is placed in a sleep-inducing environment and instructed to try to fall asleep. - On average, healthy patients fall asleep within 10-15 minutes. - Narcolepsy: often fall asleep < 8 minutes. The naps usually include sleep onset rapid eye movements. -Prior to testing, patients should discontinue antidepressants 3 weeks prior (4 weeks for Fluoxetine) and stimulants or psychoactive medications should be stopped 1 week prior. MANAGEMENT • Modafinil: first-line medical management (improves control of sleepiness, promotes wakefulness early into the evening). - Mechanism: exact mechanism unknown but thought to inhibit dopamine reuptake, increasing dopaminergic signaling. - Adverse effects: headache, dry mouth, diarrhea, decreased appetite, nausea, increased blood pressure (used cautiously in patients with arrhythmia history or heart disease). • Solriamfetol: a reasonable alternative first-line agent. - Mechanism: oral selective dopamine and norepinephrine reuptake inhibitor, improving wakefulness. Similar adverse effects to Modafinil. Cataplexy • REM-suppressing medications: g, Fluoxetine, Venlafaxine, Atomoxetine. Sodium oxybate alternative.

Major Depressive Disorder (MDD)/Unipolar depression

•Risk factors: family history, female: male (2:1). Peak onset of age in the 20s. PATHOPHYSIOLOGY •Alteration in neurotransmitters - serotonin, epinephrine, norepinephrine, dopamine, acetylcholine, & histamine. Genetic factors. •Neuroendocrine dysregulation: adrenal, thyroid, or growth hormone dysregulation. •15% of patients commit suicide (especially men 25-30y & women 40-50y). Higher suicide rates in patients with a detailed suicide plan, white males >45y, & concurrent substance abuse. •Patient Health Questionnaire (PHQ)-2 form for initial screen. If positive, may use PHQ-9 form. DIAGNOSTIC CRITERIA: •At least 2 distinct episodes of at least 5 associated symptoms (must include either depressive mood or anhedonia) almost every day for most of the days for at least 2 weeks: depressive mood, anhedonia, fatigue almost all day, insomnia or hypersomnia, feelings of guilt or worthlessness, recurring thoughts of death or suicide, psychomotor agitation or retardation (restlessness or slowness), significant weight change (gain or loss), decreased or increased appetite, & decreased concentration or indecisiveness. Not associated with mania or hypomania. •The symptoms must cause significant distress or impairment (social or occupational). •The symptoms are not due to substance use, bereavement, or medical conditions. MANAGEMENT •Psychotherapy (eg, cognitive behavioral therapy, interpersonal therapy, & supportive therapy). •SSRIs first-line medical management. If no effect after 4 weeks, switch to other SSRI. •Second-line: SNRIs (eg, Duloxetine, Venlafaxine); Bupropion. •Tricyclic antidepressants. Tetracyclics, MAO inhibitors. •Electroconvulsive therapy: rapid response in patients unresponsive to medical therapy, unable to tolerate pharmacotherapy (eg, pregnancy), or rapid reduction of symptoms.

attention-deficit/hyperactivity disorder (ADHD)

•Neurodevelopmental disorder characterized by problems paying attention, impulsivity (difficulty controlling behaviors), & hyperactivity that is not age-appropriate. •Many continue to have symptoms as adults (inattentiveness > hyperactivity). •67% comorbid with Conduct and Oppositional defiant disorders. 3 SUBCATEGORIES •1. Predominantly inattentive, 2. Predominantly hyperactive/impulsive, & 3. combined type. DIAGNOSTIC CRITERIA •The symptoms must be developmentally inappropriate for age, have symptom onset before 12 years of age and must be present for at least 6 months. •Symptoms must occur in at least 2 settings (eg, school, home, recreational activities). •At least 6 inattentive symptoms: INATTENTIVENESS 1.Easily distracted: misses details, frequently switches from one activity to another, forget things, easily distracted when multiple things are happening simultaneously. 2. Has difficulty maintaining focus on one task or learning something new. 3. Misses details and may make careless mistakes. 4. Forgets things or loses things (eg, pencils) needed to complete activities and tasks. 5. Difficulty in completing assignments. 6. Becomes bored with a task after a few minutes, unless doing something enjoyable. •At least 6 hyperactivity /impulsivity symptoms: HYPERACTIVITY/IMPULSIVITY 1. Fidgets and squirms in their seat. 2. Constantly in motion (may often leave their seat). 3. Talks nonstop or excessively. 4. Impatience. 5. Dashes around, touching or playing with everything in sight. 6. Has trouble sitting for long periods (eg, doing homework, dinner or school). 7. Difficulty doing quiet tasks. 8. Restlessness. 9. Blurts out appropriate or inappropriate comments, shows unrestrained emotions. 10. Interrupts the conversation or the activities of others. MANAGEMENT Multimodal approach • Behavior modification including social skills training, classroom modifications, and parent psychoeducation •Stimulants first-line medical treatment of choice (eg, Methylphenidate, Amphetamine/Dextroamphetamine, Dexmethylphenidate). •Nonstimulants: Atomoxetine (norepinephrine reuptake inhibitor). Adverse effects: dry mouth decreased appetite, insomnia. •Adjunctive medications: Alpha agonists (eg, Guanfacine, Clonidine); Bupropion, Venlafaxine.

Stimulant withdrawal (DSM)

A. Cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use. B. Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A: 1. Fatigue. 2. Vivid, unpleasant dreams. 3. Insomnia or hypersomnia. 4. Increased appetite. 5. Psychomotor retardation or agitation. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. Diagnostic Features The essential feature of stimulant withdrawal is the presence of a characteristic with- drawal syndrome that develops within a few hours to several days after the cessation of (or marked reduction in) stimulant use (generally high dose) that has been prolonged (Cri- terion A). The withdrawal syndrome is characterized by the development of dysphoric mood accompanied by two or more of the following physiological changes: fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation (Criterion B). Bradycardia is often present and is a reliable mea- sure of stimulant withdrawal. Anhedonia and drug craving can often be present but are not part of the diagnostic cri- teria. These symptoms cause clinically significant distress or impairment in social, occu- pational, or other important areas of functioning (Criterion C). The symptoms must not be attributable to another medical condition and are not better explained by another mental disorder (Criterion D). Associated Features Supporting Diagnosis Acute withdrawal symptoms ("a crash") are often seen after periods of repetitive high-dose use ("runs" or "binges"). These periods are characterized by intense and unpleasant feelings of lassitude and depression and increased appetite, generally requiring several days of rest and recuperation. Depressive symptoms with suicidal ideation or behavior can occur and are gen- erally the most serious problems seen during "crashing" or other forms of stimulant with- drawl. The majority of individuals with stimulant use disorder experience a withdrawal syndrome at some point, and virtually all individuals with the disorder report tolerance. Differential Diagnosis Stimulant use disorder and other stimulant-induced disorders. Stimulant withdrawal is distinguished from stimulant use disorder and from the other stimulant-induced disor- ders (e.g., stimulant-induced intoxication delirium, depressive disorder, bipolar disorder, psychotic disorder, anxiety disorder, sexual dysfunction, sleep disorder) because the symptoms of withdrawal predominate the clinical presentation and are severe enough to warrant independent clinical attention.

dependent personality disorder (DSM)

DIAGNOSTIC CRITERIA 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. 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself. Diagnostic Features The essential feature of dependent personality disorder is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. This pattern begins by early adulthood and is present in a variety of contexts. The dependent and submissive behaviors are designed to elicit caregiving and arise from a self-perception of being unable to function adequately without the help of others. Individuals with dependent personality disorder have great difficulty making every. day decisions (e.g., what color shirt to wear to work or whether to carry an umbrella) without an excessive amount of advice and reassurance from others (Criterion 1). These individu- als tend to be passive and to allow other people (often a single other person) to take the ini- tiative and assume responsibility for most major areas of their lives (Criterion 2). Adults with this disorder typically depend on a parent or spouse to decide where they should live, what kind of job they should have, and which neighbors to befriend. Adolescents with this disorder may allow their parent(s) to decide what they should wear, with whom they should associate, how they should spend their free time, and what school or college they should attend. This need for others to assume responsibility goes beyond age-appro- prate and situation-appropriate requests for assistance from others (e.g., the specific needs of children, elderly persons, and handicapped persons). Dependent personality dis- order may occur in an individual who has a serious medical condition or disability, but in such cases the difficulty in taking responsibility must go beyond what would normally be associated with that condition or disability. Because they fear losing support or approval, individuals with dependent personality disorder often have difficulty expressing disagreement with other individuals, especially those on whom they are dependent (Criterion 3). These individuals feel so unable to func- tion alone that they will agree with things that they feel are wrong rather than risk losing the help of those to whom they look for guidance. They do not get appropriately angry at others whose support and nurturance they need for fear of alienating them. If the individ- ual's concerns regarding the consequences of expressing disagreement are realistic (e.g., realistic fears of retribution from an abusive spouse), the behavior should not be consid- ered to be evidence of dependent personality disorder. Individuals with this disorder have difficulty initiating projects or doing things inde- pendently (Criterion 4). They lack self-confidence and believe that they need help to begin and carry through tasks. They will wait for others to start things because they believe that as a rule others can do them better. These individuals are convinced that they are incapable of functioning independently and present themselves as inept and requiring constant as- sistance. They are, however, likely to function adequately if given the assurance that some- one else is supervising and approving. There may be a fear of becoming or appearing to be more competent, because they may believe that this will lead to abandonment. Because they rely on others to handle their problems, they often do not learn the skills of indepen- dent living, thus perpetuating dependency. Individuals with dependent personality disorder may go to excessive lengths to obtain nurturance and support from others, even to the point of volunteering for unpleasant tasks if such behavior will bring the care they need (Criterion 5). They are willing to submit to what others want, even if the demands are unreasonable. Their need to maintain an im- portant bond will often result in imbalanced or distorted relationships. They may make ex- traordinary self-sacrifices or tolerate verbal, physical, or sexual abuse. (It should be noted that this behavior should be considered evidence of dependent personality disorder only when it can clearly be established that other options are available to the individual.) Indi- viduals with this disorder feel uncomfortable or helpless when alone, because of their ex- aggerated fears of being unable to care for themselves (Criterion 6). They will "tag along" with important others just to avoid being alone, even if they are not interested or involved in what is happening. When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver), in- dividuals with dependent personality disorder may urgently seek another relationship to provide the care and support they need (Criterion 7). Their belief that they are unable to function in the absence of a close relationship motivates these individuals to become quickly and indiscriminately attached to another individual. Individuals with this disorder are often preoccupied with fears of being left to care for themselves (Criterion 8). They see themselves as so totally dependent on the advice and help of an important other person that they worry about being abandoned by that person when there are no grounds to justify such fears. To be considered as evidence of this criterion, the fears must be excessive and unrealistic. For ex- ample, an elderly man with cancer who moves into his son's household for care is exhibiting dependent behavior that is appropriate given this person's life circumstances. Associated Features Supporting Diagnosis Individuals with dependent personality disorder are often characterized by pessimism and self-doubt, tend to belittle their abilities and assets, and may constantly refer to them- selves as "stupid." They take criticism and disapproval as proof of their worthlessness and lose faith in themselves. They may seek overprotection and dominance from others. Oc- cupational functioning may be impaired if independent initiative is required. They may avoid positions of responsibility and become anxious when faced with decisions. Social re- lations tend to be limited to those few people on whom the individual is dependent. There may be an increased risk of depressive disorders, anxiety disorders, and adjustment dis- orders. Dependent personality disorder often co-occurs with other personality disorders, especially borderline, avoidant, and histrionic personality disorders. Chronic physical ill- ness or separation anxiety disorder in childhood or adolescence may predispose the indi- vidual to the development of this disorder. Prevalence Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions yielded an estimated prevalence of dependent personality disorder of 0.49%, and dependent personality was estimated, based on a probability subsample from Part Il of the National Comorbidity Survey Replication, to be 0.6%. Development and Course This diagnosis should be used with great caution, if at all, in children and adolescents, for whom dependent behavior may be developmentally appropriate Culture-Related Diagnostic Issues The degree to which dependent behaviors are considered to be appropriate varies sub- stantially across different age and sociocultural groups. Age and cultural factors need to be considered in evaluating the diagnostic threshold of each criterion. Dependent behav- or should be considered characteristic of the disorder only when it is clearly in excess of the individual's cultural norms or reflects unrealistic concerns. An emphasis on passivity, politeness, and deferential treatment is characteristic of some societies and may be mis- interpreted as traits of dependent personality disorder. Similarly, societies may differen- tally foster and discourage dependent behavior in males and females. Gender-Related Diagnostic Issues In clinical settings, dependent personality disorder has been diagnosed more frequently in females, although some studies report similar prevalence rates among males and females. Differential Diagnosis Other mental disorders and medical conditions. Dependent personality disorder must be distinguished from dependency arising as a consequence of other mental disorders (e.g., depressive disorders, panic disorder, agoraphobia) and as a result of other medical conditions. Other personality disorders and personality traits. Other personality disorders may be confused with dependent personality disorder because they have certain features in com- mon. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet cri- teria for one or more personality disorders in addition to dependent personality disorder, all can be diagnosed. Although many personality disorders are characterized by dependent features, dependent personality disorder can be distinguished by its predominantly submis- sive, reactive, and clinging behavior. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emp- tiness, rage, and demands, whereas the individual with dependent personality disorder re- acts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by a typical pattern of unstable and intense relationships. Individuals with histrionic personality disorder, like those with de- pendent personality disorder, have a strong need for reassurance and approval and may ap- pear childlike and clinging. However, unlike dependent personality disorder, which is characterized by self-effacing and docile behavior, histrionic personality disorder is charac- terized by gregarious flamboyance with active demands for attention. Both dependent personality disorder and avoidant personality disorder are characterized by feelings of in- adequacy, hypersensitivity to criticism, and a need for reassurance; however, individuals with avoidant personality disorder have such a strong fear of humiliation and rejection that they withdraw until they are certain they will be accepted. In contrast, individuals with de- pendent personality disorder have a pattern of seeking and maintaining connections to im- portant others, rather than avoiding and withdrawing from relationships. Many individuals display dependent personality traits. Only when these traits are in- flexible, maladaptive, and persisting and cause significant functional impairment or sub- jective distress do they constitute dependent personality disorder. Personality change due to another medical condition. Dependent personality disor- der must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Dependent personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

anorexia nervosa

Failure to maintain a normal body weight, fear & preoccupation with body weight, body image, & being thin. -Most common in teenage girls ages 14-18. 90% are women. •60% incidence of depression. •Frequently seen in athletes, dancers (or other conditions requiring thinness). •Anorexia nervosa has the highest mortality rate of all psychiatric conditions (due to arrhythmias) 5-18%. CLINICAL MANIFESTATIONS •Exhibits behaviors targeted at maintaining a low weight or certain body image: eg, excess water intake, food-related obsessions (hoarding, collecting). Anorexia nervosa is ego-syntonic (their behaviors are acceptable to them and are in harmony with their self-image goals). •Restrictive type: strict, reduced calorie intake, dieting, fasting, excessive exercise, & diet pills. •Binge eating/purging type: primarily engages in self-induced vomiting as well as diuretic, laxative use, or enema abuse. PHYSICAL EXAMINATION •Emaciation, hypotension, bradycardia, skin or hair changes (eg, lanugo), dry skin, salivary gland hypertrophy, amenorrhea, arrhythmias, osteopenia. •Russel's sign: callouses on the dorsum of the hand from self-induced vomiting. •Body mass index (BMI) 17.5 kg/m? or less OR body weight <85% of ideal weight. DIAGNOSTIC CRITERIA •Restriction of calorie intake relative to requirements leading to significantly low body weight (less than minimally normal). •Intense morbid fear of fatness or gaining weight or persistent behaviors to prevent weight gain. •Distorted body image - self-perception of being overweight (even though they are underweight). LABS: •Hypokalemia (GI loss from laxatives or vomiting), increased BUN (dehydration), hypochloremic metabolic alkalosis (from vomiting), hypogonadotropic hypogonadism (low estrogen), & hypothyroidism MANAGEMENT •Medical stabilization: hospitalization for <75% expected body weight or patients who have medical complications (eg, dehydration). Electrolyte imbalances may lead to cardiac arrhythmias. •Nutritional rehabilitation: most common complication is refeeding syndrome (increased insulin leads to hypophosphatemia & cardiac complications). •Psychotherapy: cognitive behavioral therapy, supervised meals, weight monitoring. •Pharmacotherapy: if depressed eg, SSRIs (may also help with weight gain); Atypical antipsychotics. (may also help with weight gain).

Marijuana intoxication and withdrawal

MECHANISM • Binds to CB1 & CB2 cannabinoid receptors. CLINICAL MANIFESTATIONS • Euphoria, giddiness, anxiety, disinhibition, intensification of sensory experiences, dry (cotton) mouth, increased appetite, and motor impairment. • Some patients may experience fear and depression. • Psychosis may occur. • Chronic use can lead to cognitive performance issues. PHYSICAL EXAMINATION • Conjunctivitis, tachycardia, and hypotension. MANAGEMENT • Treatment is usually not needed. Symptomatic management if needed. HYPEREMESIS SYNDROME • Chronic severe emesis in chronic users. • Managed with cessation of marijuana use and antiemetics (Ondansetron & Metoclopramide). WITHDRAWAL • Irritability, insomnia, depression, restlessness, diaphoresis, diarrhea, and twitching.

Opioid use/dependence

OPIOID USE & DEPENDENCE Heroin, Oxycodone, Hydrocodone, Codeine, Morphine, Dextromethorphan, Meperidine, & Methadone OPIOID INTOXICATION: • Euphoria & sedation: drowsiness, impaired social functioning, impaired memory, slow or slurred speech. May develop nausea, vomiting, seizures, & coma. • Physical examination findings: pupillary constriction (narcotics are miotics), altered mental status & respiratory depression. May also develop Biot's breathing (groups of quick, shallow inspirations followed by regular or irregular periods of apnea), bradycardia, hypotension, nausea, vomiting, flushing. Patients on long-term narcotics may develop constipation (opioid receptors in the Gl tract reduce Gl motility), hypothermia. OPIOID WITHDRAWAL • Lacrimation, hypertension, pruritus, tachycardia, nausea, vomiting, abdominal cramps, diarrhea, sweating, yawning, piloerections (goose bumps), pupil dilation (mydriasis), flu-like symptoms: rhinorrhea, joint pains, myalgias. Withdrawal is often unpleasant but is not life threatening. MANAGEMENT • Opioid intoxication: Naloxone is an opioid antagonist used in acute intoxication or overdose to acutely reverse the effects of opioids. Onset of action ~2 minutes IV (~5 minutes IM). ~30-60 minutes duration of action. Most commonly used in patients with respiratory depression. • Opioid withdrawal: symptomatic control: (Clonidine (decreases sympathetic symptoms), Loperamide for diarrhea, Dicyclomine for abdominal cramps, & NSAIDs for joint pains & muscle cramps. Benzodiazepines may be helpful in some cases of mild withdrawal. Severe symptoms can be treated with detox with Methadone or Buprenorphine + Naloxone. • Long-term management of dependence: (Buprenorphine + Naloxone), or Naltrexone. OPIOID DEPENDENCE MANAGEMENT Methadone • Mechanism of action: long-acting opioid receptor agonist used in the control withdrawal from opioid in patients with opioid addiction. Can be used in pregnant opioid-dependent women. Given orally. • Adverse effects: can cause prolonged QT interval. Buprenorphine • Mechanism of action: partial opioid receptor agonist. Suboxone is a combination of Buprenorphine+ Naloxone (Naloxone prevents intoxication from IV injection). Naltrexone • Mechanism of action: competitive opioid antagonist. Precipitates withdrawal if used within 7 days of heroin use. Oral or monthly depot injection.

Schizophrenia

•Disorder of abnormal thinking, behavior, & emotion. • ~1% of population. Men & women are affected equally but men present earlier (early to mid 20s) compare to late 20s as seen in women. Rarely initially presents before 15 or after 55y. • Men tend to have more negative symptoms & poorer outcome. • Strong genetic predisposition - 50% concordance among monozygotic twins. 40% risk if both parents have schizophrenia. 12% risk if a first-degree relative is affected. • Substance use is common - nicotine most common (>50%), alcohol, cannabis, and cocaine. Better prognosis: • Later age at onset, acute onset, positive symptoms, good social support, female gender, few relapses, good premorbid function, mood symptoms, & no family history of mental illness. Worse prognosis: • Early age of onset, gradual onset, negative symptoms, poor social support, male gender, many relapses, poor premorbid function. • Pathophysiology: exact cause is unknown but the positive symptoms are thought to be due to excess dopamine in the mesolimbic pathway with negative symptoms due to dopamine imbalance in the mesocortical pathway. DIAGNOSTIC CRITERIA • 2 or more of the following symptoms - positive symptoms (eg, hallucination, delusion, disorganized speech), negative symptoms, grossly disorganized or catatonic behavior for at least 6 months. • At least 1 must be hallucination, delusion, or disorganized speech & must manifest for a 1 month period. • Must impair function. • Symptoms not due to the effects of a substance or medical condition. Positive symptoms: these symptoms are "added to" normal behavior • Hallucinations (sensory perception without physical stimuli) - auditory most common, visual, gustatory, tactile, olfactory, or somatic. • Delusions (firmed, fixed beliefs despite evidence to the contrary) - persecutory, grandiose, reference, control, nihilism, erotomania, doubles, & jealousy. • Disorganized speech - thoughts are disconnected & tangential rambling. • Behavioral disturbances. Negative symptoms; these symptoms "take away" from normal behavior. 6 As - • Absence of normal cognition - impairment in attention, working memory, & executive function. • Affect flattening - poor eye contact, unchanging facial expression, little change in affect, little spontaneous movement, lack of vocal inflections. • Alogia - poverty of speech, increased latency of response. • Avolition (lack of will) - poor hygiene & grooming, anergy, failure of appropriate role responsibilities. • Anhedonia - lack of interest in stimulating activities, intimacy, or sex. • Asociality - failure to engage with others socially, socially withdrawn. Not part of diagnostic criteria but findings asked on exams: Neuroimaging: • CT scan - ventricular enlargement (lateral & third) as well as decreased cortical volume & grey matter. • PET scan - hypoactive frontal lobes, hyperactivity in the basal ganglion.

Panic Disorder (DSM)

DIAGNOSTIC CRITERIA 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 one- self). 12. Fear of losing control or "going crazy." 13. Fear of dying. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrol- lable 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 or 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, car. diopulmonary disorders). D. The disturbance is not better explained by another mental disorder (e.g., the panic at- tacks do not occur only in response to feared social situations, as in social anxiety dis- order; 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). Diagnostic Features Panic disorder refers to recurrent unexpected panic attacks (Criterion A). 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 a list of 13 physical and cognitive symptoms occur. The term recurrent literally means more than one unexpected panic attack. The term unex- pected refers to a panic attack for which there is no obvious cue or trigger at the time of oc- currence-that is, the attack appears to occur from out of the blue, such as when the individual is relaxing or emerging from sleep (nocturnal panic attack). In contrast, expected panic attacks are attacks for which there is an obvious cue or trigger, such as a situation in which panic attacks typically occur. The determination of whether panic attacks are ex- pected or unexpected is made by the clinician, who makes this judgment based on a com- bination of careful questioning as to the sequence of events preceding or leading up to the attack and the individual's own judgment of whether or not the attack seemed to occur for no apparent reason. Cultural interpretations may influence the assignment of panic at- tacks as expected or unexpected (see section "Culture-Related Diagnostic Issues" for this disorder). In the United States and Europe, approximately one-half of individuals with panic disorder have expected panic attacks as well as unexpected panic attacks. Thus, the presence of expected panic attacks does not rule out the diagnosis of panic disorder. For more details regarding expected versus unexpected panic attacks, see the text accompanying panic attacks (pp. 214-217). The frequency and severity of panic attacks vary widely. In terms of frequency, there may be moderately frequent attacks (e.g., one per week) for months at a time, or short bursts of more frequent attacks (e.g., daily) separated by weeks or months without any at- tacks or with less frequent attacks (e.g., two per month) over many years. Persons who have infrequent panic attacks resemble persons with more frequent panic attacks in terms of panic attack symptoms, demographic characteristics, comorbidity with other disorders, family history, and biological data. In terms of severity, individuals with panic disorder may have both full-symptom (four or more symptoms) and limited-symptom (fewer than four symptoms) attacks, and the number and type of panic attack symptoms frequently differ from one panic attack to the next. However, more than one unexpected full-symp- tom panic attack is required for the diagnosis of panic disorder. The worries about panic attacks or their consequences usually pertain to physical con- cerns, such as worry that panic attacks reflect the presence of life-threatening illnesses (e.g., cardiac disease, seizure disorder); social concerns, such as embarrassment or fear of being judged negatively by others because of visible panic symptoms; and concerns about mental functioning, such as "going crazy" or losing control (Criterion B). The maladaptive changes in behavior represent attempts to minimize or avoid panic attacks or their conse- quences. Examples include avoiding physical exertion, reorganizing daily life to ensure that help is available in the event of a panic attack, restricting usual daily activities, and avoiding agoraphobia-type situations, such as leaving home, using public transportation, of shopping. If agoraphobia is present, a separate diagnosis of agoraphobia is given. Associated Features Supporting Diagnosis One type of unexpected panic attack is a nocturnal panic attack (ie, waking from sleep in a state of panic, which differs from panicking after fully waking from sleep). In the United States, this type of panic attack has been estimated to occur at least one time in roughly one-quarter to one-third of individuals with panic disorder, of whom the majority also have daytime panic attacks. In addition to worry about panic attacks and their conse. quences, many individuals with panic disorder report constant or intermittent feelings of anxiety that are more broadly related to health and mental health concerns. For example, individuals with panic disorder often anticipate a catastrophic outcome from a mild phys ical symptom or medication side effect (e.g, thinking that they may have heart disease or that a headache means presence of a brain tumor). Such individuals often are relatively in. tolerant of medication side effects. In addition, there may be pervasive concerns about abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (eg, alcohol, prescribed medications or illicit drugs) to control panic attacks, or extreme behav. tors aimed at controlling panic attacks (e.g., severe restrictions on food intake or avoidance of specific foods or medications because of concerns about physical symptoms that pro- voke panic attacks). Prevalence In the general population, the 12-month prevalence estimate for panic disorder across the United States and several European countries is about 2%-3% in adults and adolescents. In the United States, significantly lower rates of panic disorder are reported among Latinos. African Americans, Caribbean blacks, and Asian Americans, compared with non-Latino whites; American Indians, by contrast, have significantly higher rates. Lower estimates have been reported for Asian, African, and Latin American countries, ranging from 0.1% to 0.8%. Females are more frequently affected than males, at a rate of approximately 2:1. The gender differentiation occurs in adolescence and is already observable before age 14 years. Although panic attacks occur in children, the overall prevalence of panic disorder is low before age 14 years (<0.4%). The rates of panic disorder show a gradual increase during ad- olescence, particularly in females, and possibly following the onset of puberty, and peak dur- ing adulthood. The prevalence rates decline in older individuals (i.e., 0.7% in adults over the age of 64), possibly reflecting diminishing severity to subclinical levels. Development and Course The median age at onset for panic disorder in the United States is 20-24 years. A small number of cases begin in childhood, and onset after age 45 years is unusual but can occur. The usual course, if the disorder is untreated, is chronic but waxing and waning. Some in- dividuals may have episodic outbreaks with years of remission in between, and others may have continuous severe symptomatology. Only a minority of individuals have full remission without subsequent relapse within a few years. The course of panic disorder typically is complicated by a range of other disorders, in particular other anxiety disor- ders, depressive disorders, and substance use disorders (see section "Comorbidity" tor this disorder). Although panic disorder is very rare in childhood, first occurrence of "fearful spells" is often dated retrospectively back to childhood. As in adults, panic disorder in adolescents tends to have a chronic course and is frequently comorbid with other anxiety, depressive, and bipolar disorders. To date, no differences in the clinical presentation between adoles- cents and adults have been found. However, adolescents may be less worried about addi- tional panic attacks than are young adults. Lower prevalence of panic disorder in older adults appears to be attributable to age-related " dampening" of the autonomic nervous system response. Many older individuals with "panicky feelings" are observed to have a "hybrid" of limited-symptom panic attacks and generalized anxiety. Also, older adults tend to attribute their panic attacks to certain stressful situations, such as a medical pro- cedure or social setting. Older individuals may retrospectively endorse explanations for the panic attack (which would preclude the diagnosis of panic disorder), even if an attack might actually have been unexpected in the moment (and thus qualify as the basis for a panic disorder diagnosis). This may result in under-endorsement of unexpected panic at- tacks in older individuals. Thus, careful questioning of older adults is required to assess whether panic attacks were expected before entering the situation, so that unexpected panic attacks and the diagnosis of panic disorder are not overlooked. While the low rate of panic disorder in children could relate to difficulties in symptom reporting, this seems unlikely given that children are capable of reporting intense fear or panic in relation to separation and to phobic objects or phobic situations. Adolescents might be less willing than adults to openly discuss panic attacks. Therefore, clinicians should be aware that unexpected panic attacks do occur in adolescents, much as they do in adults, and be attuned to this possibility when encountering adolescents presenting with episodes of intense fear or distress. Risk and Prognostic Factors Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing neg- ative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of anxiety are harmful) are risk factors for the onset of panic attacks and, separately, for worry about panic, although their risk status for the diagnosis of panic disorder is un- known. History of "fearful spells" (i.e., limited-symptom attacks that do not meet full cri- teria for a panic attack) may be a risk factor for later panic attacks and panic disorder. Although separation anxiety in childhood, especially when severe, may precede the later development of panic disorder, it is not a consistent risk factor. Environmental. Reports of childhood experiences of sexual and physical abuse are more common in panic disorder than in certain other anxiety disorders. Smoking is a risk factor for panic attacks and panic disorder. Most individuals report identifiable stressors in the months before their first panic attack (e.g., interpersonal stressors and stressors related to physical well-being, such as negative experiences with illicit or prescription drugs, dis- ease, or death in the family). Genetic and physiological. It is believed that multiple genes confer vulnerability to panic disorder. However, the exact genes, gene products, or functions related to the genetic re- gions implicated remain unknown. Current neural systems models for panic disorder em- phasize the amygdala and related structures, much as in other anxiety disorders. There is an increased risk for panic disorder among offspring of parents with anxiety, depressive, and bipolar disorders. Respiratory disturbance, such as asthma, is associated with panic disorder, in terms of past history, comorbidity, and family history. Culture-Related Diagnostic Issues The rate of fears about mental and somatic symptoms of anxiety appears to vary across cultures and may influence the rate of panic attacks and panic disorder. Also, cultural ex- pectations may influence the classification of panic attacks as expected or unexpected. For example, a Vietnamese individual who has a panic attack after walking out into a windy environment (trung gió; "hit by the wind") may attribute the panic attack to exposure to wind as a result of the cultural syndrome that links these two experiences, resulting in clas- sification of the panic attack as expected. Various other cultural syndromes are associated with panic disorder, including ataque de nervios ("attack of nerves") among Latin Ameri- cans and khal attacks and "soul loss" among Cambodians. Ataque de nervios may involve trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and deper- sonalization or derealization, which may be experienced longer than the few minutes typical of panic attacks. Some clinical presentations of ataque de nervios fulfill criteria for condi. tions other than panic attack (e&;, other specified dissociative disorder), These syndromes impact the symptoms and frequency of panic disorder, including the individual's attribu. ion of unexpectedness, as cultural syndromes may create fear of certain situations, tang- ing from interpersonal arguments (associated with ataque de nervios), to types of exertion (associated with khuäl attacks), to atmospheric wind (associated with tring gió attacks). Clarification of the details of cultural attributions may aid in distinguishing expected and unexpected panic attacks. For more information regarding cultural syndromes, refer to the "Glossary of Cultural Concepts of Distress" in the Appendix. The specific worries about panic attacks or their consequences are likely to vary from one culture to another (and across different age groups and gender). For panic disorder, U.S. community samples of non-Latino whites have significantly less functional impair. ment than African Americans. There are also higher rates of objectively defined severity in non-Latino Caribbean blacks with panic disorder, and lower rates of panic disorder over. all in both African American and Afro-Caribbean groups, suggesting that among individ- uals of African descent, the criteria for panic disorder may be met only when there is substantial severity and impairment. Gender-Related Diagnostic Issues The clinical features of panic disorder do not appear to differ between males and females. There is some evidence for sexual dimorphism, with an association between panic disor- der and the catechol-O-methyltransferase (COMT) gene in females only. Diagnostic Markers Agents with disparate mechanisms of action, such as sodium lactate, caffeine, isoprotere- nol, yohimbine, carbon dioxide, and cholecystokinin, provoke panic attacks in individuals with panic disorder to a much greater extent than in healthy control subjects (and in some cases, than in individuals with other anxiety, depressive, or bipolar disorders without panic attacks). Also, for a proportion of individuals with panic disorder, panic attacks are related to hypersensitive medullary carbon dioxide detectors, resulting in hypocapnia and other respiratory irregularities. However, none of these laboratory findings are consid- ered diagnostic of panic disorder. Suicide Risk Panic attacks and a diagnosis of panic disorder in the past 12 months are related to a higher rate of suicide attempts and suicidal ideation in the past 12 months even when comorbid- ity and a history of childhood abuse and other suicide risk factors are taken into account. Functional consequences Panic disorder is associated with high levels of social, occupational, and physical disabil. ity; considerable economic costs; and the highest number of medical visits among the anx- iety disorders, although the effects are strongest with the presence of agoraphobia. Individuals with panic disorder may be frequently absent from work or school for doctor and emergency room visits, which can lead to unemployment or dropping out of school. In older adults, impairment may be seen in caregiving duties or volunteer activities. Full- symptom panic attacks typically are associated with greater morbidity (e.g., greater health care utilization, more disability, poorer quality of life) than limited-symptom attacks. Differential Diagnosis Other specified anxiety disorder or unspecified anxiety disorder. Panic disorder should not be diagnosed if full-symptom (unexpected) panic attacks have never been experienced. In the case of only limited-symptom unexpected panic attacks, an other specified anxiety dis- order or unspecified anxiety disorder diagnosis should be considered. Anxiety disorder due to another medical condition. Panic disorder is not diagnosed if the panic attacks are judged to be a direct physiological consequence of another medical condition. Examples of medical conditions that can cause panic attacks include hyperthy- roidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure dis- orders, and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia, asthma, chronic obstructive pulmonary disease [COP]). Appropriate laboratory tests (e.g., serum calcium levels for hyperparathyroidism; Holter monitor for arrhythmias) or physical examinations (e.g., for cardiac conditions) may be helpful in determining the eti- logical role of another medical condition. Substance/medication-induced anxiety disorder. Panic disorder is not diagnosed if the panic attacks are judged to be a direct physiological consequence of a substance. In- toxication with central nervous system stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, bar- biturates) can precipitate a panic attack. However, if panic attacks continue to occur out- side of the context of substance use (e.g., long after the effects of intoxication or withdrawal have ended), a diagnosis of panic disorder should be considered. In addition, because panic disorder may precede substance use in some individuals and may be associated with increased substance use, especially for purposes of self-medication, a detailed history should be taken to determine if the individual had panic attacks prior to excessive sub- stance use. If this is the case, a diagnosis of panic disorder should be considered in addition to a diagnosis of substance use disorder. Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness, loss of bladder or bowel control, slurred speech, amnesia) suggest the possibility that an- other medical condition or a substance may be causing the panic attack symptoms. Other mental disorders with panic attacks as an associated feature (e.g., other anxiety disorders and psychotic disorders). Panic attacks that occur as a symptom of other anx- iety disorders are expected (e.g., triggered by social situations in social anxiety disorder, by phobic objects or situations in specific phobia or agoraphobia, by worry in generalized anx- iety disorder, by separation from home or attachment figures in separation anxiety disorder) and thus would not meet criteria for panic disorder. (Note: Sometimes an unexpected panic attack is associated with the onset of another anxiety disorder, but then the attacks become expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If the panic attacks occur only in response to specific triggers, then only the relevant anxiety disorder is assigned. However, if the individual experiences unexpected panic attacks as well and shows persistent concern and worry or behavioral change because of the attacks, then an additional diagnosis of panic disorder should be considered. Comorbidity Panic disorder infrequently occurs in clinical settings in the absence of other psychopa- thology. The prevalence of panic disorder is elevated in individuals with other disorders, particularly other anxiety disorders (and especially agoraphobia), major depression, bipo- Jar disorder, and possibly mild alcohol use disorder. While panic disorder often has an ear- lier age at onset than the comorbid disorder(s), onset sometimes occurs after the comorbid disorder and may be seen as a severity marker of the comorbid illness. Reported lifetime rates of comorbidity between major depressive disorder and panic disorder vary widely, ranging from 10% to 65% in individuals with panic disorder. In ap- proximately one-third of individuals with both disorders, the depression precedes the on- set of panic disorder. In the remaining two-thirds, depression occurs coincident with or following the onset of panic disorder. À subset of individuals with panic disorder develop a substance-related disorder, which for some represents an attempt to treat their anxiety with alcohol or medications. Comorbidity with other anxiety disorders and illness anxiety disorder is also common. Panic disorder is significantly comorbid with numerous general medical symptoms and conditions, including, but not limited to, dizziness, cardiac arrhythmias, hyperthy- roidism, asthma, COPD, and irritable bowel syndrome. However, the nature of the asso- cation (e.g., cause and effect) between panic disorder and these conditions remains unclear. Although mitral valve prolapse and thyroid disease are more common among in- dividuals with panic disorder than in the general population, the differences in prevalence are not consistent.

Delusional disorder (DSM)

DIAGNOSTIC CRITERIA 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. 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. Specify whether: Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with the individual. Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery. Jealous type: This subtype applies when the central theme of the individual's delusion is that his or her spouse or lover is unfaithful. Persecutory type: This subtype applies when the central theme of the delusion in- volves the individual's belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations. Mixed type: This subtype applies when no one delusional theme predominates. Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delu- sions without a prominent persecutory or grandiose component). Specify if: With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., an individual's be- lief that a stranger has removed his or her internal organs and replaced them with some- one else's organs without leaving any wounds or scars). Specify if: The following course specifiers are only to be used after a 1-year duration of the disorder: First episode, currently in acute episode: First manifestation of the disorder meet- ing the defining diagnostic symptom and time criteria. An acute episode is a time pe- riod in which the symptom criteria are fulfilled. First episode, currently in partial remission: Partial remission is a time period dur- ing which an improvement after a previous episode is maintained and in which the de- fining criteria of the disorder are only partially fulfilled. First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present. Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods be- ing very brief relative to the overall course. Unspecified Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor be- havior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter "Assessment Measures.") Note: Diagnosis of delusional disorder can be made without using this severity specifier. Subtypes In erotomanic type, the central theme of the delusion is that another person is in love with the individual. The person about whom this conviction is held is usually of higher status (e.g., a famous individual or a superior at work) but can be a complete stranger. Efforts to contact the object of the delusion are common. In grandiose type, the central theme of the de- lusion is the conviction of having some great talent or insight or of having made some im- portant discovery. Less commonly, the individual may have the delusion of having a special relationship with a prominent individual or of being a prominent person (in which case the actual individual may be regarded as an impostor). Grandiose delusions may have a religious content. In jealous type, the central theme of the delusion is that of an un- faithful partner. This belief is arrived at without due cause and is based on incorrect infer- ences supported by small bits of "evidence" ' (e.g., disarrayed clothing). The individual with the delusion usually confronts the spouse or lover and attempts to intervene in the imagined infidelity. In persecutory type, the central theme of the delusion involves the individual's belief of being conspired against, cheated, spied on, followed, poisoned, mali- ciously maligned, harassed, or obstructed in the pursuit of long-term goals. Small slights may be exaggerated and become the focus of a delusional system. The affected individual may engage in repeated attempts to obtain satisfaction by legal or legislative action. Indi- viduals with persecutory delusions are often resentful and angry and may resort to vio- lence against those they believe are hurting ther. In somatic type, the central theme of the delusion involves bodily functions or sensations. Somatic delusions can occur in several forms. Most common is the belief that the individual emits a foul odor; that there is an in- festation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are misshapen or ugly; or that parts of the body are not functioning. Diagnostic Features The essential feature of delusional disorder is the presence of one or more delusions that persist for at least 1 month (Criterion A). A diagnosis of delusional disorder is not given if the individual has ever had a symptom presentation that met Criterion A for schizophre- nia (Criterion B). Apart from the direct impact of the delusions, impairments in psychoso- cial functioning may be more circumscribed than those seen in other psychotic disorders such as schizophrenia, and behavior is not obviously bizarre or odd (Criterion C). If mood episodes occur concurrently with the delusions, the total duration of these mood episodes is brief relative to the total duration of the delusional periods (Criterion D). The delusions are not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Alzheimer's disease) and are not better explained by another men- tal disorder, such as body dysmorphic disorder or obsessive-compulsive disorder (Crite- rion E). In addition to the five symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and mania symptom domains is vital for making crit- ically important distinctions between the various schizophrenia spectrum and other psy- chotic disorders. Associated Features Supporting Diagnosis Social, marital, or work problems can result from the delusional beliefs of delusional dis- order. Individuals with delusional disorder may be able to factually describe that others view their beliefs as irrational but are unable to accept this themselves (i.e., there may be "factual insight" but no true insight). Many individuals develop irritable or dysphoric mood, which can usually be understood as a reaction to their delusional beliefs. Anger and violent behavior can occur with persecutory, jealous, and erotomanic types. The individ- ual may engage in litigious or antagonistic behavior (e.g., sending hundreds of letters of protest to the government). Legal difficulties can occur, particularly in jealous and eroto- manic types. Prevalence The lifetime prevalence of delusional disorder has been estimated at around 0.2%, and the most frequent subtype is persecutory. Delusional disorder, jealous type, is probably more common in males than in females, but there are no major gender differences in the overall frequency of delusional disorder. Development and Course On average, global function is generally better than that observed in schizophrenia. Al- though the diagnosis is generally stable, a proportion of individuals go on to develop schizophrenia. Delusional disorder has a significant familial relationship with both schizophrenia and schizotypal personality disorder. Although it can occur in younger age groups, the condition may be more prevalent in older individuals. Culture-Related Diagnostic Issues An individual's cultural and religious background must be taken into account in evaluat- ing the possible presence of delusional disorder. The content of delusions also varies across cultural contexts. Functional Consequences of Delusional Disorder The functional impairment is usually more circumscribed than that seen with other psy- chotic disorders, although in some cases, the impairment may be substantial and include poor occupational functioning and social isolation. When poor psychosocial functioning is present, delusional beliefs themselves often play a significant role. A common character- istic of individuals with delusional disorder is the apparent normality of their behavior and appearance when their delusional ideas are not being discussed or acted on. Differential Diagnosis Obsessive-compulsive and related disorders. If an individual with obsessive-compul- sive disorder is completely convinced that his or her obsessive-compulsive disorder beliefs are true, then the diagnosis of obsessive-compulsive disorder, with absent insight/ delu- sional beliefs specifier, should be given rather than a diagnosis of delusional disorder. Similarly, if an individual with body dysmorphic disorder is completely convinced that his or her body dysmorphic disorder beliefs are true, then the diagnosis of body dysmor- phic disorder, with absent insight / delusional beliefs specifier, should be given rather than a diagnosis of delusional disorder. Delirium, major neurocognitive disorder, psychotic disorder due to another medical condition, and substance/medication-induced psychotic disorder. Individuals with these disorders may present with symptoms that suggest delusional disorder. For example, sim- ple persecutory delusions in the context of major neurocognitive disorder would be di- agnosed as major neurocognitive disorder, with behavioral disturbance. A substance / medication-induced psychotic disorder cross-sectionally may be identical in symptom- atology to delusional disorder but can be distinguished by the chronological relationship of substance use to the onset and remission of the delusional beliefs. Schizophrenia and schizophreniform disorder. Delusional disorder can be distinguished from schizophrenia and schizophreniform disorder by the absence of the other character- istic symptoms of the active phase of schizophrenia. Depressive and bipolar disorders and schizoaffective disorder. These disorders may be distinguished from delusional disorder by the temporal relationship between the mood disturbance and the delusions and by the severity of the mood symptoms. If delusions oc- cur exclusively during mood episodes, the diagnosis is depressive or bipolar disorder with Psychotic features. Mood symptoms that meet full criteria for a mood episode can be su- perimposed on delusional disorder. Delusional disorder can be diagnosed only if the total duration of all mood episodes remains brief relative to the total duration of the delusional disturbance. If not, then a diagnosis of other specified or unspecified schizophrenia spec- tum and other psychotic disorder accompanied by other specified depressive disorder, unspecified depressive disorder, other specified bipolar and related disorder, or unspeci- fied bipolar and related disorder is appropriate.

Schizophrenia (DSM)

DIAGNOSTIC CRITERIA 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 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). Specify if: The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria. First episode, currently in acute episode: First manifestation of the disorder meet- ing the defining diagnostic symptom and time criteria. An acute episode is a time pe- riod in which the symptom criteria are fulfilled. Diagnostic Features The characteristic symptoms of schizophrenia involve a range of cognitive, behavioral, and emotional dysfunctions, but no single symptom is pathognomonic of the disorder. The di- agnosis involves the recognition of a constellation of signs and symptoms associated with impaired occupational or social functioning. Individuals with the disorder will vary sub- stantially on most features, as schizophrenia is a heterogeneous clinical syndrome. At least two Criterion A symptoms must be present for a significant portion of time during a 1-month period or longer. At least one of these symptoms must be the clear pres- ence of delusions (Criterion A1), hallucinations (Criterion A2), or disorganized speech (Criterion A3). Grossly disorganized or catatonic behavior (Criterion A4) and negative symptoms (Criterion A5) may also be present. In those situations in which the active- phase symptoms remit within a month in response to treatment, Criterion A is still met if the clinician estimates that they would have persisted in the absence of treatment. Schizophrenia involves impairment in one or more major areas of functioning (Crite- rion B). If the disturbance begins in childhood or adolescence, the expected level of func- tion is not attained. Comparing the individual with unaffected siblings may be helpful. The dysfunction persists for a substantial period during the course of the disorder and does not appear to be a direct result of any single feature. volition (i.e., reduced drive to pursue goal-directed behavior; Criterion A5) is linked to the social dysfunction described under Criterion B. There is also strong evidence for a relationship between cognitive impairment (see the section " Associated Features Supporting Diagnosis" for this disorder) and func- tonal impairment in individuals with schizophrenia. Some signs of the disturbance must persist for a continuous period of at least 6 months (Criterion C). Prodromal symptoms often precede the active phase, and residual symp- toms may follow it, characterized by mild or subthreshold forms of hallucinations or delusions. Individuals may express a variety of unusual or odd beliefs that are not of de- lusional proportions (e.g., ideas of reference or magical thinking); they may have unusual perceptual experiences (e.g., sensing the presence of an unseen person); their speech may be generally understandable but vague; and their behavior may be unusual but not grossly disorganized (e.g., mumbling in public). Negative symptoms are common in the pro- dromal and residual phases and can be severe. Individuals who had been socially active may become withdrawn from previous routines. Such behaviors are often the first sign of a disorder. Mood symptoms and full mood episodes are common in schizophrenia and may be con- current with active-phase symptomatology. However, as distinct from a psychotic mood dis- order, a schizophrenia diagnosis requires the presence of delusions or hallucinations in the absence of mood episodes. In addition, mood episodes, taken in total, should be present for only a minority of the total duration of the active and residual periods of the illness. In addition to the five symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and mania symptom domains is vital for making crit- ically important distinctions between the various schizophrenia spectrum and other psy- chotic disorders. Associated Features Supporting Diagnosis Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the ab- sence of an appropriate stimulus); a dysphoric mood that can take the form of depression, anxiety, or anger; a disturbed sleep pattern (e.g., daytime sleeping and nighttime activity); and a lack of interest in eating or food refusal. Depersonalization, derealization, and so- matic concerns may occur and sometimes reach delusional proportions. Anxiety and pho- bias are common. Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments. These deficits can include decrements in declar- ative memory, working memory, language function, and other executive functions, as well as slower processing speed. Abnormalities in sensory processing and inhibitory capacity, as well as reductions in attention, are also found. Some individuals with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind), and may attend to and then interpret irrelevant events or stimuli as meaningful, perhaps leading to the generation of explanatory delusions. These impairments frequently persist during symptomatic remission. Some individuals with psychosis may lack insight or awareness of their disorder (i.e., anosognosia). This lack of "insight" includes unawareness of symptoms of schizophrenia and may be present throughout the entire course of the illness. Unawareness of illness is typically a symptom of schizophrenia itself rather than a coping strategy. It is comparable to the lack of awareness of neurological deficits following brain damage, termed anoso- gnosia. This symptom is the most common predictor of non-adherence to treatment, and it predicts higher relapse rates, increased number of involuntary treatments, poorer psycho- social functioning, aggression, and a poorer course of illness. Hostility and aggression can be associated with schizophrenia, although spontaneous or random assault is uncommon. Aggression is more frequent for younger males and for individuals with a past history of violence, non-adherence with treatment, substance abuse, and impulsivity. It should be noted that the vast majority of persons with schizo- Phrenia are not aggressive and are more frequently victimized than are individuals in the general population. Currently, there are no radiological, laboratory, or psychometric tests for the disorder. Differences are evident in multiple brain regions between groups of healthy individuals and persons with schizophrenia, including evidence from neuroimaging, neuropatholog- ical, and neurophysiological studies. Differences are also evident in cellular architecture, white matter connectivity, and gray matter volume in a variety of regions such as the pre. frontal and temporal cortices. Reduced overall brain volume has been observed, as well as increased brain volume reduction with age. Brain volume reductions with age are more pronounced in individuals with schizophrenia than in healthy individuals. Finally, indi- viduals with schizophrenia appear to differ from individuals without the disorder in eye- tracking and electrophysiological indices. Neurological soft signs common in individuals with schizophrenia include impairments in motor coordination, sensory integration, and motor sequencing of complex movements; left-right confusion; and disinhibition of associated movements. In addition, minor phys- ical anomalies of the face and limbs may occur. Prevalence The lifetime prevalence of schizophrenia appears to be approximately 0.3%-0.7%, al- though there is reported variation by race/ethnicity, across countries, and by geographic origin for immigrants and children of immigrants. The sex ratio differs across samples and populations: for example, an emphasis on negative symptoms and longer duration of dis- order (associated with poorer outcome) shows higher incidence rates for males, whereas definitions allowing for the inclusion of more mood symptoms and brief presentations (associated with better outcome) show equivalent risks for both sexes. Development and Course The psychotic features of schizophrenia typically emerge between the late teens and the mid-30s; onset prior to adolescence is rare. The peak age at onset for the first psychotic ep- isode is in the early- to mid-20s for males and in the late-20s for females. The onset may be abrupt or insidious, but the majority of individuals manifest a slow and gradual develop- ment of a variety of clinically significant signs and symptoms. Half of these individuals complain of depressive symptoms. Earlier age at onset has traditionally been seen as a pre- dictor of worse prognosis. However, the effect of age at onset is likely related to gender, with males having worse premorbid adjustment, lower educational achievement, more prominent negative symptoms and cognitive impairment, and in general a worse out- come. Impaired cognition is common, and alterations in cognition are present during de- velopment and precede the emergence of psychosis, taking the form of stable cognitive impairments during adulthood. Cognitive impairments may persist when other symptoms are in remission and contribute to the disability of the disease. The predictors of course and outcome are largely unexplained, and course and outcome may not be reliably predicted. The course appears to be favorable in about 20% of those with schizophrenia, and a small number of individuals are reported to recover completely. However, most individuals with schizophrenia still require formal or informal daily living supports, and many remain chronically ill, with exacerbations and remissions of active symptoms, while others have a course of progressive deterioration. Psychotic symptoms tend to diminish over the life course, perhaps in association with normal age-related declines in dopamine activity. Negative symptoms are more closely re- lated to prognosis than are positive symptoms and tend to be the most persistent. Further- more, cognitive deficits associated with the illness may not improve over the course of the illness. The essential features of schizophrenia are the same in childhood, but it is more diffi- cult to make the diagnosis. In children, delusions and hallucinations may be less elaborate than in adults, and visual hallucinations are more common and should be distinguished from normal fantasy play. Disorganized speech occurs in many disorders with childhood onset (e g, autism spectrum disorder), as does disorganized behavior (e.g, attention-deficit/hyperactivity disorder). These symptoms should not be attributed to schizophrenia with- out due consideration of the more common disorders of childhood. Childhood-onset cases tend to resemble poor-outcome adult cases, with gradual onset and prominent negative symptoms. Children who later receive the diagnosis of schizophrenia are more likely to have experienced nonspecific emotional-behavioral disturbances and psychopathology, intellectual and language alterations, and subtle motor delays. Late-onset cases (i.e., onset after age 40 years) are overrepresented by females, who may have married. Often, the course is characterized by a predominance of psychotic symptoms with preservation of affect and social functioning. Such late-onset cases can still meet the diagnostic criteria for schizophrenia, but it is not yet clear whether this is the same condition as schizophrenia diagnosed prior to mid-life (e.g., prior to age 55 years). Risk and Prognostic Factors Environmental. Season of birth has been linked to the incidence of schizophrenia, in- cluding late winter/ early spring in some locations and summer for the deficit form of the disease. The incidence of schizophrenia and related disorders is higher for children grow- ing up in an urban environment and for some minority ethnic groups. Genetic and physiological. There is a strong contribution for genetic factors in deter- mining risk for schizophrenia, although most individuals who have been diagnosed with schizophrenia have no family history of psychosis. Liability is conferred by a spectrum of risk alleles, common and rare, with each allele contributing only a small fraction to the to- tal population variance. The risk alleles identified to date are also associated with other mental disorders, including bipolar disorder, depression, and autism spectrum disorder. Pregnancy and birth complications with hypoxia and greater paternal age are associated with a higher risk of schizophrenia for the developing fetus. In addition, other prenatal and perinatal adversities, including stress, infection, malnutrition, maternal diabetes, and other medical conditions, have been linked with schizophrenia. However, the vast major- ity of offspring with these risk factors do not develop schizophrenia. Culture-Related Diagnostic Issues Cultural and socioeconomic factors must be considered, particularly when the individual and the clinician do not share the same cultural and socioeconomic background. Ideas that appear to be delusional in one culture (e.g., witchcraft) may be commonly held in another. In some cultures, visual or auditory hallucinations with a religious content (e.g., hearing God's voice) are a normal part of religious experience. In addition, the assessment of dis- organized speech may be made difficult by linguistic variation in narrative styles across cultures. The assessment of affect requires sensitivity to differences in styles of emotional expression, eye contact, and body language, which vary across cultures. If the assessment is conducted in a language that is different from the individual's primary language, care must be taken to ensure that alogia is not related to linguistic barriers. In certain cultures, distress may take the form of hallucinations or pseudo-hallucinations and overvalued ideas that may present clinically similar to true psychosis but are normative to the pa- tient's subgroup Gender-Related Diagnostic Issues A number of features distinguish the clinical expression of schizophrenia in females and males. The general incidence of schizophrenia tends to be slightly lower in females, par- ticularly among treated cases. The age at onset is later in females, with a second mid-life peak as described earlier (see the section "Development and Course" for this disorder). Symptoms tend to be more affect-laden among females, and there are more psychotic symptoms, as well as a greater propensity for psychotic symptoms to worsen in later life. Other symptom differences include less frequent negative symptoms and disorganization. Finally, social functioning tends to remain better preserved in females. There are, how- ever, frequent exceptions to these general caveats. Suicide Risk Approximately 5%-6% of individuals with schizophrenia die by suicide, about 20% attempt suicide on one or more occasions, and many more have significant suicidal ideation. Suicidal behavior is sometimes in response to command hallucinations to harm oneself or others. Suicide risk remains high over the whole lifespan for males and females, although it may be especially high for younger males with comorbid substance use. Other risk factors include having depressive symptoms or feelings of hopelessness and being unemployed, and the risk is higher, also, in the period after a psychotic episode or hospital discharge. Functional Consequences of Schizophrenia Schizophrenia is associated with significant social and occupational dysfunction. Making educational progress and maintaining employment are frequently impaired by avolition or other disorder manifestations, even when the cognitive skills are sufficient for the tasks at hand. Most individuals are employed at a lower level than their parents, and most, par- ticularly men, do not marry or have limited social contacts outside of their family. Differential Diagnosis Major depressive or bipolar disorder with psychotic or catatonic features. The distinc- tion between schizophrenia and major depressive or bipolar disorder with psychotic features or with catatonia depends on the temporal relationship between the mood distur- bance and the psychosis, and on the severity of the depressive or manic symptoms. If de- lusions or hallucinations occur exclusively during a major depressive or manic episode, the diagnosis is depressive or bipolar disorder with psychotic features. Schizoaffective disorder. A diagnosis of schizoaffective disorder requires that a major depressive or manic episode occur concurrently with the active-phase symptoms and that the mood symptoms be present for a majority of the total duration of the active periods. Schizophreniform disorder and brief psychotic disorder. These disorders are of shorter duration than schizophrenia as specified in Criterion C, which requires 6 months of symp- toms. In schizophreniform disorder, the disturbance is present less than 6 months, and in brief psychotic disorder, symptoms are present at least 1 day but less than 1 month. Delusional disorder. Delusional disorder can be distinguished from schizophrenia by the absence of the other symptoms characteristic of schizophrenia (e.g., delusions, prominent auditory or visual hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms). Schizotypal personality disorder. Schizotypal personality disorder may be distinguished frum schizophrenia by subthreshold symptoms that are associated with persistent person- ality features. Obsessive-compulsive disorder and body dysmorphic disorder. Individuals with obsessive-compulsive disorder and body dysmorphic disorder may present with poor or absent insight, and the preoccupations may reach delusional proportions. But these disorders are distinguished from schizophrenia by their prominent obsessions, compul- sions, preoccupations with appearance or body odor, hoarding, or body-focused repeti- tive behaviors. Posttraumatic stress disorder. Posttraumatic stress disorder may include flashbacks that have a hallucinatory quality, and hypervigilance may reach paranoid proportions. But a traumatic event and characteristic symptom features relating to reliving or reacting to the event are required to make the diagnosis. Autism spectrum disorder or communication disorders. These disorders may also have symptoms resembling a psychotic episode but are distinguished by their respective defi- cits in social interaction with repetitive and restricted behaviors and other cognitive and communication deficits. An individual with autism spectrum disorder or communication disorder must have symptoms that meet full criteria for schizophrenia, with prominent hallucinations or delusions for at least 1 month, in order to be diagnosed with schizophre- nia as a comorbid condition. Other mental disorders associated with a psychotic episode. The diagnosis of schizo- phrenia is made only when the psychotic episode is persistent and not attributable to the physiological effects of a substance or another medical condition. Individuals with a de- lirium or major or minor neurocognitive disorder may present with psychotic symptoms, but these would have a temporal relationship to the onset of cognitive changes consistent with those disorders. Individuals with substance / medication-induced psychotic disorder may present with symptoms characteristic of Criterion A for schizophrenia, but the sub- stance/ medication-induced psychotic disorder can usually be distinguished by the chron- ological relationship of substance use to the onset and remission of the psychosis in the absence of substance use. Comorbidity Rates of comorbidity with substance-related disorders are high in schizophrenia. Over half of individuals with schizophrenia have tobacco use disorder and smoke cigarettes regularly. Comorbidity with anxiety disorders is increasingly recognized in schizophre- nia. Rates of obsessive-compulsive disorder and panic disorder are elevated in individuals with schizophrenia compared with the general population. Schizotypal or paranoid per- sonality disorder may sometimes precede the onset of schizophrenia. Life expectancy is reduced in individuals with schizophrenia because of associated medical conditions. Weight gain, diabetes, metabolic syndrome, and cardiovascular and pulmonary disease are more common in schizophrenia than in the general population. Poor engagement in health maintenance behaviors (e.g., cancer screening, exercise) in- creases the risk of chronic disease, but other disorder factors, including medications, life- style, cigarette smoking, and diet, may also play a role. A shared vulnerability for psychosis and medical disorders may explain some of the medical comorbidity of schizo- phrenia.

Pyromania

A. Deliberate and purposeful fire setting on more than one occasion. B. Tension or affective arousal before the act. C. Fascination with, interest in, curiosity about, or attraction to fire and its situational con- texts (e.g., paraphernalia, uses, consequences). D. Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath. E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to a delusion or hallucinations, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental disorder], substance intoxication). F. The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Intermittent Explosive Disorder (IED) criteria

A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following: 1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not re. sult in damage or destruction of property and does not result in physical injury to animals or other individuals. 2. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occur. ring within a 12-month period. B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors. C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/ or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation). D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with finan- cial or legal consequences. E. Chronological age is at least 6 years (or equivalent developmental level). F. The recurrent aggressive outbursts are not better explained by another mental disor- der (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocial personality disorder, borderline personality disorder) and are not attributable to another medical condition (e.g., head trauma, Alz- heimer's disease) or to the physiological effects of a substance (e.g., a drug of abuse, a medication). For children ages 6-18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis. Note: This diagnosis can be made in addition to the diagnosis of attention-deficit/hyper- activity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum dis- order when recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical attention.

Rumination Disorder

A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out. B. The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis). C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder. D. If the symptoms occur in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder] or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention. Specify if: In remission: After full criteria for rumination disorder were previously met, the criteria have not been met for a sustained period of time.

Disruptive Mood Dysregulation Disorder (DMDD) (DSM)

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts are inconsistent with developmental level. C. The temper outbursts occur, on average, three or more times per week. D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). E. Criteria A-D have been present for 12 or more months. Throughout that time, the indi- vidual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D. F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these. G. The diagnosis should not be made for the first time before age 6 years or after age 18 years. H. By history or observation, the age at onset of Criteria A-E is before 10 years. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of ma- nia or hypomania. J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disor- der, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent ex- plosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experi- enced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned. K. The symptoms are not attributable to the physiological effects of a substance or to an- other medical or neurological condition.

Catatonia

A. The clinical picture is dominated by three (or more) of the following symptoms: 1. Stupor (i.e., no psychomotor activity; not actively relating to environment). 2. Catalepsy (i.e., passive induction of a posture held against gravity). 3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner). 4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]). 5. Negativism (i.e., opposition or no response to instructions or external stimuli). 6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity). 7. Mannerism (i.e., odd, circumstantial caricature of normal actions). 8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements). 9. Agitation, not influenced by external stimuli. 10. Grimacing. 11. Echolalia (i.e., mimicking another's speech) 12. Echopraxia (i.e., mimicking another's movements).

Generalized Anxiety Disorder (DSM)

DIAGNOSTIC CRITERIA A. Excessive anxiety and worry (apprehensive expectation), occurring more days then 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). Diagnostic Features The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation) about a number of events or activities. The intensity, duration, or frequency of the anxiety and worry is out of proportion to the actual likelihood or impact of the anticipated event. The individual finds it difficult to control the worry and to keep Worrisome thoughts from interfering with attention to tasks at hand. Adults with generalized anxiety disorder often worry about everyday, routine life circumstances, such as possible job responsibilities, health and finances, the health of family members, misfortune to their children, or minor matters (e.g., doing household chores or being late for appointments). Children with generalized anxiety disorder tend to worry excessively about their competence or the quality of their performance. During the course of the disorder, the focus of worry may shift from one concern to another. Several features distinguish generalized anxiety disorder from nonpathological anxiety. First, the worries associated with generalized anxiety disorder are excessive and typically interfere significantly with psychosocial functioning, whereas the worries of everyday life are not excessive and are perceived as more manageable and may be put off when more pressing matters arise. Second, the worries associated with generalized anxiety disorder are more pervasive, pronounced, and distressing; have longer duration; and frequently occur without precipitants. The greater the range of life circumstances about which a person worries (e.g., finances, children's safety, job performance), the more likely his or her symptoms are to meet criteria for generalized anxiety disorder. Third, everyday worries are much less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up or on edge). Individuals with generalized anxiety disorder report subjective distress due to constant worry and related impairment in social, occupational, or other important areas of functioning. The anxiety and worry are accompanied by at least three of the following additional symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and disturbed sleep, although only one additional symptom is required in children. Associated Features Supporting Diagnosis Associated with muscle tension, there may be trembling, twitching, feeling shaky, and muscle aches or soreness. Many individuals with generalized anxiety disorder also experience somatic symptoms (e.g., sweating, nausea, diarrhea) and an exaggerated startle response. Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of breath, dizziness) are less prominent in generalized anxiety disorder than in other anxiety disorders, such as panic disorder. Other conditions that may be associated with stress (e.g., irritable bowel syndrome, headaches) frequently accompany generalized anxiety disorder. Prevalence The 12-month prevalence of generalized anxiety disorder is 0.9% among adolescents and 2.9% among adults in the general community of the United States. The 12-month prevalence for the disorder in other countries ranges from 0.4% to 3.6%. The lifetime morbid risk is 9.0%. Females are twice as likely as males to experience generalized anxiety disorder. The prevalence of the diagnosis peaks in middle age and declines across the later years of life. Individuals of European descent tend to experience generalized anxiety disorder more frequently than do individuals of non-European descent (i.e., Asian, African, Native American and Pacific Islander). Furthermore, individuals from developed countries are more likely than individuals from nondeveloped countries to report that they have experienced symptoms that meet criteria for generalized anxiety disorder in their Lifetime Development and Course Many individuals with generalized anxiety disorder report that they have felt anxious and nervous all of their lives. The median age at onset for generalized anxiety disorder is 30 years; however, age at onset is spread over a very broad range. The median age at onset is later than that for the other anxiety disorders. The symptoms of excessive worry and anxiety may occur early in life but are then manifested as an anxious temperament. Onset of the disorder rarely occurs prior to adolescence. The symptoms of generalized anxiety disorder tend to be chronic and wax and wane across the lifespan, fluctuating between syndromal and subsyndromal forms of the disorder. Rates of full remission are very low. The primary difference across age groups is in the content of the individual's worry. Children and adolescents tend to worry more about school and sporting performance, whereas older adults report greater concern about the well-being of family or their own physical heath. Thus, the content of an individual's worry tends to be age appropriate. Younger adults experience greater severity of symptoms than do older adults. The earlier in life individuals have symptoms that meet criteria for generalized anxiety, the more comorbidity they tend to have and the more impaired they are likely to be. The advent of chronic physical disease can be a potent issue for excessive worty in the elderly: In the frail elderly worries about safety- and especially about falling may limit activities. In those with early cognitive impairment, what appears to be excessive worry about, for example, the whereabouts of things is probably better regarded as realistic given the cognitive impairment. In children and adolescents with generalized anxiety disorder, the anxieties and worries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others. There may be excessive concerns about punctuality. They may also worry about catastrophic events, such as earthquakes or nuclear war. Children with the disorder may be overly conforming, perfectionist, and unsure of themselves and tend to redo tasks because of excessive dissatisfaction with less-than-perfect performance. They are typically overzealous in seeking reassurance and approval and require excessive reassurance about their performance and other things they are worried about. Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis is being considered in children, a thorough evaluation for the presence of other childhood anxiety disorders and other mental disorders should be done to determine whether the Worries may be better explained by one of these disorders. Separation anxiety disorder, social anxiety disorder (social phobia), and obsessive-compulsive disorder are often accompanied by worries that may mimic those described in generalized anxiety disorder. For example, a child with social anxiety disorder may be concerned about school performance because of fear of humiliation. Worries about illness may also be better explained by sepration anxiety disorder or obsessive compulsive disorder. Risk and Prognostic Factors Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm avoidance have been associated with generalized anxiety disorder. Environmental. Although childhood adversities and parental overprotection have been associated with generalized anxiety disorder, no environmental factors have been identified as specific to generalized anxiety disorder or necessary or sufficient for making the diagnosis. Genetic and physiological. One-third of the risk of experiencing generalized anxiety disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are shared with other anxiety and mood disorders, particularly major depressive disorder. Culture-Related Diagnostic Issues GAD is considerable cultural variation in the expression of generalized anxiety disorder. For example, in some cultures, somatic symptoms predominate in the expression of the disorder, whereas in other cultures cognitive symptoms tend to predominate. This difference may be more evident on initial presentation than subsequently, as more symptoms are reported over time. There is no information as to whether the propensity for excessive worrying is related to culture, although the topic being worried about can be culture specific. It is important to consider the social and cultural context when evaluating whether worries about certain situations are excessive. Gender-Related Diagnostic Issues In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently in females than in males (about 55%-60% of those presenting with the disorder are female). In epidemiological studies, approximately two-thirds are female. Females and males who experience generalized anxiety disorder appear to have similar symptoms but demonstrate different patterns of comorbidity consistent with gender differences in the prevalence. In females, comorbidity is confined to anxiety disorders and unipolar depression, whereas males have comorbid conditions as substance use disorders as well Differential diagnosis Anxiety disorder due to another medical condition. The diagnosis of anxiety disorder associated with another medical condition should be assigned if the individual's anxiety and worry are judged, based on history, laboratory findings, or physical examination, to be a physiological effect of another specific medical condition (e.g., pheochromocytoma, hyperthyroidism). Substance/medication-induced anxiety disorder. A substance/ medication-induced anxiety disorder is distinguished from generalized anxiety disorder by the fact that a substance or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically related to the anxiety. For example, severe anxiety that occurs only in the context of heavy coffee consumption would be diagnosed as caffeine-induced anxiety disorder. Social anxiety disorder. Individuals with social anxiety disorder often have anticipatory anxiety that is focused on upcoming social situations in which they must perform or be evaluated by others, whereas individuals with generalized anxiety disorder worry, whether or not they are being evaluated. Obsessive-compulsive disorder. Several features distinguish the excessive worry of General anxiety disorder from the obsessional thoughts of obsessive-compulsive disorder. In generalized anxiety disorder the focus of the worry is about forthcoming problems, and it is the excessiveness of the worry about future events that is abnormal. In obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of intrusive and unwanted thoughts, urges, or images. Posttraumatic stress disorder and adjustment disorders. Anxiety is invariably present in posttraumatic stress disorder. Generalized anxiety disorder is not diagnosed if the anxiety and worry are better explained by symptoms of posttraumatic stress disorder. Anxiety may also be present in adjustment disorder, but this residual category should be used only when the criteria are not met for any other disorder (including generalized anx- iety disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an identifiable stressor within 3 months of the onset of the stressor and does not persist for more than 6 months after the termination of the stressor or its consequences. Depressive, bipolar, and psychotic disorders. Generalized anxiety/ worry is a common associated feature of depressive, bipolar, and psychotic disorders and should not be diagnosed separately if the excessive worry has occurred inky during the course of the conditions Comorbidity Individuals whose presentation meets criteria for GAD are likely to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders. The neuroticism or emotional liability that underpins this pattern of comorbidity is associated with temperamental antecedents and genetic and environmental risk factors shared between these disorders, although independent pathways are also possible. comorbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive disorders is less common.

Cocaine intoxication and withdrawal

COCAINE INTOXICATION • Mechanism: produces a stimulant effect via inhibition of the reuptake of dopamine, norepinephrine, and epinephrine in the synaptic cleft. • Dopamine plays a role in the "reward" system of the brain. INTOXICATION • Elevated or euphoric mood, psychomotor agitation, and pressured speech. • May progress to nausea, vomiting, & seizures. • Physical examination: findings include sympathetic hyperactivity - increased motor activity, tremor, flushing, hyperthermia, cold sweats, & pupillary dilation. May develop hypertension or hypotension, & tachycardia or bradycardia. SEVERE INTOXICATION • Respiratory depression, arrhythmias, hypertension, seizures, repetitive behaviors (eg, picking at skin), agitation, aggression, hallucinations, and paranoia. • Deadly complications include myocardial infarction, stroke, or intracranial hemorrhage. MANAGEMENT • Mild: reassurance and Benzodiazepines. • Severe or psychosis: antipsychotics (eg, Haloperidol), treatment of arrhythmias. Do not place in restraints (may lead to Rhabdomyolysis). • Cardiovascular effects: Benzodiazepines are first-line because most of the cardiovascular effects are centrally mediated via the sympathetic system. Phentolamine can reduce the blood pressure but may cause tachycardia. Nitroglycerin or nitroprusside may be used. If a beta-blocker is used, a mixed alpha-1/beta blocker (eg, Labetalol) is preferred over the other beta blockers. • Hyperthermia; cooling blankets and possibly ice baths. COCAINE WITHDRAWAL • Characterized by craving with resultant dysphoria, post-intoxication depression, anhedonia, hypersomnia, increased appetite, constricted pupils. • Patients may develop nightmares, suicide ideation, headache, and increased irritability. MANAGEMENT • Mainly symptomatic. • Hospitalization may be required for severe psychiatric symptoms.

Social Anxiety Disorder (Social Phobia) (DSM)

DIAGNOSTIC CRITERIA A. 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., hav. ing a conversation, meeting unfamiliar people), being observed (e.g., eating or drink- ing), 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 interac. tions with adults. B. The individual fears that he or she will act in a way or show anxiety sympioms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). C. 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. D. The social situations are avoided or endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation 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. The fear, anxiety, or avoidance is not attributable to the physiological effects of a sub- stance (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. J. 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. Specify if: Performance only: If the fear is restricted to speaking or performing in public. Specifiers Individuals with the performance only type of social anxiety disorder have performance fears that are typically most impairing in their professional lives (e.g., musicians, dancers, performers, athletes) or in roles that require regular public speaking. Performance fears may also manifest in work, school, or academic settings in which regular public presenta- tions are required. Individuals with performance only social anxiety disorder do not fear or avoid nonperformance social situations. Diagnostic Features The essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of so- cial situations in which the individual may be scrutinized by others. In children the fear or anxiety must occur in peer settings and not just during interactions with adults (Criterion A). When exposed to such social situations, the individual fears that he or she will be neg- atively evaluated. The individual is concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable. The individual fears that he or she will act or appear in a certain way or show anxiety symptoms, such as blushing, trembling, sweating, stumbling over one's words, or staring, that will be negatively eval- uated by others (Criterion B). Some individuals fear offending others or being rejected as a result. Fear of offending others--for example, by a gaze or by showing anxiety symp- toms-may be the predominant fear in individuals from cultures with strong collectivistic orientations. An individual with fear of trembling of the hands may avoid drinking, eat- ing, writing, or pointing in public; an individual with fear of sweating may avoid shaking hands or eating spicy foods; and an individual with fear of blushing may avoid public per- formance, bright lights, or discussion about intimate topics. Some individuals fear and avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or "shy bladder syndrome"). The social situations almost always provoke fear or anxiety (Criterion C). Thus, an in- dividual who becomes anxious only occasionally in the social situation(s) would not be di- agnosed with social anxiety disorder. However, the degree and type of fear and anxiety may vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The antici- patory anxiety may occur sometimes far in advance of upcoming situations (e.g., worrying every day for weeks before attending a social event, repeating a speech for days in advance). In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or shrinking in social situations. The individual will often avoid the feared social situations. Alternatively, the situations are endured with intense fear or anxiety (Criterion D). Avoidance can be extensive (e g, not going to parties, refusing school) or subtle (e8, overpre paring the text of a speech, diverting attention to others, limiting eye contact). The rear or anxiety is judged to be out of proportion to the actual risk of being nege. tively evaluated or to the consequences of such negative evaluation (Criterion E). Some times, the anxiety may not be judged to be excessive, because it is related to an actual danger (e.&, being bullied or tormented by others). However, individuals with social anx. iety disorder often overestimate the negative consequences of social situations, and thus the judgment of being out of proportion is made by the clinician. The individual's socio cultural context needs to be taken into account when this judgment is being made. For ex. ample, in certain cultures, behavior that might otherwise appear socially anxious may be considered appropriate in social situations (e.g., might be seen as a sign of respect). The duration of the disturbance is typically at least 6 months (Criterion F). This dura- tion threshold helps distinguish the disorder from transient social fears that are com- mon, particularly among children and in the community. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility. The fear, anxiety, and avoidance must interfere significantly with the individual's normal routine, occupational or academic functioning, or social activities or relationships, or must cause clinically significant distress or impairment in social, occupational, or other important ar- eas of functioning (Criterion G). For example, an individual who is afraid to speak in pub- lic would not receive a diagnosis of social anxiety disorder if this activity is not routinely encountered on the job or in classroom work, and if the individual is not significantly dis- tressed about it. However, if the individual avoids, or is passed over for, the job or educa- tion he or she really wants because of social anxiety symptoms, Criterion G is met. Associated Features Supporting Diagnosis Individuals with social anxiety disorder may be inadequately assertive or excessively sub. indie or less commorly, highly controlling of the conversation They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice. These in. dividuals may be shy or withdrawn, and they may be less open in conversations and dis. close little about themselves. They may seek employment in jobs that do not require social contact, although this is not the case for individuals with social anxiety disorder, perfor. mance Only. They may live at home longer. Men may be delayed in marrying and having a family, whereas women who would want to work outside the home may live a life as homemaker and mother. Self-medication with substances is common (e.g., drinking be- fore going to a party). Social anxiety among older adults may also include exacerbation of symptoms of medical illnesses, such as increased tremor or tachycardia. Blushing is a hallmark physical response of social anxiety disorder. Prevalence The 12-month prevalence estimate of social anxiety disorder for the United States is ap- proximately 7%. Lower 12-month prevalence estimates are seen in much of the world us- ing the same diagnostic instrument, clustering around 0.5%-2.0%; median prevalence in Europe is 2.3%. The 12-month prevalence rates in children and adolescents are comparable to those in adults. Prevalence rates decrease with age. The 12-month prevalence for older adults ranges from 2% to 5%. In general, higher rates of social anxiety disorder are found in females than in males in the general population (with odds ratios ranging from 1.5 to 2.2, and the gender difference in prevalence is more pronounced in adolescents and young adults. Gender rates are equivalent or slightly higher for males in clinical samples, and it is assumed that gender roles and social expectations play a significant role in ex paining the heightened help-seeking behavior in male patients. Prevalence in the United Stales is higher in American Indians and lower in persons of Asian, Latino, African Amer ican, and Afro-Caribbean descent compared with non-Hispanic whites. Development and Course Median age at onset of social anxiety disorder in the United States is 13 years, and 75% of individuals have an age at onset between 8 and 15 years. The disorder sometimes emerges out of a childhood history of social inhibition or shyness in U.S. and European studies. On- set can also occur in early childhood. Onset of social anxiety disorder may follow a stress- ful or humiliating experience (e.g., being bullied, vomiting during a public speech), or it may be insidious, developing slowly. First onset in adulthood is relatively rare and is more likely to occur after a stressful or humiliating event or after life changes that require new social roles (e.g., marrying someone from a different social class, receiving a job promo- Hon). Social anxiety disorder may diminish after an individual with fear of dating marries and may reemerge after divorce. Among individuals presenting to clinical care, the disor- der tends to be particularly persistent. Adolescents endorse a broader pattern of fear and avoidance, including of dating, compared with younger children. Older adults express social anxiety at lower levels but across a broader range of situations, whereas younger adults express higher levels of so- cial anxiety for specific situations. In older adults, social anxiety may concern disability due to declining sensory functioning (hearing, vision) or embarrassment about one's ap- pearance (e.g., tremor as a symptom of Parkinson's disease) or functioning due to medical conditions, incontinence, or cognitive impairment (e.g., forgetting people's names). In the community approximately 30% of individuals with social anxiety disorder experience re- mission of symptoms within 1 year, and about 50% experience remission within a few years. For approximately 60% of individuals without a specific treatment for social anxiety disorder, the course takes several years or longer. Detection of social anxiety disorder in older adults may be challenging because of sev- eral factors, including a focus on somatic symptoms, comorbid medical illness, limited insight, changes to social environment or roles that may obscure impairment in social functioning, or reticence about describing psychological distress. Risk and Prognostic Factors Temperamental. Underlying traits that predispose individuals to social anxiety disor- der include behavioral inhibition and fear of negative evaluation. Environmental. There is no causative role of increased rates of childhood maltreatment or other early-onset psychosocial adversity in the development of social anxiety disorder. How- ever, childhood maltreatment and adversity are risk factors for social anxiety disorder. Genetic and physiological. Traits predisposing individuals to social anxiety disorder, such as behavioral inhibition, are strongly genetically influenced. The genetic influence is subject to gene-environment interaction; that is, children with high behavioral inhibition are more susceptible to environmental influences, such as socially anxious modeling by parents. Also, social anxiety disorder is heritable (but performance-only anxiety less so). First-degree relatives have a two to six times greater chance of having social anxiety dis- order, and liability to the disorder involves the interplay of disorder-specific (e.g., fear of negative evaluation) and nonspecific (e.g., neuroticism) genetic factors. Culture-Related Diagnostic Issues The syndrome of taijin kyofusho (e.g., in Japan and Korea) is often characterized by social- evaluative concerns, fulfilling criteria for social anxiety disorder, that are associated with the fear that the individual makes other people uncomfortable (e.g., "My gaze upsets peo- ple so they look away and avoid me"), a fear that is at times experienced with delusional intensity. This symptom may also be found in non-Asian settings. Other presentations of faijin kyofusho may fulfill criteria for body dysmorphic disorder or delusional disorder. Gender-Related Diagnostic Issues Females with social anviety disorder report a greater number of social tears and comorbid depressive, bipolar and anxiety disorders, whereas males are more likely to fear dating, have oppositional defiant disorder or conduct disorder, and use alcohol and illicit drugs in relieve symptoms of the disorder. Paruresis is more common in males. Functional Consequences of Social Anxiety Disorder Social anxiety disorder is associated with elevated rates of school dropout and with de- creased well-being, employment, workplace productivity, socioeconomic status, and quality of life. Social anxiety disorder is also associated with being single, unmarried, or divorced and with not having children, particularly among men. In older adults, there may be impair- ment in caregiving duties and volunteer activities. Social anxiety disorder also impedes lei- sure activities. Despite the extent of distress and social impairment associated with social anxiety disorder, only about half of individuals with the disorder in Western societies ever seek treatment, and they tend to do so only after 15-20 years of experiencing symptoms. Not being employed is a strong predictor for the persistence of social anxiety disorder. Differential Diagnosis Normative shyness. Shyness (ie, social reticence) is a common personality trait and is not by itself pathological. In some societies, shyness is even evaluated positively. How. ever. when there is a significant adverse impact on social, occupational, and other important areas of functioning, a diagnosis of social anxiety disorder should be considered, and when full diagnostic criteria for social anxiety disorder are met, the disorder should be di agnosed. Only a minority (12%) of self-identified shy individuals in the United States have symptoms that meet diagnostic criteria for social anxiety disorder. Agoraphobia. Individuals with agoraphobia may fear and avoid social situations (e.g, go- ing to a movie) because escape might be difficult or help might not be available in the event of incapacitation or panic-like symptoms, whereas individuals with social anxiety disorder are most fearful of scrutiny by others. Moreover, individuals with social anxiety disorder are likely to be calm when left entirely alone, which is often not the case in agoraphobia. Panic disorder. Individuals with social anxiety disorder may have panic attacks, but the concern is about fear of negative evaluation, whereas in panic disorder the concern is about the panic attacks themselves. Generalized anxiety disorder. Social worries are common in generalized anxiety disorder, but the focus is more on the nature of ongoing relationships rather than on fear of negative evaluation. Individuals with generalized anxiety disorder, particularly children, may have ex- cessive worries about the quality of their social performance, but these worries also pertain to nonsocial performance and when the individual is not being evaluated by others. In social ant- iety disorder, the worries focus on social performance and others' evaluation. Separation anxiety disorder. Individuals with separation anxiety disorder may avoid social settings (including school refusal) because of concerns about being separated from attachment figures or, in children, about requiring the presence of a parent when it is not developmentally appropriate. Individuals with separation anxiety disorder are usually comfortable in social settings when their attachment figure is present or when they are at Home, where is those with social anxiety disorder may be uncomfortable when social situation occur at home or in the presence of attachment figures Specific phobias. Individuals with specific phobias may fear embarrassment or humil- lation (e.g., embarrassment about fainting when they have their blood drawn), but they do not generally fear negative evaluation in other social situations. Selective mutism. Individuals with selective mutism may fail to speak because of fear of negative evaluation, but they do not fear negative evaluation in social situations where no speaking is required (e.g., nonverbal play). Major depressive disorder. Individuals with major depressive disorder may be con- cerned about being negatively evaluated by others because they feel they are bad or not worthy of being liked. In contrast, individuals with social anxiety disorder are worried about being negatively evaluated because of certain social behaviors or physical symptoms. Body dysmorphic disorder. Individuals with body dysmorphic disorder are preoccu- pied with one or more perceived defects or flaws in their physical appearance that are not observable or appear slight to others; this preoccupation often causes social anxiety and avoidance. If their social fears and avoidance are caused only by their beliefs about their appearance, a separate diagnosis of social anxiety disorder is not warranted. Delusional disorder. Individuals with delusional disorder may have nonbizarre delu- sions and/ or hallucinations related to the delusional theme that focus on being rejected by or offending others. Although extent of insight into beliefs about social situations may vary, many individuals with social anxiety disorder have good insight that their beliefs are out of proportion to the actual threat posed by the social situation. Autism spectrum disorder. Social anxiety and social communication deficits are hall- marks of autism spectrum disorder. Individuals with social anxiety disorder typically have adequate age-appropriate social relationships and social communication capacity, although they may appear to have impairment in these areas when first interacting with unfamiliar peers or adults. Personality disorders. Given its frequent onset in childhood and its persistence into and through adulthood, social anxiety disorder may resemble a personality disorder. The most apparent overlap is with avoidant personality disorder. Individuals with avoidant person- ality disorder have a broader avoidance pattern than those with social anxiety disorder. Nonetheless, social anxiety disorder is typically more comorbid with avoidant personality disorder than with other personality disorders, and avoidant personality disorder is more comorbid with social anxiety disorder than with other anxiety disorders. Other mental disorders. Social fears and discomfort can occur as part of schizophrenia, but other evidence for psychotic symptoms is usually present. In individuals with an eat- ing disorder, it is important to determine that fear of negative evaluation about eating disorder symptoms or behaviors (e.g., purging and vomiting) is not the sole source of so- cial anxiety before applying a diagnosis of social anxiety disorder. Similarly, obsessive- compulsive disorder may be associated with social anxiety, but the additional diagnosis of social anxiety disorder is used only when social fears and avoidance are independent of the foci of the obsessions and compulsions. Other medical conditions. Medical conditions may produce symptoms that may be em- barrassing (e.g. trembling in Parkinson's disease). When the fear of negative evaluation due to other medical conditions is excessive, a diagnosis of social anxiety disorder should be considered. Oppositional defiant disorder. Refusal to speak due to opposition to authority figures should be differentiated from failure to speak due to fear of negative evaluation. Comorbidity Social anxiety disorder is often comorbid with other anxiety disorders, major depressive disordet, and substance use disorders, and the onset of social anxiety disprder general, precedes that of the other disorders, except for specific phobia and separation anxiety dis order. Chronic social isolation in the course of a social anxiety disorder may result in major depressive disorder. Comorbidity with depression is high also in older adults. Substances may be used as self-medication for social fears, but the symptoms of substance intoxica. tion or withdrawal, such as trembling, may also be a source of (further) social fear. Social anxiety disorder is frequently comorbid with bipolar disorder or body dysmorphic disor. der; for example, an individual has body dysmorphic disorder concerning a preoccupa- tion with a slight irregularity of her nose, as well as social anxiety disorder because of a severe fear of sounding unintelligent. The more generalized form of social anxiety disor. der, but not social anxiety disorder, performance only, is often comorbid with avoidant personality disorder. In children, comorbidities with high-functioning autism and selec- tive mutism are common.

Hoarding Disorder (DSM)

DIAGNOSTIC CRITERIA A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). D. The hoarding causes clinically significant distress or impairment in social, occupa- tional, or other important areas of functioning (including maintaining a safe environ- ment for self and others). E. The hoarding is not attributable to another medical condition (e.g., brain injury, cere- brovascular disease, Prader-Willi syndrome). F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder). Associated Features Supporting Diagnosis Other common features of hoarding disorder include indecisiveness, perfectionism, avoidance, procrastination, difficulty planning and organizing tasks, and distractibility. Some individuals with hoarding disorder live in unsanitary conditions that may be a log- ical consequence of severely cluttered spaces and/ or that are related to planning and or- ganizing difficulties. Animal hoarding can be defined as the accumulation of a large number of animals and a failure to provide minimal standards of nutrition, sanitation, and veter- inary care and to act on the deteriorating condition of the animals (including disease, star- vation, or death) and the environment (e.g., severe overcrowding, extremely unsanitary conditions). Animal hoarding may be a special manifestation of hoarding disorder. Most individuals who hoard animals also hoard inanimate objects. The most prominent differ- ences between animal and object hoarding are the extent of unsanitary conditions and the poorer insight in animal hoarding. Prevalence Nationally representative prevalence studies of hoarding disorder are not available. Com- munity surveys estimate the point prevalence of clinically significant hoarding in the United States and Europe to be approximately 2%-6%. Hoarding disorder affects both males and females, but some epidemiological studies have reported a significantly greater prevalence among males. This contrasts with clinical samples, which are predominantly female. Hoarding symptoms appear to be almost three times more prevalent in older adults (ages 55-94 years) compared with younger adults (ages 34 44 years). Development and Course Hoarding appears to begin early in life and spans well into the late stages. Hoarding symp- toms may first emerge around ages 11-15 years, start interfering with the individual's ev- eryday functioning by the mid-20s, and cause clinically significant impairment by the mid-30s. Participants in clinical research studies are usually in their 50s. Thus, the severity of hoarding increases with each decade of life. Once symptoms begin, the course of hoard- ing is often chronic, with few individuals reporting a waxing and waning course. Pathological hoarding in children appears to be easily distinguished from develop- mentally adaptive saving and collecting behaviors. Because children and adolescents typically do not control their living environment and discarding behaviors, the possible intervention of third parties (e.g., parents keeping the spaces usable and thus reducing in- terference) should be considered when making the diagnosis. Risk and Prognostic Factors Temperamental. Indecisiveness is a prominent feature of individuals with hoarding dis- order and their first-degree relatives. Environmental. Individuals with hoarding disorder often retrospectively report stressful and traumatic life events preceding the onset of the disorder or causing an exacerbation. Genetic and physiological. Hoarding behavior is familial, with about 50% of individu- als who hoard reporting having a relative who also hoards. Twin studies indicate that ap proximately 50% of the variability in hoarding behavior is attributable to additive genetic

illness anxiety disorder (DSM)

DIAGNOSTIC CRITERIA 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 medial condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate. C. 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. Specify whether: Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used. Care-avoidant type: Medical care is rarely used. Diagnostic features Most individuals with hypochondriasis are now classified as having somatic symptom disorder; however, in a minority of cases, the diagnosis of illness anxiety disorder applies instead. Illness anxiety disorder entails a preoccupation with having or acquiring a seri- ous, undiagnosed medical illness (Criterion A). Somatic symptoms are not present or, if present, are only mild in intensity (Criterion B). A thorough evaluation fails to identify a serious medical condition that accounts for the individual's concerns. While the concern may be derived from a nonpathological physical sign or sensation, the individual's dis- tress emanates not primarily from the physical complaint itself but rather from his or her anxiety about the meaning, significance, or cause of the complaint (i.e., the suspected med- ical diagnosis). If a physical sign or symptom is present, it is often a normal physiological sensation (e.g., orthostatic dizziness), a benign and self-limited dysfunction (e.g., transient tinnitus), or a bodily discomfort not generally considered indicative of disease (e.g., belch- ing). If a diagnosable medical condition is present, the individual's anxiety and preoccu- pation are clearly excessive and disproportionate to the severity of the condition (Criterion B). Empirical evidence and existing literature pertain to previously defined DM hypo- chondriasis, and it is unclear to what extent and how precisely they apply to the descrip- tion of this new diagnosis. The preoccupation with the idea that one is sick is accompanied by substantial anxiety about health and disease (Criterion C). Individuals with illness anxiety disorder are easily alarmed about illness, such as by hearing about someone else falling ill or reading a health- related news story. Their concerns about undiagnosed disease do not respond to appro- priate medical reassurance, negative diagnostic tests, or benign course. The physician's at- tempts at reassurance and symptom palliation generally do not alleviate the individual's concerns and may heighten them. Illness concerns assume a prominent place in the indi- vidual's life, affecting daily activities, and may even result in invalidism. Illness becomes a central feature of the individual's identity and self-image, a frequent topic of social dis- course, and a characteristic response to stressful life events. Individuals with the disorder often examine themselves repeatedly (e.g., examining one's throat in the mirror) (Crite- rion D). They research their suspected disease excessively (e.g., on the Internet) and re- peatedly seek reassurance from family, friends, or physicians. This incessant worrying often becomes frustrating for others and may result in considerable strain within the family. In some cases, the anxiety leads to maladaptive avoidance of situations (e.g., visiting sick family members) or activities (e.g., exercise) that these individuals fear might jeopardize their health. Associated Features Supporting Diagnosis Because they believe they are medically ill, individuals with illness anxiety disorder are encountered far more frequently in medical than in mental health settings. The majority of individuals with illness anxiety disorder have extensive yet unsatisfactory medical care, though some may be too anxious to seek medical attention. They generally have elevated rates of medical utilization but do not utilize mental health services more than the general population. They often consult multiple physicians for the same problem and obtain re- peatedly negative diagnostic test results. At times, medical attention leads to a paradoxical exacerbation of anxiety or to iatrogenic complications from diagnostic tests and proce- dures. Individuals with the disorder are generally dissatisfied with their medical care and find it unhelpful, often feeling they are not being taken seriously by physicians. At times, these concerns may be justified, since physicians sometimes are dismissive or respond with frustration or hostility. This response can occasionally result in a failure to diagnose a medical condition that is present. Prevalence Prevalence estimates of illness anxiety disorder are based on estimates of the DSM-Ill and DSM-IV diagnosis hypochondriasis. The 1- to 2-year prevalence of health anxiety and/or disease conviction in community surveys and population-based samples ranges from 1.3% to 10%. In ambulatory medical populations, the 6-month/1-year prevalence rates are be- tween 3% and 8%. The prevalence of the disorder is similar in males and females. Development and Course The development and course of illness anxiety disorder are unclear. Illness anxiety disor- der is generally thought to be a chronic and relapsing condition with an age at onset in early and middle adulthood. In population-based samples, health-related anxiety in- creases with age, but the ages of individuals with high health anxiety in medical settings do not appear to differ from those of other patients in those settings. In older individuals, health-related anxiety often focuses on memory loss; the disorder is thought to be rare in children. Risk and Prognostic Factors Environmental. Illness anxiety disorder may sometimes be precipitated by a major lite stress or a serious but ultimately benign threat to the individual's health. A history of childhood abuse or of a serious childhood illness may predispose to development of the disorder in adulthood Course modifiers. Approximately one-third to one-half of individuals with illness anxiety disorder have a transient form, which is associated with less psychiatric comorbidity, more medical comorbidity, and less severe illness anxiety disorder. Culture-Related Diagnostic Issues The diagnosis should be made with caution in individuals whose ideas about disease are congruent with widely held, culturally sanctioned beliefs. Little is known about the phe- nomenology of the disorder across cultures, although the prevalence appears to be similar across different countries with diverse cultures. Functional Consequences of Illness Anxiety Disorder Illness anxiety disorder causes substantial role impairment and decrements in physical function and health-related quality of life. Health concerns often interfere with interper- sonal relationships, disrupt family life, and damage occupational performance. Differential Diagnosis Other medical conditions. The first differential diagnostic consideration is an underly- ing medical condition, including neurological or endocrine conditions, occult malignan- cies, and other diseases that affect multiple body systems. The presence of a medical condition does not rule out the possibility of coexisting illness anxiety disorder. If a med- ical condition is present, the health-related anxiety and disease concerns are clearly dis- proportionate to its seriousness. Transient preoccupations related to a medical condition do not constitute illness anxiety disorder. Adjustment disorders. Health-related anxiety is a normal response to serious illness and is not a mental disorder. Such nonpathological health anxiety is clearly related to the medical condition and is typically time-limited. If the health anxiety is severe enough, an adjustment disorder may be diagnosed. However, only when the health anxiety is of suf- ficient duration, severity, and distress can illness anxiety disorder be diagnosed. Thus, the diagnosis requires the continuous persistence of disproportionate health-related anxiety for at least 6 months. Somatic symptom disorder. Somatic symptom disorder is diagnosed when significant somatic symptoms are present. In contrast, individuals with illness anxiety disorder have minimal somatic symptoms and are primarily concerned with the idea they are ill. Anxiety disorders. In generalized anxiety disorder, individuals worry about multiple events, situations, or activities, only one of which may involve health. In panic disorder, the individual may be concerned that the panic attacks reflect the presence of a medical ill- ness; however, although these individuals may have health anxiety, their anxiety is typi- cally very acute and episodic. In illness anxiety disorder, the health anxiety and fears are more persistent and enduring. Individuals with illness anxiety disorder may experience panic attacks that are triggered by their illness concerns. Obsessive-compulsive and related disorders. Individuals with illness anxiety disor- der may have intrusive thoughts about having a disease and also may have associated compulsive behaviors (e.g., seeking reassurance). However, in illness anxiety disorder, the preoccupations are usually focused on having a disease, whereas in obsessive-compulsive disorder (OCD), the thoughts are intrusive and are usually focused on fears of getting a disease in the future. Most individuals with OCD have obsessions or compulsions involv- ing other concerns in addition to fears about contracting disease. In body dysmorphic disorder. concerns are limited to the individual's physical appearance, which is viewed as defective or flawed. Major depressive disorder. Some individuals with a major depressive episode ruminate about their health and worry excessively about illness. A separate diagnosis of illness anxiety disorder is not made if these concerns occur only during majou depressive epi- sodes. However, if excessive illness worry persists after remission of an episode of major depressive disorder, the diagnosis of illness anxiety disorder should be considered. Psychotic disorders. Individuals with illness anxiety disorder are not delusional and can acknowledge the possibility that the feared disease is not present. Their ideas do not attain the rigidity and intensity seen in the somatic delusions occurring in psychotic dis- orders (e.g., schizophrenia; delusional disorder, somatic type; major depressive disorder, with psychotic features). True somatic delusions are generally more bizarre (e.g., that an organ is rotting or dead) than the concerns seen in illness anxiety disorder. The concerns seen in illness anxiety disorder, though not founded in reality, are plausible. Comorbidity Because illness anxiety disorder is a new disorder, exact comorbidities are unknown. Hy- pochondriasis co-occurs with anxiety disorders (in particular, generalized anxiety disor- der, panic disorder, and OCD) and depressive disorders. Approximately two-thirds of individuals with illness anxiety disorder are likely to have at least one other comorbid ma- jor mental disorder. Individuals with illness anxiety disorder may have an elevated risk for somatic symptom disorder and personality disorders.

Body Dysmorphic Disorder (DSM)

DIAGNOSTIC CRITERIA 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. Specify if: With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the indi- vidual is preoccupied with other body areas, which is often the case. Specify if: Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., "I look ugly" or "| look deformed"). With good or fair insight: The individual recognizes that the body dysmorphic disor- der beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true. With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true. Diagnostic Features Individuals with body dysmorphic disorder (formerly known as dysmorphophobia) are pre- occupied with one or more perceived defects or flaws in their physical appearance, which they believe look ugly, unattractive, abnormal, or deformed (Criterion A). The perceived flaws are not observable or appear only slight to other individuals. Concerns range from looking "unattractive" or "not right" to looking "hideous" or "like a monster." Preoccu- pations can focus on one or many body areas, most commonly the skin (e.g., perceived acne, scars, lines, wrinkles, paleness), hair (e.g., "thinning" hair or "excessive" body or fa- cial hair), or nose (e.g., size or shape). However, any body area can be the focus of concern (e.g., eyes, teeth, weight, stomach, breasts, legs, face size or shape, lips, chin, eyebrows, genitals). Some individuals are concerned about perceived asymmetry of body areas. The preoccupations are intrusive, unwanted, time-consuming (occurring, on average, 3-8 hours per day), and usually difficult to resist or control. Excessive repetitive behaviors or mental acts (e.g., comparing) are performed in re- sponse to the preoccupation (Criterion B). The individual feels driven to perform these be- haviors, which are not pleasurable and may increase anxiety and dysphoria. They are typically time-consuming and difficult to resist or control. Common behaviors are com- paring one's appearance with that of other individuals; repeatedly checking perceived defects in mirrors or other reflecting surfaces or examining them directly; excessively grooming (e.g., combing, styling, shaving, plucking, or pulling hair); camouflaging (e.g., repeatedly applying makeup or covering disliked areas with such things as a hat, clothing, makeup, or hair); seeking reassurance about how the perceived flaws look; touching dis- liked areas to check them; excessively exercising or weight lifting; and seeking cosmetic procedures. Some individuals excessively tan (e.g., to darken "pale" skin or diminish per- ceived acne), repeatedly change their clothes (e.g., to camouflage perceived defects), or compulsively shop (e.g., for beauty products). Compulsive skin picking intended to improve perceived skin defects is common and can cause skin damage, infections, or ruptured blood vessels. The preoccupation must cause clinically significant distress or im- pairment in social, occupational, or other important areas of functioning (Criterion C); usually both are present. Body dysmorphic disorder must be differentiated from an eating disorder. Muscle dysmorphia, a form of body dysmorphic disorder occurring almost exclusively in males, consists of preoccupation with the idea that one's body is too small or insuffi- ciently lean or muscular. Individuals with this form of the disorder actually have a nor- mal-looking body or are even very muscular. They may also be preoccupied with other body areas, such as skin or hair, A majority (but not all) diet, exercise, and/ or lift weights excessively, sometimes causing bodily damage. Some use potentially dangerous anabolic-androgenic androgenic steroids and other substances to try to make their body bigger and more mus. cular. Body dysmorphic disorder by proxy is a form of body dysmorphic disorder in which individuals are preoccupied with defects they perceive in another person's appear. ance. Insight regarding body dysmorphic disorder beliefs can range from good to absent/ delusional (i.e., delusional beliefs consisting of complete conviction that the individual's view of their appearance is accurate and undistorted). On average, insight is poor; one- third or more of individuals currently have delusional body dysmorphic disorder beliefs. Individuals with delusional body dysmorphic disorder tend to have greater morbidity in some areas (e.g., suicidality), but this appears accounted for by their tendency to have more severe body dysmorphic disorder symptoms. Associated Features Supporting Diagnosis Many individuals with body dysmorphic disorder have ideas or delusions of reference, believing that other people take special notice of them or mock them because of how they look. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety, social avoidance, depressed mood, neuroticism, and perfectionism as well as low extro- version and low self-esteem. Many individuals are ashamed of their appearance and their excessive focus on how they look, and are reluctant to reveal their concerns to others. A majority of individuals receive cosmetic treatment to try to improve their perceived de- fects. Dermatological treatment and surgery are most common, but any type (e.g., dental, electrolysis) may be received. Occasionally, individuals may perform surgery on them- selves. Body dysmorphic disorder appears to respond poorly to such treatments and sometimes becomes worse. Some individuals take legal action or are violent toward the clinician because they are dissatisfied with the cosmetic outcome. Body dysmorphic disorder has been associated with executive dysfunction and visual processing abnormalities, with a bias for analyzing and encoding details rather than ho- listic or configural aspects of visual stimuli. Individuals with this disorder tend to have a bias for negative and threatening interpretations of facial expressions and ambiguous sce- narios. Prevalence The point prevalence among U.S. adults is 2.4% (2.5% in females and 2.2% in males). Out- side the United States (i.e., Germany), current prevalence is approximately 1.7%-1.8%, with a gender distribution similar to that in the United States. The current prevalence is 9%-15% among dermatology patients, 7%-8% among U.S. cosmetic surgery patients, 3%- 16% among international cosmetic surgery patients (most studies), 8% among adult orth- odontia patients, and 10% among patients presenting for oral or maxillofacial surgery. Development and Course The mean age at disorder onset is 16-17 years, the median age at onset is 15 years, and the most common age at onset is 12-13 years. Two-thirds of individuals have disorder onset before age 18. Subclinical body dysmorphic disorder symptoms begin, on average, at age 12 or 13 years. Subclinical concerns usually evolve gradually to the full disorder, although some individuals experience abrupt onset of body dysmorphic disorder. The disorder appears to usually be chronic, although improvement is likely when evidence-based treatment is received. The disorder's clinical features appear largely similar in children/ adolescents and adults. Body dysmorphic disorder occurs in the elderly, but little is known about the disorder in this age group. Individuals with disorder onset before age 18 years are more likely to attempt suicide, have more comorbidity, and have gradual (rather than acute) disorder onset than those with adult-onset body dysmorphic disorder. Risk and Prognostic Factors Environmental. Body dysmorphic disorder has been associated with high rates of child- hood neglect and abuse. Genetic and physiological. The prevalence of body dysmorphic disorder is elevated in first-degree relatives of individuals with obsessive-compulsive disorder (OCD). Culture-Related Diagnostic Issues Body dysmorphic disorder has been reported internationally. It appears that the disorder may have more similarities than differences across races and cultures but that cultural values and preferences may influence symptom content to some degree. Taijin kyofusho, included in the traditional Japanese diagnostic system, has a subtype similar to body dys- morphic disorder: shubo-kyofu ("the phobia of a deformed body'). Gender-Related Diagnostic Issues Females and males appear to have more similarities than differences in terms of most clin- ical features- - for example, disliked body areas, types of repetitive behaviors, symptom severity, suicidality, comorbidity, illness course, and receipt of cosmetic procedures for body dysmorphic disorder. However, males are more likely to have genital preoccupa- tions, and females are more likely to have a comorbid eating disorder. Muscle dysmorphia occurs almost exclusively in males. Suicide Risk Rates of suicidal ideation and suicide attempts are high in both adults and children/ ado- lescents with body dysmorphic disorder. Furthermore, risk for suicide appears high in ad- olescents. A substantial proportion of individuals attribute suicidal ideation or suicide attempts primarily to their appearance concerns. Individuals with body dysmorphic dis- order have many risk factors for completed suicide, such as high rates of suicidal ideation and suicide attempts, demographic characteristics associated with suicide, and high rates of comorbid major depressive disorder. Functional Consequences of Body Dysmorphic Disorder Nearly all individuals with body dysmorphic disorder experience impaired psychosocial functioning because of their appearance concerns. Impairment can range from moderate (e.g., avoidance of some social situations) to extreme and incapacitating (e.g., being com- pletely housebound). On average, psychosocial functioning and quality of life are mark- edly poor. More severe body dysmorphic disorder symptoms are associated with poorer functioning and quality of life. Most individuals experience impairment in their job, aca- demic, or role functioning (e.g., as a parent or caregiver), which is often severe (e.g., per- forming poorly, missing school or work, not working). About 20% of youths with body dysmorphic disorder report dropping out of school primarily because of their body dys- morphic disorder symptoms. Impairment in social functioning (e.g., social activities, rela- tionships, intimacy), including avoidance, is common. Individuals may be housebound because of their body dysmorphic disorder symptoms, sometimes for years. A high pro- portion of adults and adolescents have been psychiatrically hospitalized Differential Diagnosis Normal appearance concerns and clearly noticeable physical defects. Body dysmor- phic disorder differs from normal appearance concerns in being characterized by excessive sive appearance-related preoccupations and repetitive behaviors that are time consuming are usually difficult to resist or control, and cause clinically significant distress or impais. ment in functioning. Physical defects that are clearly noticeable (i.e, not slight) are not diagnosed as body dysmorphic disorder. However, skin picking as a symptom of body dysmorphic disorder can cause noticeable skin lesions and scarring; in such cases, body dys- morphic disorder should be diagnosed. Eating disorders. In an individual with an eating disorder, concerns about being fat are considered a symptom of the eating disorder rather than body dysmorphic disorder. However, weight concerns may occur in body dysmorphic disorder. Eating disorders and body dysmorphic disorder can be comorbid, in which case both should be diagnosed. Other obsessive-compulsive and related disorders. The preoccupations and repetitive behaviors of body dysmorphic disorder differ from obsessions and compulsions in OCD in that the former focus only on appearance. These disorders have other differences, such as poorer insight in body dysmorphic disorder. When skin picking is intended to improve the appearance of perceived skin defects, body dysmorphic disorder, rather than excoria- tion (skin-picking) disorder, is diagnosed. When hair removal (plucking, pulling, or other types of removal) is intended to improve perceived defects in the appearance of facial or body hair, body dysmorphic disorder is diagnosed rather than trichotillomania (hair- pulling disorder). Illness anxiety disorder. Individuals with body dysmorphic disorder are not preoccu- pied with having or acquiring a serious illness and do not have particularly elevated levels of somatization. Major depressive disorder. The prominent preoccupation with appearance and exces- sive repetitive behaviors in body dysmorphic disorder differentiate it from major de- pressive disorder. However, major depressive disorder and depressive symptoms are common in individuals with body dysmorphic disorder, often appearing to be secondary to the distress and impairment that body dysmorphic disorder causes. Body dysmorphic disorder should be diagnosed in depressed individuals if diagnostic criteria for body dys- morphic disorder are met. Anxiety disorders. Social anxiety and avoidance are common in body dysmorphic dis- order. However, unlike social anxiety disorder (social phobia), agoraphobia, and avoidant personality disorder, body dysmorphic disorder includes prominent appearance-related preoccupation, which may be delusional, and repetitive behaviors, and the social anxiety and avoidance are due to concerns about perceived appearance defects and the belief or fear that other people will consider these individuals ugly, ridicule them, or reject them be- cause of their physical features. Unlike generalized anxiety disorder, anxiety and worry in body dysmorphic disorder focus on perceived appearance flaws. Psychotic disorders. Many individuals with body dysmorphic disorder have delu- sional appearance beliefs (i.e., complete conviction that their view of their perceived de- fects is accurate), which is diagnosed as body dysmorphic disorder, with absent insight/ delusional beliefs, not as delusional disorder. Appearance-related ideas or delusions of reference are common in body dysmorphic disorder; however, unlike schizophrenia or schizoaffective disorder, body dysmorphic disorder involves prominent appearance pre- occupations and related repetitive behaviors, and disorganized behavior and other psy- chotic symptoms are absent (except for appearance beliefs, which may be delusional). Other disorders and symptoms. Body dysmorphic disorder should not be diagnosed if the preoccupation is limited to discomfort with or a desire to be rid of one's primary and/ or secondary sex characteristics in an individual with gender dysphoria or if the preoccu- pation focuses on the belief that one emits a foul or offensive body odor as in olfactory reference syndrome (which is not a DSM-5 disorder). Body identity integrity disorder (apotemnophilia) (which is not a DSM-5 disorder) involves a desire to have a limb ampu- tated to correct an experience of mismatch between a person's sense of body identity and his or her actual anatomy. However, the concern does not focus on the limb's appearance, as it would in body dysmorphic disorder. Koro, a culturally related disorder that usually occurs in epidemics in Southeastern Asia, consists of a fear that the penis (labia, nipples, or breasts in females) is shrinking or retracting and will disappear into the abdomen, often accompanied by a belief that death will result. Koro differs from body dysmorphic disor- der in several ways, including a focus on death rather than preoccupation with perceived ugliness. Dysmorphic concern (which is not a DSM-5 disorder) is a much broader construct than, and is not equivalent to, body dysmorphic disorder. It involves symptoms reflecting an overconcern with slight or imagined flaws in appearance. Comorbidity Major depressive disorder is the most common comorbid disorder, with onset usually af- ter that of body dysmorphic disorder. Comorbid social anxiety disorder (social phobia), OCD, and substance-related disorders are also common.

Delusion types

DELUSIONS Persecutory Reference Control Grandiose Nihilism Erotomania Jealousy Doubles A fixed belief held with strong conviction despite evidence to the contrary Person or force is interfering with them, observing them or wishes harm to the patient Random events take on a personal significance (directed at them). Some agency takes control of the patient's thoughts, feelings & behaviors. Unrealistic beliefs in one's powers & abilities. Exaggerated belief in the futility of everything & catastrophic events Believes another person is in love with them. Somebody is suspected of being unfaithful. Believes a family member or close person has been replaced by an identical double.

obsessive-compulsive personality disorder (DSM)

DIAGNOSTIC CRITERIA 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. Diagnostic Features The essential feature of obsessive-compulsive personality disorder is a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. This pattern begins by early adulthood and is present in a variety of contexts. Individuals with obsessive-compulsive personality disorder attempt to maintain a sense of control through painstaking attention to rules, trivial details, procedures, lists, schedules, or form to the extent that the major point of the activity is lost (Criterion 1). They are excessively careful and prone to repetition, paying extraordinary attention to detail and repeatedly checking for possible mistakes. They are oblivious to the fact that other people tend to become very annoyed at the delays and inconveniences that result from this behavior. For example, when such individuals misplace a list of things to be done, they will spend an inordinate amount of time looking for the list rather than spending a few moments re-creating it from memory and proceeding to accomplish the tasks. Time is poorly allocated, and the most important tasks are left to the last moment. The perfection- ism and self-imposed high standards of performance cause significant dysfunction and distress in these individuals. They may become so involved in making every detail of a project absolutely perfect that the project is never finished (Criterion 2). For example, the completion of a written report is delayed by numerous time-consuming rewrites that all come up short of "perfection. Deadlines are missed, and aspects of the individual's life that are not the current focus of activity may fall into disarray. Individuals with obsessive-compulsive personality disorder display excessive devotion to work and productivity to the exclusion of leisure activities and friendships (Criterion 3). This behavior is not accounted for by economic necessity. They often feel that they do not have time to take an evening or a weekend day off to go on an outing or to just relax. They may keep postponing a pleasurable activity, such as a vacation, so that it may never occur. When they do take time for leisure activities or vacations, they are very uncomfortable un- less they have taken along something to work on so they do not "waste time. ." There may be a great concentration on household chores (e.g., repeated excessive cleaning so that "one could eat off the floor"). If they spend time with friends, it is likely to be in some kind of for- mally organized activity (e.g., sports). Hobbies or recreational activities are approached as serious tasks requiring careful organization and hard work to master. The emphasis is on perfect performance. These individuals turn play into a structured task (e.g., correcting an infant for not putting rings on the post in the right order; telling a toddler to ride his or her tri- cycle in a straight line; turning a baseball game into a harsh "lesson'). Individuals with obsessive-compulsive personality disorder may be excessively con- scientious, scrupulous, and inflexible about matters of morality, ethics, or values (Crite- rion 4). They may force themselves and others to follow rigid moral principles and very strict standards of performance. They may also be mercilessly self-critical about their own mistakes. Individuals with this disorder are rigidly deferential to authority and rules and insist on quite literal compliance, with no rule bending for extenuating circumstances. For example, the individual will not lend a quarter to a friend who needs one to make a tele- phone call because "neither a borrower nor a lender be" or because it would be "bad" for the person's character. These qualities should not be accounted for by the individual's cultural or religious identification. Individuals with this disorder may be unable to discard worn-out or worthless objects, even when they have no sentimental value (Criterion 5). Often these individuals will ad- mit to being "pack rats." They regard discarding objects as wasteful because " you never know when you might need something' and will become upset if someone tries to get rid of the things they have saved. Their spouses or roommates may complain about the amount of space taken up by old parts, magazines, broken appliances, and so on. Individuals with obsessive-compulsive personality disorder are reluctant to delegate tasks or to work with others (Criterion 6). They stubbornly and unreasonably insist that everything be done their way and that people conform to their way of doing things. They often give very detailed instructions about how things should be done (e.g., there is one and only one way to mow the lawn, wash the dishes, build a doghouse) and are surprised and irritated if others suggest creative alternatives. At other times they may reject offers of help even when behind schedule because they believe no one else can do it right. Individuals with this disorder may be miserly and stingy and maintain a standard of living far below what they can afford, believing that spending must be tightly controlled to provide for future catastrophes (Criterion 7). Obsessive-compulsive personality disorder is characterized by rigidity and stubbornness (Criterion 8). Individuals with this disorder are so concerned about having things done the one "correct" way that they have trouble going along with anyone else's ideas. These individuals plan ahead in meticulous detail and are unwilling to consider changes. Totally wrapped up in their own perspective, they have difficulty acknowledging the viewpoints of others. Friends and colleagues may be- come frustrated by this constant rigidity. Even when individuals with obsessive-compul- sive personality disorder recognize that it may be in their interest to compromise, they may stubbornly refuse to do so, arguing that it is "the principle of the thing" Associated Features Supporting Diagnosis When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, often painful process. Individuals with obsessive- compulsive personality disorder may have such difficulty deciding which tasks take pri- ority or what is the best way of doing some particular task that they may never get started on anything. They are prone to become upset or angry in situations in which they are not able to maintain control of their physical or interpersonal environment, although the an- ger is typically not expressed directly. For example, an individual may be angry when ser- vice in a restaurant is poor, but instead of complaining to the management, the individual ruminates about how much to leave as a tip. On other occasions, anger may be expressed with righteous indignation over a seemingly minor matter. Individuals with this disorder may be especially attentive to their relative status in dominance-submission relationships and may display excessive deference to an authority they respect and excessive resistance to authority they do not respect. Individuals with this disorder usually express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally ex- pressive. Their everyday relationships have a formal and serious quality, and they may be stiff in situations in which others would smile and be happy (e.g., greeting a lover at the airport). They carefully hold themselves back until they are sure that whatever they say will be perfect. They may be preoccupied with logic and intellect, and intolerant of affec- tive behavior in others. They often have difficulty expressing tender feelings, rarely pay- ing compliments. Individuals with this disorder may experience occupational difficulties and distress, particularly when confronted with new situations that demand flexibility and compromise Individuals with anxiety disorders, including generalized anxiety disorder, social anx- iety disorder (social phobia), and specific phobias, and obsessive-compulsive disorder (OCD) have an increased likelihood of having a personality disturbance that meets criteria for obsessive-compulsive personality disorder. Even so, it appears that the majority of individ- uals with OCD do not have a pattern of behavior that meets criteria for this personality disorder. Many of the features of obsessive-compulsive personality disorder overlap with "type A" personality characteristics (e.g., preoccupation with work, competitiveness, time urgency), and these features may be present in people at risk for myocardial infarction. There may be an association between obsessive-compulsive personality disorder and de- pressive and bipolar disorders and eating disorders. Prevalence Obsessive-compulsive personality disorder is one of the most prevalent personality dis- orders in the general population, with estimated prevalence ranging from 2.1% to 7.9%. Culture-Related Diagnostic Issues In assessing an individual for obsessive-compulsive personality disorder, the clinician should not include those behaviors that reflect habits, customs, or interpersonal styles that are culturally sanctioned by the individual's reference group. Certain cultures place sub- stantial emphasis on work and productivity; the resulting behaviors in members of those societies need not be considered indications of obsessive-compulsive personality disorder. Gender-Related Diagnostic Issues In systematic studies, obsessive-compulsive personality disorder appears to be diagnosed about twice as often among males. Differential Diagnosis Obsessive-compulsive disorder. Despite the similarity in names, OCD is usually easily distinguished from obsessive-compulsive personality disorder by the presence of true ob- sessions and compulsions in OCD. When criteria for both obsessive-compulsive person- ality disorder and OCD are met, both diagnoses should be recorded. Hoarding disorder. A diagnosis of hoarding disorder should be considered especially when hoarding is extreme (e.g., accumulated stacks of worthless objects present a fire haz- ard and make it difficult for others to walk through the house). When criteria for both ob- sessive-compulsive personality disorder and hoarding disorder are met, both diagnoses should be recorded. Other personality disorders and personality traits. Other personality disorders may be confused with obsessive-compulsive personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to obsessive- compulsive personality disorder, all can be diagnosed. Individuals with narcissistic per- sonality disorder may also profess a commitment to perfectionism and believe that others cannot do things as well, but these individuals are more likely to believe that they have achieved perfection, whereas those with obsessive-compulsive personality disorder are usually self-critical. Individuals with narcissistic or antisocial personality disorder lack generosity but will indulge themselves, whereas those with obsessive-compulsive person- ality disorder adopt a miserly spending style toward both self and others. Both schizoid personality disorder and obsessive-compulsive personality disorder may be characterized by an apparent formality and social detachment. In obsessive-compulsive personality dis- order, this stems from discomfort with emotions and excessive devotion to work, whereas in schizoid personality disorder there is a fundamental lack of capacity for intimacy. Obsessive-compulsive personality traits in moderation may be especially adaptive, par- ticularly in situations that reward high performance. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective dis- tress do they constitute obsessive-compulsive personality disorder. Personality change due to another medical condition. Obsessive-compulsive person- ality disorder must be distinguished from personality change due to another medical con- dition, in which the traits emerge attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Obsessive-compulsive personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

schizoaffective disorder (DSM)

DIAGNOSTIC CRITERIA A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. 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. Diagnostic Features The diagnosis of schizoaffective disorder is based on the assessment of an uninterrupted period of illness during which the individual continues to display active or residual symptoms of psychotic illness. The diagnosis is usually, but not necessarily, made during the period of psychotic illness. At some time during the period, Criterion A for schizophrenia has to be met. Criteria B (social dysfunction) and F (exclusion of autism spectrum disorder or other communication disorder of childhood onset) for schizophrenia do not have to be met. In addition to meeting Criterion A for schizophrenia, there is a major mood episode (major depressive or manic) (Criterion A for schizoaffective disorder). Because loss of in- terest or pleasure is common in schizophrenia, to meet Criterion A for schizoaffective dis- order, the major depressive episode must include pervasive depressed mood (i.e., the presence of markedly diminished interest or pleasure is not sufficient). Episodes of de- pression or mania are present for the majority of the total duration of the illness (i.e., after Criterion A has been met) (Criterion C for schizoaffective disorder). To separate schizoaf- fective disorder from a depressive or bipolar disorder with psychotic features, delusions or hallucinations must be present for at least 2 weeks in the absence of a major mood epi- sode (depressive or manic) at some point during the lifetime duration of the illness (Cri- terion B for schizoaffective disorder). The symptoms must not be attributable to the effects of a substance or another medical condition (Criterion D for schizoaffective disorder). Criterion C for schizoaffective disorder specifies that mood symptoms meeting criteria for a major mood episode must be present for the majority of the total duration of the ac- tive and residual portion of the illness. Criterion C requires the assessment of mood symp- toms for the entire course of a psychotic illness, which differs from the criterion in DSM-IV. which required only an assessment of the current period of illness. If the mood symptoms are present for only a relatively brief period, the diagnosis is schizophrenia, not schizoaf- fective disorder. When deciding whether an individual's presentation meets Criterion C, the clinician should review the total duration of psychotic illness (i.e., both active and re- sidual symptoms) and determine when significant mood symptoms (untreated or in need of treatment with antidepressant and / or mood-stabilizing medication) accompanied the psychotic symptoms. This determination requires sufficient historical information and clinical judgment. For example, an individual with a 4-year history of active and residual symptoms of schizophrenia develops depressive and manic episodes that, taken together, do not occupy more than 1 year during the 4-year history of psychotic illness. This presen- tation would not meet Criterion C. In addition to the five symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and mania symptom domains is vital for making crit- ically important distinctions between the various schizophrenia spectrum and other psy- chotic disorders. Associated Features Supporting Diagnosis Occupational functioning is frequently impaired, but this is not a defining criterion (in contrast to schizophrenia). Restricted social contact and difficulties with self-care are as- sociated with schizoaffective disorder, but negative symptoms may be less severe and less persistent than those seen in schizophrenia. Anosognosia (i.e., poor insight) is also com- mon in schizoaffective disorder, but the deficits in insight may be less severe and perva- sive than those in schizophrenia. Individuals with schizoaffective disorder may be at increased risk for later developing episodes of major depressive disorder or bipolar disor- der if mood symptoms continue following the remission of symptoms meeting Criterion A for schizophrenia. There may be associated alcohol and other substance-related disorders. There are no tests or biological measures that can assist in making the diagnosis of schizoaffective disorder. Whether schizoaffective disorder differs from schizophrenia with regard to associated features such as structural or functional brain abnormalities, cognitive deficits, or genetic risk factors is not clear. Prevalence Schizoaffective disorder appears to be about one-third as common as schizophrenia. Life- time prevalence of schizoaffective disorder is estimated to be 0.3%. The incidence of schizoaffective disorder is higher in females than in males, mainly due to an increased in- cidence of the depressive type among females. Development and Course The typical age at onset of schizoaffective disorder is early adulthood, although onset can occur anywhere from adolescence to late in life. A significant number of individuals diag- nosed with another psychotic illness initially will receive the diagnosis schizoaffective dis- order later when the pattern of mood episodes has become more apparent. With the current diagnostic Criterion C, it is expected that the diagnosis for some individuals will convert from schizoaffective disorder to another disorder as mood symptoms become less prominent. The prognosis for schizoaffective disorder is somewhat better than the prog- nosis for schizophrenia but worse than the prognosis for mood disorders. Schizoaffective disorder may occur in a variety of temporal patterns. The following is a typical pattern: An individual may have pronounced auditory hallucinations and per- secutory delusions for 2 months before the onset of a prominent major depressive episode. The psychotic symptoms and the full major depressive episode are then present for 3 months. Then, the individual recovers completely from the major depressive episode, but the psy- chotic symptoms persist for another month before they too disappear. During this period of illness, the individual's symptoms concurrently met criteria for a major depressive ep- isode and Criterion A for schizophrenia, and during this same period of illness, auditory hallucinations and delusions were present both before and after the depressive phase. The total period of illness lasted for about 6 months, with psychotic symptoms alone present during the initial 2 months, both depressive and psychotic symptoms present during the next 3 months, and psychotic symptoms alone present during the last month. In this in- stance, the duration of the depressive episode was not brief relative to the total duration of the psychotic disturbance, and thus the presentation qualifies for a diagnosis of schizoaf- fective disorder. The expression of psychotic symptoms across the lifespan is variable. Depressive or manic symptoms can occur before the onset of psychosis, during acute psychotic episodes, during residual periods, and after cessation of psychosis. For example, an individual might present with prominent mood symptoms during the prodromal stage of schizo- phrenia. This pattern is not necessarily indicative of schizoaffective disorder, since it is the co-occurrence of psychotic and mood symptoms that is diagnostic. For an individual with symptoms that clearly meet the criteria for schizoaffective disorder but who on further fol- low-up only presents with residual psychotic symptoms (such as subthreshold psychosis and/or prominent negative symptoms), the diagnosis may be changed to schizophrenia, as the total proportion of psychotic illness compared with mood symptoms becomes more prominent. Schizoaffective disorder, bipolar type, may be more common in young adults, whereas schizoaffective disorder, depressive type, may be more common in older adults. Risk and Prognostic Factors Genetic and physiological. Among individuals with schizophrenia, there may be an increased risk for schizoaffective disorder in first-degree relatives. The risk for schizoaffective disorder may be increased among individuals who have a first-degree relative with schizophrenia, bipolar disorder, or schizoaffective disorder. Culture-Related Diagnostic Issues Cultural and socioeconomic factors must be considered, particularly when the individual and the clinician do not share the same cultural and economic background. Ideas that ap- pear to be delusional in one culture (e.g., witchcraft) may be commonly held in another. There is also some evidence in the literature for the overdiagnosis of schizophrenia compared with schizoaffective disorder in African American and Hispanic populations, so care must be taken to ensure a culturally appropriate evaluation that includes both psy- chotic and affective symptoms. Suicide Risk The lifetime risk of suicide for schizophrenia and schizoaffective disorder is 5%, and the presence of depressive symptoms is correlated with a higher risk for suicide. There is ev- idence that suicide rates are higher in North American populations than in European, Eastern European, South American, and Indian populations of individuals with schizo- phrenia or schizoaffective disorder. Functional Consequences of Schizoaffective Disorder Schizoaffective disorder is associated with social and occupational dysfunction, but dys- function is not a diagnostic criterion (as it is for schizophrenia), and there is substantial variability between individuals diagnosed with schizoaffective disorder. Differential Diagnosis Other mental disorders and medical conditions. A wide variety of psychiatric and medical conditions can manifest with psychotic and mood symptoms that must be considered in the differential diagnosis of schizoaffective disorder. These include psychotic disorder due to another medical condition; delirium; major neurocognitive disorder; substance / medication-induced psychotic disorder or neurocognitive disorder; bipolar disorders with psychotic features; major depressive disorder with psychotic features; depressive or bipolar disorders with catatonic features; schizotypal, schizoid, or paranoid personality disorder; brief psychotic disorder; schizophreniform disorder; schizophrenia; delusional disorder; and other specified and unspecified schizophrenia spectrum and other psychotic disorders. Medical conditions and substance use can present with a combination of psy- chotic and mood symptoms, and thus psychotic disorder due to another medical condition needs to be excluded. Distinguishing schizoaffective disorder from schizophrenia and from depressive and bipolar disorders with psychotic features is often difficult. Criterion C is designed to separate schizoaffective disorder from schizophrenia, and Criterion B is designed to distinguish schizoaffective disorder from a depressive or bipolar disorder with psychotic features. More specifically, schizoaffective disorder can be distinguished from a depressive or bipolar disorder with psychotic features due to the presence of prom- inent delusions and / or hallucinations for at least 2 weeks in the absence of a major mood episode. In contrast, in depressive or bipolar disorders with psychotic features, the psy- chotic features primarily occur during the mood episode(s). Because the relative propor- tion of mood to psychotic symptoms may change over time, the appropriate diagnosis may change from and to schizoaffective disorder (e.g., a diagnosis of schizoaffective dis- order for a severe and prominent major depressive episode lasting 3 months during the first 6 months of a persistent psychotic illness would be changed to schizophrenia if active psychotic or prominent residual symptoms persist over several years without a recurrence of another mood episode). Psychotic disorder due to another medical condition. Other medical conditions and substance use can manifest with a combination of psychotic and mood symptoms, and thus psychotic disorder due to another medical condition needs to be excluded. Schizophrenia, bipolar, and depressive disorders. Distinguishing schizoaffective dis- order from schizophrenia and from depressive and bipolar disorders with psychotic fea- tures is often difficult. Criterion C is designed to separate schizoaffective disorder from schizophrenia, and Criterion B is designed to distinguish schizoaffective disorder from a depressive or bipolar disorder with psychotic features. More specifically, schizoaffective disorder can be distinguished from a depressive or bipolar disorder with psychotic features based on the presence of prominent delusions and /or hallucinations for at least 2 weeks in the absence of a major mood episode. In contrast, in depressive or bipolar disorder with Psychotic features, the psychotic features primarily occur during the mood episode(s). Be- cause the relative proportion of mood to psychotic symptoms may change over time, the appropriate diagnosis may change from and to schizoaffective disorder. (For example, a diagnosis of schizoaffective disorder for a severe and prominent major depressive episode lasting 3 months during the first 6 months of a chronic psychotic illness would be changed to schizophrenia if active psychotic or prominent residual symptoms persist over several years without a recurrence of another mood episode.) Comorbidity Many individuals diagnosed with schizoaffective disorder are also diagnosed with other mental disorders, especially substance use disorders and anxiety disorders. Similarly, the incidence of medical conditions is increased above base rate for the general population and leads to decreased life expectancy.

PTSD (Post Traumatic Stress Disorder)

DIAGNOSTIC CRITERIA • Exposure to actual or threatened death, serious injury or sexual violence via 1) direct experience of the traumatic event, 2) witnessing the event in person, 3) learning the event happened to someone close (family member or friend) or 4) experiencing extreme or repeated exposure to aversive details of the traumatic event (eg, first responders collecting human remains during 9/11, war, rape, natural disasters). • Traumatic event occurred anytime in the past. • Presence of at least 1 of the following intrusion symptoms after the event that may lead to significant distress or impairment in function (eg, occupational, social or other areas). • Re-experiencing: >1 month as repetitive recollections (eg, distressing dreams) & dissociative reactions (eg, flashbacks in which the person feels/acts as if the event is recurring), leading to physiologic distress &/or physiologic reactions. • Avoidance of stimuli associated with the traumatic event (reminders of the events). • At least 2 negative alterations in cognition & mood: inability to remember an important aspect of the event, dissociative amnesia, negative feelings of self, world or others, anhedonia, negative emotions (eg, horror guilt, anger or shame), feelings of detachment or inability to experience positive emotions. • At least 2 arousal & reactivity symptoms: angry outbursts, irritable behavior, reckless or self- destructive behaviors, hypervigilance, sleep disturbances, concentration issues, & exaggerated startle response. MANAGEMENT • SSRIs first-line medical treatment (eg, Paroxetine, Sertraline, Fluoxetine). Tricyclic antidepressants (eg, Imipramine). MAO inhibitors. May be augmented with atypical antipsychotics. • Trazodone may be helpful for insomnia. • Cognitive behavioral therapy: psychotherapy including individual or group counseling. Relaxation techniques. • Prazosin may be used for nightmares and hypervigilance.

Acute stress disorder

DIAGNOSTIC CRITERIA • Symptoms similar to PTSD except the traumatic event occurred < 1 month ago and the symptoms last < 1 month. • The symptoms include intrusive symptoms, avoidance, increased arousal, and negative alterations in thought and mood. MANAGEMENT: • Counseling & psychotherapy first-line because by definition the symptoms will resolve in 1 month. • If symptoms > 1 month, treat as PTSD.

Specific phobias

DIAGNOSTIC CRITERIA •Persistent (at least 6 months) intense fear or anxiety of a specific situation (eg, heights, flying), object (eg, pigeons, snakes, blood) or place (eg, hospital). •Exposure to the situation triggers an immediate response •The fear is out of proportion to any real danger. •The phobic object or situation is actively avoided or endured with intense fear or anxiety. •Everyday activities must be impaired by distress or avoidance of the situation or object. •Not due to substance use or medical condition SUBTYPES •Animal (eg, spiders, dogs, mice), situational (eg, airplanes, elevators), natural environment (eg, heights, thunder, water) & blood-injection injury (injuries, needle injections, or blood). MANAGEMENT •Exposure & desensitization therapy treatment of choice. •Short-term benzodiazepines or beta-blockers can be used in some patients.

binge eating disorder

DIAGNOSTIC CRITERIA •Recurrent episodes of binge eating - recurrent episodes characterized by eating within a 2-hour period more than people would in a similar period with lack of control during an overeating episode. Occurs at least weekly for 3 months. •Severe distress over binge eating. •May be triggered by stress or mood changes. Patients are often obese. •Unlike Bulimia nervosa, Binge-eating episodes are not associated with compensatory behaviors (eg, purging or restrictive behaviors) and they are not as fixated on their body shape or weight. MANAGEMENT •Psychotherapy (eg, cognitive behavioral therapy, interpersonal, dialectic behavioral) •Strict diet & exercise plan. •Topiramate (antiepileptic associated with weight loss). •Stimulants: appetite suppressants (eg, Lisdexamfetamine, Amphetamine).

narcissistic personality disorder (DSM)

DIAGNOSTIC CRITERIA 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. Diagnostic Features The essential feature of narcissistic personality disorder is a pervasive pattern of grandi- osity, need for admiration, and lack of empathy that begins by early adulthood and is pres- ent in a variety of contexts. Individuals with this disorder have a grandiose sense of self-importance (Criterion 1). They routinely overestimate their abilities and inflate their accomplishments, often appearing boastful and pretentious. They may blithely assume that others attribute the same value to their efforts and may be surprised when the praise they expect and feel they deserve is not forthcoming. Often implicit in the inflated judgments of their own accomplishments is an un- derestimation (devaluation) of the contributions of others. Individuals with narcissistic per- sonality disorder are often preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love (Criterion 2). They may ruminate about "long overdue " admiration and privilege and compare themselves favorably with famous or privileged people. Individuals with narcissistic personality disorder believe that they are superior, spe- cial, or unique and expect others to recognize them as such (Criterion 3). They may feel that they can only be understood by, and should only associate with, other people who are special or of high status and may attribute "unique, "perfect, ," or "gifted" qualities to those with whom they associate. Individuals with this disorder believe that their needs are spe- cial and beyond the ken of ordinary people. Their own self-esteem is enhanced (i.e., "mir- rored") by the idealized value that they assign to those with whom they associate. They are likely to insist on having only the "top "person (doctor, lawyer, hairdresser, instructor) or being affiliated with the "best" institutions but may devalue the credentials of those who dis- appoint them. Individuals with this disorder generally require excessive admiration (Criterion 4). Their self-esteem is almost invariably very fragile. They may be preoccupied with how well they are doing and how favorably they are regarded by others. This often takes the form of a need for constant attention and admiration. They may expect their arrival to be greeted with great fanfare and are astonished if others do not covet their possessions. They may constantly fish for compliments, often with great charm. A sense of entitlement is evident in these individ- uals' unreasonable expectation of especially favorable treatment (Criterion 5). They expect to be catered to and are puzzled or furious when this does not happen. For example, they may assume that they do not have to wait in line and that their priorities are so important that others should defer to them, and then get irritated when others fail to assist "in their very important work." This sense of entitlement, combined with a lack of sensitivity to the wants and needs of others, may result in the conscious or unwitting exploitation of others (Criterion 6). They expect to be given whatever they want or feel they need, no matter what it might mean to others. For example, these individuals may expect great dedication from others and may overwork them without regard for the impact on their lives. They tend to form friendships or romantic relationships only if the other person seems likely to advance their purposes or otherwise enhance their self-esteem. They often usurp special privileges and extra resources that they believe they deserve because they are so special. Individuals with narcissistic personality disorder generally have a lack of empathy and have difficulty recognizing the desires, subjective experiences, and feelings of others (Crite- rion7). They may assume that others are totally concerned about their welfare. They tend to discuss their own concerns in inappropriate and lengthy detail, while failing to recognize that others also have feelings and needs. They are often contemptuous and impatient with others who talk about their own problems and concerns. These individuals may be oblivious to the hurt their remarks may inflict (e.g., exuberantly telling a former lover that "I am now in the relationship of a lifetime!"; boasting of health in front of someone who is sick). When recognized, the needs, desires, or feelings of others are likely to be viewed disparagingly as signs of weakness or vulnerability. Those who relate to individuals with narcissistic person- ality disorder typically find an emotional coldness and lack of reciprocal interest. These individuals are often envious of others or believe that others are envious of them (Criterion 8). They may begrudge others their successes or possessions, feeling that they better deserve those achievements, admiration, or privileges. They may harshly devalue the contri- butions of others, particularly when those individuals have received acknowledgment or praise for their accomplishments. Arrogant, haughty behaviors characterize these individuals; they often display snobbish, disdainful, or patronizing attitudes (Criterion 9). For example, an individual with this disorder may complain about a clumsy waiter's "rudeness" or "stupidity" or conclude a medical evaluation with a condescending evaluation of the physician. Associated Features Supporting Diagnosis Vulnerability in self-esteem makes individuals with narcissistic personality disorder very sensitive to "injury" from criticism or defeat. Although they may not show it outwardly, criticism may haunt these individuals and may leave them feeling humiliated, degraded, hollow, and empty. They may react with disdain, rage, or defiant counterattack. Such ex- periences often lead to social withdrawal or an appearance of humility that may mask and protect the grandiosity. Interpersonal relations are typically impaired because of problems derived from entitlement, the need for admiration, and the relative disregard for the sen- sitivities of others. Though overweening ambition and confidence may lead to high achievement, performance may be disrupted because of intolerance of criticism or defeat. Sometimes vocational functioning can be very low, reflecting an unwillingness to take a risk in competitive or other situations in which defeat is possible. Sustained feelings of shame or humiliation and the attendant self-criticism may be associated with social with- drawl, depressed mood, and persistent depressive disorder (dysthymia) or major de- pressive disorder. In contrast, sustained periods of grandiosity may be associated with a hypomanic mood. Narcissistic personality disorder is also associated with anorexia ner- vosa and substance use disorders (especially related to cocaine). Histrionic, borderline, antisocial, and paranoid personality disorders may be associated with narcissistic person- ality disorder. Prevalence Prevalence estimates for narcissistic personality disorder, based on DSM-IV definitions, range from 0% to 6.2% in community samples. Development and Course Narcissistic traits may be particularly common in adolescents and do not necessarily in- dicate that the individual will go on to have narcissistic personality disorder. Individuals with narcissistic personality disorder may have special difficulties adjusting to the onset of physical and occupational limitations that are inherent in the aging process. Gender-Related Diagnostic Issues Of those diagnosed with narcissistic personality disorder, 50%-75% are male. Differential Diagnosis Other personality disorders and personality traits. Other personality disorders may be confused with narcissistic personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differ. ences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to narcissistic person- ality disorder, all can be diagnosed. The most useful feature in discriminating narcissistic personality disorder from histrionic, antisocial, and borderline personality disorders, in which the interactive styles are coquettish, callous, and needy, respectively, is the grandi- osity characteristic of narcissistic personality disorder. The relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns also help distinguish narcissistic personality disorder from borderline personality disor- der. Excessive pride in achievements, a relative lack of emotional display, and disdain for others' sensitivities help distinguish narcissistic personality disorder from histrionic personality disorder. Although individuals with borderline, histrionic, and narcissistic personality disorders may require much attention, those with narcissistic personality dis- order specifically need that attention to be admiring. Individuals with antisocial and nar- cissistic personality disorders share a tendency to be tough-minded, glib, superficial, exploitative, and unempathic. However, narcissistic personality disorder does not neces- sarily include characteristics of impulsivity, aggression, and deceit. In addition, individu- als with antisocial personality disorder may not be as needy of the admiration and envy of others, and persons with narcissistic personality disorder usually lack the history of con- duct disorder in childhood or criminal behavior in adulthood. In both narcissistic person- ality disorder and obsessive-compulsive personality disorder, the individual may profess a commitment to perfectionism and believe that others cannot do things as well. In con- trast to the accompanying self-criticism of those with obsessive-compulsive personality disorder, individuals with narcissistic personality disorder are more likely to believe that they have achieved perfection. Suspiciousness and social withdrawal usually distinguish those with schizotypal or paranoid personality disorder from those with narcissistic per- sonality disorder. When these qualities are present in individuals with narcissistic person- ality disorder, they derive primarily from fears of having imperfections or flaws revealed. Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute narcissistic per- sonality disorder. Mania or hypomania. Grandiosity may emerge as part of manic or hypomanic episodes, but the association with mood change or functional impairments helps distinguish these episodes from narcissistic personality disorder. Substance use disorders. Narcissistic personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

borderline personality disorder (DSM)

DIAGNOSTIC CRITERIA 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 selfmutilating 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. Diagnostic Features The essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts. Individuals with borderline personality disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They ex- perience intense abandonment fears and inappropriate anger even when faced with a real- istic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician's announcing the end of the hour; panic or fury when some- one important to them is just a few minutes late or must cancel an appointment). They may believe that this "abandonment" implies they are "bad." These abandonment fears are re- lated to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or sui- cidal behaviors, which are described separately in Criterion 5 Individuals with borderline personality disorder have a pattern of unstable and intense relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, or is not "there" enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will "be there" in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected. There may be an identity disturbance characterized by markedly and persistently un- stable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self- image, characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to that of a righteous avenger of past mistreatment. Although they usually have a self- image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These in- dividuals may show worse performance in unstructured work or school situations. Individuals with borderline personality disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). They may gamble, spend money irrespon- sibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilat- ing behavior (Criterion 5). Completed suicide occurs in 8%-10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that the individual assumes increased responsibility. Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual's sense of being evil. Individuals with borderline personality disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anx- iety usually lasting a few hours and only rarely more than a few days) (Criterion 6). The basic dysphoric mood of those with borderline personality disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satis- faction. These episodes may reflect the individual's extreme reactivity to interpersonal stresses. Individuals with borderline personality disorder may be troubled by chronic feel- ings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with this disorder frequently express inappropriate, intense anger or have dif- ficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., de- personalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in re- sponse to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver's nurturance may result in a remission of symptoms. Associated Features Supporting Diagnosis Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; de- stroying a good relationship just when it is clear that the relationship could last). Some in- dividuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individu- als with this disorder, especially in those with co-occurring depressive disorders or sub- stance use disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted education, and separation or di- vorce are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in the childhood histories of those with borderline personality dis- order. Common co-occurring disorders include depressive and bipolar disorders, sub- stance use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress disorder, and attention-deficit /hyperactivity disorder. Borderline personality disorder also frequently co-occurs with the other personality disorders. Prevalence The median population prevalence of borderline personality disorder is estimated to be 1.6% but may be as high as 5.9%. The prevalence of borderline personality disorder is about 6% in primary care settings, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. The prevalence of borderline personality disorder may decrease in older age groups. Development and Course There is considerable variability in the course of borderline personality disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health re- sources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. Although the tendency to- ward intense emotions, impulsivity, and intensity in relationships is often lifelong, indi- viduals who engage in therapeutic intervention often show improvement beginning sometime during the first year. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. Fol- low-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of be- havior that meets full criteria for borderline personality disorder. Risk and Prognostic Factors Genetic and physiological. Borderline personality disorder is about five times more common among first-degree biological relatives of those with the disorder than in the gen- eral population. There is also an increased familial risk for substance use disorders, anti- social personality disorder, and depressive or bipolar disorders. Culture-Related Diagnostic Issues The pattern of behavior seen in borderline personality disorder has been identified in many settings around the world. Adolescents and young adults with identity problems (especially when accompanied by substance use) may transiently display behaviors that misleadingly give the impression of borderline personality disorder. Such situations are characterized by emotional instability, "existential" dilemmas, uncertainty, anxiety-provoking choices, con- flicts about sexual orientation, and competing social pressures to decide on careers. Gender-Related Diagnostic issues Borderline personality disorder is diagnosed predominantly (about 75%) in females. Differential Diagnosis Depressive and bipolar disorders. Borderline personality disorder often co-occurs with depressive or bipolar disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar disorder, the clinician should avoid giving an additional diagnosis of borderline personality disorder based only on cross-sectional presentation without having documented that the pattern of behavior had an early onset and a long-standing course. Other personality disorders. Other personality disorders may be confused with border- line personality disorder because they have certain features in common. It is therefore im- portant to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to borderline personality disorder, all can be diag- nosed. Although histrionic personality disorder can also be characterized by attention seek- ing, manipulative behavior, and rapidly shifting emotions, borderline personality disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be pres- ent in both borderline personality disorder and schizotypal personality disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structur- ing in borderline personality disorder. Although paranoid personality disorder and narcis- sistic personality disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image, as well as the relative lack of self-destructiveness, impul- sivity, and abandonment concerns, distinguishes these disorders from borderline person- ality disorder. Although antisocial personality disorder and borderline personality disorder are both characterized by manipulative behavior, individuals with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in borderline personality disorder is directed more toward gaining the con- cern of caretakers. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline person- ality disorder reacts to abandonment with feelings of emotional emptiness, rage, and de- mands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by the typical pattern of unstable and intense relationships. Personality change due to another medical condition. Borderline personality disor- der must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Borderline personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use. Identity problems. Borderline personality disorder should be distinguished from an identity problem, which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder.

avoidant personality disorder (DSM)

DIAGNOSTIC CRITERIA 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. Diagnostic Features The essential feature of avoidant personality disorder is a pervasive pattern of social inhi- bition, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by early adulthood and is present in a variety of contexts. Individuals with avoidant personality disorder avoid work activities that involve sig- nificant interpersonal contact because of fears of criticism, disapproval, or rejection (Cri- terion 1). Offers of job promotions may be declined because the new responsibilities might result in criticism from co-workers. These individuals avoid making new friends unless they are certain they will be liked and accepted without criticism (Criterion 2). Until they pass stringent tests proving the contrary, other people are assumed to be critical and dis- approving. Individuals with this disorder will not join in group activities unless there are repeated and generous offers of support and nurturance. Interpersonal intimacy is often difficult for these individuals, although they are able to establish intimate relationships when there is assurance of uncritical acceptance. They may act with restraint, have difficulty talking about themselves, and withhold intimate feelings for fear of being exposed, ridiculed, or shamed (Criterion 3). Because individuals with this disorder are preoccupied with being criticized or re- jected in social situations, they may have a markedly low threshold for detecting such re- actions (Criterion 4). If someone is even slightly disapproving or critical, they may feel extremely hurt. They tend to be shy, quiet, inhibited, and "invisible" because of the fear that any attention would be degrading or rejecting. They expect that no matter what they say, others will see it as "wrong, " and so they may say nothing at all. They react strongly to subtle cues that are suggestive of mockery or derision. Despite their longing to be active participants in social life, they fear placing their welfare in the hands of others. Individuals with avoidant personality disorder are inhibited in new interpersonal situations because they feel inadequate and have low self-esteem (Criterion 5). Doubts concerning social competence and personal appeal become especially manifest in settings involving inter- actions with strangers. These individuals believe themselves to be socially inept, person- ally unappealing, or inferior to others (Criterion 6). They are unusually reluctant to take personal risks or to engage in any new activities because these may prove embarrassing (Criterion 7). They are prone to exaggerate the potential dangers of ordinary situations, and a restricted lifestyle may result from their need for certainty and security. Someone with this disorder may cancel a job interview for fear of being embarrassed by not dressing appropriately. Marginal somatic symptoms or other problems may become the reason for avoiding new activities. Associated Features Supporting Diagnosis Individuals with avoidant personality disorder often vigilantly appraise the movements and expressions of those with whom they come into contact. Their fearful and tense de- meanor may elicit ridicule and derision from others, which in turn confirms their self- doubts. These individuals are very anxious about the possibility that they will react to criticism with blushing or crying. They are described by others as being "shy," "timid, "lonely," and "isolated." The major problems associated with this disorder occur in social and occupational functioning. The low self-esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals may become relatively isolated and usually do not have a large social support network that can help them weather crises. They desire affection and acceptance and may fantasize about idealized relation- ships with others. The avoidant behaviors can also adversely affect occupational function- ing because these individuals try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement. Other disorders that are commonly diagnosed with avoidant personality disorder in- clude depressive, bipolar, and anxiety disorders, especially social anxiety disorder (social phobia). Avoidant personality disorder is often diagnosed with dependent personality disorder, because individuals with avoidant personality disorder become very attached to and dependent on those few other people with whom they are friends. Avoidant per- sonality disorder also tends to be diagnosed with borderline personality disorder and with the Cluster A personality disorders (i.e., paranoid, schizoid, or schizotypal personality disorders). Prevalence Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of about 2.4% for avoidant personality disorder. Development and Course The avoidant behavior often starts in infancy or childhood with shyness, isolation, and fear of strangers and new situations. Although shyness in childhood is a common precur- sor of avoidant personality disorder, in most individuals it tends to gradually dissipate as they get older. In contrast, individuals who go on to develop avoidant personality disor- der may become increasingly shy and avoidant during adolescence and early adulthood, when social relationships with new people become especially important. There is some evidence that in adults, avoidant personality disorder tends to become less evident or to remit with age. This diagnosis should be used with great caution in children and adoles- cents, for whom shy and avoidant behavior may be developmentally appropriate. Culture-Related Diagnostic Issues There may be variation in the degree to which different cultural and ethnic groups regard diffidence and avoidance as appropriate. Moreover, avoidant behavior may be the result of problems in acculturation following immigration. Gender-Related Diagnostic Issues Avoidant personality disorder appears to be equally frequent in males and females. Differential Diagnosis Anxiety disorders. There appears to be a great deal of overlap between avoidant person- ality disorder and social anxiety disorder (social phobia), so much so that they may be alternative conceptualizations of the same or similar conditions. Avoidance also character- izes both avoidant personality disorder and agoraphobia, and they often co-occur. Other personality disorders and personality traits. Other personality disorders may be confused with avoidant personality disorder because they have certain features in com- mon. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to avoidant personality disorder. all can be diagnosed. Both avoidant personality disorder and dependent personal- ity disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance. Although the primary focus of concern in avoidant personality disorder is avoidance of humiliation and rejection, in dependent personality disorder the focus is on being taken care of. However, avoidant personality disorder and dependent personality disorder are particularly likely to co-occur. Like avoidant personality disor- der, schizoid personality disorder and schizotypal personality disorder are characterized by social isolation. However, individuals with avoidant personality disorder want to have relationships with others and feel their loneliness deeply, whereas those with schizoid or schizotypal personality disorder may be content with and even prefer their social isola- tion. Paranoid personality disorder and avoidant personality disorder are both character- ized by a reluctance to confide in others. However, in avoidant personality disorder, this reluctance is attributable more to a fear of being embarrassed or being found inadequate than to a fear of others' malicious intent. Many individuals display avoidant personality traits. Only when these traits are in- flexible, maladaptive, and persisting and cause significant functional impairment or sub- jective distress do they constitute avoidant personality disorder. Personality change due to another medical condition. Avoidant personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Avoidant personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use

Phencyclidine Use Disorder (DSM)

DIAGNOSTIC CRITERIA A. A pattern of phencyclidine (or a pharmacologically similar substance) use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Phencyclidine 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 phencyclidine use. 3. A great deal of time is spent in activities necessary to obtain phencyclidine, use the phencyclidine, or recover from its effects. 4. Craving, or a strong desire or urge to use phencyclidine. 5. Recurrent phencyclidine use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences from work or poor work performance related to phencyclidine use; phencyclidine-related absences, suspensions, or expulsions from school; neglect of children or household). 6. Continued phencyclidine use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the phencyclidine (e.g., arguments with a spouse about consequences of intoxication; physical fights). 7. Important social, occupational, or recreational activities are given up or reduced because of phencyclidine use. 8. Recurrent phencyclidine use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by a phencyclidine). 9. Phencyclidine 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 the phencyclidine. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the phencyclidine to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of the phencyclidine. Specifiers "In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units. Diagnostic Features The phencyclidines (or phencyclidine-like substances) include phencyclidine (e.g., PCP, "angel dust") and less potent but similarly acting compounds such as ketamine, cyclohex- amine, and dizocilpine. These substances were first developed as dissociative anesthetics in the 1950s and became street drugs in the 1960s. They produce feelings of separation from mind and body (hence "dissociative") in low doses, and at high doses, stupor and coma can result. These substances are most commonly smoked or taken orally, but they may also be snorted or injected. Although the primary psychoactive effects of PCP last for a few hours, the total elimination rate of this drug from the body typically extends 8 days or longer. The hallucinogenic effects in vulnerable individuals may last for weeks and may precipitate a persistent psychotic episode resembling schizophrenia. Ketamine has been observed to have utility in the treatment of major depressive disorder. Withdrawal symptoms have not been clearly established in humans, and therefore the withdrawal criterion is not included in the diagnosis of phencyclidine use disorder. Associated Features Supporting Diagnosis Phencyclidine may be detected in urine for up to 8 days or even longer at very high doses. In addition to laboratory tests to detect its presence, characteristic symptoms resulting from intoxication with phencyclidine or related substances may aid in its diagnosis. Phencycli- dine is likely to produce dissociative symptoms, analgesia, nystagmus, and hypertension, with risk of hypotension and shock. Violent behavior can also occur with phencyclidine use, as intoxicated persons may believe that they are being attacked. Residual symptoms following use may resemble schizophrenia. Prevalence The prevalence of phencyclidine use disorder is unknown. Approximately 2.5% of the pop- ulation reports having ever used phencyclidine. The proportion of users increases with age, from 0.3% of 12- to 17-year-olds, to 1.3% of 18- to 25-year-olds, to 2.9% of those age 26 years and older reporting ever using phencyclidine. There appears to have been an in- crease among 12th graders in both ever used (to 2.3% from 1.8%) and past-year use (to 1.3% from 1.0%) of phencyclidine. Past-year use of ketamine appears relatively stable among 12th graders (1.6%-1.7% over the past 3 years). Risk and Prognostic Factors There is little information about risk factors for phencyclidine use disorder. Among indi- viduals admitted to substance abuse treatment, those for whom phencyclidine was the primary substance were younger than those admitted for other substance use, had lower educational levels, and were more likely to be located in the West and Northeast regions of the United States, compared with other admissions. Culture-Related Diagnostic Issues Ketamine use in youths ages 16-23 years has been reported to be more common among whites (0.5%) than among other ethnic groups (range 0%-0.3%). Among individuals ad- mitted to substance abuse treatment, those for whom phencyclidine was the primary sub- stance were predominantly black (49%) or Hispanic (29%). Gender-Related Diagnostic Issues Males make up about three-quarters of those with phencyclidine-related emergency room visits. Diagnostic Markers Laboratory testing may be useful, as phencyclidine is present in the urine in intoxicated in- dividuals up to 8 days after ingestion. The individual's history, along with certain physical signs, such as nystagmus, analgesia and prominent hypertension, may aid in distinguish- ing the phencyclidine clinical picture from that of other hallucinogens. Functional Consequences of Phencyclidine Use Disorder In individuals with phencyclidine use disorder, there may be physical evidence of injuries from accidents, fights, and falls. Chronic use of phencyclidine may lead to deficits in mem- ory, speech, and cognition that may last for months. Cardiovascular and neurological tox- cities (e.g., seizures, dystonias, dyskinesias, catalepsy, hypothermia or hyperthermia) may result from intoxication with phencyclidine. Other consequences include intracranial hemorrhage, rhabdomyolysis, respiratory problems, and (occasionally) cardiac arrest. Differential Diagnosis Other substance use disorders. Distinguishing the effects of phencyclidine from those of other substances is important, since it may be a common additive to other substances (e.g., cannabis, cocaine). Schizophrenia and other mental disorders. Some of the effects of phencyclidine and related substance use may resemble symptoms of other psychiatric disorders, such as psy- chosis (schizophrenia), low mood (major depressive disorder), violent aggressive be- haviors (conduct disorder, antisocial personality disorder). Discerning whether these behaviors occurred before the intake of the drug is important in the differentiation of acute drug effects from preexisting mental disorder. Phencyclidine-induced psychotic disorder should be considered when there is impaired reality testing in individuals experiencing disturbances in perception resulting from ingestion of phencyclidine.

attention-deficit/hyperactivity disorder (ADHD) (DSM)

DIAGNOSTIC CRITERIA A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that nega- tively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defi- ance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has diffi- culty remaining focused during lectures, conversations, or lengthy reading). C. Often does not seem to listen when spoken to directly (e.g., mind seems else- where, even in the absence of any obvious distraction). d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing se- quential tasks; difficulty keeping materials and belongings in order; messy, dis- organized work; has poor time management; fails to meet deadlines). f Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pen- cils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). on i Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have per. sisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defi- ance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). C. Often runs about or climbs in situations where it is inappropriate. (Note: In ad- olescents or adults, may be limited to feeling restless.) d. Often unable to play or engage in leisure activities quietly. e. Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or un- comfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., com- pletes people's sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). I Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving per- mission; for adolescents and adults, may intrude into or take over what others are doing). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more set- tings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, so- cial, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intox- cation or withdrawal). Diagnostic Features The essential feature of attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention and / or hyperactivity-impulsivity that interferes with functioning or development. Inattention manifests behaviorally in ADHD as wandering off task, lacking persistence, having difficulty sustaining focus, and being disorganized and is not due to defiance or lack of comprehension. Hyperactivity refers to excessive motor activity (such as a child running about) when it is not appropriate, or excessive fidgeting, tapping, or talk- ativeness. In adults, hyperactivity may manifest as extreme restlessness or wearing others out with their activity. Impulsivity refers to hasty actions that occur in the moment without forethought and that have high potential for harm to the individual (e.g., darting into the street without looking). Impulsivity may reflect a desire for immediate rewards or an in- ability to delay gratification. Impulsive behaviors may manifest as social intrusiveness (e.g., interrupting others excessively) and/ or as making important decisions without con- sideration of long-term consequences (e.g., taking a job without adequate information). ADHD begins in childhood. The requirement that several symptoms be present before age 12 years conveys the importance of a substantial clinical presentation during child- hood. At the same time, an earlier age at onset is not specified because of difficulties in es tablishing precise childhood onset retrospectively. Adult recall of childhood symptoms tends to be unreliable, and it is beneficial to obtain ancillary information. Manifestations of the disorder must be present in more than one setting (e.g., home and school, work). Confirmation of substantial symptoms across settings typically cannot be done accurately without consulting informants who have seen the individual in those set- tings. Typically, symptoms vary depending on context within a given setting. Signs of the disorder may be minimal or absent when the individual is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in espe- cially interesting activities, has consistent external stimulation (e.g., via electronic screens), or is interacting in one-on-one situations (e.g., the clinician's office). Associated Features Supporting Diagnosis Mild delays in language, motor, or social development are not specific to ADHD but often co- occur. Associated features may include low frustration tolerance, irritability, or mood lability. Even in the absence of a specific learning disorder, academic or work performance is often im- paired. Inattentive behavior is associated with various underlying cognitive processes, and in- dividuals with ADHD may exhibit cognitive problems on tests of attention, executive function, or memory, although these tests are not sufficiently sensitive or specific to serve as di- agnostic indices. By early adulthood, ADHD is associated with an increased risk of suicide at- tempt, primarily when comorbid with mood, conduct, or substance use disorders. No biological marker is diagnostic for ADHD. As a group, compared with peers, chil- dren with ADHD display increased slow wave electroencephalograms, reduced total brain volume on magnetic resonance imaging, and possibly a delay in posterior to anterior cortical maturation, but these findings are not diagnostic. In the uncommon cases where there is a known genetic cause (e.g., Fragile X syndrome, 22q11 deletion syndrome), the ADHD presentation should still be diagnosed. Prevalence Population surveys suggest that ADHD occurs in most cultures in about 5% of children and about 2.5% of adults. Development and Course Many parents first observe excessive motor activity when the child is a toddler, but symp- toms are difficult to distinguish from highly variable normative behaviors before age 4 years. ADHD is most often identified during elementary school years, and inattention be- comes more prominent and impairing. The disorder is relatively stable through early ad- olescence, but some individuals have a worsened course with development of antisocial behaviors. In most individuals with ADHD, symptoms of motoric hyperactivity become less obvious in adolescence and adulthood, but difficulties with restlessness, inattention, poor planning, and impulsivity persist. A substantial proportion of children with ADHD remain relatively impaired into adulthood. In preschool, the main manifestation is hyperactivity. Inattention becomes more prom- inent during elementary school. During adolescence, signs of hyperactivity (e.g., running and climbing) are less common and may be confined to fidgetiness or an inner feeling of jitteriness, restlessness, or impatience. In adulthood, along with inattention and restless- ness, impulsivity may remain problematic even when hyperactivity has diminished. Risk and Prognostic Factors Temperamental. ADHD is associated with reduced behavioral inhibition, effortful con- trol, or constraint; negative emotionality; and / or elevated novelty seeking. These traits may predispose some children to ADHD but are not specific to the disorder. Environmental. Very low birth weight (less than 1,500 grams) conveys a two- to three- fold risk for ADHD, but most children with low birth weight do not develop ADHD. Al- though ADHD is correlated with smoking during pregnancy, some of this association reflects common genetic risk. A minority of cases may be related to reactions to aspects of diet. There may be a history of child abuse, neglect, multiple foster placements, neurotoxin exposure (e.g., lead), infections (e.g., encephalitis), or alcohol exposure in utero. Exposure to environmental toxicants has been correlated with subsequent ADHD, but it is not known whether these associations are causal. Genetic and physiological. ADHD is elevated in the first-degree biological relatives of individuals with ADHD. The heritability of ADHD is substantial. While specific genes have been correlated with ADHD, they are neither necessary nor sufficient causal factors. Visual and hearing impairments, metabolic abnormalities, sleep disorders, nutritional de- ficiencies, and epilepsy should be considered as possible influences on ADHD symptoms. ADHD is not associated with specific physical features, although rates of minor phys- ical anomalies (e.g., hypertelorism, highly arched palate, low-set ears) may be relatively elevated. Subtle motor delays and other neurological soft signs may occur. (Note that marked co-occurring clumsiness and motor delays should be coded separately [e.g., de- velopmental coordination disorder].) Course modifiers. Family interaction patterns in early childhood are unlikely to cause ADHD but may influence its course or contribute to secondary development of conduct problems. Culture-Related Diagnostic Issues Differences in ADHD prevalence rates across regions appear attributable mainly to differ- ent diagnostic and methodological practices. However, there also may be cultural varia- tion in attitudes toward or interpretations of children's behaviors. Clinical identification rates in the United States for African American and Latino populations tend to be lower than for Caucasian populations. Informant symptom ratings may be influenced by cul- tural group of the child and the informant, suggesting that culturally appropriate practices are relevant in assessing ADHD. Gender-Related Diagnostic Issues ADHD is more frequent in males than in females in the general population, with a ratio of approximately 2:1 in children and 1.6:1 in adults. Females are more likely than males to present primarily with inattentive features. Functional Consequences of Attention-Deficit/Hyperactivity Disorder ADHD is associated with reduced school performance and academic attainment, social rejection, and, in adults, poorer occupational performance, attainment, attendance, and higher probability of unemployment as well as elevated interpersonal conflict. Children with ADHD are significantly more likely than their peers without ADHD to develop con- duct disorder in adolescence and antisocial personality disorder in adulthood, conse- quently increasing the likelihood for substance use disorders and incarceration. The risk of subsequent substance use disorders is elevated, especially when conduct disorder or an- tisocial personality disorder develops. Individuals with ADHD are more likely than peers to be injured. Traffic accidents and violations are more frequent in drivers with ADHD. There may be an elevated likelihood of obesity among individuals with ADHD. Inadequate or variable self-application to tasks that require sustained effort is often in- terpreted by others as laziness, irresponsibility, or failure to cooperate. Family relation- ships may be characterized by discord and negative interactions. Peer relationships are often disrupted by peer rejection, neglect, or teasing of the individual with ADHD. On av- erage, individuals with ADHD obtain less schooling, have poorer vocational achievement, and have reduced intellectual scores than their peers, although there is great variability. In its severe form, the disorder is markedly impairing, affecting social, familial, and scholas- tic/occupational adjustment. Academic deficits, school-related problems, and peer neglect tend to be most associ- ated with elevated symptoms of inattention, whereas peer rejection and, to a lesser extent, accidental injury are most salient with marked symptoms of hyperactivity or impulsivity. Differential Diagnosis Oppositional defiant disorder. Individuals with oppositional defiant disorder may re- sist work or school tasks that require self-application because they resist conforming to others' demands. Their behavior is characterized by negativity, hostility, and defiance. These symptoms must be differentiated from aversion to school or mentally demanding tasks due to difficulty in sustaining mental effort, forgetting instructions, and impulsivity in individuals with ADHD. Complicating the differential diagnosis is the fact that some individuals with ADHD may develop secondary oppositional attitudes toward such tasks and devalue their importance. Intermittent explosive disorder. ADHD and intermittent explosive disorder share high levels of impulsive behavior. However, individuals with intermittent explosive disorder showserious aggression toward others, which is not characteristic of ADHD, and they do not experience problems with sustaining attention as seen in ADHD. In addition, intermit- tent explosive disorder is rare in childhood. Intermittent explosive disorder may be diag- nosed in the presence of ADHD. Other neurodevelopmental disorders. The increased motoric activity that may occur in ADHD must be distinguished from the repetitive motor behavior that characterizes stereo- typic movement disorder and some cases of autism spectrum disorder. In stereotypic movement disorder, the motoric behavior is generally fixed and repetitive (e.g., body rock- ing, self-biting), whereas the fidgetiness and restlessness in ADHD are typically general- ized and not characterized by repetitive stereotypic movements. In Tourette's disorder, frequent multiple tics can be mistaken for the generalized fidgetiness of ADHD. Prolonged observation may be needed to differentiate fidgetiness from bouts of multiple tics. Specific learning disorder. Children with specific learning disorder may appear inat. tentive because of frustration, lack of interest, or limited ability. However, inattention in individuals with a specific learning disorder who do not have ADHD is not impairing out. side of academic work. Intellectual disability (intellectual developmental disorder). Symptoms of ADHD are common among children placed in academic settings that are inappropriate to their intel- lectual ability. In such cases, the symptoms are not evident during non-academic tasks. A diagnosis of ADHD in intellectual disability requires that inattention or hyperactivity be excessive for mental age. Autism spectrum disorder. Individuals with ADHD and those with autism spectrum disorder exhibit inattention, social dysfunction, and difficult-to-manage behavior. The so- cial dysfunction and peer rejection seen in individuals with ADHD must be distinguished from the social disengagement, isolation, and indifference to facial and tonal communica- tion cues seen in individuals with autism spectrum disorder. Children with autism spec- trum disorder may display tantrums because of an inability to tolerate a change from their expected course of events. In contrast, children with ADHD may misbehave or have a tan- trum during a major transition because of impulsivity or poor self-control. Reactive attachment disorder. Children with reactive attachment disorder may show social disinhibition, but not the full ADHD symptom cluster, and display other features such as a lack of enduring relationships that are not characteristic of ADHD. Anxiety disorders. ADHD shares symptoms of inattention with anxiety disorders. Indi- viduals with ADHD are inattentive because of their attraction to external stimuli, new activities, or preoccupation with enjoyable activities. This is distinguished from the inat- tention due to worry and rumination seen in anxiety disorders. Restlessness might be seen in anxiety disorders. However, in ADHD, the symptom is not associated with worry and rumination. Depressive disorders. Individuals with depressive disorders may present with inabil- ity to concentrate. However, poor concentration in mood disorders becomes prominent only during a depressive episode. Bipolar disorder. Individuals with bipolar disorder may have increased activity, poor concentration, and increased impulsivity, but these features are episodic, occurring sev- eral days at a time. In bipolar disorder, increased impulsivity or inattention is accompa- nied by elevated mood, grandiosity, and other specific bipolar features. Children with ADHD may show significant changes in mood within the same day; such lability is dis- tinct from a manic episode, which must last 4 or more days to be a clinical indicator of bi- polar disorder, even in children. Bipolar disorder is rare in preadolescents, even when severe irritability and anger are prominent, whereas ADHD is common among children and adolescents who display excessive anger and irritability. Disruptive mood dysregulation disorder. Disruptive mood dysregulation disorder is characterized by pervasive irritability, and intolerance of frustration, but impulsiveness and disorganized attention are not essential features. However, most children and adoles- cents with the disorder have symptoms that also meet criteria for ADHD, which is diag- nosed separately. Substance use disorders. Differentiating ADHD from substance use disorders may be problematic if the first presentation of ADHD symptoms follows the onset of abuse or fre- quent use. Clear evidence of ADHD before substance misuse from informants or previous records may be essential for differential diagnosis. Personality disorders. In adolescents and adults, it may be difficult to distinguish ADHD from borderline, narcissistic, and other personality disorders. All these disorders tend to share the features of disorganization, social intrusiveness, emotional dysregulation, and cognitive dysregulation. However, ADHD is not characterized by fear of abandonment, self-injury, extreme ambivalence, or other features of personality disorder. It may take extended clinical observation, informant interview, or detailed history to distinguish im- pulsive, socially intrusive, or inappropriate behavior from narcissistic, aggressive, or dom- ineering behavior to make this differential diagnosis. Psychotic disorders. ADHD is not diagnosed if the symptoms of inattention and hyperac- tivity occur exclusively during the course of a psychotic disorder. Medication-induced symptoms of ADHD. Symptoms of inattention, hyperactivity, or impulsivity attributable to the use of medication (e.g., bronchodilators, isoniazid, neuro- leptics [resulting in akathisia], thyroid replacement medication) are diagnosed as other specified or unspecified other (or unknown) substance-related disorders. Neurocognitive disorders. Early major neurocognitive disorder (dementia) and/ or mild neurocognitive disorder are not known to be associated with ADHD but may present with similar clinical features. These conditions are distinguished from ADHD by their late onset. Comorbidity In clinical settings, comorbid disorders are frequent in individuals whose symptoms meet criteria for ADHD. In the general population, oppositional defiant disorder co-occurs with ADHD in approximately half of children with the combined presentation and about a quarter with the predominantly inattentive presentation. Conduct disorder co-occurs in about a quarter of children or adolescents with the combined presentation, depending on age and setting. Most children and adolescents with disruptive mood dysregulation dis- order have symptoms that also meet criteria for ADHD; a lesser percentage of children with ADHD have symptoms that meet criteria for disruptive mood dysregulation disor- der. Specific learning disorder commonly co-occurs with ADHD. Anxiety disorders and major depressive disorder occur in a minority of individuals with ADHD but more often than in the general population. Intermittent explosive disorder occurs in a minority of adults with ADHD, but at rates above population levels. Although substance use disorders are relatively more frequent among adults with ADHD in the general population, the disorders are present in only a minority of adults with ADHD. In adults, antisocial and other personality disorders may co-occur with ADHD. Other disorders that may co-occur with ADHD include obsessive-compulsive disorder, tic disorders, and autism spectrum disorder.

paranoid personality disorder (DSM)

DIAGNOSTIC CRITERIA 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. Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," i.e., "paranoid personality disorder (premorbid)." Diagnostic Features The essential feature of paranoid personality disorder is a pattern of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. This Pattern begins by early adulthood and is present in a variety of contexts. Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to support this expectation (Criterion A1). They suspect on the basis of little or no evidence that others are plotting against them and may attack them suddenly, at any time and without reason. They often feel that they have been deeply and irreversibly injured by another person or persons even when there is no objective evidence for this. They are preoccupied with unjustified doubts about the loyalty or trustworthiness of their friends and associates, whose actions are minutely scrutinized for evidence of hos- tile intentions (Criterion A2). Any perceived deviation from trustworthiness or loyalty serves to support their underlying assumptions. They are so amazed when a friend or as- sociate shows loyalty that they cannot trust or believe it. If they get into trouble, they ex- pect that friends and associates will either attack or ignore them. Individuals with paranoid personality disorder are reluctant to confide in or become close to others because they fear that the information they share will be used against them (Criterion A3). They may refuse to answer personal questions, saying that the information is "nobody's business." They read hidden meanings that are demeaning and threatening into benign temarks or events (Criterion A4). For example, an individual with this disor- der may misinterpret an honest mistake by a store clerk as a deliberate attempt to short- change, or view a casual humorous remark by a co-worker as a serious character attack. Compliments are often misinterpreted (e.g., a compliment on a new acquisition is mis- interpreted as a criticism for selfishness; a compliment on an accomplishment is misinter- preted as an attempt to coerce more and better performance). They may view an offer of help as a criticism that they are not doing well enough on their own. Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received (Criterion A5). Minor slights arouse major hostility, and the hostile feelings persist for a long time. Because they are constantly vigilant to the harmful intentions of others, they very often feel that their character or reputation has been attacked or that they have been slighted in some other way. They are quick to counterattack and react with anger to perceived insults (Criterion A6). Individuals with this disorder may be pathologically jealous, often suspecting that their spouse or sexual partner is unfaithful without any adequate justification (Criterion A7). They may gather trivial and circumstantial "evidence" to support their jealous beliefs. They want to maintain complete control of intimate relationships to avoid being betrayed and may constantly question and challenge the whereabouts, actions, intentions, and fi- delity of their spouse or partner. Paranoid personality disorder should not be diagnosed if the pattern of behavior oc- curs exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder, or if it is attributable to the physiological effects of a neurological (e.g, temporal lobe epilepsy) or another medical condition (Criterion B). Associated Features Supporting Diagnosis Individuals with paranoid personality disorder are generally difficult to get along with and often have problems with close relationships. Their excessive suspiciousness and hos- tility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet, apparently hostile aloofness. Because they are hypervigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be "cold" and lacking in tender feelings. Although they may appear to be objective, rational, and unemotional, they more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations. Because individuals with paranoid personality disorder lack trust in others, they have an excessive need to be self-sufficient and a strong sense of autonomy. They also need to have a high degree of control over those around them. They are often rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism them- selves. They may blame others for their own shortcomings. Because of their quickness to counterattack in response to the threats they perceive around them, they may be litigious and frequently become involved in legal disputes. Individuals with this disorder seek to confirm their preconceived negative notions regarding people or situations they encounter, attributing malevolent motivations to others that are projections of their own fears. They may exhibit thinly hidden, unrealistic grandiose fantasies, are often attuned to issues of power and rank, and tend to develop negative stereotypes of others, particularly those from population groups distinct from their own. Attracted by simplistic formulations of the world, they are often wary of ambiguous situations. They may be perceived as "fanatics" and form tightly knit "cults" or groups with others who share their paranoid belief systems. Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, paranoid personal- ity disorder may appear as the premorbid antecedent of delusional disorder or schizo- phrenia. Individuals with paranoid personality disorder may develop major depressive disorder and may be at increased risk for agoraphobia and obsessive-compulsive dis- order. Alcohol and other substance use disorders frequently occur. The most common co- occurring personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and borderline. Prevalence A prevalence estimate for paranoid personality based on a probability subsample from Part Il of the National Comorbidity Survey Replication suggests a prevalence of 23%, while the National Epidemiologic Survey on Alcohol and Related Conditions data suggest a prevalence of paranoid personality disorder of 4.4%. Development and Course Paranoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hyper- sensitivity, peculiar thoughts and language, and idiosyncratic fantasies. These children may appear to be "odd" or "eccentric" and attract teasing. In clinical samples, this disorder appears to be more commonly diagnosed in males. Risk and Prognostic Factors Genetic and physiological. There is some evidence for an increased prevalence of par- anoid personality disorder in relatives of probands with schizophrenia and for a more spe- cific familial relationship with delusional disorder, persecutor type. Culture-Related Diagnostic Issues Some behaviors that are influenced by sociocultural contexts or specific life circumstances may be erroneously labeled paranoid and may even be reinforced by the process of clinical evaluation. Members of minority groups, immigrants, political and economic refugees, or individuals of different ethnic backgrounds may display guarded or defensive behaviors because of unfamiliarity (e.g., language barriers or lack of knowledge of rules and regula- tions) or in response to the perceived neglect or indifference of the majority society. These behaviors can, in turn, generate anger and frustration in those who deal with these indi- viduals, thus setting up a vicious cycle of mutual mistrust, which should not be confused with paranoid personality disorder. Some ethnic groups also display culturally related be- haviors that can be misinterpreted as paranoid. Differential Diagnosis Other mental disorders with psychotic symptoms. Paranoid personality disorder can be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). For an additional diagnosis of paranoid personality disorder to be given, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. When an individual has another persistent mental disorder (e.g., schizophrenia) that was preceded by paranoid personality disorder, paranoid personality dis- order should also be recorded, followed by "premorbid" in parentheses. Personality change due to another medical condition. Paranoid personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the direct effects of another medical condi- tion on the central nervous system. Substance use disorders. Paranoid personality disorder must be distinguished from symptoms that may develop in association with persistent substance use. Paranoid traits associated with physical handicaps. The disorder must also be distin- guished from paranoid traits associated with the development of physical handicaps (e.g., a hearing impairment). Other personality disorders and personality traits. Other personality disorders may be confused with paranoid personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to paranoid personality disorder, all can be diagnosed. Paranoid personality disorder and schizotypal personality disorder share the traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but schizotypal per- sonality disorder also includes symptoms such as magical thinking, unusual perceptual ex- periences, and odd thinking and speech. Individuals with behaviors that meet criteria for schizoid personality disorder are often perceived as strange, eccentric, cold, and aloof, but they do not usually have prominent paranoid ideation. The tendency of individuals with paranoid personality disorder to react to minor stimuli with anger is also seen in borderline and histrionic personality disorders. However, these disorders are not necessarily associ- ated with pervasive suspiciousness. People with avoidant personality disorder may also be reluctant to confide in others, but more from fear of being embarrassed or found inadequate than from fear of others' malicious intent. Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is more often attributable to a desire for revenge. Individuals with narcissistic personality disorder may occasionally display suspiciousness, social withdrawal, or alienation, but this derives primarily from fears of having their imperfections or flaws revealed. Paranoid traits may be adaptive, particularly in threatening environments. Paranoid personality disorder should be diagnosed only when these traits are inflexible, maladap tive, and persisting and cause significant functional impairment or subjective distress.

schizoid personality disorder (DSM)

DIAGNOSTIC CRITERIA 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. Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," i.e., "schizoid personality disorder (premorbid)." DIAGNOSTIC FEATURES The essential feature of schizoid personality disorder is a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings. This pattern begins by early adulthood and is present in a variety of contexts. Individuals with schizoid personality disorder appear to lack a desire for intimacy, seem indifferent to opportunities to develop close relationships, and do not seem to derive much satisfaction from being part of a family or other social group (Criterion A1). They prefer spending time by themselves, rather than being with other people. They often ap- pear to be socially isolated or "loners" and almost always choose solitary activities or hob- bies that do not include interaction with others (Criterion A2). They prefer mechanical or abstract tasks, such as computer or mathematical games. They may have very little interest in having sexual experiences with another person (Criterion A3) and take pleasure in few, if any, activities (Criterion A4). There is usually a reduced experience of pleasure from sen- sory, bodily, or interpersonal experiences, such as walking on a beach at sunset or having sex. These individuals have no close friends or confidants, except possibly a first-degree relative (Criterion A5). Individuals with schizoid personality disorder often seem indifferent to the approval or criticism of others and do not appear to be bothered by what others may think of them (Criterion A6). They may be oblivious to the normal subtleties of social interaction and of- ten do not respond appropriately to social cues so that they seem socially inept or super- ficial and self-absorbed. They usually display a "bland" exterior without visible emotional reactivity and rarely reciprocate gestures or facial expressions, such as smiles or nods (Cri- terion A7). They claim that they rarely experience strong emotions such as anger and joy. They often display a constricted affect and appear cold and aloof. However, in those very unusual circumstances in which these individuals become at least temporarily comfort- able in revealing themselves, they may acknowledge having painful feelings, particularly related to social interactions. Schizoid personality disorder should not be diagnosed if the pattern of behavior occurs exclusively during the course of schizophrenia, a bipolar or depressive disorder with psy- chotic features, another psychotic disorder, or autism spectrum disorder, or if it is attributable to the physiological effects of a neurological (e&, temporal lobe epilepsy) or another medical condition (Criterion B). Associated features supporting diagnosis Individuals with schizoid personality disorder may have particular difficulty expressing anger, even in response to direct provocation, which contributes to the impression that they lack emotion. Their lives sometimes seem directionless, and they may appear to "drift" in their goals. Such individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events. Because of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infrequently, and often do not marry. Occupational functioning may be impaired, particularly if interpersonal involvement is required, but individuals with this disorder may do well when they work under conditions of social isolation. Particu- larly in response to stress, individuals with this disorder may experience very brief psy- chotic episodes (lasting minutes to hours). In some instances, schizoid persdhality disorder may appear as the premorbid antecedent of delusional disorder or schizophre- nia. Individuals with this disorder may sometimes develop major depressive disorder. Schizoid personality disorder most often co-occurs with schizotypal, paranoid, and avoid- ant personality disorders. Prevalence Schizoid personality disorder is uncommon in clinical settings. A prevalence estimate for schizoid personality based on a probability subsample from Part Il of the Natiotal Co- morbidity Survey Replication suggests a prevalence of 4.9%. Data from the 2001-2002 tonal Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of 3.1% Development and Course Schizoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, and underachievement in school, which mark these children or adolescents as different and make them subject to teasing. Risk and Prognostic Factors Genetic and physiological. Schizoid personality disorder may have increased prevalence in the relatives of individuals with schizophrenia or schizotypal personality disorder. Culture-Related Diagnostic Issues Individuals from a variety of cultural backgrounds sometimes exhibit defensive behaviors and interpersonal styles that may be erroneously labeled as "schizoid." For example, those who have moved from rural to metropolitan environments may react with "emotional freezing" that may last for several months and manifest as solitary activities, constricted affect, and other deficits in communication. Immigrants from other countries are sometimes mistakenly perceived as cold, hostile, or indifferent. Gender-Related Diagnostic Issues Schizoid personality disorder is diagnosed slightly more often in males and may cause more impairment in them. Differential Diagnosis Other mental disorders with psychotic symptoms. Schizoid personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or depressive dis- order with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of schizoid personality disorder, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. When an individual has a persistent psychotic disorder (eg, schizophrenia) that was preceded by schizoid personality disorder, schizoid personality disorder should also be recorded, followed by "premorbid" in parentheses. Autism spectrum disorder. There may be great difficulty differehtating individuals with schizoid personality disorder from those with milder forms of autism spectrum disorder, which may be differentiated by more severely impaired social interaction and stereotyped behaviors and interests. Personality change due to another medical condition. Schizoid personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Schizoid personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use. Other personality disorders and personality traits. Other personality disorders may be confused with schizoid personality disorder because they have certain features in com- mon. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to schizoid personality dis- order, all can be diagnosed. Although characteristics of social isolation and restricted af- fectivity are common to schizoid, schizotypal, and paranoid personality disorders, schizoid personality disorder can be distinguished from schizotypal personality disorder by the lack of cognitive and perceptual distortions and from paranoid personality disorder by the lack of suspiciousness and paranoid ideation. The social isolation of schizoid per- sonality disorder can be distinguished from that of avoidant personality disorder, which is attributable to fear of being embarrassed or found inadequate and excessive anticipation of rejection. In contrast, people with schizoid personality disorder have a more pervasive detachment and limited desire for social intimacy. Individuals with obsessive-compulsive personality disorder may also show an apparent social detachment stemming from devo- tion to work and discomfort with emotions, but they do have an underlying capacity for intimacy. Individuals who are "loners" may display personality traits that might be considered schizoid. Only when these traits are inflexible and maladaptive and cause significant func- tonal impairment or subjective distress do they constitute schizoid personality disorder.

antisocial personality disorder (DSM)

DIAGNOSTIC CRITERIA 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. Diagnostic Features The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder. Because deceit and manipulation are central features of an- tisocial personality disorder, it may be especially helpful to integrate information acquired from systematic clinical assessment with information collected from collateral sources. For this diagnosis to be given, the individual must be at least age 18 years (Criterion B) and must have had a history of some symptoms of conduct disorder before age 15 years (Criterion C). Conduct disorder involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. The specific behaviors characteristic of conduct disorder fall into one of four categories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violation of rules. The pattern of antisocial behavior continues into adulthood. Individuals with antiso- cial personality disorder fail to conform to social norms with respect to lawful behavior (Criterion A1). They may repeatedly perform acts that are grounds for arrest (whether they are arrested or not), such as destroying property, harassing others, stealing, or pur- suing illegal occupations. Persons with this disorder disregard the wishes, rights, or feel. ings of others. They are frequently deceitful and manipulative in order to gain personal profit or pleasure (e.g., to obtain money, sex, or power) (Criterion A2). They may repeat- edly lie, use an alias, con others, or malinger. A pattern of impulsivity may be manifested by a failure to plan ahead (Criterion A3). Decisions are made on the spur of the moment, without forethought and without consideration for the consequences to self or others; this may lead to sudden changes of jobs, residences, or relationships. Individuals with antiso- cial personality disorder tend to be irritable and aggressive and may repeatedly get into physical fights or commit acts of physical assault (including spouse beating or child beat- ing) (Criterion A4). (Aggressive acts that are required to defend oneself or someone else are not considered to be evidence for this item.) These individuals also display a reckless disregard for the safety of themselves or others (Criterion A5). This may be evidenced in their driving behavior (i.e., recurrent speeding, driving while intoxicated, multiple acci- dents). They may engage in sexual behavior or substance use that has a high risk for harm- ful consequences. They may neglect or fail to care for a child in a way that puts the child in danger. Individuals with antisocial personality disorder also tend to be consistently and ex- tremely irresponsible (Criterion A6). Irresponsible work behavior may be indicated by sig- nificant periods of unemployment despite available job opportunities, or by abandonment of several jobs without a realistic plan for getting another job. There may also be a pattern of repeated absences from work that are not explained by illness either in themselves or in their family. Financial irresponsibility is indicated by acts such as defaulting on debts, fail- ing to provide child support, or failing to support other dependents on a regular basis. In- dividuals with antisocial personality disorder show little remorse for the consequences of their acts (Criterion A7). They may be indifferent to, or provide a superficial rationaliza- tion for, having hurt, mistreated, or stolen from someone (e.g., "life's unfair," "losers de- serve to lose"). These individuals may blame the victims for being foolish, helpless, or deserving their fate (e.g., "he had it coming anyway"); they may minimize the harmfui consequences of their actions; or they may simply indicate complete indifference. They generally fail to compensate or make amends for their behavior. They may believe that everyone is out to "help number one" and that one should stop at nothing to avoid being pushed around. The antisocial behavior must not occur exclusively during the course of schizophrenia or bipolar disorder (Criterion D). Associated Features Supporting Diagnosis Individuals with antisocial personality disorder frequently lack empathy and tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They may have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath them or lack a realistic concern about their current problems or their future) and may be excessively opinionated, self-assured, or cocky. They may display a glib, superficial charm and can be quite voluble and verbally facile (e.g., using technical terms or jargon that might impress someone who is unfamiliar with the topic). Lack of empathy, inflated self- appraisal, and superficial charm are features that have been commonly included in tradi- tional conceptions of psychopathy that may be particularly distinguishing of the disorder and more predictive of recidivism in prison or forensic settings, where criminal, delin- quent, or aggressive acts are likely to be nonspecific. These individuals may also be irre- sponsible and exploitative in their sexual relationships. They may have a history of many sexual partners and may never have sustained a monogamous relationship. They may be irresponsible as parents, as evidenced by malnutrition of a child, an illness in the child re. sulting from a lack of minimal hygiene, a child's dependence on neighbors or nonresident relatives for food or shelter, a failure to arrange for a caretaker for a young child when the individual is away from home, or repeated squandering of money réquired for household necessities. These individuals may receive dishonorable discharges from the armed ser- vices, may fail to be self-supporting, may become impoverished or even homeless, or may spend many years in penal institutions. Individuals with antisocial personality disorder are more likely than people in the general population to die prematurely by violent means (e.g., suicide, accidents, homicides). Individuals with antisocial personality disorder may also experience dysphoria, in- cluding complaints of tension, inability to tolerate boredom, and depressed mood. They may have associated anxiety disorders, depressive disorders, substance use disorders, so- matic symptom disorder, gambling disorder, and other disorders of impulse control. In- dividuals with antisocial personality disorder also often have personality features that meet criteria for other personality disorders, particularly borderline, histrionic, and nar- cissistic personality disorders. The likelihood of developing antisocial personality disor- der in adult life is increased if the individual experienced childhood onset of conduct disorder (before age 10 years) and accompanying attention-deficit/hyperactivity disorder. Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline may increase the likelihood that conduct disorder will evolve into antisocial personality disorder. Prevalence Twelve-month prevalence rates of antisocial personality disorder, using criteria from pre- vous DSMs, are between 0.2% and 3.3%. The highest prevalence of antisocial personality disorder (greater than 70%) is among most severe samples of males with alcohol use dis- order and from substance abuse clinics, prisons, or other forensic settings. Prevalence is higher in samples affected by adverse socioeconomic (i.e., poverty) or sociocultural (i.e., migration) factors. Development and Course Antisocial personality disorder has a chronic course but may become less evident or remit as the individual grows older, particularly by the fourth decade of life. Although this re- mission tends to be particularly evident with respect to engaging in criminal behavior, there is likely to be a decrease in the full spectrum of antisocial behaviors and substance use. By definition, antisocial personality cannot be diagnosed before age 18 years. Risk and Prognostic Factors Genetic and physiological. Antisocial personality disorder is more common among the first-degree biological relatives of those with the disorder than in the general population. The risk to biological relatives of females with the disorder tends to be higher than the risk to biological relatives of males with this disorder. Biological relatives of individuals with this disorder are also at increased risk for somatic symptom disorder and substance use disorders. Within a family that has a member with antisocial personality disorder, males more often have antisocial personality disorder and substance use disorders, whereas fe- males more often have somatic symptom disorder. However, in such families, there is an increase in prevalence of all of these disorders in both males and females compared with the general population. Adoption studies indicate that both genetic and environmental factors contribute to the risk of developing antisocial personality disorder. Both adopted and biological children of parents with antisocial personality disorder have an increased risk of developing antisocial personality disorder, somatic symptom disorder, and substance use disorders. Adopted-away children resemble their biological parents more than their adoptive parents, but the adoptive family environment influences the risk of devel- oping a personality disorder and related psychopathology. Culture-Related Diagnostic Issues Antisocial personality disorder appears to be associated with low socioeconomic status and urban settings. Concerns have been raised that the diagnosis may at times be misap- plied to individuals in settings in which seemingly antisocial behavior may be part of a protective survival strategy. In assessing antisocial traits, it is helpful for the clinician to consider the social and economic context in which the behaviors occur. Gender-Related Diagnostic Issues Antisocial personality disorder is much more common in males than in females. There has been some concern that antisocial personality disorder may be underdiagnosed in fe- males, particularly because of the emphasis on aggressive items in the definition of con- duct disorder Differential Diagnosis The diagnosis of antisocial personality disorder is not given to individuals younger than 18 years and is given only if there is a history of some symptoms of conduct disorder be- fore age 15 years. For individuals older than 18 years, a diagnosis of conduct disorder is given only if the criteria for antisocial personality disorder are not met. Substance use disorders. When antisocial behavior in an adult is associated with a substance use disorder, the diagnosis of antisocial personality disorder is not made unless the signs of antisocial personality disorder were also present in childhood and have con- tinued into adulthood. When substance use and antisocial behavior both began in childhood and continued into adulthood, both a substance use disorder and antisocial personality disorder should be diagnosed if the criteria for both are met, even though some antisocial acts may be a consequence of the substance use disorder (e.g., illegal selling of drugs, thefts to obtain money for drugs). Schizophrenia and bipolar disorders. Antisocial behavior that occurs exclusively dur- ing the course of schizophrenia or a bipolar disorder should not be diagnosed as antisocial personality disorder. Other personality disorders. Other personality disorders may be confused with antiso- cial personality disorder because they have certain features in common. It is therefore im- portant to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to antisocial personality disorder, all can be diag- nosed. Individuals with antisocial personality disorder and narcissistic personality disor- der share a tendency to be tough-minded, glib, superficial, exploitative, and lack empathy. However, narcissistic personality disorder does not include characteristics of impulsivity, aggression, and deceit. In addition, individuals with antisocial personality disorder may not be as needy of the admiration and envy of others, and persons with narcissistic per- sonality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood. Individuals with antisocial personality disorder and histrionic personality disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with histrionic personality disorder tend to be more exaggerated in their emotions and do not characteristically engage in an- lisocial behaviors. Individuals with histrionic and borderline personality disorders are manipulative to gain nurturance, whereas those with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification. Individuals with antisocial personality disorder tend to be less emotionally unstable and more aggressive than those with borderline personality disorder. Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually moti- vated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is more often attributable to a desire for revenge. Criminal behavior not associated with a personality disorder. Antisocial personality disorder must be distinguished from criminal behavior undertaken for gain that is not accompanied by the personality features characteristic of this disorder. Only when antisocial personality traits are inflexible, maladaptive, and persistent and cause significant functional impairment or subjective distress do they constitute antisocial personality disorder

Schizotypal Personality Disorder (Cluster A) (DSM)

DIAGNOSTIC CRITERIA 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. Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," e.g., "schizotypal personality disorder (premorbid). Diagnostic Features The essential feature of schizotypal personality disorder is 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 be- havior. This pattern begins by early adulthood and is present in a variety of contexts. Individuals with schizotypal personality disorder often have ideas of reference (i.e., in- correct interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person) (Criterion A1). These should be distin- guished from delusions of reference, in which the beliefs are held with delusional convic- tion. These individuals may be superstitious or preoccupied with paranormal phenomena that are outside the norms of their subculture (Criterion A2). They may feel that they have special powers to sense events before they happen or to read others' thoughts. They may believe that they have magical control over others, which can be implemented directly (e.g., believing that their spouse's taking the dog out for a walk is the direct result of think- ing an hour earlier it should be done) or indirectly through compliance with magical rit- uals (e.g., walking past a specific object three times to avoid a certain harmful outcome). Perceptual alterations may be present (e.g., sensing that another person is present or hear- ing a voice murmuring his or her name) (Criterion A3). Their speech may include unusual or idiosyncratic phrasing and construction. It is often loose, digressive, or vague, but with- out actual derailment or incoherence (Criterion A4). Responses can be either overly con- crete or overly abstract, and words or concepts are sometimes applied in unusual ways (e.g., the individual may state that he or she was not "talkable" at work). Individuals with this disorder are often suspicious and may have paranoid ideation (e.g., believing their colleagues at work are intent on undermining their reputation with the boss) (Criterion A5). They are usually not able to negotiate the full range of affects and interpersonal cuing required for successful relationships and thus often appear to interact with others in an inappropriate, stiff, or constricted fashion (Criterion A6). These individ- uals are often considered to be odd or eccentric because of unusual mannerisms, an often unkempt manner of dress that does not quite "fit together, " and inattention to the usual social conventions (e.g., the individual may avoid eye contact, wear clothes that are ink stained and ill-fitting, and be unable to join in the give-and-take banter of co-workers) (Criterion A7). Individuals with schizotypal personality disorder experience interpersonal related- ness as problematic and are uncomfortable relating to other people. Although they may express unhappiness about their lack of relationships, their behavior suggests a decreased desire for intimate contacts. As a result, they usually have no or few close friends or con- fidants other than a first-degree relative (Criterion A8). They are anxious in social situa- tions, particularly those involving unfamiliar people (Criterion A9). They will interact with other individuals when they have to but prefer to keep to themselves because they feel that they are different and just do not "fit in." Their social anxiety does not easily abate, even when they spend more time in the setting or become more familiar with the other people, because their anxiety tends to be associated with suspiciousness regarding others' motivations. For example, when attending a dinner party, the individual with schizotypal personality disorder will not become more relaxed as time goes on, but rather may become increasingly tense and suspicious. Schizotypal personality disorder should not be diagnosed if the pattern of behavior oc- curs exclusively during the course of schizophrenia, a bipolar or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder (Criterion B). Associated Features Supporting Diagnosis Individuals with schizotypal personality disorder often seek treatment for the associated symptoms of anxiety or depression rather than for the personality disorder features per se. Particularly in response to stress, individuals with this disorder may experience transient psychotic episodes (lasting minutes to hours), although they usually are insufficient in du- ration to warrant an additional diagnosis such as brief psychotic disorder or schizophreni- form disorder. In some cases, clinically significant psychotic symptoms may develop that meet criteria for brief psychotic disorder, schizophreniform disorder, delusional disorder, or schizophrenia. Over half may have a history of at least one major depressive episode. From 30% to 50% of individuals diagnosed with this disorder have a concurrent diagnosis of major depressive disorder when admitted to a clinical setting. There is considerable co- occurrence with schizoid, paranoid, avoidant, and borderline personality disorders. Prevalence In community studies of schizotypal personality disorder, reported rates range from 0.6% in Norwegian samples to 4.6% in a U.S. community sample. The prevalence of schizotypal personality disorder in clinical populations seems to be infrequent (0%-1.9%), with a higher estimated prevalence in the general population (3.9%) found in the National Epi- demiologic Survey on Alcohol and Related Conditions. Development and Course Schizotypal personality disorder has a relatively stable course, with only a small propor- tion of individuals going on to develop schizophrenia or another psychotic disorder. Schizotypal personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hyper- sensitivity, peculiar thoughts and language, and bizarre fantasies. These children may appear "odd" or "eccentric" and attract teasing. Risk and Prognostic Factors Genetic and physiological. Schizotypal personality disorder appears to aggregate fa- milially and is more prevalent among the first-degree biological relatives of individuals with schizophrenia than among the general population. There may also be a modest in- crease in schizophrenia and other psychotic disorders in the relatives of probands with schizotypal personality disorder. Cultural-Related Diagnostic Issues Cognitive and perceptual distortions must be evaluated in the context of the individual's cultural milieu. Pervasive culturally determined characteristics, particularly those regard- ing religious beliefs and rituals, can appear to be schizotypal to the uninformed outsider (e.g., voodoo, speaking in tongues, life beyond death, shamanism, mind reading, sixth sense, evil eye, magical beliefs related to health and illness). Gender-related diagnostic issues Schizotypal personality disorder may be slightly more common in males Differential Diagnosis Other mental disorders with psychotic symptoms. Schizotypal personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an addi- tional diagnosis of schizotypal personality disorder, the personality disorder must have been present before the onset of psychotic symptoms and persist when the psychotic symptoms are in remission. When an individual has a persistent psychotic disorder (e.g, schizophrenia) that was preceded by schizotypal personality disorder, schizotypal per- sonality disorder should also be recorded, followed by "premorbid" in parentheses. Neurodevelopmental disorders. There may be great difficulty differentiating children with schizotypal personality disorder from the heterogeneous group of solitary, odd chil- dren whose behavior is characterized by marked social isolation, eccentricity, or peculiar- ities of language and whose diagnoses would probably include milder forms of autism spectrum disorder or language communication disorders. Communication disorders may be differentiated by the primacy and severity of the disorder in language and by the char- acteristic features of impaired language found in a specialized language assessment. Milder forms of autism spectrum disorder are differentiated by the even greater lack of so- cal awareness and emotional reciprocity and stereotyped behaviors and interests. Personality change due to another medical condition. Schizotypal personality disor- der must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Schizotypal personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use. Other personality disorders and personality traits. Other personality disorders may be confused with schizotypal personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differ- ences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to schizotypal person- ality disorder, all can be diagnosed. Although paranoid and schizoid personality disor- ders may also be characterized by social detachment and restricted affect, schizotypal personality disorder can be distinguished from these two diagnoses by the presence of cognitive or perceptual distortions and marked eccentricity or oddness. Close relation- ships are limited in both schizotypal personality disorder and avoidant personality dis- order; however, in avoidant personality disorder an active desire for relationships is constrained by a fear of rejection, whereas in schizotypal personality disorder there is a lack of desire for relationships and persistent detachment. Individuals with narcissistic personality disorder may also display suspiciousness, social withdrawal, or alienation, but in narcissistic personality disorder these qualities derive primarily from fears of hav- ing imperfections or flaws revealed. Individuals with borderline personality disorder may also have transient, psychotic-like symptoms, but these are usually more closely related to affective shifts in response to stress (e.g., intense anger, anxiety, disappointment) and are usually more dissociative (e.g., derealization, depersonalization). In contrast, individuals with schizotypal personality disorder are more likely to have enduring psychotic-like symptoms that may worsen under stress but are less likely to be inyariably associated with pronounced affective symptoms. Although social isolation may occur in borderline personality disorder, it is usually secondary to repeated interpersonal failures due to angry outbursts and frequent mood shifts, rather than a result of a persistent lack of social contacts and de- sire for intimacy. Furthermore, individuals with schizotypal personality disorder do not usually demonstrate the impulsive or manipulative behaviors of the individual with borderline personality disorder. However, there is a high rate of co-occurrence between the two disorders, so that making such distinctions is not always feasible. Schizotypal features during adolescence may be reflective of transient emotional turmoil, rather than an enduring personality disorder.

Alcohol use disorder (DSM)

DIAGNOSTIC CRITERIA 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. Specify if: In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, "Craving, or a strong desire or urge to use alcohol," may be met). In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, "Craving, or a strong desire or urge to use alcohol," may be met). Specify if: In a controlled environment: This additional specifier is used if the individual is in an environment where access to alcohol is restricted. Code based on current severity: Note for ICD-10-CM codes: If an alcohol intoxication, alcohol withdrawal, or another alcohol-induced mental disorder is also present, do not use the codes below for alcohol use disorder. Instead, the comorbid alcohol use disorder is indicated in the 4th character of the alcohol-induced disorder code (see the coding note for alcohol intoxication, alcohol withdrawal, or a specific alcohol-induced mental disorder). For example, if there is comorbid alcohol intoxication and alcohol use disorder, only the alcohol intoxication code is given, with the 4th character indicating whether the comorbid alcohol use disorder is mild, moderate, or severe: F10.129 for mild alcohol use disorder with alcohol intoxication or F10.229 for a moderate or severe alcohol use disorder with al- cool intoxication. Specify current severity: 305.00 (F10.10) Mild: Presence of 2-3 symptoms. 303.90 (F10.20) Moderate: Presence of 4-5 symptoms. 303.90 (F10.20) Severe: Presence of 6 or more symptoms. Specifiers "In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units. Severity of the disorder is based on the number of diagnostic criteria endorsed. For a given individual, changes in severity of alcohol use disorder across time are also reflected by reductions in the frequency (e.g., days of use per month) and/or dose (e.g., number of standard drinks consumed per day) of alcohol used, as assessed by the individual's self- report, report of knowledgeable others, clinician observations, and, when practical, bio- logical testing (e.g., elevations in blood tests as described in the section "Diagnostic Markers for this disorder). Diagnostic Features Alcohol use disorder is defined by a cluster of behavioral and physical symptoms, which can include withdrawal, tolerance, and craving. Alcohol withdrawal is chardcterized by withdrawal symptoms that develop approximately 4-12 hours after the reduction of in- take following prolonged, heavy alcohol ingestion. Because withdrawal from alcohol can be unpleasant and intense, individuals may continue to consume alcohol despite adverse consequences, often to avoid or to relieve withdrawal symptoms. Some withdrawal symp- toms (e.g., sleep problems) can persist at lower intensities for months and can contribute to relapse. Once a pattern of repetitive and intense use develops, individuals with alcohol use disorder may devote substantial periods of time to obtaining and consuming alcoholic beverages. Craving for alcohol is indicated by a strong desire to drink that makes it difficult to think of anything else and that often results in the onset of drinking. School and job per- formance may also suffer either from the aftereffects of drinking or from actual intoxica- tion at school or on the job; child care or household responsibilities may be neglected; and alcohol-related absences may occur from school or work. The individual may use alcohol in physically hazardous circumstances (e.g., driving an automobile, swimming, operating machinery while intoxicated). Finally, individuals with an alcohol use disorder may con- tinue to consume alcohol despite the knowledge that continued consumption poses sig- nificant physical (e.g., blackouts, liver disease), psychological (e.g., depression), social, or interpersonal problems (e.g., violent arguments with spouse while intoxicated, child abuse). Associated Features Supporting Diagnosis Alcohol use disorder is often associated with problems similar to those associated with other substances (e.g., cannabis; cocaine; heroin; amphetamines; sedatives, hypnotics, or anxiolytics). Alcohol may be used to alleviate the unwanted effects of these other substances or to substitute for them when they are not available. Symptoms of conduct problems, depression, anxiety, and insomnia frequently accompany heavy drinking and sometimes precede it. Repeated intake of high doses of alcohol can affect nearly every organ system, espe- cially the gastrointestinal tract, cardiovascular system, and the central and peripheral ner- vous systems. Gastrointestinal effects include gastritis, stomach or duodenal ulcers, and, in about 15% of individuals who use alcohol heavily, liver cirrhosis and/ or pancreatitis. There is also an increased rate of cancer of the esophagus, stomach, and other parts of the gastrointestinal tract. One of the most commonly associated conditions is low-grade hy- pertension. Cardiomyopathy and other myopathies are less common but occur at an increased rate among those who drink very heavily. These factors, along with marked increases in levels of triglycerides and low-density lipoprotein cholesterol, contribute to an elevated risk of heart disease. Peripheral neuropathy may be evidenced by muscular weakness, paresthesias, and decreased peripheral sensation. More persistent central ner- vous system effects include cognitive deficits, severe memory impairment, and degener- ative changes in the cerebellum. These effects are related to the direct effects of alcohol or of trauma and to vitamin deficiencies (particularly of the B vitamins, including thiamine). One devastating central nervous system effect is the relatively rare alcohol-induced per- sisting amnestic disorder, or Wernicke-Korsakoff syndrome, in which the ability to encode new memory is severely impaired. This condition would now be described within the chap- ter "Neurocognitive Disorders" and would be termed a substance/medication-induced neuro- cognitive disorder. Alcohol use disorder is an important contributor to suicide risk during severe intoxi- There is an increased rate of suicidal behavior as well as of completed suicide among in- dividuals with the disorder. Prevalence Alcohol use disorder is a common disorder. In the United States, the 12-month prevalence of alcohol use disorder is estimated to be 4.6% among 12- to 17-year-olds and 8.5% among adults age 18 years and older in the United States. Rates of the disorder are greater among adult men (12.4%) than among adult women (4.9%). Twelve-month prevalence of alcohol use disorder among adults decreases in middle age, being greatest among individuals 18- to 29-years-old (16.2%) and lowest among individuals age 65 years and older (1.5%). Twelve-month prevalence varies markedly across race / ethnic subgroups of the U.S. population. For 12- to 17-year-olds, rates are greatest among Hispanics (6.0%) and Native Americans and Alaska Natives (5.7%) relative to whites (5.0%), African Americans (1.8%), and Asian Americans and Pacific Islanders (1.6%). In contrast, among adults, the 12-month prevalence of alcohol use disorder is clearly greater among Native Americans and Alaska Natives (12.1%) than among whites (8.9%), Hispanics (7.9%), African Americans (6.9%), and Asian Americans and Pacific Islanders (4.5%). Development and Course The first episode of alcohol intoxication is likely to occur during the mid-teens. Alcohol- related problems that do not meet full criteria for a use disorder or isolated problems may occur prior to age 20 years, but the age at onset of an alcohol use disorder with two or more of the criteria clustered together peaks in the late teens or early to mid 20s. The large ma- jority of individuals who develop alcohol-related disorders do so by their late 30s. The first evidence of withdrawal is not likely to appear until after many other aspects of an alcohol use disorder have developed. An earlier onset of alcohol use disorder is observed in ado- lescents with preexisting conduct problems and those with an earlier onset of intoxication. Alcohol use disorder has a variable course that is characterized by periods of remission and relapse. A decision to stop drinking, often in response to a crisis, is likely to be followed by a period of weeks or more of abstinence, which is often followed by limited periods of controlled or nonproblematic drinking. However, once alcohol intake resumes, it is highly likely that consumption will rapidly escalate and that severe problems will once again develop. Alcohol use disorder is often erroneously perceived as an intractable condition, per- haps based on the fact that individuals who present for treatment typically have a history of many years of severe alcohol-related problems. However, these most severe cases rep- resent only a small proportion of individuals with this disorder, and the typical individual with the disorder has a much more promising prognosis. Among adolescents, conduct disorder and repeated antisocial behavior often co-occur with alcohol- and with other substance-related disorders. While most individuals with al- cohol use disorder develop the condition before age 40 years, perhaps 10% have later onset. Age-related physical changes in older individuals result in increased brain suscep- tibility to the depressant effects of alcohol; decreased rates of liver metabolism of a variety of substances, including alcohol; and decreased percentages of body water. These changes can cause older people to develop more severe intoxication and subsequent problems at lower levels of consumption. Alcohol-related problems in older people are also especially likely to be associated with other medical complications. Risk and Prognostic Factors Environmental. Environmental risk and prognostic factors may include cultural atti- tudes toward drinking and intoxication, the availability of alcohol (including price), acquired personal experiences with alcohol, and stress levels. Additional potential medi- ators of how alcohol problems develop in predisposed individuals include heavier peer substance use, exaggerated positive expectations of the effects of alcohol, and suboptimal ways of coping with stress. Genetic and physiological. Alcohol use disorder runs in families, with 40%-60% of the variance of risk explained by genetic influences. The rate of this condition is three to four times higher in close relatives of individuals with alcohol use disorder, with values highest for individuals with a greater number of affected relatives, closer genetic relationships to the affected person, and higher severity of the alcohol-related problems in those relatives. A significantly higher rate of alcohol use disorders exists in the monozygotic twin than in the dizygotic twin of an individual with the condition. A three- to fourfold increase in risk has been observed in children of individuals with alcohol use disorder, even when these children were given up for adoption at birth and raised by adoptive parents who did not have the disorder. Recent advances in our understanding of genes that operate through intermediate characteristics (or phenotypes) to affect the risk of alcohol use disorder can help to identify individuals who might be at particularly low or high risk for alcohol use disorder. Among the low-risk phenotypes are the acute alcohol-related skin flush (seen most prominently in Asians). High vulnerability is associated with preexisting schizophrenia or bipolar disor- der, as well as impulsivity (producing enhanced rates of all substance use disorders and gambling disorder), and a high risk specifically for alcohol use disorder is associated with a low level of response (low sensitivity) to alcohol. A number of gene variations may ac- count for low response to alcohol or modulate the dopamine reward systems; it is impor- tant to note, however, that any one gene variation is likely to explain only 1%-2% of the risk for these disorders. Course modifiers. In general, high levels of impulsivity are associated with an earlier onset and more severe alcohol use disorder. Culture-Related Diagnostic Issues In most cultures, alcohol is the most frequently used intoxicating substance and contrib- utes to considerable morbidity and mortality. An estimated 3.8% of all global deaths and 4.6% of global disability-adjusted life-years are attributable to alcohol. In the United States, 80% of adults (age 18 years and older) have consumed alcohol at some time in their lives, and 65% are current drinkers (last 12 months). An estimated 3.6% of the world population (15-64 years old) has a current (12-month) alcohol use disorder, with a lower prevalence (1.1%) found in the African region, a higher rate (5.2%) found in the American region (North, South, and Central America and the Caribbean), and the highest rate (10.9%) found in the Eastern Europe region. Polymorphisms of genes for the alcohol-metabolizing enzymes alcohol dehydroge- nase and aldehyde dehydrogenase are most often seen in Asians and affect the response to alcohol. When consuming alcohol, individuals with these gene variations can experience a flushed face and palpitations, reactions that can be so severe as to limit or preclude future alcohol consumption and diminish the risk for alcohol use disorder. These gene variations are seen in as many as 40% of Japanese, Chinese, Korean, and related groups worldwide and are related to lower risks for the disorder. Despite small variations regarding individual criterion items, the diagnostic criteria perform equally well across most race/ ethnicity groups. Gender-Related Diagnostic Issues Males have higher rates of drinking and related disorders than females. However, because females generally weigh less than males, have more fat and less water in their bodies, and metabolize less alcohol in their esophagus and stomach, they are likely to develop higher blood alcohol levels per drink than males. Females who drink heavily may also be more vulnerable than males to some of the physical consequences associated with alcohol, including liver disease. Diagnostic Markers Individuals whose heavier drinking places them at elevated risk for alcohol use disorder can be identified both through standardized questionnaires and by elevations in blood test results likely to be seen with regular heavier drinking. These measures do not establish a diagnosis of an alcohol-related disorder but can be useful in highlighting individuals for whom more information should be gathered. The most direct test available to measure al- cohol consumption cross-sectionally is blood alcohol concentration, which can also be used to judge tolerance to alcohol. For example, an individual with a concentration of 150 mg of ethanol per deciliter (dL) of blood who does not show signs of intoxication can be pre- sumed to have acquired at least some degree of tolerance to alcohol. At 200 mg/ dL, most nontolerant individuals demonstrate severe intoxication. Regarding laboratory tests, one sensitive laboratory indicator of heavy drinking is a modest elevation or high-normal levels (>35 units) of gamma-glutamyltransferase (GGT). This may be the only laboratory finding. At least 70% of individuals with a high GGT level are persistent heavy drinkers (i.e., consuming eight or more drinks daily on a regular basis). A second test with comparable or even higher levels of sensitivity and specificity is carbo- hydrate-deficient transferrin (CDT), with levels of 20 units or higher useful in identifying in- dividuals who regularly consume eight or more drinks daily. Since both GGT and CDT levels return toward normal within days to weeks of stopping drinking, both state markers may be useful in monitoring abstinence, especially when the clinician observes increases, rather than decreases, in these values over time-_a finding indicating that the person is likely to have returned to heavy drinking. The combination of tests for CDT and GGT may have even higher levels of sensitivity and specificity than either test used alone. Additional useful tests include the mean corpuscular volume (MCV), which may be elevated to high- normal values in individuals who drink heavily--a change that is due to the direct toxic ef- fects of alcohol on erythropoiesis. Although the MCV can be used to help identify those who drink heavily, it is a poor method of monitoring abstinence because of the long half-life of red blood cells. Liver function tests (e.g., alanine aminotransferase [ALT] and alkaline phos- phatase) can reveal liver injury that is a consequence of heavy drinking. Other potential markers of heavy drinking that are more nonspecific for alcohol but can help the clinician think of the possible effects of alcohol include elevations in blood levels or lipids (e.g., tri- glycerides and high-density lipoprotein cholesterol) and high-normal levels of uric acid. Additional diagnostic markers relate to signs and symptoms that reflect the consequences often associated with persistent heavy drinking. For example, dyspepsia, nausea, and bloating can accompany gastritis, and hepatomegaly, esophageal varices, and hemorrhoids may reflect alcohol-induced changes in the liver. Other physical signs of heavy drinking include tremor, unsteady gait, insomnia, and erectile dysfunction. Males with chronic alcohol use dis- order may exhibit decreased testicular size and feminizing effects associated with reduced testosterone levels. Repeated heavy drinking in females is associated with menstrual irregu- larities and, during pregnancy, spontaneous abortion and fetal alcohol syndrome. Individu- als with preexisting histories of epilepsy or severe head trauma are more likely to develop alcohol-related seizures. Alcohol withdrawal may be associated with nausea, vomiting, gas- tritis, hematemesis, dry mouth, puffy blotchy complexion, and mild peripheral edema. Functional Consequences of Alcohol Use Disorder The diagnostic features of alcohol use disorder highlight major areas of life functioning likely to be impaired. These include driving and operating machinery, school and work, interpersonal relationships and communication, and health. Alcohol-related disorders contribute to absenteeism from work, job-related accidents, and low employee productiv ity. Rates are elevated in homeless individuals, perhaps reflecting a downward spiral social and occupational functioning, although most individuals with alcohol use disorder continue to live with their families and function within their jobs. Alcohol use disorder is associated with a significant increase in the risk of accidents, vi- olence, and suicide. It is estimated that one in five intensive care unit admissions in some urban hospitals is related to alcohol and that 40% of individuals in the United States ex- perience an alcohol-related adverse event at some time in their lives, with alcohol account- ing for up to 55% of fatal driving events. Severe alcohol use disorder, especially in individuals with antisocial personality disorder, is associated with the commission of criminal acts, including homicide. Severe problematic alcohol use also contributes to dis- inhibition and feelings of sadness and irritability, which contribute to suicide attempts and completed suicides. Unanticipated alcohol withdrawal in hospitalized individuals for whom a diagnosis of alcohol use disorder has been overlooked can add to the risks and costs of hospitalization and to time spent in the hospital. Differential Diagnosis Nonpathological use of alcohol. The key element of alcohol use disorder is the use of heavy doses of alcohol with resulting repeated and significant distress or impaired func- toning. While most drinkers sometimes consume enough alcohol to feel intoxicated, only a minority (less than 20%) ever develop alcohol use disorder. Therefore, drinking, even daily, in low doses and occasional intoxication do not by themselves make this diagnosis. Sedative, hypnotic, or anxiolytic use disorder. The signs and symptoms of alcohol use disorder are similar to those seen in sedative, hypnotic, or anxiolytic use disorder. The two must be distinguished, however, because the course may be different, especially in rela- ton to medical problems. Conduct disorder in childhood and adult antisocial personality disorder. Alcohol use disorder, along with other substance use disorders, is seen in the majority of individuals with antisocial personality and preexisting conduct disorder. Because these diagnoses are associated with an early onset of alcohol use disorder as well as a worse prognosis, it is im- portant to establish both conditions. Comorbidity Bipolar disorders, schizophrenia, and antisocial personality disorder are associated with a markedly increased rate of alcohol use disorder, and several anxiety and depressive disorders may relate to alcohol use disorder as well. At least a part of the reported association between depression and moderate to severe alcohol use disorder may be attributable to temporary, al- cohol-induced comorbid depressive symptoms resulting from the acute effects of intoxication or withdrawal. Severe, repeated alcohol intoxication may also suppress immune mechanisms and predispose individuals to infections and increase the risk for cancers.

Cannabis Use Disorder (DSM)

DIAGNOSTIC CRITERIA A. A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Cannabis 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 cannabis use. 3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects. 4. Craving, or a strong desire or urge to use cannabis. 5. Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis. 7. Important social, occupational, or recreational activities are given up or reduced because of cannabis use. 8. Recurrent cannabis use in situations in which it is physically hazardous. 9. Cannabis 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 cannabis. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of cannabis. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal, pp. 517-518). b. Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. Specify if: In early remission: After full criteria for cannabis use disorder were previously met, none of the criteria for cannabis use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, "Craving, or a strong de- sire or urge to use cannabis," may be met). In sustained remission: After full criteria for cannabis use disorder were previously met, none of the criteria for cannabis use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, "Craving, or a strong desire or urge to use cannabis," may be present). Specify if: In a controlled environment: This additional specifier is used if the individual is in an environment where access to cannabis is restricted. Specifiers "In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units. Changing severity across time in an individual may also be reflected by changes in the frequency (e.g., days of use per month or times used per day) and/ or dose (e.g., amount used per episode) of cannabis, as assessed by individual self-report, report of knowledge- able others, clinician's observations, and biological testing. Diagnostic Features Cannabis use disorder and the other cannabis-related disorders include problems that are associated with substances derived from the cannabis plant and chemically similar syn- thetic compounds. Over time, this plant material has accumulated many names (e.g., weed, pot, herb, grass, reefer, mary jane, dagga, dope, bhang, skunk, boom, gangster, kit, and ganja). A concentrated extraction of the cannabis plant that is also commonly used is hashish. Cannabis is the generic and perhaps the most appropriate scientific term for the psychoactive substance(s) derived from the plant, and as such it is used in this manual to refer to all forms of cannabis-like substances, including synthetic cannabinoid compounds. Synthetic oral formulations (pill/capsules) of delta-9-tetrahydrocannabinol (delta-9- THC) are available by prescription for a number of approved medical indications (e.g., for nausea and vomiting caused by chemotherapy; for anorexia and weight loss in individuals With AIDS). Other synthetic cannabinoid compounds have been manufactured and dis Tributed for nonmedical use in the form of plant material that has been sprayed with a can- nabinoid formulation (e.g., K2, Spice, JWH-018, JWH-073). The cannabinoids have diverse effects in the brain, prominent among which are actions on CB1 and CB2 cannabinoid receptors that are found throughout the central nervous sys- tem. Endogenous ligands for these receptors behave essentially like neurotransmitters. The potency of cannabis (delta-9-THC concentration) that is generally available varies greatly, ranging from 1% to approximately 15% in typical cannabis plant material and 90%-20% in hashish. During the past two decades, a steady increase in the potency of seized cannabis has been observed. Cannabis is most commonly smoked via a variety of methods: pipes, water pipes (bongs or hookahs), cigarettes (joints or reefers), or, most recently, in the paper from hol- lowed out cigars (blunts). Cannabis is also sometimes ingested orally, typically by mixing it into food. More recently, devices have been developed in which cannabis is "vapor- ized." Vaporization involves heating the plant material to release psychoactive cannabi- noids for inhalation. As with other psychoactive substances, smoking (and vaporization) typically produces more rapid onset and more intense experiences of the desired effects. Individuals who regularly use cannabis can develop all the general diagnostic features of a substance use disorder. Cannabis use disorder is commonly observed as the only sub- stance use disorder experienced by the individual; however, it also frequently occurs con- currently with other types of substance use disorders (i.e., alcohol, cocaine, opioid). In cases for which multiple types of substances are used, many times the individual may minimize the symptoms related to cannabis, as the symptoms may be less severe or cause less harm than those directly related to the use of the other substances. Pharmacological and behavioral tolerance to most of the effects of cannabis has been reported in individuals who use cannabis persistently. Generally, tolerance is lost when cannabis use is discontin- ed for a significant period of time (i.e., for at least several months). New to DSM-5 is the recognition that abrupt cessation of daily or near-daily cannabis use often results in the onset of a cannabis withdrawal syndrome. Common symptoms of withdrawal include irritability, anger or aggression, anxiety, depressed mood, restless- ness, sleep difficulty, and decreased appetite or weight loss. Although typically not as severe as alcohol or opiate withdrawal, the cannabis withdrawal syndrome can cause sig- nificant distress and contribute to difficulty quitting or relapse among those trying to abstain. Individuals with cannabis use disorder may use cannabis throughout the day over a period of months or years, and thus may spend many hours a day under the influence. Others may use less frequently, but their use causes recurrent problems related to family, school, work, or other important activities (.g, repeated absences at work; neglect of fam- ily obligations). Periodic cannabis use and intoxication can negatively affect behavioral and cognitive functioning and thus interfere with optimal performance at work or school, or place the individual at increased physical risk when performing activities that could be Physically hazardous (e.g., driving a car; playing certain sports; performing manual work activities, including operating machinery). Arguments with spouses or parents over the use of cannabis in the home, or its use in the presence of children, can adversely impact family functioning and are common features of those with cannabis use disorder. Last, in- dividuals with cannabis use disorder may continue using despite knowledge of physical problems (e,g, chronic cough related to smoking) or psychological problems (e.&., exces- sive sedation or exacerbation of other mental health problems) associated with its use. Whether or not cannabis is being used for legitimate medical reasons may also affect diagnosis. When a substance is taken as indicated for a medical condition, symptoms of tolerance and withdrawal will naturally occur and should not be used as the primary cri- teria for determining a diagnosis of a substance use disorder. Although medical uses of cannabis remain controversial and equivocal, use for medical circumstances should be considered when a diagnosis is being made. Associated Features Supporting Diagnosis Individuals who regularly use cannabis often report that it is being used to cope with mood, sleep, pain, or other physiological or psychological problems, and those diagnosed with cannabis use disorder frequently do have concurrent other mental disorders. Careful assessment typically reveals reports of cannabis use contributing to exacerbation of these same symptoms, as well as other reasons for frequent use (e.g., to experience euphoria, to forget about problems, in response to anger, as an enjoyable social activity). Related to this issue, some individuals who use cannabis multiple times per day for the aforementioned reasons do not perceive themselves as (and thus do not report) spending an excessive amount of time under the influence or recovering from the effects of cannabis, despite be- ing intoxicated on cannabis or coming down from it effects for the majority of most days. An important marker of a substance use disorder diagnosis, particularly in milder cases, is continued use despite a clear risk of negative consequences to other valued activities or re- lationships (e.g., school, work, sport activity, partner or parent relationship). Because some cannabis users are motivated to minimize their amount or frequency of use, it is important to be aware of common signs and symptoms of cannabis use and intox- ication so as to better assess the extent of use. As with other substances, experienced users of cannabis develop behavioral and pharmacological tolerance such that it can be difficult to detect when they are under the influence. Signs of acute and chronic use include red eyes (conjunctival injection), cannabis odor on clothing, yellowing of finger tips (from smoking joints), chronic cough, burning of incense (to hide the odor), and exaggerated craving and impulse for specific foods, sometimes at unusual times of the day or night. Prevalence Cannabinoids, especially cannabis, are the most widely used illicit psychoactive sub- stances in the United States. The 12-month prevalence of cannabis use disorder (DSM-IV abuse and dependence rates combined) is approximately 3.4% among 12- to 17-year-olds and 1.5% among adults age 18 years and older. Rates of cannabis use disorder are greater among adult males (2.2%) than among adult females (0.8%) and among 12- to 17-year-old males (3.8%) than among 12- to 17-year-old females (3.0%). Twelve-month prevalence rates of cannabis use disorder among adults decrease with age, with rates highest among 18- to 29-year-olds (4.4%) and lowest among individuals age 65 years and older (0.01%). The high prevalence of cannabis use disorder likely reflects the much more widespread use of cannabis relative to other illicit drugs rather than greater addictive potential. Ethnic and racial differences in prevalence are moderate. Twelve-month prevalences of cannabis use disorder vary markedly across racial-ethnic subgroups in the United States. For 12- to 17-year-olds, rates are highest among Native American and Alaska Na- tives (7.1%) compared with Hispanics (4.1%), whites (3.4%), African Americans (2.7%), and Asian Americans and Pacific Islanders (0.9%). Among adults, the prevalence of can- nabis use disorder is also highest among Native Americans and Alaska Natives (3.4%) rel- ative to rates among African Americans (1.8%), whites (1.4%), Hispanics (1.2%), and Asian and Pacific Islanders (1.2%). During the past decade the prevalence of cannabis use disor- der has increased among adults and adolescents. Gender differences in cannabis use dis- order generally are concordant with those in other substance use disorders. Cannabis use disorder is more commonly observed in males, although the magnitude of this difference is less among adolescents. Development and Course The onset of cannabis use disorder can occur at any time during or following adolescence, but onset is most commonly during adolescence or young adulthood. Although much less frequent, onset of cannabis use disorder in the preteen years or in the late 20s or older can occur. Recent acceptance by some of the use and availability of "medical marijuana" may increase the rate of onset of cannabis use disorder among older adults. Generally, cannabis use disorder develops over an extended period of time, although the progression appears to be more rapid in adolescents, particularly those with pervasive conduct problems. Most people who develop a cannabis use disorder typically establish a pattern of cannabis use that gradually increases in both frequency and amount. Cannabis, along with tobacco and alcohol, is traditionally the first substance that adolescents try. Many perceive cannabis use as less harmful than alcohol or tobacco use, and this percep- Hon likely contributes to increased use. Moreover, cannabis intoxication does not typically result in as severe behavioral and cognitive dysfunction as does significant alcohol intox- cation, which may increase the probability of more frequent use in more diverse situa- tons than with alcohol. These factors likely contribute to the potential rapid transition from cannabis use to a cannabis use disorder among some adolescents and the common pattern of using throughout the day that is commonly observed among those with more severe cannabis use disorder. Cannabis use disorder among preteens, adolescents, and young adults is typically ex- pressed as excessive use with peers that is a component of a pattern of other delinquent behaviors usually associated with conduct problems. Milder cases primarily reflect con- tinued use despite clear problems related to disapproval of use by other peers, school ad- ministration, or family, which also places the youth at risk for physical or behavioral consequences. In more severe cases, there is a progression to using alone or using through- out the day such that use interferes with daily functioning and takes the place of previ- ously established, prosocial activities. With adolescent users, changes in mood stability, energy level, and eating patterns are commonly observed. These signs and symptoms are likely due to the direct effects of can- nabis use (intoxication) and the subsequent effects following acute intoxication (coming down), as well as attempts to conceal use from others. School-related problems are com- moly associated with cannabis use disorder in adolescents, particularly a dramatic drop in grades, truancy, and reduced interest in general school activities and outcomes. Cannabis use disorder among adults typically involves well-established patterns of daily cannabis use that continue despite clear psychosocial or medical problems. Many adults have experienced repeated desire to stop or have failed at repeated cessation attempts. Milder adult cases may resemble the more common adolescent cases in that cannabis use is not as frequent or heavy but continues despite potential significant consequences of sustained use. The rate of use among middle-age and older adults appears to be increasing, likely because of a cohort ef- fect resulting from high prevalence of use in the late 1960s and the 1970s. Early onset of cannabis use (e.g., prior to age 15 years) is a robust predictor of the de- velopment of cannabis use disorder and other types of substance use disorders and mental disorders during young adulthood. Such early onset is likely related to concurrent other externalizing problems, most notably conduct disorder symptoms. However, early onset is also a predictor of internalizing problems and as such probably reflects a general risk factor for the development of mental health disorders. Risk and Prognostic Factors Temperamental. A history of conduct disorder in childhood or adolescence and antiso- cial personality disorder are risk factors for the development of many substance-related disorders, including cannabis-related disorders. Other risk factors include externalizing or internalizing disorders during childhood or adolescence. Youths with high behavioral disinhibition scores show early-onset substance use disorders, including cannabis use dis order, multiple substance involvement, and early conduct problems. Environmental. Risk factors include academic failure, tobacco smoking, unstable or abu- sive family situation, use of cannabis among immediate family members, a family history of a substance use disorder, and low socioeconomic status. As with all substances of abusé, the ease of availability of the substance is a risk factor; cannabis is relatively easy to obtain in most cultures, which increases the risk of developing a cannabis use disorder. Genetic and physiological. Genetic influences contribute to the development of canna- bis use disorders. Heritable factors contribute between 30% and 80% of the total variance in risk of cannabis use disorders. It should be noted that common genetic and shared en- vironmental influences between cannabis and other types of substance use disorders sug. gest a common genetic basis for adolescent substance use and conduct problems. Culture-Related Diagnostic Issues Cannabis is probably the world's most commonly used illicit substance. Occurrence of cannabis use disorder across countries is unknown, but the prevalence rates are likely sim- ilar among developed countries. It is frequently among the first drugs of experimentation (often in the teens) of all cultural groups in the United States. Acceptance of cannabis for medical purposes varies widely across and within cultures. Cultural factors (acceptability and legal status) that might impact diagnosis relate to dif- ferential consequences across cultures for detection of use (i.e., arrest, school suspensions, or employment suspension). The general change in substance use disorder diagnostic cri- teria from DSM-IV to DSM-5 (i.e., removal of the recurrent substance-related legal prob- lems criterion) mitigates this concern to some degree. Diagnostic Markers Biological tests for cannabinoid metabolites are useful for determining if an individual has recently used cannabis. Such testing is helpful in making a diagnosis, particularly in milder cases if an individual denies using while others (family, work, school) purport con- cern about a substance use problem. Because cannabinoids are fat soluble, they persist in bodily fluids for extended periods of time and are excreted slowly. Expertise in urine test- ing methods is needed to reliably interpret results. Functional Consequences of Cannabis Use Disorder Functional consequences of cannabis use disorder are part of the diagnostic criteria. Many areas of psychosocial, cognitive, and health functioning may be compromised in relation to cannabis use disorder. Cognitive function, particularly higher executive function, ap- pears to be compromised in cannabis users, and this relationship appears to be dose de- pendent (both acutely and chronically). This may contribute to increased difficulty at school or work. Cannabis use has been related to a reduction in prosocial goal-directed ac- tivity, which some have labeled an motivational syndrome, that manifests itself in poor school performance and employment problems. These problems may be related to perva- sive intoxication or recovery from the effects of intoxication. Similarly, cannabis-associated problems with social relationships are commonly reported in those with cannabis use dis- order. Accidents due to engagement in potentially dangerous behaviors while under the influence (e.g., driving, sport, recreational or employment activities) are also of concern. Cannabis smoke contains high levels of carcinogenic compounds that place chronic users at risk for respiratory illnesses similar to those experienced by tobacco smokers. Chronic cannabis use may contribute to the onset or exacerbation of many other mental disorders. In particular, concern has been raised about cannabis use as a causal factor in schizophrenia and other psychotic disorders. Cannabis use can contribute to the onset of an acute psychotic episode, can exacerbate some symptoms, and can adversely affect treatment of a major psychotic illness Differential Diagnosis Nonproblematic use of cannabis. The distinction between nonproblematic use of can- nabis and cannabis use disorder can be difficult to make because social, behavioral, or psy- chological problems may be difficult to attribute to the substance, especially in the context of use of other substances. Also, denial of heavy cannabis use and the attribution that can- nabis is related to or causing substantial problems are common among individuals who are referred to treatment by others (i.e., school, family, employer, criminal justice system). Other mental disorders. Cannabis-induced disorder may be characterized by symp- toms (e.g., anxiety) that resemble primary mental disorders (e.g., generalized anxiety dis- order vs. cannabis-induced anxiety disorder, with generalized anxiety, with onset during intoxication). Chronic intake of cannabis can produce a lack of motivation that resembles persistent depressive disorder (dysthymia). Acute adverse reactions to cannabis should be differentiated from the symptoms of panic disorder, major depressive disorder, delusional disorder, bipolar disorder, or schizophrenia, paranoid type. Physical examination will usually show an increased pulse and conjunctival injection. Urine toxicological testing can be helpful in making a diagnosis. Comorbidity Cannabis has been commonly thought of as a "gateway" drug because individuals who frequently use cannabis have a much greater lifetime probability than nonusers of using what are commonly considered more dangerous substances, like opioids or cocaine. Can- nabis use and cannabis use disorder are highly comorbid with other substance use disor- ders. Co-occurring mental conditions are common in cannabis use disorder. Cannabis use has been associated with poorer life satisfaction; increased mental health treatment and hospitalization; and higher rates of depression, anxiety disorders, suicide attempts, and conduct disorder. Individuals with past-year or lifetime cannabis use disorder have high rates of alcohol use disorder (greater than 50%) and tobacco use disorder (53%). Rates of other substance use disorders are also likely to be high among individuals with cannabis use disorder. Among those seeking treatment for a cannabis use disorder, 74% report problematic use of a secondary or tertiary substance: alcohol (40%), cocaine (12%), meth- amphetamine (6%), and heroin or other opiates (2%). Among those younger than 18 years, 61% reported problematic use of a secondary substance: alcohol (48%), cocaine (4%), meth- amphetamine (2%), and heroin or other opiates (2%). Cannabis use disorder is also often observed as a secondary problem among those with a primary diagnosis of other substance use disorders, with approximately 25%-80% of those in treatment for another substance use disorder reporting use of cannabis. Individuals with past-year or lifetime diagnoses of cannabis use disorder also have high rates of concurrent mental disorders other than substance use disorders. Major de- pressive disorder (11%), any anxiety disorder (24%), and bipolar I disorder (13%) are quite common among individuals with a past-year diagnosis of a cannabis use disorder, as are antisocial (30%), obsessive-compulsive, (19%), and paranoid (18%) personality disorders. Approximately 33% of adolescents with cannabis use disorder have internalizing disor- ders (e.g., anxiety, depression, posttraumatic stress disorder), and 60% have externalizing disorders (e.g., conduct disorder, attention-deficit/hyperactivity disorder). Although cannabis use can impact multiple aspects of normal human functioning, in- cluding the cardiovascular, immune, neuromuscular, ocular, reproductive, and respira- tory systems, as well as appetite and cognition/perception, there are few clear medical conditions that commonly co-occur with cannabis use disorder. The most significant health effects of cannabis involve the respiratory system, and chronic cannabis smokers exhibit high rates of respiratory symptoms of bronchitis, sputum production, shortness of breath, and wheezing.

Other Hallucinogen Use Disorder (DSM)

DIAGNOSTIC CRITERIA A. A problematic pattern of hallucinogen (other than phencyclidine) use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. The hallucinogen 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 hallucinogen use. 3. A great deal of time is spent in activities necessary to obtain the hallucinogen, use the hallucinogen, or recover from its effects. 4. Craving, or a strong desire or urge to use the hallucinogen. 5. Recurrent hallucinogen use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences from work or poor work performance related to hallucinogen use; hallucinogen-related absences, suspensions, or expulsions from school; neglect of children or household). 6. Continued hallucinogen use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the hallucinogen (e.g., arguments with a spouse about consequences of intoxication; physical fights). 7. Important social, occupational, or recreational activities are given up or reduced because of hallucinogen use. 8. Recurrent hallucinogen use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by the hallucinogen). 9. Hallucinogen 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 the hallucinogen. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the hallucinogen to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of the hallucinogen. Note: Withdrawal symptoms and signs are not established for hallucinogens, and so this criterion does not apply. Specifiers "In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units. Diagnostic Features Hallucinogens comprise a diverse group of substances that, despite having different chem- cal structures and possibly involving different molecular mechanisms, produce similar alterations of perception, mood, and cognition in users. Hallucinogens included are phenyl- alkylamines (e.g., mescaline, DOM [2,5-dimethoxy-4-methylamphetamine], and MDMA [3,4-methylenedioxymethamphetamine; also called "ecstasy" ]I); the indoleamines, includ- ing psilocybin (i.e., psilocin) and dimethyltryptamine (DMT); and the ergolines, such as LSD (lysergic acid diethylamide) and morning glory seeds. In addition, miscellaneous other ethnobotanical compounds are classified as "hallucinogens, " of which Salvia divinorum and jimsonweed are two examples. Excluded from the hallucinogen group are cannabis and its active compound, delta-9-tetrahydrocannabinol (THC) (see the section "Cannabis-Related Disorders"). These substances can have hallucinogenic effects but are diagnosed separately because of significant differences in their psychological and behavioral effects. Hallucinogens are usually taken orally, although some forms are smoked (e.g., DMI, salvia) or (rarely) taken intranasally or by injection (e.g., ecstasy). Duration of effects varies across types of hallucinogens. Some of these substances (i.e., LSD, MDMA) have a long half-life and extended duration such that users may spend hours to days using and/or re- covering from the effects of these drugs. However, other hallucinogenic drugs (e.g., DMT, salvia) are short acting. Tolerance to hallucinogens develops with repeated use and has been reported to have both autonomic and psychological effects. Cross-tolerance exists be- tween LSD and other hallucinogens (e.g., psilocybin, mescaline) but does not extend to other drug categories such as amphetamines and cannabis. MDMA/ecstasy as a hallucinogen may have distinctive effects attributable to both its hal- lucinogenic and its stimulant properties. Among heavy ecstasy users, continued use despite physical or psychological problems, tolerance, hazardous use, and spending a great deal of time obtaining the substance are the most commonly reported criteria- over 50% in adults and over 30% in a younger sample, while legal problems related to substance use and persis- tent desire /inability to quit are rarely reported. As found for other substances, diagnostic cri- teria for other hallucinogen use disorder are arrayed along a single continuum of severity. One of the generic criteria for substance use disorders, a clinically significant with- drawal syndrome, has not been consistently documented in humans, and therefore the di- agnosis of hallucinogen withdrawal syndrome is not included in DSM-5. However, there is evidence of withdrawal from MDMA, with endorsement of two or more withdrawal symptoms observed in 59%-98% in selected samples of ecstasy users. Both psychological and physical problems have been commonly reported as withdrawal problems. Associated Features Supporting Diagnosis The characteristic symptom features of some of the hallucinogens can aid in diagnosis if urine or blood toxicology results are not available. For example, individuals who use LSD tend to experience visual hallucinations that can be frightening. Individuals intoxicated with hallucinogens may exhibit a temporary increase in suicidality. Prevalence Of all substance use disorders, other hallucinogen use disorder is one of the rarest. The 12-month prevalence is estimated to be 0.5% among 12- to 17-year-olds and 0.1% among adults age 18 and older in the United States. Rates are higher in adult males (0.2%) compared with females (0.1%), but the opposite is observed in adolescent samples ages 12-17, in which the 12-month rate is slightly higher in females (0.6%) than in males (0.4%). Rates are highest in individuals younger than 30 years, with the peak occurring in individuals ages 18-29 years (0.6%) and decreasing to virtually 0.0% among individuals age 45 and older. There are marked ethnic differences in 12-month prevalence of other hallucinogen use disorder. Among youths ages 12-17 years, 12-month prevalence is higher among Native Americans and Alaska Natives (1.2%) than among Hispanics (0.6%), whites (0.6%), Afri- can Americans (0.2%), and Asian Americans and Pacific Islanders (0.2%). Among adults, 12-month prevalence of other hallucinogen use disorder is similar for Native Americans and Alaska Natives, whites, and Hispanics (all 0.2%) but somewhat lower for Asian Amer- icans and Pacific Islanders (0.07%) and African Americans (0.03%). Past-year prevalence is higher in clinical samples (e.g., 19% in adolescents in treatment). Among individuals cur- rently using hallucinogens in the general population, 7.8% (adult) to 17% (adolescent) had a problematic pattern of use that met criteria for past-year other hallucinogen use disorder. Among select groups of individuals who use hallucinogens (e.g., recent heavy ecstasy use), 73.5% of adults and 77% of adolescents have a problematic pattern of use that may meet other hallucinogen use disorder criteria. Development and Course Unlike most substances where an early age at onset is associated with elevations in risk for the corresponding use disorder, it is unclear whether there is an association of an early age at onset with elevations in risk for other hallucinogen use disorder. However, patterns of drug consumption have been found to differ by age at onset, with early-onset ecstasy users more likely to be polydrug users than their later-onset counterparts. There may be a dis- proportionate influence of use of specific hallucinogens on risk of developing other hallu- cinogen use disorder, with use of ecstasy/ MDMA increasing the risk of the disorder relative to use of other hallucinogens. Little is known regarding the course of other hallucinogen use disorder, but it is generally thought to have low incidence, low persistence, and high rates of recovery. Adolescents are es- pecially at risk for using these drugs, and it is estimated that 2.7% of youths ages 12-17 years have used one or more of these drugs in the past 12 months, with 44% having used ecstasy / MDMA. Other hallucinogen use disorder is a disorder observed primarily in individuals younger than 30 years, with rates vanishingly rare among older adults. Risk and Prognostic Factors Temperamental. In adolescents but not consistently in adults, MDMA use is associated with an elevated rate of other hallucinogen use disorder. Other substance use disorders, particu- larly alcohol, tobacco, and cannabis, and major depressive disorder are associated with ele- vated rates of other hallucinogen use disorder. Antisocial personality disorder may be elevated among individuals who use more than two other drugs in addition to hallucinogens, compared with their counterparts with less extensive use history. The influence of adult anti- social behaviors- but not conduct disorder or antisocial personality disorder- on other hal- lucinogen use disorder may be stronger in females than in males. Use of specific hallucinogens (e.g., salvia) is prominent among individuals ages 18-25 years with other risk-taking behaviors and illegal activities. Cannabis use has also been implicated as a precursor to initiation of use of hallucinogens (e.g., ecstasy), along with early use of alcohol and tobacco. Higher drug use by peers and high sensation seeking have also been associated with elevated rates of ecstasy use. MDMA/ecstasy use appears to signify a more severe group of hallucinogen users. Genetic and physiological. Among male twins, total variance due to additive genetics has been estimated to range from 26% to 79%, with inconsistent evidence for shared envi- ronmental influences. Culture-Related Diagnostic Issues Historically, hallucinogens have been used as part of established religious practices, such as the use of peyote in the Native American Church and in Mexico. Ritual use by indige- nous populations of psilocybin obtained from certain types of mushrooms has occurred in South America, Mexico, and some areas in the United States, or of ayahuasca in the Santo Daime and União de Vegetal sects. Regular use of peyote as part of religious rituals is not linked to neuropsychological or psychological deficits. For adults, no race or ethnicity dif- ferences for the full criteria or for any individual criterion are apparent at this time. Gender-Related Diagnostic Issues In adolescents, females may be less likely than males to endorse "hazardous use," and fe- male gender may be associated with increased odds of other hallucinogen use disorder. Diagnostic Markers Laboratory testing can be useful in distinguishing among the different hallucinogens. However, because some agents (e.g., LSD) are so potent that as little as 75 micrograms can produce severe reactions, typical toxicological examination will not always reveal which substance has been used Functional Consequences of Other Hallucinogen Use Disorder There is evidence for long-term neurotoxic effects of MDMA/ecstasy use, including im- pairments in memory, psychological function, and neuroendocrine function; serotonin system dysfunction; and sleep disturbance; as well as adverse effects on brain microvas- culture, white matter maturation, and damage to axons. Use of MDMA/ ecstasy may di- minish functional connectivity among brain regions. Differential Diagnosis Other substance use disorders. The effects of hallucinogens must be distinguished from those of other substances (e.g., amphetamines), especially because contamination of the hallucinogens with other drugs is relatively common. Schizophrenia. Schizophrenia also must be ruled out, as some affected individuals (e.g., individuals with schizophrenia who exhibit paranoia) may falsely attribute their symp- toms to use of hallucinogens. Other mental disorders or medical conditions. Other potential disorders or conditions to consider include panic disorder, depressive and bipolar disorders, alcohol or sedative withdrawal, hypoglycemia and other metabolic conditions, seizure disorder, stroke, oph- thalmological disorder, and central nervous system tumors. Careful history of drug tak- ing, collateral reports from family and friends (if possible), age, clinical history, physical examination, and toxicology reports should be useful in arriving at the final diagnostic de- cision. Comorbidity Adolescents who use MDMA/ ecstasy and other hallucinogens, as well as adults who have recently used ecstasy, have a higher prevalence of other substance use disorders compared with nonhallucinogen substance users. Individuals who use hallucinogens exhibit eleva- tions of nonsubstance mental disorders (especially anxiety, depressive, and bipolar disor- ders), particularly with use of ecstasy and salvia. Rates of antisocial personality disorder (but not conduct disorder) are significantly elevated among individuals with other hallucinogen use disorder, as are rates of adult antisocial behavior. However, it is unclear whether the mental illnesses may be precursors to rather than consequences of other hallucinogen use disorder (see the section "Risk and Prognostic Factors" for this disorder). Both adults and adolescents who use ecstasy are more likely than other drug users to be polydrug users and to have other drug use disorders.

Opioid use disorder (DSM)

DIAGNOSTIC CRITERIA A. A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Opioids are 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 opioid use. 3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects. 4. Craving, or a strong desire or urge to use opioids. 5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. 7. Important social, occupational, or recreational activities are given up or reduced because of opioid use. 8. Recurrent opioid use in situations in which it is physically hazardous. 9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of an opioid. Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision. 11. Withdrawal, as manifested by either of the following: a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal, pp. 547-548). b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms. Note: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision. Specifiers The " on maintenance therapy" specifier applies as a further specifier of remission if the in- dividual is both in remission and receiving maintenance therapy. "In a controlled environ- ment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely super- vised and substance-free jails, therapeutic communities, and locked hospital units. Changing severity across time in an individual is also reflected by reductions in the fre- quency (e.g., days of use per month) and / or dose (e.g., injections or number of pills) of an opioid, as assessed by the individual's self-report, report of knowledgeable others, clini- can's observations, and biological testing. Diagnostic Features Opioid use disorder includes signs and symptoms that reflect compulsive, prolonged self- administration of opioid substances that are used for no legitimate medical purpose or, if another medical condition is present that requires opioid treatment, that are used in doses greatly in excess of the amount needed for that medical condition. (For example, an indi- vidual prescribed analgesic opioids for pain relief at adequate dosing will use significantly more than prescribed and not only because of persistent pain.) Individuals with opioid use disorder tend to develop such regular patterns of compulsive drug use that daily activities are planned around obtaining and administering opioids. Opioids are usually purchased on the illegal market but may also be obtained from physicians by falsifying or exagger- ating general medical problems or by receiving simultaneous prescriptions from several physicians. Health care professionals with opioid use disorder will often obtain opioids by writing prescriptions for themselves or by diverting opioids that have been prescribed for patients or from pharmacy supplies. Most individuals with opioid use disorder have significant levels of tolerance and will experience withdrawal on abrupt discontinuation of opioid substances. Individuals with opioid use disorder often develop conditioned responses to drug-related stimuli (e.g., craving on seeing any heroin powder-like sub- stance) a phenomenon that occurs with most drugs that cause intense psychological changes. These responses probably contribute to relapse, are difficult to extinguish, and typ- ically persist long after detoxification is completed. Associated Features Supporting Diagnosis Opioid use disorder can be associated with a history of drug-related crimes (e.g, posses- sion or distribution of drugs, forgery, burglary, robbery, larceny, receiving stolen goods). Among health care professionals and individuals who have ready access to controlled substances, there is often a different pattern of illegal activities involving problems with state licensing boards, professional staffs of hospitals, or other administrative agencies. Marital difficulties (including divorce), unemployment, and irregular employment are of- ten associated with opioid use disorder at all socioeconomic levels. Prevalence The 12-month prevalence of opioid use disorder is approximately 0.37% among adults age 18 years and older in the community population. This may be an underestimate because of the large number of incarcerated individuals with opioid use disorders. Rates are higher in males than in females (0.49% vs. 0.26%), with the male-to-female ratio typically being 1.5:1 for opioids other than heroin (i.e., available by prescription) and 3:1 for heroin. Female ad- olescents may have a higher likelihood of developing opioid use disorders. The preva- lence decreases with age, with the prevalence highest (0.82%) among adults age 29 years or younger, and decreasing to 0.09% among adults age 65 years and older. Among adults, the prevalence of opioid use disorder is lower among African Americans at 0.18% and over- represented among Native Americans at 1.25%. It is close to average among whites (0.38%), Asian or Pacific Islanders (0.35%), and Hispanics (0.39%). Among individuals in the United States ages 12-17 years, the overall 12-month prev- alence of opioid use disorder in the community population is approximately 1.0%, but the prevalence of heroin use disorder is less than 0.1%. By contrast, analgesic use disorder is prevalent in about 1.0% of those ages 12-17 years, speaking to the importance of opioid an- algesics as a group of substances with significant health consequences. The 12-month prevalence of problem opioid use in European countries in the commu- nity population ages 15-64 years is between 0.1% and 0.8%. The average prevalence of problem opioid use in the European Union and Norway is between 0.36% and 0.44%. Development and Course Opioid use disorder can begin at any age, but problems associated with opioid use are most commonly first observed in the late teens or early 20s. Once opioid use disorder develops, it usually continues over a period of many years, even though brief periods of abstinence are frequent. In treated populations, relapse following abstinence is common. Even though relapses do occur, and while some long-term mortality rates may be as high as 2% per year, about 20%-30% of individuals with opioid use disorder achieve long-term abstinence. An exception concerns that of military service personnel who became depen- dent on opioids in Vietnam; over 90% of this population who had been dependent on opi- ids during deployment in Vietnam achieved abstinence after they returned, but they experienced increased rates of alcohol or amphetamine use disorder as well as increased suicidality. Increasing age is associated with a decrease in prevalence as a result of early mortality and the remission of symptoms after age 40 years (i.e., "maturing out"). However, many individuals continue have presentations that meet opioid use disorder criteria for decades. Risk and Prognostic Factors Genetic and physiological. The risk for opiate use disorder can be related to individual, family, peer, and social environmental factors, but within these domains, genetic factors Play a particularly important role both directly and indirectly. For instance, impulsivity and novelty seeking are individual temperaments that relate to the propensity to develop a substance use disorder but may themselves be genetically determined. Peer factors may relate to genetic predisposition in terms of how an individual selects his or her environ- ment. Culture-Related Diagnostic Issues Despite small variations regarding individual criterion items, opioid use disorder diag- nostic criteria perform equally well across most race/ ethnicity groups. Individuals from ethnic minority populations living in economically deprived areas have been overrep- resented among individuals with opioid use disorder. However, over time, opioid use disorder is seen more often among white middle-class individuals, especially females, suggesting that differences in use reflect the availability of opioid drugs and that other so- cial factors may impact prevalence. Medical personnel who have ready access to opioids may be at increased risk for opioid use disorder. Diagnostic Markers Routine urine toxicology test results are often positive for opioid drugs in individuals with opioid use disorder. Urine test results remain positive for most opioids (e.g., heroin, mor- phine, codeine, oxycodone, propoxyphene) for 12-36 hours after administration. Fentanyl is not detected by standard urine tests but can be identified by more specialized proce- dures for several days. Methadone, buprenorphine (or buprenorphine / naloxone combi- nation), and LAAM (L-alpha-acetylmethadol) have to be specifically tested for and will not cause a positive result on routine tests for opiates. They can be detected for several days up to more than 1 week. Laboratory evidence of the presence of other substances (e.g., co- caine, marijuana, alcohol, amphetamines, benzodiazepines) is common. Screening test re- sults for hepatitis A, B, and C virus are positive in as many as 80%-90% of injection opioid users, either for hepatitis antigen (signifying active infection) or for hepatitis antibody (sig- nifying past infection). HIV is prevalent in injection opioid users as well. Mildly elevated liver function test results are common, either as a result of resolving hepatitis or from toxic injury to the liver due to contaminants that have been mixed with the injected opioid. Sub- tle changes in cortisol secretion patterns and body temperature regulation have been ob- served for up to 6 months following opioid detoxification. Suicide Risk Similar to the risk generally observed for all substance use disorders, opioid use disorder is associated with a heightened risk for suicide attempts and completed suicides. Particu- larly notable are both accidental and deliberate opioid overdoses. Some suicide risk factors overlap with risk factors for an opioid use disorder. In addition, repeated opioid intoxica- tion or withdrawal may be associated with severe depressions that, although temporary, can be intense enough to lead to suicide attempts and completed suicides. Available data suggest that nonfatal accidental opioid overdose (which is common) and attempted sui- cide are distinct clinically significant problems that should not be mistaken for each other. Functional Consequences of Opioid Use Disorder Opioid use is associated with a lack of mucous membrane secretions, causing dry mouth and nose. Slowing of gastrointestinal activity and a decrease in gut motility can produce severe constipation. Visual acuity may be impaired as a result of pupillary constriction with acute administration. In individuals who inject opioids, sclerosed veins ("tracks") and puncture marks on the lower portions of the upper extremities are common. Veins sometimes become so severely sclerosed that peripheral edema develops, and individuals switch to injecting in veins in the legs, neck, or groin. When these veins become unusable, individuals often inject directly into their subcutaneous tissue ("skin-popping"), resulting Differential Diagnosis Opioid-induced mental disorders. Opioid-induced disorders occur frequently in individ- uals with opioid use disorder. Opioid-induced disorders may be characterized by symptoms (e.g., depressed mood) that resemble primary mental disorders (e.g., persistent depressive dis- order [dysthymia] vs. opioid-induced depressive disorder, with depressive features, with on- set during intoxication). Opioids are less likely to produce symptoms of mental disturbance than are most other drugs of abuse. Opioid intoxication and opioid withdrawal are distin- guished from the other opioid-induced disorders (e.g., opioid-induced depressive disorder, with onset during intoxication) because the symptoms in these latter disorders predominate the clinical presentation and are severe enough to warrant independent clinical attention. Other substance intoxication. Alcohol intoxication and sedative, hypnotic, or anxiolytic intoxication can cause a clinical picture that resembles that for opioid intoxication. A diag- nosis of alcohol or sedative, hypnotic, or anxiolytic intoxication can usually be made based on the absence of pupillary constriction or the lack of a response to naloxone challenge. In some cases, intoxication may be due both to opioids and to alcohol or other sedatives. In these cases, the naloxone challenge will not reverse all of the sedative effects. Other withdrawal disorders. The anxiety and restlessness associated with opioid with- drawl resemble symptoms seen in sedative-hypnotic withdrawal. However, opioid withdrawal is also accompanied by rhinorrhea, lacrimation, and pupillary dilation, which are not seen in sedative-type withdrawal. Dilated pupils are also seen in hallucinogen intoxication and stimulant intoxication. However, other signs or symptoms of opioid withdrawal, such as nausea, vomiting, diarrhea, abdominal cramps, rhinorrhea, or lacri- mation, are not present. Comorbidity The most common medical conditions associated with opioid use disorder are viral (e.g., HIV, hepatitis C virus) and bacterial infections, particularly among users of opioids by in- jection. These infections are less common in opioid use disorder with prescription opioids. Opioid use disorder is often associated with other substance use disorders, especially those involving tobacco, alcohol, cannabis, stimulants, and benzodiazepines, which are often taken to reduce symptoms of opioid withdrawal or craving for opioids, or to enhance the ef- fects of administered opioids. Individuals with opioid use disorder are at risk for the devel- opment of mild to moderate depression that meets symptomatic and duration criteria for persistent depressive disorder (dysthymia) or, in some cases, for major depressive disorder. These symptoms may represent an opioid-induced depressive disorder or an exacerbation of a preexisting primary depressive disorder. Periods of depression are especially common during chronic intoxication or in association with physical or psychosocial stressors that are related to the opioid use disorder. Insomnia is common, especially during withdrawal. An- tisocial personality disorder is much more common in individuals with opioid use disorder than in the general population. Posttraumatic stress disorder is also seen with increased fre- quency. A history of conduct disorder in childhood or adolescence has been identified as a significant risk factor for substance-related disorders, especially opioid use disorder.

Sedative, hypnotic, or anxiolytic use disorder (DSM)

DIAGNOSTIC CRITERIA A. A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Sedatives, hypnotics, or anxiolytics are 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 sedative, hypnotic, or anxiolytic use. 3. A great deal of time is spent in activities to obtain the sedative, hypnotic, or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects. 4. Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic. 5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences from work or poor work performance related to sedative, hypnotic, or anxiolytic use; sedative-, hypnotic-, or anxiolytic-related absences, suspensions, or expulsions from school; neglect of children or household). 6 Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedatives, hypnotics, or anxiolytics (e.g., arguments with a spouse about consequences of intoxication; physical fights). 7. Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic use. 8. Recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by sedative, hypnotic, or anxiolytic use). 9. Sedative, hypnotic, or anxiolytic 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 the sedative, hypnotic, or anxiolytic. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of the sedative, hypnotic, or anxiolytic. Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics (refer to Criteria A and B of the criteria set for sedative, hypnotic, or anxiolytic withdrawal, pp. 557-558). b. Sedatives, hypnotics, or anxiolytics (or a closely related substance, such as alcohol) are taken to relieve or avoid withdrawal symptoms. Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision. Specifiers "In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units. Diagnostic Features Sedative, hypnotic, or anxiolytic substances include benzodiazepines, benzodiazepine- like drugs (e.g., zolpidem, zaleplon), carbamates (e.g., glutethimide, meprobamate), barbiturates (e.g., secobarbital), and barbiturate-like hypnotics (e.g., glutethimide, meth- aqualone). This class of substances includes all prescription sleeping medications and almost all prescription antianxiety medications. Nonbenzodiazepine antianxiety agents (e.g., buspirone, gepirone) are not included in this class because they do not appear to be associated with significant misuse. Like alcohol, these agents are brain depressants and can produce similar substance/ medication-induced and substance use disorders. Sedative, hypnotic, or anxiolytic sub- stances are available both by prescription and illegally. Some individuals who obtain these substances by prescription will develop a sedative, hypnotic, or anxiolytic use disorder, while others who misuse these substances or use them for intoxication will not develop a use disorder. In particular, sedatives, hypnotics, or anxiolytics with rapid onset and/or short to intermediate lengths of action may be taken for intoxication purposes, although longer acting substances in this class may be taken for intoxication as well. Craving (Criterion A4), either while using or during a period of abstinence, is a typical feature of sedative, hypnotic, or anxiolytic use disorder. Misuse of substances from this class may occur on its own or in conjunction with use of other substances. For example, in- dividuals may use intoxicating doses of sedatives or benzodiazepines to "come down" from cocaine or amphetamines or use high doses of benzodiazepines in combination with methadone to "boost" its effects. Repeated absences or poor work performance, school absences, suspensions or expul- sions, and neglect of children or household (Criterion A5) may be related to sedative, hyp- notic, or anxiolytic use disorder, as may the continued use of the substances despite arguments with a spouse about consequences of intoxication or despite physical fights (Criterion A6). Limiting contact with family or friends, avoiding work or school, or stop- ping participation in hobbies, sports, or games (Criterion A7) and recurrent sedative, hypnotic, or anxiolytic use when driving an automobile or operating a machine when im- paired by sedative, hypnotic, or anxiolytic use (Criterion A8) are also seen in sedative, hypnotic, or anxiolytic use disorder. Very significant levels of tolerance and withdrawal can develop to the sedative, hyp- notic, or anxiolytic. There may be evidence of tolerance and withdrawal in the absence of a diagnosis of a sedative, hypnotic, or anxiolytic use disorder in an individual who has abruptly discontinued use of benzodiazepines that were taken for long periods of time at prescribed and therapeutic doses. In these cases, an additional diagnosis of sedative, hyp- notic, or anxiolytic use disorder is made only if other criteria are met. That is, sedative, hypnotic, or anxiolytic medications may be prescribed for appropriate medical purposes, and depending on the dose regimen, these drugs may then produce tolerance and withdrawal If these drugs are prescribed or recommended for appropriate medical purposes, and if they are used as prescribed, the resulting tolerance or withdrawal does not meet the criteria for diagnosing a substance use disorder. However, it is necessary to determine whether the drugs were appropriately prescribed and used (e.g., falsifying medical symp- toms to obtain the medication; using more medication than prescribed; obtaining the med- cation from several doctors without informing them of the others' involvement). Given the unidimensional nature of the symptoms of sedative, hypnotic, or anxiolytic use disorder, severity is based on the number of criteria endorsed. Associated Features Supporting Diagnosis Sedative, hypnotic, or anxiolytic use disorder is often associated with other substance use dis- orders (e.g., alcohol, cannabis, opioid, stimulant use disorders). Sedatives are often used to al- leviate the unwanted effects of these other substances. With repeated use of the substance, tolerance develops to the sedative effects, and a progressively higher dose is used. However, tolerance to brain stem depressant effects develops much more slowly, and as the individual takes more substance to achieve euphoria or other desired effects, there may be a sudden onset of respiratory depression and hypotension, which may result in death. Intense or repeated sedative, hypnotic, or anxiolytic intoxication may be associated with severe depression that, although temporary, can lead to suicide attempt and completed suicide. Prevalence The 12-month prevalences of DSM-IV sedative, hypnotic, or anxiolytic use disorder are es- timated to be 0.3% among 12- to 17-year-olds and 0.2% among adults age 18 years and older. Rates of DSM-IV sedative, hypnotic, or anxiolytic use disorder are slightly greater among adult males (0.3%) than among adult females, but for 12- to 17-year-olds, the rate for females (0.4%) exceeds that for males (0.2%). The 12-month prevalence of DSM-IV sedative, hypnotic, or anxiolytic use disorder decreases as a function of age and is great- est among 18- to 29-year-olds (0.5%) and lowest among individuals 65 years and older (0.04%). Twelve-month prevalence of sedative, hypnotic, or anxiolytic use disorder varies across racial/ ethnic subgroups of the U.S. population. For 12- to 17-year-olds, rates are greatest among whites (0.3%) relative to African Americans (0.2%), Hispanics (0.2%), Native Amer- icans (0.1%), and Asian Americans and Pacific Islanders (0.1%). Among adults, 12-month prevalence is greatest among Native Americans and Alaska Natives (0.8%), with rates of approximately 0.2% among African Americans, whites, and Hispanics and 0.1% among Asian Americans and Pacific Islanders. Development and Course The usual course of sedative, hypnotic, or anxiolytic use disorder involves individuals in their teens or 20s who escalate their occasional use of sedative, hypnotic, or anxiolytic agents to the point at which they develop problems that meet criteria for a diagnosis. This pattern may be especially likely among individuals who have other substance use disor- ders (e.g., alcohol, opioids, stimulants). An initial pattern of intermittent use socially (e.g., at parties) can lead to daily use and high levels of tolerance. Once this occurs, an increasing level of interpersonal difficulties, as well as increasingly severe episodes of cognitive dys- function and physiological withdrawal, can be expected. The second and less frequently observed clinical course begins with an individual who originally obtained the medication by prescription from a physician, usually for the treat- ment of anxiety, insomnia, or somatic complaints. As either tolerance or a need for higher doses of the medication develops, there is a gradual increase in the dose and frequency of self-administration. The individual is likely to continue to justify use on the basis of his or her original symptoms of anxiety or insomnia, but substance-seeking behavior becomes Risk and Prognostic Factors Temperamental. Impulsivity and novelty seeking are individual temperaments that re- late to the propensity to develop a substance use disorder but may themselves be geneti- cally determined. Environmental. Since sedatives, hypnotics, or anxiolytics are all pharmaceuticals, a key risk factor relates to availability of the substances. In the United States, the historical pat- terns of sedative, hypnotic, or anxiolytic misuse relate to the broad prescribing patterns. For instance, a marked decrease in prescription of barbiturates was associated with an in- crease in benzodiazepine prescribing. Peer factors may relate to genetic predisposition in terms of how individuals select their environment. Other individuals at heightened risk might include those with alcohol use disorder who may receive repeated prescriptions in response to their complaints of alcohol-related anxiety or insomnia. Genetic and physiological. As for other substance use disorders, the risk for sedative, hypnotic, or anxiolytic use disorder can be related to individual, family, peer, social, and environmental factors. Within these domains, genetic factors play a particularly important role both directly and indirectly. Overall, across development, genetic factors seem to play a larger role in the onset of sedative, hypnotic, or anxiolytic use disorder as individuals age through puberty into adult life. Course modifiers. Early onset of use is associated with greater likelihood for develop- ing a sedative, hypnotic, or anxiolytic use disorder. Culture-Related Diagnostic Issues There are marked variations in prescription patterns (and availability) of this class of sub- stances in different countries, which may lead to variations in prevalence of sedative, hyp- notic, or anxiolytic use disorders. Gender-Related Diagnostic Issues Females may be at higher risk than males for prescription drug misuse of sedative, hyp- notic, or anxiolytic substances. Diagnostic Markers Almost all sedative, hypnotic, or anxiolytic substances can be identified through labora- tory evaluations of urine or blood (the latter of which can quantify the amounts of these agents in the body). Urine tests are likely to remain positive for up to approximately 1 week after the use of long-acting substances, such as diazepam or flurazepam. Functional Consequences of Sedative, Hypnotic, or Anxiolytic Use Disorder The social and interpersonal consequences of sedative, hypnotic, or anxiolytic use disorder mimic those of alcohol in terms of the potential for disinhibited behavior. Accidents, interper- sonal difficulties (such as arguments or fights), and interference with work or school perfor- mance are all common outcomes. Physical examination is likely to reveal evidence of a mild decrease in most aspects of autonomic nervous system functioning, including a slower pulse, a slightly decreased respiratory rate, and a slight drop in blood pressure (most likely to occur with postural changes). At high doses, sedative, hypnotic, or anxiolytic substances can be le- thal, particularly when mixed with alcohol, although the lethal dosage varies considerably among the specific substances. Overdoses may be associated with a deterioration in vital signs that signals an impending medical emergency (e.g., respiratory arrest from barbiturates). There may be consequences of trauma (e.g., internal bleeding or a subdural hematoma) from accidents that occur while intoxicated. Intravenous use of these substances can result in med- ical complications related to the use of contaminated needles (e.g., hepatitis and HIV). Acute intoxication can result in accidental injuries and automobile accidents. For elderly individuals, even short-term use of these sedating medications at prescribed doses can be as- sociated with an increased risk for cognitive problems and falls. The disinhibiting effects of these agents, like alcohol, may potentially contribute to overly aggressive behavior, with sub- sequent interpersonal and legal problems. Accidental or deliberate overdoses, similar to those observed for alcohol use disorder or repeated alcohol intoxication, can occur. In contrast to their wide margin of safety when used alone, benzodiazepines taken in combination with al- cohol can be particularly dangerous, and accidental overdoses are reported commonly. Acci- dental overdoses have also been reported in individuals who deliberately misuse barbiturates and other nonbenzodiazepine sedatives (e.g., methaqualone), but since these agents are much less available than the benzodiazepines, the frequency of overdosing is low in most settings. Differential Diagnosis Other mental disorders or medical conditions. Individuals with sedative-, hypnotic-, or anxiolytic-induced disorders may present with symptoms (e.g., anxiety) that resemble primary mental disorders (e.g., generalized anxiety disorder vs. sedative-, hypnotic-, or anxiolytic-induced anxiety disorder, with onset during withdrawal). The slurred speech, incoordination, and other associated features characteristic of sedative, hypnotic, or anx- iolytic intoxication could be the result of another medical condition (e.g., multiple sclero- sis) or of a prior head trauma (e.g., a subdural hematoma). Alcohol use disorder. Sedative, hypnotic, or anxiolytic use disorder must be differenti- ated from alcohol use disorder. Clinically appropriate use of sedative, hypnotic, or anxiolytic medications. Individuals may continue to take benzodiazepine medication according to a physician's direction for a legitimate medical indication over extended periods of time. Even if physiological signs of tolerance or withdrawal are manifested, many of these individuals do not develop symp- toms that meet the criteria for sedative, hypnotic, or anxiolytic use disorder because they are not preoccupied with obtaining the substance and its use does not interfere with their performance of usual social or occupational roles. Comorbidity Nonmedical use of sedative, hypnotic, or anxiolytic agents is associated with alcohol use disorder, tobacco use disorder, and, generally, illicit drug use. There may also be an overlap between sedative, hypnotic, or anxiolytic use disorder and antisocial personality dis- order; depressive, bipolar, and anxiety disorders; and other substance use disorders, such as alcohol use disorder and illicit drug use disorders. Antisocial behavior and antisocial personality disorder are especially associated with sedative, hypnotic, or anxiolytic use disorder when the substances are obtained illegally.

Tobacco Use Disorder (DSM)

DIAGNOSTIC CRITERIA A. A problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Tobacco 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 tobacco use. 3. A great deal of time is spent in activities necessary to obtain or use tobacco. 4. Craving, or a strong desire or urge to use tobacco. 5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work). 6. Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use). 7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use. 8. Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in bed). 9. Tobacco 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 tobacco. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of tobacco to achieve the desired effect. b. A markedly diminished effect with continued use of the same amount of tobacco. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for tobacco withdrawal). b. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms. Specifiers "On maintenance therapy" applies as a further specifier to individuals being maintained on other tobacco cessation medication (e.g., bupropion, varenicline) and as a further specifier of remission if the individual is both in remission and on maintenance therapy. "In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sus- tained remission in a controlled environment). Examples of these environments are closely su- pervised and substance-free jails, therapeutic communities, and locked hospital units. Diagnostic Features Tobacco use disorder is common among individuals who use cigarettes and smokeless to- bacco daily and is uncommon among individuals who do not use tobacco daily or who use nicotine medications. Tolerance to tobacco is exemplified by the disappearance of nausea and dizziness after repeated intake and with a more intense effect of tobacco the first time it is used during the day. Cessation of tobacco use can produce a well-defined withdrawal syndrome. Many individuals with tobacco use disorder use tobacco to relieve or to avoid withdrawal symptoms (e.g., after being in a situation where use is restricted). Many indi- viduals who use tobacco have tobacco-related physical symptoms or diseases and con- tinue to smoke. The large majority report craving when they do not smoke for several hours. Spending excessive time using tobacco can be exemplified by chain-smoking (i.e., smok- ing one cigarette after another with no time between cigarettes). Because tobacco sources are readily and legally available, and because nicotine intoxication is very rare, spending a great deal of time attempting to procure tobacco or recovering from its effects is uncom- mon. Giving up important social, occupational, or recreational activities can occur when an individual forgoes an activity because it occurs in tobacco use-restricted areas. Use of tobacco rarely results in failure to fulfill major role obligations (e.g., interference with work, interference with home obligations), but persistent social or interpersonal problems (e.g., having arguments with others about tobacco use, avoiding social situations because of others' disapproval of tobacco use) or use that is physically hazardous (e.g., smoking in bed, smoking around flammable chemicals) occur at an intermediate prevalence. Although these criteria are less often endorsed by tobacco users, if endorsed, they can indicate a more severe disorder. Associated Features Supporting Diagnosis Smoking within 30 minutes of waking, smoking daily, smoking more cigarettes per day, and waking at night to smoke are associated with tobacco use disorder. Environmental cues can evoke craving and withdrawal. Serious medical conditions, such as lung and other cancers, cardiac and pulmonary disease, perinatal problems, cough, shortness of breath, and accelerated skin aging, often occur. Prevalence Cigarettes are the most commonly used tobacco product, representing over 90% of to- bacco/nicotine use. In the United States, 57% of adults have never been smokers, 22% are former smokers, and 21% are current smokers. Approximately 20% of current U.S. smok- ers are nondaily smokers. The prevalence of smokeless tobacco use is less than 5%, and the prevalence of tobacco use in pipes and cigars is less than 1%. DSM-IV nicotine dependence criteria can be used to estimate the prevalence of tobacco use disorder, but since they are a subset of tobacco use disorder criteria, the prevalence of tobacco use disorder will be somewhat greater. The 12-month prevalence of DSM-IV nic- otine dependence in the United States is 13% among adults age 18 years and older. Rates are similar among adult males (14%) and females (12%) and decline in age from 17% among 18- to 29-year-olds to 4% among individuals age 65 years and older. The prevalence of current nicotine dependence is greater among Native American and Alaska Natives (23%) than among whites (14%) but is less among African Americans (10%), Asian Amer- icans and Pacific Islanders (6%), and Hispanics (6%). The prevalence among current daily smokers is approximately 50%. In many developing nations, the prevalence of smoking is much greater in males than in females, but this is not the case in developed nations. However, there often is a lag in the demographic transition such that smoking increases in females at a later time. Development and Course The majority of U.S. adolescents experiment with tobacco use, and by age 18 years, about 20% smoke at least monthly. Most of these individuals become daily tobacco users. Initi- ation of smoking after age 21 years is rare. In general, some of the tobacco use disorder cri- teria symptoms occur soon after beginning tobacco use, and many individuals' pattern of use meets current tobacco use disorder criteria by late adolescence. More than 80% of in- dividuals who use tobacco attempt to quit at some time, but 60% relapse within 1 week and less than 5% remain abstinent for life. However, most individuals who use tobacco make multiple attempts such that one-half of tobacco users eventually abstain. Individuals who use tobacco who do quit usually do not do so until after age 30 years. Although non- daily smoking in the United States was previously rare, it has become more prevalent in the last decade, especially among younger individuals who use tobacco. Risk and Prognostic Factors Temperamental. Individuals with externalizing personality traits are more likely to initiate tobacco use. Children with attention-deficit/hyperactivity disorder or conduct disorder, and adults with depressive, bipolar, anxiety, personality, psychotic, or other substance use disorders, are at higher risk of starting and continuing tobacco use and of to- bacco use disorder. Environmental. Individuals with low incomes and low educational levels are more likely to initiate tobacco use and are less likely to stop. Genetic and physiological. Genetic factors contribute to the onset of tobacco use, the continuation of tobacco use, and the development of tobacco use disorder, with a degree of heritability equivalent to that observed with other substance use disorders (i.e., about 50%). Some of this risk is specific to tobacco, and some is common with the vulnerability to developing any substance use disorder. Culture-Related Diagnostic Issues Cultures and subcultures vary widely in their acceptance of the use of tobacco. The prev- alence of tobacco use declined in the United States from the 1960s through the 1990s, but this decrease has been less evident in African American and Hispanic populations. Also, smoking in developing countries is more prevalent than in developed nations. The degree to which these cultural differences are due to income, education, and tobacco control ac- tivities in a country is unclear. Non-Hispanic white smokers appear to be more likely to develop tobacco use disorder than are smokers. Some ethnic differences may be biologi- cally based. African American males tend to have higher nicotine blood levels for a given number of cigarettes, and this might contribute to greater difficulty in quitting. Also, the speed of nicotine metabolism is significantly different for whites compared with African Americans and can vary by genotypes associated with ethnicities. Diagnostic Markers Carbon monoxide in the breath, and nicotine and its metabolite cotinine in blood, saliva, or urine, can be used to measure the extent of current tobacco or nicotine use; however, these are only weakly related to tobacco use disorder. Functional Consequences of Tobacco Use Disorder Medical consequences of tobacco use often begin when tobacco users are in their 40s and usually become progressively more debilitating over time. One-half of smokers who do not stop using tobacco will die early from a tobacco-related illness, and smoking-related morbidity occurs in more than one-half of tobacco users. Most medical conditions result from exposure to carbon monoxide, tars, and other non-nicotine components of tobacco. The major predictor of reversibility is duration of smoking. Secondhand smoke increases the risk of heart disease and cancer by 30%. Long-term use of nicotine medications does not appear to cause medical harm. Comorbidity The most common medical diseases from smoking are cardiovascular illnesses, chronic obstructive pulmonary disease, and cancers. Smoking also increases perinatal problems, such as low birth weight and miscarriage. The most common psychiatric comorbidities are alcohol/substance, depressive, bipolar, anxiety, personality, and attention-deficit/hyper- activity disorders. In individuals with current tobacco use disorder, the prevalence of cur- rent alcohol, drug, anxiety, depressive, bipolar, and personality disorders ranges from 22% to 32%. Nicotine-dependent smokers are 2.7-8.1 times more likely to have these dis- orders than nondependent smokers, never-smokers, or ex-smokers.

Inhalant Use Disorder (DSM)

DIAGNOSTIC CRITERIA A. A problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. The inhalant substance 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 use of the inhalant substance. 3. A great deal of time is spent in activities necessary to obtain the inhalant substance, use it, or recover from its effects. 4. Craving, or a strong desire or urge to use the inhalant substance. 5. Recurrent use of the inhalant substance resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued use of the inhalant substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use. 7. Important social, occupational, or recreational activities are given up or reduced because of use of the inhalant substance. 8. Recurrent use of the inhalant substance in situations in which it is physically hazardous. 9. Use of the inhalant substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the inhalant substance to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of the inhalant substance. Specify the particular inhalant: When possible, the particular substance involved should be named (e.g., "solvent use disorder"). Specify if: In early remission: After full criteria for inhalant use disorder were previously met, none of the criteria for inhalant use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, "Craving, or a strong de- sire or urge to use the inhalant substance," may be met). In sustained remission: After full criteria for inhalant use disorder were previously met, none of the criteria for inhalant use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, "Craving, or a strong desire or urge to use the inhalant substance," may be met). Specifiers This manual recognizes volatile hydrocarbon use meeting the above diagnostic criteria as inhalant use disorder. Volatile hydrocarbons are toxic gases from glues, fuels, paints, and named (e.g., other volatile compounds. When possible, the particular substance involved should be "toluene use disorder"). However, most compounds that are inhaled are a mixture of several substances that can produce psychoactive effects, and it is often difficult to ascertain the exact substance responsible for the disorder. Unless there is clear evidence that a single, unmixed substance has been used, the general term inhalant should be used in recording the diagnosis. Disorders arising from inhalation of nitrous oxide or of amyl-, butyl-, or isobutylnitrite are considered as other (or unknown) substance use disorder. "In a controlled environment" applies as a further specifier of remission if the individ- ual is both in remission and in a controlled environment (i.e., in early remission in a con- trolled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communi- ties, and locked hospital units. The severity of individuals' inhalant use disorder is assessed by the number of diag- nostic criteria endorsed. Changing severity of individuals' inhalant use disorder across time is reflected by reductions in the frequency (e.g., days used per month) and/or dose (e.g., tubes of glue per day) used, as assessed by the individual's self-report, report of oth- ers, clinician's observations, and biological testing (when practical). Diagnostic Features Features of inhalant use disorder include repeated use of an inhalant substance despite the individual's knowing that the substance is causing serious problems for the individual (Criterion A9). Those problems are reflected in the diagnostic criteria. Missing work or school or inability to perform typical responsibilities at work or school (Criterion A5), and continued use of the inhalant substance even though it causes arguments with family or friends, fights, and other social or interpersonal problems (Criterion A6), may be seen in inhalant use disorder. Limiting family contact, work or school obligations, or rec- rational activities (e.g., sports, games, hobbies) may also occur (Criterion A7). Use of inhal- ants when driving or operating dangerous equipment (Criterion A8) is also seen. Tolerance (Criterion A10) and mild withdrawal are each reported by about 10% of in- dividuals who use inhalants, and a few individuals use inhalants to avoid withdrawal. However, because the withdrawal symptoms are mild, this manual neither recognizes a diagnosis of inhalant withdrawal nor counts withdrawal complaints as a diagnostic crite- rion for inhalant use disorder. Associated Features Supporting Diagnosis A diagnosis of inhalant use disorder is supported by recurring episodes of intoxication with negative results in standard drug screens (which do not detect inhalants); possession, or lingering odors, of inhalant substances; peri-oral or peri-nasal "glue-sniffer's rash"; as- sociation with other individuals known to use inhalants; membership in groups with prev- alent inhalant use (e.g., some native or aboriginal communities, homeless children in street gangs); easy access to certain inhalant substances; paraphernalia possession; presence of the disorder's characteristic medical complications (e.g., brain white matter pathology, rhabdomyolysis); and the presence of multiple substance use disorders. Inhalant use and inhalant use disorder are associated with past suicide attempts, especially among adults reporting previous episodes of low mood or anhedonia. Prevalence About 0.4% of Americans ages 12-17 years have a pattern of use that meets criteria for in- halant use disorder in the past 12 months. Among those youths, the prevalence is highest in Native Americans and lowest in African Americans. Prevalence falls to about 0.1% among Americans ages 18-29 years, and only 0.02% when all Americans 18 years or older are con- sidered, with almost no females and a preponderance of European Americans. Of course, in isolated subgroups, prevalence may differ considerably from these overall rates. Development and Course About 10% of 13-year-old American children report having used inhalants at least once; that percentage remains stable through age 17 years. Among those 12-to 17-year-olds who use inhalants, the more-used substances include glue, shoe polish, or toluene; gasoline or lighter fluid; or spray paints. Only 0.4% of 12- to 17-year-olds progress to inhalant use disorder; those youths tend to exhibit multiple other problems. The declining prevalence of inhalant use disorder after adolescence indicates that this disorder usually remits in early adulthood. Volatile hydrocarbon use disorder is rare in prepubertal children, most common in ad- olescents and young adults, and uncommon in older persons. Calls to poison-control cen- ters for "intentional abuse" of inhalants peak with calls involving individuals at age 14 years. Of adolescents who use inhalants, perhaps one-fifth develop inhalant use disorder; a few die from inhalant-related accidents, or "sudden sniffing death ". But the disorder apparently remits in many individuals after adolescence. Prevalence declines dramatically among in- dividuals in their 20s. Those with inhalant use disorder extending into adulthood often have severe problems: substance use disorders, antisocial personality disorder, and sui- cidal ideation with attempts. Risk and Prognostic Factors Temperamental. Predictors of progression from nonuse of inhalants, to use, to inhalant use disorder include comorbid non-inhalant substance use disorders and either conduct disorder or antisocial personality disorder. Other predictors are earlier onset of inhalant use and prior use of mental health services. Environmental. Inhalant gases are widely and legally available, increasing the risk of mis- use. Childhood maltreatment or trauma also is associated with youthful progression from inhalant non-use to inhalant use disorder. Genetic and physiological. Behavioral disinhibition is a highly heritable general propensity to not constrain behavior in socially acceptable ways, to break social norms and rules, and to take dangerous risks, pursuing rewards excessively despite dangers of adverse consequences. Youths with strong behavioral disinhibition show risk factors for inhalant use disorder: early- onset substance use disorder, multiple substance involvement, and early conduct problems. Because behavioral disinhibition is under strong genetic influence, youths in families with substance and antisocial problems are at elevated risk for inhalant use disorder. Culture-Related Diagnostic Issues Certain native or aboriginal communities have experienced a high prevalence of inhalant problems. Also, in some countries, groups of homeless children in street gangs have ex- tensive inhalant use problems. Gender-Related Diagnostic Issues Although the prevalence of inhalant use disorder is almost identical in adolescent males and females, the disorder is very rare among adult females. Diagnostic Markers Urine, breath, or saliva tests may be valuable for assessing concurrent use of non-inhalant substances by individuals with inhalant use disorder. However, technical problems and the considerable expense of analyses make frequent biological testing for inhalant themselves impractical Functional Consequences of Inhalant Use Disorder Because of inherent toxicity, use of butane or propane is not infrequently fatal. Moreover, any inhaled volatile hydrocarbons may produce "sudden sniffing death" from cardiac ar- rhythmia. Fatalities may occur even on the first inhalant exposure and are not thought to be dose-related. Volatile hydrocarbon use impairs neurobehavioral function and causes various neurological, gastrointestinal, cardiovascular, and pulmonary problems. Long-term inhalant users are at increased risk for tuberculosis, HIV / AIDS, sexually transmitted diseases, depression, anxiety, bronchitis, asthma, and sinusitis. Deaths may occur from respiratory depression, arrhythmias, asphyxiation, aspiration of vomitus, or accident and injury. Differential Diagnosis Inhalant exposure (unintentional) from industrial or other accidents. This designation is used when findings suggest repeated or continuous inhalant exposure but the involved individual and other informants deny any history of purposeful inhalant use. Inhalant use (intentional), without meeting criteria for inhalant use disorder. Inhalant use is common among adolescents, but for most of those individuals, the inhalant use does not meet the diagnostic standard of two or more Criterion A items for inhalant use disorder in the past year. Inhalant intoxication, without meeting criteria for inhalant use disorder. Inhalant intox- cation occurs frequently during inhalant use disorder but also may occur among individ- uals whose use does not meet criteria for inhalant use disorder, which requires at least two of the 10 diagnostic criteria in the past year. Inhalant-induced disorders (i.e., inhalant-induced psychotic disorder, depressive dis- order, anxiety disorder, neurocognitive disorder, other inhalant-induced disorders) without meeting criteria for inhalant use disorder. Criteria are met for a psychotic, de- pressive, anxiety, or major neurocognitive disorder, and there is evidence from history, physical examination, or laboratory findings that the deficits are etiologically related to the effects of inhalant substances. Yet, criteria for inhalant use disorder may not be met (i.e., fewer than 2 of the 10 criteria were present). Other substance use disorders, especially those involving sedating substances (e.g., alcohol, benzodiazepines, barbiturates). Inhalant use disorder commonly co-occurs with other substance use disorders, and the symptoms of the disorders may be similar and overlapping. To disentangle symptom patterns, it is helpful to inquire about which symp- toms persisted during periods when some of the substances were not being used. Other toxic, metabolic, traumatic, neoplastic, or infectious disorders impairing central or peripheral nervous system function. Individuals with inhalant use disorder may pre- sent with symptoms of pernicious anemia, subacute combined degeneration of the spinal cord, psychosis, major or minor cognitive disorder, brain atrophy, leukoencephalopathy, and many other nervous system disorders. Of course, these disorders also may occur in the absence of inhalant use disorder. A history of little or no inhalant use helps to exclude inhalant use disorder as the source of these problems. Disorders of other organ systems. Individuals with inhalant use disorder may present with symptoms of hepatic or renal damage, rhabdomyolysis, methemoglobinemia, or symp- toms of other gastrointestinal, cardiovascular, or pulmonary diseases. A history of little or no inhalant use helps to exclude inhalant use disorder as the source of such medical problems. Comorbidity Individuals with inhalant use disorder receiving clinical care often have numerous other substance use disorders. Inhalant use disorder commonly co-occurs with adolescent con- duct disorder and adult antisocial personality disorder. Adult inhalant use and inhalant use disorder also are strongly associated with suicidal ideation and suicide attempts.

Conduct disorder (DSM)

DIAGNOSTIC CRITERIA A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to People and Animals 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). 7. Has forced someone into sexual activity. Destruction of Property 8. Has deliberately engaged in fire setting with the intention of causing serious damage. 9. Has deliberately destroyed others' property (other than by fire setting). Deceitfulness or Theft 10. Has broken into someone else's house, building, or car. 11. Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others). 12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). Serious Violations of Rules 13. Often stays out at night despite parental prohibitions, beginning before age 13 years. 14. Has run away from home overnight at least twice while living in the parental or pa- rental surrogate home, or once without returning for a lengthy period. 15. Is often truant from school, beginning before age 13 years. B. The disturbance in behavior causes clinically significant impairment in social, aca- demic, or occupational functioning. C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. Specify whether: 312.81 (F91.1) Childhood-onset type: Individuals show at least one symptom char- acteristic of conduct disorder prior to age 10 years. 312.82 (F91.2) Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years. 312.89 (F91.9) Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years. Specify if: With limited prosocial emotions: To qualify for this specifier, an individual must have dis- played at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual's typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple infor- mation sources are necessary. In addition to the individual's self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (e.g., parents, teachers, co-workers, extended family members, peers). Lack of remorse or guilt: Does not feel bad or guilty when he or she does some- thing wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules. Callous--lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others. Unconcerned about performance: Does not show concern about poor/problem- atic performance at school, at work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance. Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions "on" or "off"' quickly) or when emotional expres- sions are used for gain (e.g., emotions displayed to manipulate or intimidate others). Specify current severity: Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule breaking). Moderate: The number of conduct problems and the effect on others are intermediate between those specified in "mild" and those in "severe" (e.g., stealing without confront- ing a victim, vandalism). Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering). Subtypes Three subtypes of conduct disorder are provided based on the age at onset of the disorder. Onset is most accurately estimated with information from both the youth and the care- giver; estimates are often 2 years later than actual onset. Both subtypes can occur in a mild, moderate, or severe form. An unspecified-onset subtype is designated when there is in- sufficient information to determine age at onset. In childhood-onset conduct disorder, individuals are usually male, frequently display physical aggression toward others, have disturbed peer relationships, may have had op- positional defiant disorder during early childhood, and usually have symptoms that meet full criteria for conduct disorder prior to puberty. Many children with this subtype also have concurrent attention-deficit/hyperactivity disorder (ADHD) or other neurodevel- opmental difficulties. Individuals with childhood-onset type are more likely to have per- sistent conduct disorder into adulthood than are those with adolescent-onset type. As compared with individuals with childhood-onset type, individuals with adolescent-onset conduct disorder are less likely to display aggressive behaviors and tend to have more normative peer relationships (although they often display conduct problems in the com- pany of others). These individuals are less likely to have conduct disorder that persists into adulthood. The ratio of males to females with conduct disorder is more balanced for the adolescent-onset type than for the childhood-onset type. Specifiers A minority of individuals with conduct disorder exhibit characteristics that qualify for the "with limited prosocial emotions" specifier. The indicators of this specifier are those that have often been labeled as callous and unemotional traits in research. Other personality features, such as thrill seeking, fearlessness, and insensitivity to punishment, may also dis- tinguish those with characteristics described in the specifier. Individuals with character- istics described in this specifier may be more likely than other individuals with conduct disorder to engage in aggression that is planned for instrumental gain. Individuals with conduct disorder of any subtype or any level of severity can have characteristics that qual- ify for the specifier "with limited prosocial emotions, " although individuals with the spec- ifier are more likely to have childhood-onset type and a severity specifier rating of severe. Although the validity of self-report to assess the presence of the specifier has been sup- ported in some research contexts, individuals with conduct disorder with this specifier may not readily admit to the traits in a clinical interview. Thus, to assess the criteria for the specifier, multiple information sources are necessary. Also, because the indicators of the specifier are characteristics that reflect the individual's typical pattern of interpersonal and emotional functioning, it is important to consider reports by others who have known the individual for extended periods of time and across relationships and settings (e.g., par- ents, teachers, co-workers, extended family members, peers). Prevalence One year population prevalence estimates range from 2% to more than 10%, with a median of 4%. The prevalence of conduct disorder appears to be fairly consistent across various countries that differ in race and ethnicity. Prevalence rates rise from childhood to adoles- duct disorder receive treatment. cence and are higher among males than among females. Few children with impairing conduct disorder receive treatment Development and Course The onset of conduct disorder may occur as early as the preschool years, but the first sig. nificant symptoms usually emerge during the period from middle childhood through middle adolescence. Oppositional defiant disorder is a common precursor to the child- hood-onset type of conduct disorder. Conduct disorder may be diagnosed in adults, how- ever, symptoms of conduct disorder usually emerge in childhood or adolescence, and onset is rare after age 16 years. The course of conduct disorder after onset is variable. In a majority of individuals, the disorder remits by adulthood. Many individuals with conduct disorder- particularly those with adolescent-onset type and those with few and milder symptoms--achieve adequate social and occupational adjustment as adults. However, the early-onset type predicts a worse prognosis and an increased risk of criminal behavior, conduct disorder, and substance-related disorders in adulthood. Individuals with conduct disorder are at risk for later mood disorders, anxiety disorders, posttraumatic stress dis- order, impulse-control disorders, psychotic disorders, somatic symptom disorders, and substance-related disorders as adults. Symptoms of the disorder vary with age as the individual develops increased physical strength, cognitive abilities, and sexual maturity. Symptom behaviors that emerge first tend to be less serious (e.g., lying, shoplifting), whereas conduct problems that emerge last tend to be more severe (e.g., rape, theft while confronting a victim). However, there are wide differences among individuals, with some engaging in the more damaging behaviors at an early age (which is predictive of a worse prognosis). When individuals with conduct disorder reach adulthood, symptoms of aggression, property destruction, deceitfulness, and rule violation, including violence against co-workers, partners, and children, may be ex- hibited in the workplace and the home, such that antisocial personality disorder may be considered Risk and Prognostic Factors Temperamental. Temperamental risk factors include a difficult undercontrolled infant temperament and lower-than-average intelligence, particularly with regard to verbal IQ. Environmental. Family-level risk factors include parental rejection and neglect, inconsis- tent child-rearing practices, harsh discipline, physical or sexual abuse, lack of supervision, early institutional living, frequent changes of caregivers, large family size, parental criminal- ity, and certain kinds of familial psychopathology (e.g., substance-related disorders). Com- munity-level risk factors include peer rejection, association with a delinquent peer group, and neighborhood exposure to violence. Both types of risk factors tend to be more common and severe among individuals with the childhood-onset subtype of conduct disorder. Genetic and physiological. Conduct disorder is influenced by both genetic and envi- ronmental factors. The risk is increased in children with a biological or adoptive parent or a sibling with conduct disorder. The disorder also appears to be more common in children of biological parents with severe alcohol use disorder, depressive and bipolar disorders, or schizophrenia or biological parents who have a history of ADHD or conduct disorder. Family history particularly characterizes individuals with the childhood-onset subtype of conduct disorder. Slower resting heart rate has been reliably noted in individuals with conduct disorder compared with those without the disorder, and this marker is not char- acteristic of any other mental disorder. Reduced autonomic fear conditioning, particularly low skin conductance, is also well documented. However, these psychophysiological find- ings are not diagnostic of the disorder. Structural and functional differences in brain areas associated with affect regulation and affect processing, particularly frontotemporal-limbic connections involving the brain's ventral prefrontal cortex and amygdala, have been con- sistently noted in individuals with conduct disorder compared with those without the dis- order. However, neuroimaging findings are not diagnostic of the disorder. Course modifiers. Persistence is more likely for individuals with behaviors that meet criteria for the childhood-onset subtype and qualify for the specifier "with limited pro- social emotions". The risk that conduct disorder will persist is also increased by co-occurring ADHD and by substance abuse. Culture-Related Diagnostic Issues Conduct disorder diagnosis may at times be potentially misapplied to individuals in set- tings where patterns of disruptive behavior are viewed as near-normative (e.g., in very threatening, high-crime areas or war zones). Therefore, the context in which the undesir- able behaviors have occurred should be considered. Gender-Related Diagnostic Issues Males with a diagnosis of conduct disorder frequently exhibit fighting, stealing, vandalism, and school discipline problems. Females with a diagnosis of conduct disorder are more likely to exhibit lying, truancy, running away, substance use, and prostitution. Whereas males tend to exhibit both physical aggression and relational aggression (behavior that harms social re- lationships of others), females tend to exhibit relatively more relational aggression. Functional Consequences of Conduct Disorder Conduct disorder behaviors may lead to school suspension or expulsion, problems in work adjustment, legal difficulties, sexually transmitted diseases, unplanned pregnancy, and physical injury from accidents or fights. These problems may preclude attendance in ordinary schools or living in a parental or foster home. Conduct disorder is often associ- ated with an early onset of sexual behavior, alcohol use, tobacco smoking, use of illegal substances, and reckless and risk-taking acts. Accident rates appear to be higher among in- dividuals with conduct disorder compared with those without the disorder. These func- tonal consequences of conduct disorder may predict health difficulties when individuals reach midlife. It is not uncommon for individuals with conduct disorder to come into con- tact with the criminal justice system for engaging in illegal behavior. Conduct disorder is a common reason for treatment referral and is frequently diagnosed in mental health fa- cilities for children, especially in forensic practice. It is associated with impairment that is more severe and chronic than that experienced by other clinic-referred children. Differential Diagnosis Oppositional defiant disorder. Conduct disorder and oppositional defiant disorder are both related to symptoms that bring the individual in conflict with adults and other Authority figures (e.g, parents, teachers, work supervisors). The behaviors of oppositional defiant disorder are typically of a less severe nature than those of individuals with conduct disorder and do not include aggression toward individuals or animals, destruction of property, or a pattern of theft or deceit. Furthermore, oppositional defiant disorder in- cludes problems of emotional dysregulation (i.e., angry and irritable mood) that are not in- cluded in the definition of conduct disorder. When criteria are met for both oppositional defiant disorder and conduct disorder, both diagnoses can be given. Attention-deficit/hyperactivity disorder. Although children with ADHD often exhibit hyperactive and impulsive behavior that may be disruptive, this behavior does not by it- self violate societal norms or the rights of others and therefore does not usually meet cri- teria for conduct disorder. When criteria are met for both ADHD and conduct disorder, both diagnoses should be given. Depressive and bipolar disorders. Irritability, aggression, and conduct problems can occur in children or adolescents with a major depressive disorder, a bipolar disorder, or disruptive mood dysregulation disorder. The behavioral problems associated with these mood disorders can usually be distinguished from the pattern of conduct problems seen in conduct disorder based on their course. Specifically, persons with conduct disorder will display substantial levels of aggressive or non-aggressive conduct problems during peri- ods in which there is no mood disturbance, either historically (i.e., a history of conduct problems predating the onset of the mood disturbance) or concurrently (i.e., display of some conduct problems that are premeditated and do not occur during periods of intense emotional arousal). In those cases in which criteria for conduct disorder and a mood dis- order are met, both diagnoses can be given Intermittent explosive disorder. Both conduct disorder and intermittent explosive dis- order involve high rates of aggression. However, the aggression in individuals with inter- mittent explosive disorder is limited to impulsive aggression and is not premeditated, and it is not committed in order to achieve some tangible objective (e.g., money, power, intim- idation). Also, the definition of intermittent explosive disorder does not include the non- aggressive symptoms of conduct disorder. If criteria for both disorders are met, the diag- nosis of intermittent explosive disorder should be given only when the recurrent impul- sive aggressive outbursts warrant independent clinical attention. Adjustment disorders. The diagnosis of an adjustment disorder (with disturbance of con- duct or with mixed disturbance of emotions and conduct) should be considered if clinically significant conduct problems that do not meet the criteria for another specific disorder de- velop in clear association with the onset of a psychosocial stressor and do not resolve within 6 months of the termination of the stressor (o) its consequences). Conduct disorder is diag- nosed only when the conduct problems represent a repetitive and persistent pattern that is associated with impairment in social, academic, or occupational functioning. Comorbidity ADHD and oppositional defiant disorder are both common in individuals with conduct disorder, and this comorbid presentation predicts worse outcomes. Individuals who show the personality features associated with antisocial personality disorder often violate the basic rights of others or violate major age-appropriate societal norms, and as a result their pattern of behavior often meets criteria for conduct disorder. Conduct disorder may also co-occur with one or more of the following mental disorders: specific learning disorder, anxiety disorders, depressive or bipolar disorders, and substance-related disorders. Aca- demic achievement, particularly in reading and other verbal skills, is often below the level expected on the basis of age and intelligence and may justify the additional diagnosis of specific learning disorder or a communication disorder.

Avoidant/Restrictive Food Intake Disorder (DSM)

DIAGNOSTIC CRITERIA A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). 2. Significant nutritional deficiency. 3. Dependence on enteral feeding or oral nutritional supplements. 4. Marked interference with psychosocial functioning. B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one's body weight or shape is experienced. D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. Specify if: In remission: After full criteria for avoidant/restrictive food intake disorder were previously met, the criteria have not been met for a sustained period of time. DIFFERENTIAL DIAGNOSIS Specific neurological/neuromuscular, structural, or congenital disorders and conditions associated with feeding difficulties. Feeding difficulties are common in a number of congenital and neurological conditions often related to problems with oral/esophageal/ pharyngeal structure and function, such as hypotonia of musculature, tongue protrusion, and unsafe swallowing. Avoidant / restrictive food intake disorder can be diagnosed in in- dividuals with such presentations as long as all diagnostic criteria are met. Reactive attachment disorder. Some degree of withdrawal is characteristic of reactive attachment disorder and can lead to a disturbance in the caregiver-child relationship that can affect feeding and the child's intake. Avoidant / restrictive food intake disorder should be diagnosed concurrently only if all criteria are met for both disorders and the feeding disturbance is a primary focus for intervention. front or Autism spectrum disorder. Individuals with autism spectrum disorder often present with rigid eating behaviors and heightened sensory sensitivities. However, these features do not always result in the level of impairment that would be required for a diagnosis of avoidant / restrictive food intake disorder. Avoidant / restrictive food intake disorder should be diagnosed concurrently only if all criteria are met for both disorders and when the eat- ing disturbance requires specific treatment. Specific phobia, social anxiety disorder (social phobia), and other anxiety disorders. Specific phobia, other type, specifies " situations that may lead to choking or vomiting" and can represent the primary trigger for the fear, anxiety, or avoidance required for diagnosis. Distinguishing specific phobia from avoidant / restrictive food intake disorder can be dif- ficult when a fear of choking or vomiting has resulted in food avoidance. Although avoid- ance or restriction of food intake secondary to a pronounced fear of choking or vomiting can be conceptualized as specific phobia, in situations when the eating problem becomes the primary focus of clinical attention, avoidant / restrictive food intake disorder becomes the appropriate diagnosis. In social anxiety disorder, the individual may present with a fear of being observed by others while eating, which can also occur in avoidant / restrictive food intake disorder. Anorexia nervosa. Restriction of energy intake relative to requirements leading to sig- nificantly low body weight is a core feature of anorexia nervosa. However, individuals with anorexia nervosa also display a fear of gaining weight or of becoming fat, or persis- tent behavior that interferes with weight gain, as well as specific disturbances in relation to perception and experience of their own body weight and shape. These features are not present in avoidant / restrictive food intake disorder, and the two disorders should not be diagnosed concurrently. Differential diagnosis between avoidant / restrictive food intake disorder and anorexia nervosa may be difficult, especially in late childhood and early ad- olescence, because these disorders may share a number of common symptoms (e.g., food avoidance, low weight). Differential diagnosis is also potentially difficult in individuals with anorexia nervosa who deny any fear of fatness but nonetheless engage in persistent behaviors that prevent weight gain and who do not recognize the medical seriousness of their low weight--a presentation sometimes termed "non-fat phobic anorexia nervosa." Full consideration of symptoms, course, and family history is advised, and diagnosis may

Alcohol withdrawal (DSM)

DIAGNOSTIC CRITERIA A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A: 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm). 2. Increased hand tremor. 3. Insomnia. 4. Nausea or vomiting. 5. Transient visual, tactile, or auditory hallucinations or illusions. 6. Psychomotor agitation. 7. Anxiety. 8. Generalized tonic-clonic seizures. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. Specify if: With perceptual disturbances: This specifier applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual, or tactile illusions occur in the absence of a delirium. Specifiers When hallucinations occur in the absence of delirium (i.e., in a clear sensorium), a diagno- sis of substance/ medication-induced psychotic disorder should be considered. Diagnostic Features The essential feature of alcohol withdrawal is the presence of a characteristic withdrawal syndrome that develops within several hours to a few days after the cessation of (or re- duction in) heavy and prolonged alcohol use (Criteria A and B). The withdrawal syn- drome includes two or more of the symptoms reflecting autonomic hyperactivity and anxiety listed in Criterion B, along with gastrointestinal symptoms. Withdrawal symptoms cause clinically significant distress or impairment in social, oc- cupational, or other important areas of functioning (Criterion C). The symptoms must not be attributable to another medical condition and are not better explained by another men- tal disorder (e.g., generalized anxiety disorder), including intoxication or withdrawal from another substance (e.g., sedative, hypnotic, or anxiolytic withdrawal) (Criterion D). Symptoms can be relieved by administering alcohol or benzodiazepines (e.g., diazepam). The withdrawal symptoms typically begin when blood concentrations of alcohol decline sharply (i.e., within 4-12 hours) after alcohol use has been stopped or reduced. Reflecting the relatively fast metabolism of alcohol, symptoms of alcohol withdrawal usually peak in inten- sity during the second day of abstinence and are likely to improve markedly by the fourth or fifth day. Following acute withdrawal, however, symptoms of anxiety, insomnia, and auto- nomic dysfunction may persist for up to 3-6 months at lower levels of intensity. Fewer than 10% of individuals who develop alcohol withdrawal will ever develop dra- matic symptoms (e.g., severe autonomic hyperactivity, tremors, alcohol withdrawal delir- ium). Tonic-clonic seizures occur in fewer than 3% of individuals. Associated Features Supporting Diagnosis Although confusion and changes in consciousness are not core criteria for alcohol with- drawal, alcohol withdrawal delirium (see "Delirium" in the chapter "Neurocognitive Dis- orders") may occur in the context of withdrawal. As is true for any agitated, confused state, regardless of the cause, in addition to a disturbance of consciousness and cognition, with- drawal delirium can include visual, tactile, or (rarely) auditory hallucinations (delirium tre- mens). When alcohol withdrawal delirium develops, it is likely that a clinically relevant medical condition may be present (e.g., liver failure, pneumonia, gastrointestinal bleeding, sequelae of head trauma, hypoglycemia, an electrolyte imbalance, postoperative status) Prevalence It is estimated that approximately 50% of middle-class, highly functional individuals with alcohol use disorder have ever experienced a full alcohol withdrawal syndrome. Among individuals with alcohol use disorder who are hospitalized or homeless, the rate of al- cohol withdrawal may be greater than 80%. Less than 10% of individuals in withdrawal ever demonstrate alcohol withdrawal delirium or withdrawal seizures. Development and Course Acute alcohol withdrawal occurs as an episode usually lasting 4-5 days and only after extended periods of heavy drinking. Withdrawal is relatively rare in individuals younger than 30 years, and the risk and severity increase with increasing age. Risk and Prognostic Factors Environmental. The probability of developing alcohol withdrawal increases with the quantity and frequency of alcohol consumption. Most individuals with this condition are drinking daily, consuming large amounts (approximately more than eight drinks per day) for multiple days. However, there are large inter-individual differences, with enhanced risks for individuals with concurrent medical conditions, those with family histories of al- cohol withdrawal (i.e., a genetic component), those with prior withdrawals, and individ- uals who consume sedative, hypnotic, or anxiolytic drugs. Diagnostic Markers Autonomic hyperactivity in the context of moderately high but falling blood alcohol levels and a history of prolonged heavy drinking indicate a likelihood of alcohol withdrawal. Functional Consequences of Alcohol Withdrawal Symptoms of withdrawal may serve to perpetuate drinking behaviors and contribute to relapse, resulting in persistently impaired social and occupational functioning. Symptoms requiring medically supervised detoxification result in hospital utilization and loss of work productivity. Overall, the presence of withdrawal is associated with greater func- tional impairment and poor prognosis. Differential Diagnosis Other medical conditions. The symptoms of alcohol withdrawal can also be mimicked by some medical conditions (e.g:, hypoglycemia and diabetic ketoacidosis). Essential tremor, a disorder that frequently runs in families, may erroneously suggest the tremu- lousness associated with alcohol withdrawal. Sedative, hypnotic, or anxiolytic withdrawal. Sedative, hypnotic, or anxiolytic with- drawl produces a syndrome very similar to that of alcohol withdrawal. Comorbidity Withdrawal is more likely to occur with heavier alcohol intake, and that might be most of- ten observed in individuals with conduct disorder and antisocial personality disorder. Withdrawal states are also more severe in older individuals, individuals who are also de- pendent on other depressant drugs (sedative-hypnotics), and individuals who have had more alcohol withdrawal experiences in the past.

Sedative, hypnotic, anxiolytic withdrawal (DSM)

DIAGNOSTIC CRITERIA A. Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been prolonged. B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) sedative, hypnotic, or anxiolytic use described in Criterion A: 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm). 2. Hand tremor. 3. Insomnia. 4 Nausea or vomiting. 5. Transient visual, tactile, or auditory hallucinations or illusions. 6. Psychomotor agitation. 7. Anxiety. 8. Grand mal seizures. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. Diagnostic Features The essential feature of sedative, hypnotic, or anxiolytic withdrawal is the presence of a char- acteristic syndrome that develops after a marked decrease in or cessation of intake after several weeks or more of regular use (Criteria A and B). This withdrawal syndrome is characterized by two or more symptoms (similar to alcohol withdrawal) that include autonomic hyperactivity (e.g., increases in heart rate, respiratory rate, blood pressure, or body temperature, along with sweating); a tremor of the hands; insomnia; nausea, sometimes accompanied by vomiting; anxiety; and psychomotor agitation. A grand mal seizure may occur in perhaps as many as 20%-30% of individuals undergoing untreated withdrawal from these substances. In severe withdrawal, visual, tactile, or auditory hallucinations or illusions can occur but are usually in the context of a delirium. If the individual's reality testing is intact (i.e., he or she knows the substance is causing the hallucinations) and the illusions occur in a clear sensorium, the spec- ifier "with perceptual disturbances" can be noted. When hallucinations occur in the absence of intact reality testing, a diagnosis of substance / medication-induced psychotic disorder should be considered. The symptoms cause clinically significant distress or impairment in social, oc- cupational, or other important areas of functioning (Criterion C). The symptoms must not be attributable to another medical condition and are not better explained by another mental dis- order (e.g., alcohol withdrawal or generalized anxiety disorder) (Criterion D). Relief of with- drawl symptoms with administration of any sedative-hypnotic agent would support a diagnosis of sedative, hypnotic, or anxiolytic withdrawal. Associated Features Supporting Diagnosis The timing and severity of the withdrawal syndrome will differ depending on the specific substance and its pharmacokinetics and pharmacodynamics. For example, withdrawal from shorter-acting substances that are rapidly absorbed and that have no active metabo- lites (e.g., triazolam) can begin within hours after the substance is stopped; withdrawal from substances with long-acting metabolites (e.g., diazepam) may not begin for 1-2 days or longer. The withdrawal syndrome produced by substances in this class may be charac- terized by the development of a delirium that can be life-threatening. There may be evi- dence of tolerance and withdrawal in the absence of a diagnosis of a substance use disorder in an individual who has abruptly discontinued benzodiazepines that were taken for long periods of time at prescribed and therapeutic doses. However, ICD-10-CM codes only allow a diagnosis of sedative, hypnotic, or anxiolytic withdrawal in the presence of comorbid moderate to severe sedative, hypnotic, or anxiolytic use disorder. The time course of the withdrawal syndrome is generally predicted by the half-life of the substance. Medications whose actions typically last about 10 hours or less (e.g., loraz- epam, oxazepam, temazepam) produce withdrawal symptoms within 6-8 hours of de- creasing blood levels that peak in intensity on the second day and improve markedly by the fourth or fifth day. For substances with longer half-lives (e.g., diazepam), symptoms may not develop for more than 1 week, peak in intensity during the second week, and de- crease markedly during the third or fourth week. There may be additional longer-term symptoms at a much lower level of intensity that persist for several months. The longer the substance has been taken and the higher the dosages used, the more likely it is that there will be severe withdrawal. However, withdrawal has been reported with as little as 15 mg of diazepam (or its equivalent in other benzodiazepines) when taken daily for several months. Doses of approximately 40 mg of diazepam (or its equivalent) daily are more likely to produce clinically relevant withdrawal symptoms, and even higher doses (e.g., 100 mg of di- azepam) are more likely to be followed by withdrawal seizures or delirium. Sedative, hyp- notic, or anxiolytic withdrawal delirium is characterized by disturbances in consciousness and cognition, with visual, tactile, or auditory hallucinations. When present, sedative, hypnotic, or anxiolytic withdrawal delirium should be diagnosed instead of withdrawal. Prevalence The prevalence of sedative, hypnotic, or anxiolytic withdrawal is unclear. Diagnostic Markers Seizures and autonomic instability in the setting of a history of prolonged exposure to sed- ative, hypnotic, or anxiolytic medications suggest a high likelihood of sedative, hypnotic, or anxiolytic withdrawal. Differential Diagnosis Other medical disorders. The symptoms of sedative, hypnotic, or anxiolytic with- drawal may be mimicked by other medical conditions (e.g., hypoglycemia, diabetic keto- acidosis). If seizures are a feature of the sedative, hypnotic, or anxiolytic withdrawal, the differential diagnosis includes the various causes of seizures (e.g., infections, head injury, poisonings). Essential tremor. Essential tremor, a disorder that frequently runs in families, may erroneously suggest the tremulousness associated with sedative, hypnotic, or anxiolytic withdrawal. Alcohol withdrawal. Alcohol withdrawal produces a syndrome very similar to that of sedative, hypnotic, or anxiolytic withdrawal. Other sedative-, hypnotic-, or anxiolytic-induced disorders. Sedative, hypnotic, or anx- iolytic withdrawal is distinguished from the other sedative-, hypnotic-, or anxiolytic- induced disorders (e.g., sedative-, hypnotic-, or anxiolytic-induced anxiety disorder, with onset during withdrawal) because the symptoms in the latter disorders predominate in the clinical presentation and are severe enough to warrant clinical attention. Anxiety disorders. Recurrence or worsening of an underlying anxiety disorder pro- duces a syndrome similar to sedative, hypnotic, or anxiolytic withdrawal. Withdrawal would be suspected with an abrupt reduction in the dosage of a sedative, hypnotic, or anx- iolytic medication. When a taper is under way, distinguishing the withdrawal syndrome from the underlying anxiety disorder can be difficult. As with alcohol, lingering with- drawal symptoms (e.g., anxiety, moodiness, and trouble sleeping) can be mistaken for non-substance/ medication-induced anxiety or depressive disorders (e.g., generalized anxiety disorder).

Cannabis withdrawal (DSM)

DIAGNOSTIC CRITERIA A. Cessation of cannabis use that has been heavy and prolonged (i.e., usually daily or almost daily use over a period of at least a few months). B. Three (or more) of the following signs and symptoms develop within approximately 1 week after Criterion A: 1. Irritability, anger, or aggression. 2. Nervousness or anxiety. 3. Sleep difficulty (e.g., insomnia, disturbing dreams). 4. Decreased appetite or weight loss. 5. Restlessness. 6. Depressed mood. 7. At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. Diagnostic Features The essential feature of cannabis withdrawal is the presence of a characteristic withdrawal syndrome that develops after the cessation of or substantial reduction in heavy and pro- longed cannabis use. In addition to the symptoms in Criterion B, the following may also be observed postabstinence: fatigue, yawning, difficulty concentrating, and rebound periods of increased appetite and hypersomnia that follow initial periods of loss of appetite and in- somnia. For the diagnosis, withdrawal symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). Many cannabis users report smoking cannabis or taking other substances to help re- lieve withdrawal symptoms, and many report that withdrawal symptoms make quitting difficult or have contributed to relapse. The symptoms typically are not of sufficient se- verity to require medical attention, but medication or behavioral strategies may help alle- viate symptoms and improve prognosis in those trying to quit using cannabis. Cannabis withdrawal is commonly observed in individuals seeking treatment for can- nabis use as well as in heavy cannabis users who are not seeking treatment. Among indi- viduals who have used cannabis regularly during some period of their lifetime, up to one- third report having experienced cannabis withdrawal. Among adults and adolescents en- rolled in treatment or heavy cannabis users, 50%-95% report cannabis withdrawal. These findings indicate that cannabis withdrawal occurs among a substantial subset of regular cannabis users who try to quit. Development and Course The amount, duration, and frequency of cannabis smoking that is required to produce an associated withdrawal disorder during a quit attempt are unknown. Most symptoms have their onset within the first 24-72 hours of cessation, peak within the first week, and last approximately 1-2 weeks. Sleep difficulties may last more than 30 days. Cannabis with- drawal has been documented among adolescents and adults. Withdrawal tends to be more common and severe among adults, most likely related to the more persistent and greater frequency and quantity of use among adults. Risk and Prognostic Factors Environmental. Most likely, the prevalence and severity of cannabis withdrawal are greater among heavier cannabis users, and particularly among those seeking treatment for cannabis use disorders. Withdrawal severity also appears to be positively related to the se- verity of comorbid symptoms of mental disorders. Functional Consequences of Cannabis Withdrawal Cannabis users report using cannabis to relieve withdrawal symptoms, suggesting that withdrawal might contribute to ongoing expression of cannabis use disorder. Worse out- comes may be associated with greater withdrawal. A substantial proportion of adults and adolescents in treatment for moderate to severe cannabis use disorder acknowledge mod- erate to severe withdrawal symptoms, and many complain that these symptoms make ces- sation more difficult. Cannabis users report having relapsed to cannabis use or initiating use of other drugs (e.g., tranquilizers) to provide relief from cannabis withdrawal symp- toms. Last, individuals living with cannabis users observe significant withdrawal effects, suggesting that such symptoms are disruptive to daily living. Differential Diagnosis Because many of the symptoms of cannabis withdrawal are also symptoms of other sub- stance withdrawal syndromes or of depressive or bipolar disorders, careful evaluation should focus on ensuring that the symptoms are not better explained by cessation from an- other substance (e.g., tobacco or alcohol withdrawal), another mental disorder (general- ized anxiety disorder, major depressive disorder), or another medical condition.

Tobacco Withdrawal (DSM)

DIAGNOSTIC CRITERIA A. Daily use of tobacco for at least several weeks. B. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by four (or more) of the following signs or symptoms: 1. Irritability, frustration, or anger. 2. Anxiety. 3. Difficulty concentrating. 4. Increased appetite. 5. Restlessness. 6. Depressed mood. 7. Insomnia. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributed to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. Diagnostic Features Withdrawal symptoms impair the ability to stop tobacco use. The symptoms after absti- nence from tobacco are in large part due to nicotine deprivation. Symptoms are much more intense among individuals who smoke cigarettes or use smokeless tobacco than among those who use nicotine medications. This difference in symptom intensity is likely due to the more rapid onset and higher levels of nicotine with cigarette smoking. Tobacco withdrawal is common among daily tobacco users who stop or reduce but can also occur among nondaily users. Typically, heart rate decreases by 5-12 beats per minute in the first few days after stopping smoking, and weight increases an average of 4-7 lb (2-3 kg) over the first year after stopping smoking. Tobacco withdrawal can produce clinically signifi- cant mood changes and functional impairment. Associated Features Supporting Diagnosis Craving for sweet or sugary foods and impaired performance on tasks requiring vigilance are associated with tobacco withdrawal. Abstinence can increase constipation, coughing, dizziness, dreaming/ nightmares, nausea, and sore throat. Smoking increases the metab- olism of many medications used to treat mental disorders; thus, cessation of smoking can increase the blood levels of these medications, and this can produce clinically significant outcomes. This effect appears to be due not to nicotine but rather to other compounds in tobacco. Prevalence Approximately 50% of tobacco users who quit for 2 or more days will have symptoms that meet criteria for tobacco withdrawal. The most commonly endorsed signs and symptoms are anxiety, irritability, and difficulty concentrating. The least commonly endorsed symp- toms are depression and insomnia. Development and Course Tobacco withdrawal usually begins within 24 hours of stopping or cutting down on to- bacco use, peaks at 2-3 days after abstinence, and lasts 2-3 weeks. Tobacco withdrawal symptoms can occur among adolescent tobacco users, even prior to daily tobacco use. Pro- longed symptoms beyond 1 month are uncommon. Risk and Prognostic Factors Temperamental. Smokers with depressive disorders, bipolar disorders, anxiety disor- ders, attention-deficit/hyperactivity disorder, and other substance use disorders have more severe withdrawal. Genetic and physiological. Genotype can influence the probability of withdrawal upon abstinence. Diagnostic Markers Carbon monoxide in the breath, and nicotine and its metabolite cotinine in blood, saliva, or urine, can be used to measure the extent of tobacco or nicotine use but are only weakly re- lated to tobacco withdrawal. Functional Consequences of Tobacco Withdrawal Abstinence from cigarettes can cause clinically significant distress. Withdrawal impairs the ability to stop or control tobacco use. Whether tobacco withdrawal can prompt a new mental disorder or recurrence of a mental disorder is debatable, but if this occurs, it would be in a small minority of tobacco users. Differential Diagnosis The symptoms of tobacco withdrawal overlap with those of other substance withdrawal syndromes (e.g., alcohol withdrawal; sedative, hypnotic, or anxiolytic withdrawal; stim- ulant withdrawal; caffeine withdrawal; opioid withdrawal); caffeine intoxication; anxiety, depressive, bipolar, and sleep disorders; and medication-induced akathisia. Admission to smoke-free inpatient units or voluntary smoking cessation can induce withdrawal symp- toms that mimic, intensify, or disguise other disorders or adverse effects of medications used to treat mental disorders (e.g., irritability thought to be due to alcohol withdrawal could be due to tobacco withdrawal). Reduction in symptoms with the use of nicotine medications confirms the diagnosis.

Cyclothymic disorder (DSM)

DIAGNOSTIC CRITERIA A. For at least 2 years (at least 1 year in children and adolescents) there have been nu- merous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met. D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or un- specified schizophrenia spectrum and other psychotic disorder. E. 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., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupa- tional, or other important areas of functioning. Specify if: With anxious distress (see p. 149) Diagnostic Features The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symp- toms that are distinct from each other (Criterion A). The hypomanic symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a hypo- manic episode, and the depressive symptoms are of insufficient number, severity, perva- siveness, or duration to meet full criteria for a major depressive episode. During the initial 2-year period (1 year for children or adolescents), the symptoms must be persistent (pres- ent more days than not), and any symptom-free intervals last no longer than 2 months (Criterion B). The diagnosis of cyclothymic disorder is made only if the criteria for a major depressive, manic, or hypomanic episode have never been met (Criterion C). If an individual with cyclothymic disorder subsequently (i.e., after the initial 2 years in adults or 1 year in children or adolescents) experiences a major depressive, manic, or hy- pomanic episode, the diagnosis changes to major depressive disorder, bipolar I disorder, or other specified or unspecified bipolar and related disorder (subclassified as hypomanic episode without prior major depressive episode), respectively, and the cyclothymic disor- der diagnosis is dropped. The cyclothymic disorder diagnosis is not made if the pattern of mood swings is better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delu- sional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders (Criterion D), in which case the mood symptoms are considered asso- cited features of the psychotic disorder. The mood disturbance must also not be attribut- able to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism) (Criterion E). Although some individ- uals may function particularly well during some of the periods of hypomania, over the prolonged course of the disorder, there must be clinically significant distress or impair- ment in social, occupational, or other important areas of functioning as a result of the mood disturbance (Criterion F). The impairment may develop as a result of prolonged pe- riods of cyclical, often unpredictable mood changes (e.g., the individual may be regarded as temperamental, moody, unpredictable, inconsistent, or unreliable). Prevalence The lifetime prevalence of cyclothymic disorder is approximately 0.4%-1%. Prevalence in mood disorders clinics may range from 3% to 5%. In the general population, cyclothymic disorder is apparently equally common in males and females. In clinical settings, females with cyclothymic disorder may be more likely to present for treatment than males. Development and Course Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes considered to reflect a temperamental predisposition to other disorders in this chapter. Cyclothymic disorder usually has an insidious onset and a persistent course. There is a 15%-50% risk that an individual with cyclothymic disorder will subsequently develop bi- polar I disorder or bipolar Il disorder. Onset of persistent, fluctuating hypomanic and de- pressive symptoms late in adult life needs to be clearly differentiated from bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition (e.g., multiple sclerosis) before the cyclothymic disorder diagnosis is as- signed. Among children with cyclothymic disorder, the mean age at onset of symptoms is 6.5 years of age. Risk and Prognostic Factors Genetic and physiological. Major depressive disorder, bipolar I disorder, and bipolar Il disorder are more common among first-degree biological relatives of individuals with cyclo- thymic disorder than in the general population. There may also be an increased familial risk of substance-related disorders. Cyclothymic disorder may be more common in the first-degree biological relatives of individuals with bipolar I disorder than in the general population. Differential Diagnosis Bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition. The diagnosis of bipolar and related disorder due to another medical condition or depressive disorder due to another medical condition is made when the mood disturbance is judged to be attributable to the physiological effect of a specific, usually chronic medical condition (e.g., hyperthyroidism). This determination is based on the history, physical examination, or laboratory findings. If it is judged that the hypomanic and depressive symptoms are not the physiological consequence of the med- ical condition, then the primary mental disorder (i.e., cyclothymic disorder) and the med- ical condition are coded. For example, this would be the case if the mood symptoms are considered to be the psychological (not the physiological) consequence of having a chronic medical condition, or if there is no etiological relationship between the hypomanic and de- pressive symptoms and the medical condition. Substance/medication-induced bipolar and related disorder and substance/medica- tion-induced depressive disorder. Substance/medication-induced bipolar and related disorder and substance/ medication-induced depressive disorder are distinguished from cyclothymic disorder by the judgment that a substance/ medication (especially stimu- lants) is etiologically related to the mood disturbance. The frequent mood swings in these disorders that are suggestive of cyclothymic disorder usually resolve following cessation of substance / medication use. Bipolar I disorder, with rapid cycling, and bipolar Il disorder, with rapid cycling. Both disorders may resemble cyclothy mic disorder by virtue of the frequent marked shifts in mood. By definition, in cyclothymic disorder the criteria for a major depressive, manic, or hypomanic episode has never been met, whereas the bipolar I disorder and bipolar Il disorder specifier "with rapid cycling" requires that full mood episodes be present. Borderline personality disorder. Borderline personality disorder is associated with marked shifts in mood that may suggest cyclothymic disorder. If the criteria are met for both disorders, both borderline personality disorder and cyclothymic disorder may be di- agnosed. Comorbidity Substance-related disorders and sleep disorders (i.e., difficulties in initiating and main- taining sleep) may be present in individuals with cyclothymic disorder. Most children with cyclothymic disorder treated in outpatient psychiatric settings have comorbid mental conditions; they are more likely than other pediatric patients with mental disorders to have comorbid attention-deficit/hyperactivity disorder.

PCP intoxication

MECHANISM: • Phencyclidine (PCP) is a dissociative, anesthetic, hallucinogenic drug that is a NDA glutamate receptor antagonist "angel dust" • PCP also activates the dopaminergic neurons. • It can cause CNS stimulant or depressive effects. • Short onset of action with a brief duration (1-4 hours). CLINICAL MANIFESTATIONS: • Impulsiveness, fear, homicidality, rage, psychosis, delirium, psychomotor agitation, hallucinations, multidirectional nystagmus, ataxia, tachycardia, erythematous and dry skin. • In severe cases, it may be associated with hyperthermia, seizures. MANAGEMENT • Supportive care (eg, airway, breathing and circulation monitoring, placement in a low stimulus environment). • Benzodiazepines are the first line agent for chemical sedation if agitated, hyperthermic, & for PCP-induced hypertension & seizures. • Antipsychotics (eg, Haloperidol) if psychotic. • Physical restraints may be required in some cases of severe agitation.

premenstrual dysphoric disorder (DSM)

DIAGNOSTIC CRITERIA A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses. B. One (or more) of the following symptoms must be present: 1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or in- creased sensitivity to rejection). 2. Marked irritability or anger or increased interpersonal conflicts. 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge. C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above. 1. Decreased interest in usual activities (e.g., work, school, friends, hobbies). 2. Subjective difficulty in concentration. 3. Lethargy, easy fatigability, or marked lack of energy. 4. Marked change in appetite; overeating; or specific food cravings. 5. Hypersomnia or insomnia. 6. A sense of being overwhelmed or out of control. 7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," or weight gain. Note: The symptoms in Criteria AC must have been met for most menstrual cycles that occurred in the preceding year. D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home). E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders). F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.) G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism)

transvestic disorder (DSM)

DIAGNOSTIC CRITERIA A. Over a period of at least 6 months, recurrent and intense sexual arousal from crossdressing, as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With fetishism: If sexually aroused by fabrics, materials, or garments. With autogynephilia: If sexually aroused by thoughts or images of self as female. Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to cross-dress are restricted. In full remission: There has been no distress or impairment in social, occupational, or other areas of functioning for at least 5 years while in an uncontrolled environment.

sexual masochism disorder (DSM)

DIAGNOSTIC CRITERIA A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With asphyxiophilia: If the individual engages in the practice of achieving sexual arousal related to restriction of breathing. Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in masochistic sexual behaviors are restricted. In full remission: There has been no distress or impairment in social, occupational, or other areas of functioning for at last 5 years while in an uncontrolled environment. Diagnostic Features The diagnostic criteria for sexual masochism disorder are intended to apply to individuals who freely admit to having such paraphilic interests. Such individuals openly acknowl- edge intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors. If these individuals also re- port psychosocial difficulties because of their sexual attractions or preferences for being humiliated, beaten, bound, or otherwise made to suffer, they may be diagnosed with sex- ual masochism disorder. In contrast, if they declare no distress, exemplified by anxiety, ob- sessions, guilt, or shame, about these paraphilic impulses, and are not hampered by them in pursuing other personal goals, they could be ascertained as having masochistic sexual interest but should not be diagnosed with sexual masochism disorder. The Criterion A time frame, indicating that the signs or symptoms of sexual masoch- ism must have persisted for at least 6 months, should be understood as a general guideline, not a strict threshold, to ensure that the sexual interest in being humiliated, beaten, bound, or otherwise made to suffer is not merely transient. However, the disorder can be diag- nosed in the context of a clearly sustained but shorter time period. Associated Features Supporting Diagnosis The extensive use of pornography involving the act of being humiliated, beaten, bound, or oth- erwise made to suffer is sometimes an associated feature of sexual masochism disorder. Prevalence The population prevalence of sexual masochism disorder is unknown. In Australia, it has been estimated that 2.2% of males and 1.3% of females had been involved in bondage and discipline, sadomasochism, or dominance and submission in the past 12 months. Development and Course Community individuals with paraphilias have reported a mean age at onset for masoch- ism of 19.3 years, although earlier ages, including puberty and childhood, have also been reported for the onset of masochistic fantasies. Very little is known about persistence over time. Sexual masochism disorder per definition requires one or more contributing factors, which may change over time with or without treatment. These include subjective distress (eg, guilt, shame, intense sexual frustration, loneliness), psychiatric morbidity, hypersex- uality and sexual impulsivity, and psychosocial impairment. Therefore, the course of sex- ual masochism disorder is likely to vary with age. Advancing age is likely to have the same reducing effect on sexual preference involving sexual masochism as it has on other para- philic or normophilic sexual behavior. Functional Consequences of Sexual Masochism Disorder The functional consequences of sexual masochism disorder are unknown. However, mas- ochists are at risk of accidental death while practicing asphyxiophilia or other autoerotic procedures. Differential Diagnosis Many of the conditions that could be differential diagnoses for sexual masochism disorder (e.g., transvestic fetishism, sexual sadism disorder, hypersexuality, alcohol and substance use disorders) sometimes occur also as comorbid diagnoses. Therefore, it is necessary to carefully evaluate the evidence for sexual masochism disorder, keeping the possibility of other paraphilias or other mental disorders as part of the differential diagnosis. Sexual masochism in the absence of distress (i.e., no disorder) is also included in the differential, as individuals who conduct the behaviors may be satisfied with their masochistic interest. Comorbidity Known comorbidities with sexual masochism disorder are largely based on individuals in treatment. Disorders that occur comorbidly with sexual masochism disorder typically in- clude other paraphilic disorders, such as transvestic fetishism.

exhibitionistic disorder (DSM)

DIAGNOSTIC CRITERIA A. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors. B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify whether: Sexually aroused by exposing genitals to prepubertal children Sexually aroused by exposing genitals to physically mature individuals Sexually aroused by exposing genitals to prepubertal children and to physically mature individuals Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to expose one's genitals are restricted. In full remission: The individual has not acted on the urges with a nonconsenting per- son, and there has been no distress or impairment in social, occupational, or other ar- eas of functioning, for at least 5 years while in an uncontrolled environment. Subtypes The subtypes for exhibitionistic disorder are based on the age or physical maturity of the non- consenting individuals to whom the individual prefers to expose his or her genitals. The non- consenting individuals could be prepubescent children, adults, or both. This specifier should help draw adequate attention to characteristics of victims of individuals with exhibitionistic disorder to prevent co-occurring pedophilic disorder from being overlooked. However, indi- cations that the individual with exhibitionistic disorder is sexually attracted to exposing his or her genitals to children should not preclude a diagnosis of pedophilic disorder. Specifiers The "' in full remission" specifier does not address the continued presence or absence of ex- hibitionism per se, which may still be present after behaviors and distress have remitted Diagnostic Features The diagnostic criteria for exhibitionistic disorder can apply both to individuals who more or less freely disclose this paraphilia and to those who categorically deny any sexual attraction to exposing their genitals to unsuspecting persons despite substantial objective evidence to the contrary. If disclosing individuals also report psychosocial difficulties because of their sexual attractions or preferences for exposing, they may be diagnosed with exhibitionistic disorder. In contrast, if they declare no distress (exemplified by absence of anxiety, obsessions, and guilt or shame about these paraphilic impulses) and are not impaired by this sexual interest in other important areas of functioning, and their self-reported, psychiatric, or legal histories indicate that they do not act on them, they could be ascertained as having exhibitionistic sexual interest but not be diagnosed with exhibitionistic disorder. Examples of nondisclosing individuals include those who have exposed themselves repeatedly to unsuspecting persons on separate occasions but who deny any urges or fantasies about such sexual behavior and who report that known episodes of exposure were all accidental and nonsexual. Others may disclose past episodes of sexual behavior involv- ing genital exposure but refute any significant or sustained sexual interest in such behav- or. Since these individuals deny having urges or fantasies involving genital exposure, it follows that they would also deny feeling subjectively distressed or socially impaired by such impulses. Such individuals may be diagnosed with exhibitionistic disorder despite their negative self-report. Recurrent exhibitionistic behavior constitutes sufficient support for exhibitionism (Criterion A) and simultaneously demonstrates that this paraphilically motivated behavior is causing harm to others (Criterion B).° 09/26 26 "Recurrent" genital exposure to unsuspecting others (i.e., multiple victims, each on a separate occasion) may, as a general rule, be interpreted as three or more victims on sep- arate occasions. Fewer victims can be interpreted as satisfying this criterion if there were multiple occasions of exposure to the same victim, or if there is corroborating evidence of a strong or preferential interest in genital exposure to unsuspecting persons. Note that multiple victims, as suggested earlier, are a sufficient but not a necessary condition for di- agnosis, as criteria may be met by an individual's acknowledging intense exhibitionistic sexual interest with distress and/or impairment. The Criterion A time frame, indicating that signs or symptoms of exhibitionism must have persisted for at least 6 months, should also be understood as a general guideline, not a strict threshold, to ensure that the sexual interest in exposing one's genitals to unsuspect- ing others is not merely transient. This might be expressed in clear evidence of repeated behaviors or distress over a nontransient period shorter than 6 months. Prevalence The prevalence of exhibitionistic disorder is unknown. However, based on exhibitionistic sexual acts in nonclinical or general populations, the highest possible prevalence for exhi- bitionistic disorder in the male population is 2%-4%. The prevalence of exhibitionistic dis- order in females is even more uncertain but is generally believed to be much lower than in males. Adult males with exhibitionistic disorder often report that they first became aware of sex- ual interest in exposing their genitals to unsuspecting persons during adolescence, at a somewhat later time than the typical development of normative sexual interest in women or men. Although there is no minimum age requirement for the diagnosis of exhibitionis- tic disorder, it may be difficult to differentiate exhibitionistic behaviors from age-appro- priate sexual curiosity in adolescents. Whereas exhibitionistic impulses appear to emerge n adolescence or early adulthood, very little is known about persistence over time. By det- inition, exhibitionistic disorder requires one or more contributing factors, which may change over time with or without treatment; subjective distress (e.g., guilt, shame, intense sexual frustration, loneliness), mental disorder comorbidity, hypersexuality, and sexual impulsivity; psychosocial impairment; and / or the propensity to act out sexually by expos- ing the genitals to unsuspecting persons. Therefore, the course of exhibitionistic disorder is likely to vary with age. As with other sexual preferences, advancing age may be associ- ated with decreasing exhibitionistic sexual preferences and behavior. Risk and Prognostic Factors Temperamental. Since exhibitionism is a necessary precondition for exhibitionistic dis- order, risk factors for exhibitionism should also increase the rate of exhibitionistic disor- der. Antisocial history, antisocial personality disorder, alcohol misuse, and pedophilic sexual preference might increase risk of sexual recidivism in exhibitionistic offenders. Hence, antisocial personality disorder, alcohol use disorder, and pedophilic interest may be considered risk factors for exhibitionistic disorder in males with exhibitionistic sexual preferences Environmental. Childhood sexual and emotional abuse and sexual preoccupation/hyper- Setuality have been suggested as risk factors for exhibitionism, although the causal fell: Honship to exhibitionism is uncertain and the specificity unclear. Gender-Related Diagnostic Issues Exhibitionistic disorder is highly unusual in females, whereas single sexually arousing ex- hibitionistic acts might occur up to half as often among women compared with men. Functional Consequences of Exhibitionistic Disorder The functional consequences of exhibitionistic disorder have not been addressed in re- search involving individuals who have not acted out sexually by exposing their genitals to unsuspecting strangers but who fulfill Criterion B by experiencing intense emotional dis- tress over these preferences. Differential Diagnosis Potential differential diagnoses for exhibitionistic disorder sometimes occur also as co- morbid disorders. Therefore, it is generally necessary to evaluate the evidence for exhibi- tionistic disorder and other possible conditions as separate questions. Conduct disorder and antisocial personality disorder. Conduct disorder in adolescents and antisocial personality disorder would be characterized by additional norm-breaking and antisocial behaviors, and the specific sexual interest in exposing the genitals should be lacking. Substance use disorders. Alcohol and substance use disorders might involve single exhibitionistic episodes by intoxicated individuals but should not involve the typical sex- al interest in exposing the genitals to unsuspecting persons. Hence, recurrent exhibition- istic sexual fantasies, urges, or behaviors that occur also when the individual is not intoxicated suggest that exhibitionistic disorder might be present. Comorbidity Known comorbidities in exhibitionistic disorder are largely based on research with indi- viduals (almost all males) convicted for criminal acts involving genital exposure to non- consenting individuals. Hence, these comorbidities might not apply to all individuals who qualify for a diagnosis of exhibitionistic disorder. Conditions that occur comorbidly with exhibitionistic disorder at high rates include depressive, bipolar, anxiety, and substance use disorders; hypersexuality; attention-deficit/hyperactivity disorder; other paraphilic disorders; and antisocial personality disorder.

sexual sadism disorder (DSM)

DIAGNOSTIC CRITERIA A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors. B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in sadistic sexual behaviors are restricted. In full remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment.

frotteuristic disorder (DSM)

DIAGNOSTIC CRITERIA A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors. B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social. occupational, or other important areas of functioning. Differential Diagnosis Conduct disorder and antisocial personality disorder. Conduct disorder in adolescents and antisocial personality disorder would be characterized by additional norm-breaking and antisocial behaviors, and the specific sexual interest in touching or rubbing against a nonconsenting individual should be lacking. Substance use disorders. Substance use disorders, particularly those involving stimu- lants such as cocaine and amphetamines, might involve single frotteuristic episodes by in- toxicated individuals but should not involve the typical sustained sexual interest in touching or rubbing against unsuspecting persons. Fence, recurrent frotteuristic sexual fantasies, urges, or behaviors that occur also when the individual is not intoxicated sug gest that frotteuristic disorder might be present. Comorbidity Known comorbidities in frotteuristic disorder are largely based on research with males suspected of or convicted for criminal acts involving sexually motivated touching of or rubbing against a nonconsenting individual. Hence, these comorbidities might not apply to other individuals with a diagnosis of frotteuristic disorder based on subjective distress over their sexual interest. Conditions that occur comorbidly with frotteuristic disorder in- clue hypersexuality and other paraphilic disorders, particularly exhibitionistic disorder and voyeuristic disorder. Conduct disorder, antisocial personality disorder, depressive disorders, bipolar disorders, anxiety disorders, and substance use disorders also co-occur. Potential differential diagnoses for frotteuristic disorder sometimes occur also as comor- bid disorders. Therefore, it is generally necessary to evaluate the evidence for frotteuristic disorder and possible comorbid conditions as separate questions.

pedophilic disorder (DSM)

DIAGNOSTIC CRITERIA A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger). B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty. C. The individual is at least age 16 years and at least 5 years older than the child or children in Criterion A. Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old. Specify whether: Exclusive type (attracted only to children) Nonexclusive type Specify if: Sexually attracted to males Sexually attracted to females Sexually attracted to both Specify if: Limited to incest Diagnostic Features The diagnostic criteria for pedophilic disorder are intended to apply both to individuals who freely disclose this paraphilia and to individuals who deny any sexual attraction to prepuber- tal children (generally age 13 years or younger), despite substantial objective evidence to the contrary. Examples of disclosing this paraphilia include candidly acknowledging an intense sexual interest in children and indicating that sexual interest in children is greater than or equal to sexual interest in physically mature individuals. If individuals also complain that their sex- ual attractions or preferences for children are causing psychosocial difficulties, they may be di- agnosed with pedophilic disorder. However, if they report an absence of feelings of guilt, shame, or anxiety about these impulses and are not functionally limited by their paraphilic im- pulses (according to self-report, objective assessment, or both), and their self-reported and le- gally recorded histories indicate that they have never acted on their impulses, then these individuals have a pedophilic sexual interest but not pedophilic disorder. Examples of individuals who deny attraction to children include individuals who are known to have sexually approached multiple children on separate occasions but who deny any urges or fantasies about sexual behavior involving children, and who may further claim that the known episodes of physical contact were all unintentional and nonsexual. Other indi- viduals may acknowledge past episodes of sexual behavior involving children but deny any significant or sustained sexual interest in children. Since these individuals may deny experi- ences impulses or fantasies involving children, they may also deny feeling subjectively dis- tressed. Such individuals may still be diagnosed with pedophilic disorder despite the absence of self-reported distress, provided that there is evidence of recurrent behaviors persisting for 6 months (Criterion A) and evidence that the individual has acted on sexual urges or experi- enced interpersonal difficulties as a consequence of the disorder (Criterion B). Presence of multiple victims, as discussed above, is sufficient but not necessary for di- agnosis; that is, the individual can still meet Criterion A by merely acknowledging intense or preferential sexual interest in children. The Criterion A clause, indicating that the signs or symptoms of pedophilia have per- sisted for 6 months or longer, is intended to ensure that the sexual attraction to children is not merely transient. However, the diagnosis may be made if there is clinical evidence of sustained persistence of the sexual attraction to children even if the 6-month duration can- not be precisely determined. Associated Features Supporting Diagnosis The extensive use of pornography depicting prepubescent children is a useful diagnostic indicator of pedophilic disorder. This is a specific instance of the general case that individ- uals are likely to choose the kind of pornography that corresponds to their sexual interests. Prevalence The population prevalence of pedophilic disorder is unknown. The highest possible prev- alence for pedophilic disorder in the male population is approximately 3%-5%. The pop- ulation prevalence of pedophilic disorder in females is even more uncertain, but it is likely a small fraction of the prevalence in males. Development and Course Adult males with pedophilic disorder may indicate that they become aware of strong or preferential sexual interest in children around the time of puberty- the same time frame in which males who later prefer physically mature partners became aware of their sexual interest in women or men. Attempting to diagnose pedophilic disorder at the age at which it first manifests is problematic because of the difficulty during adolescent development in differentiating it from age-appropriate sexual interest in peers or from sexual curiosity. Hence, Criterion C requires for diagnosis a minimum age of 16 years and at least 5 years older than the child or children in Criterion A. Pedophilia per se appears to be a lifelong condition. Pedophilic disorder, however, necessarily includes other elements that may change over time with or without treatment: subjective distress (e.g., guilt, shame, intense sexual frustration, or feelings of isolation) or psychosocial impairment, or the propensity to act out sexually with children, or both. Therefore, the course of pedophilic disorder may fluctuate, increase, or decrease with age. Adults with pedophilic disorder may report an awareness of sexual interest in children that preceded engaging in sexual behavior involving children or self-identification as a pedo- phile. Advanced age is as likely to similarly diminish the frequency of sexual behavior involv- ing children as it does other paraphilically motivated and normophilic sexual behavior. Risk and Prognostic Factors Temperamental. There appears to be an interaction between pedophilia and antisocial- ity, such that males with both traits are more likely to act out sexually with children. Thus, antisocial personality disorder may be considered a risk factor for pedophilic disorder in males with pedophilia. Environmental. Adult males with pedophilia often report that they were sexually abused as children. It is unclear, however, whether this correlation reflects a causal influence of childhood sexual abuse on adult pedophilia. Genetic and physiological. Since pedophilia is a necessary condition for pedophilic dis- order, any factor that increases the probability of pedophilia also increases the risk of pe- dophilic disorder. There is some evidence that neurodevelopmental perturbation in utero increases the probability of development of a pedophilic interest. Gender-Related Diagnostic Issues Psychophysiological laboratory measures of sexual interest, which are sometimes useful in di- agnosing pedophilic disorder in males, are not necessarily useful in diagnosing this disorder in females, even when an identical procedure (e.g., viewing time) or analogous procedures (e.g., penile plethysmography and vaginal photoplethysmography) are available. Diagnostic Markers Psychophysiological measures of sexual interest may sometimes be useful when an indi- vidual's history suggests the possible presence of pedophilic disorder but the individual denies strong or preferential attraction to children. The most thoroughly researched and longest used of such measures is penile plethysmography, although the sensitivity and spec ificity of diagnosis may vary from one site to another. Viewing time, using photographs of hude or minimally clothed persons as visual stimuli, is also used to diagnose pedophilic disorder, especially in combination with self-report measures. Mental health professionals in the United States, however, should be aware that possession of such visual stimuli, even for diagnostic purposes, may violate American law regarding possession of child pomog- taphy and leave the mental health professional susceptible to criminal prosecution. Differential Diagnosis Many of the conditions that could be differential diagnoses for pedophilic disorder also sometimes occur as comorbid diagnoses. It is therefore generally necessary to evaluate the evidence for pedophilic disorder and other possible conditions as separate questions. Antisocial personality disorder. This disorder increases the likelihood that a person who is primarily attracted to the mature physique will approach a child, on one or a few occa- sions, on the basis of relative availability. The individual often shows other signs of this personality disorder, such as recurrent law-breaking. Alcohol and substance use disorders. The disinhibiting effects of intoxication may also increase the likelihood that a person who is primarily attracted to the mature physique will sexually approach a child. Obsessive-compulsive disorder. There are occasional individuals who complain about ego-dystonic thoughts and worries about possible attraction to children. Clinical inter- viewing usually reveals an absence of sexual thoughts about children during high states of sexual arousal (e.g., approaching orgasm during masturbation) and sometimes additional ego-dystonic, intrusive sexual ideas (e.g., concerns about homosexuality). Comorbidity Psychiatric comorbidity of pedophilic disorder includes substance use disorders; depres- sive, bipolar, and anxiety disorders; antisocial personality disorder; and other paraphilic disorders. However, findings on comorbid disorders are largely among individuals con- victed for sexual offenses involving children (almost all males) and may not be general- izable to other individuals with pedophilic disorder (e.g., individuals who have never approached a child sexually but who qualify for the diagnosis of pedophilic disorder on the basis of subjective distress).

Autism Spectrum Disorder (ASD) (DSM)

DIAGNOSTIC CRITERIA A. Persistent deficits in social communication and social interaction across multiple con- texts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text): 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnor- malities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. 3. Deficits in developing, maintaining, and understanding relationships, ranging, for ex- ample, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Specify current severity: Severity is based on social communication impairments and restricted, re- petitive patterns of behavior (seeTable 2). B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaus- tive; see text): 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circum- scribed or perseverative interests). 4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse re- sponse to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Specify current severity: Severity is based on social communication impairments and restricted, re- petitive patterns of behavior (see Table 2). C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other im- portant areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual devel- opmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spec- trum disorder and intellectual disability, social communication should be below that ex- pected for general developmental level. Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic condition or environmental factor (Coding note: Use additional code to identify the associated medical or genetic condition.) Associated with another neurodevelopmental, mental, or behavioral disorder (Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder[s].) With catatonia (refer to the criteria for catatonia associated with another mental dis- order, pp. 119-120, for definition) (Coding note: Use additional code 293.89 [F06.1] catatonia associated with autism spectrum disorder to indicate the presence of the co- morbid catatonia.) Recording Procedures For autism spectrum disorder that is associated with a known medical or genetic condition or environmental factor, or with another neurodevelopmental, mental, or behavioral dis- order, record autism spectrum disorder associated with (name of condition, disorder, or factor) (e.g., autism spectrum disorder associated with Rett syndrome). Severity should be recorded as level of support needed for each of the two psychopathological domains in Table 2 (e.g., "requiring very substantial support for deficits in social communication and requiring substantial support for restricted, repetitive behaviors"). Specification of "with accompanying intellectual impairment" or "without accompanying intellectual impair- ment" should be recorded next. Language impairment specification should be recorded thereafter. If there is accompanying language impairment, the current level of verbal func- toning should be recorded (e.g., "with accompanying language impairment--no intelligi- ble speech" or "with accompanying language impairment--phrase speech"). If catatonia is present, record separately "catatonia associated with autism spectrum disorder. Specifiers The severity specifiers (see Table 2) may be used to describe succinctly the current symp- tomatology (which might fall below level 1), with the recognition that severity may vary by context and fluctuate over time. Severity of social communication difficulties and re- stricted, repetitive behaviors should be separately rated. The descriptive severity categories should not be used to determine eligibility for and provision of services; these can only be developed at an individual level and through discussion of personal priorities and targets. Regarding the specifier "with or without accompanying intellectual impairment,' derstanding the (often uneven) intellectual profile of a child or adult with autism spectrum disorder is necessary for interpreting diagnostic features. Separate estimates of verbal and nonverbal skill are necessary (e.g., using untimed nonverbal tests to assess potential strengths in individuals with limited language). To use the specifier "with or without accompanying language impairment," the cur- rent level of verbal functioning should be assessed and described. Examples of the specific descriptions for "with accompanying language impairment" might include no intelligible speech (nonverbal), single words only, or phrase speech. Language level in individuals "without accompanying language impairment" might be further described by speaks in full sentences or has fluent speech. Since receptive language may lag behind expressive language development in autism spectrum disorder, receptive and expressive language skills should be considered separately. The specifier "associated with a known medical or genetic condition or environmental fac- tor" should be used when the individual has a known genetic disorder (e.g., Rett syndrome, Fragile X syndrome, Down syndrome), a medical disorder (e.g. epilepsy), or a history of envi- ronmental exposure (e.g., valproate, fetal alcohol syndrome, very low birth weight). Additional neurodevelopmental, mental or behavioral conditions should also be noted (e.g., attention-deficit/hyperactivity disorder; developmental coordination disorder; dis- ruptive behavior, impulse-control, or conduct disorders; anxiety, depressive, or bipolar disorders; tics or Tourette's disorder; self-injury; feeding, elimination, or sleep disorders). Diagnostic Features The essential features of autism spectrum disorder are persistent impairment in reciprocal social communication and social interaction (Criterion A), and restricted, repetitive pat- terns of behavior, interests, or activities (Criterion B). These symptoms are present from early childhood and limit or impair everyday functioning (Criteria C and D). The stage at which functional impairment becomes obvious will vary according to characteristics of the individual and his or her environment. Core diagnostic features are evident in the developmental period, but intervention, compensation, and current supports may mask difficulties in at least some contexts. Manifestations of the disorder also vary greatly de- pending on the severity of the autistic condition, developmental level, and chronological age; hence, the term spectrum. Autism spectrum disorder encompasses disorders previously re- ferred to as early infantile autism, childhood autism, Kanner's autism, high-functioning autism, atypical autism, pervasive developmental disorder not otherwise specified, child- hood disintegrative disorder, and Asperger's disorder. The impairments in communication and social interaction specified in Criterion A are pervasive and sustained. Diagnoses are most valid and reliable when based on multiple sources of information, including clinician's observations, caregiver history, and, when possible, self-report. Verbal and nonverbal deficits in social communication have varying manifestations, depending on the individual's age, intellectual level, and language ability, as well as other factors such as treatment history and current support. Many individuals have language deficits, ranging from complete lack of speech through language delays, poor comprehension of speech, echoed speech, or stilted and overly literal language. Even when formal language skills (e.g., vocabulary, grammar) are intact, the use of language for reciprocal social communication is impaired in autism spectrum disorder, Deficits in social-emotional reciprocity (i.e., the ability to engage with others and share thoughts and feelings) are clearly evident in young children with the disorder, who may show little or no initiation of social interaction and no sharing of emotions, along with re- duced or absent imitation of others' behavior. What language exists is often one-sided, lacking in social reciprocity, and used to request or label rather than to comment, share feelings, or converse. In adults without intellectual disabilities or language delays, deficits in social-emotional reciprocity may be most apparent in difficulties processing and re- sponding to complex social cues (e.g., when and how to join a conversation, what not to say). Adults who have developed compensation strategies for some social challenges still struggle in novel or unsupported situations and suffer from the effort and anxiety of con- sciously calculating what is socially intuitive for most individuals. Deficits in nonverbal communicative behaviors used for social interaction are mani- fested by absent, reduced, or atypical use of eye contact (relative to cultural norms), ges. tures, facial expressions, body orientation, or speech intonation. An early feature of autism spectrum disorder is impaired joint attention as manifested by a lack of pointing, showing, or bringing objects to share interest with others, or failure to follow someone's pointing or eye gaze. Individuals may learn a few functional gestures, but their repertoire is smaller than that of others, and they often fail to use expressive gestures spontaneously in com- munication. Among adults with fluent language, the difficulty in coordinating nonverbal communication with speech may give the impression of odd, wooden, or exaggerated "body language" during interactions. Impairment may be relatively subtle within indi- vidual modes (e.g., someone may have relatively good eye contact when speaking) but noticeable in poor integration of eye contact, gesture, body posture, prosody, and facial ex- pression for social communication. Deficits in developing, maintaining, and understanding relationships should be judged against norms for age, gender, and culture. There may be absent, reduced, or atyp- ical social interest, manifested by rejection of others, passivity, or inappropriate ap- proaches that seem aggressive or disruptive. These difficulties are particularly evident in young children, in whom there is often a lack of shared social play and imagination (e.g., age-appropriate flexible pretend play) and, later, insistence on playing by very fixed rules. Older individuals may struggle to understand what behavior is considered appropriate in one situation but not another (e.g., casual behavior during a job interview), or the different ways that language may be used to communicate (e.g., irony, white lies). There may be an apparent preference for solitary activities or for interacting with much younger or older people. Frequently, there is a desire to establish friendships without a complete or realistic idea of what friendship entails (e.g., one-sided friendships or friendships based solely on shared special interests). Relationships with siblings, co-workers, and caregivers are also important to consider (in terms of reciprocity). Autism spectrum disorder is also defined by restricted, repetitive patterns of behavior, interests, or activities (as specified in Criterion B), which show a range of manifestations according to age and ability, intervention, and current supports. Stereotyped or repetitive behaviors include simple motor stereotypes (e.g., hand flapping, finger flicking), repeti- tive use of objects (e.g., spinning coins, lining up toys), and repetitive speech (e.g., echola- lia, the delayed or immediate parroting of heard words; use of "you" when referring to self; stereotyped use of words, phrases, or prosodic patterns). Excessive adherence to rou- tines and restricted patterns of behavior may be manifest in resistance to change (e.g., dis- tress at apparently small changes, such as in packaging of a favorite food; insistence on adherence to rules; rigidity of thinking) or ritualized patterns of verbal or nonverbal be- havior (e.g., repetitive questioning, pacing a perimeter). Highly restricted, fixated interests in autism spectrum disorder tend to be abnormal in intensity or focus (e.g., a toddler strongly attached to a pan; a child preoccupied with vacuum cleaners; an adult spending hours writing out timetables). Some fascinations and routines may relate to apparent hy- per- or hyporeactivity to sensory input, manifested through extreme responses to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects, and sometimes apparent indifference to pain, heat, or cold. Extreme re- action to or rituals involving taste, smell, texture, or appearance of food or excessive food restrictions are common and may be a presenting feature of autism spectrum disorder. Many adults with autism spectrum disorder without intellectual or language disabili- ties learn to suppress repetitive behavior in public. Special interests may be a source of pleasure and motivation and provide avenues for education and employment later in life. Diagnostic criteria may be met when restricted, repetitive patterns of behavior, interests, or activities were clearly present during childhood or at some time in the past, even it symptoms are no longer present. Criterion D requires that the features must cause clinically significant impairment in so- cial, occupational, or other important areas of current functioning. Criterion E specifies that the social communication deficits, although sometimes accompanied by intellectual disabil- itv (intellectual developmental disorder), are not in line with the individual's developmental level; impairments exceed difficulties expected on the basis of developmental level. Standardized behavioral diagnostic instruments with good psychometric properties, including caregiver interviews, questionnaires and clinician observation measures, are available and can improve reliability of diagnosis over time and across clinicians. Associated Features Supporting Diagnosis Many individuals with autism spectrum disorder also have intellectual impairment and / or language impairment (e.g., slow to talk, language comprehension behind production). Even those with average or high intelligence have an uneven profile of abilities. The gap between intellectual and adaptive functional skills is often large. Motor deficits are often present, in- cluding odd gait, clumsiness, and other abnormal motor signs (e.g., walking on tiptoes). Self- injury (e.g., head banging, biting the wrist) may occur, and disruptive/challenging behav- iors are more common in children and adolescents with autism spectrum disorder than other disorders, including intellectual disability. Adolescents and adults with autism spec- trum disorder are prone to anxiety and depression. Some individuals develop catatonic-like motor behavior (slowing and "freezing" mid-action), but these are typically not of the mag- nitude of a catatonic episode. However, it is possible for individuals with autism spectrum disorder to experience a marked deterioration in motor symptoms and display a full cata- tonic episode with symptoms such as mutism, posturing, grimacing and waxy flexibility. The risk period for comorbid catatonia appears to be greatest in the adolescent years. Prevalence In recent years, reported frequencies for autism spectrum disorder across U.S. and non- U.S. countries have approached 1% of the population, with similar estimates in child and adult samples. It remains unclear whether higher rates reflect an expansion of the diag- nostic criteria of DSM-IV to inclüde subthreshold cases, increased awareness, differences in study methodology, or a true increase in the frequency of autism spectrum disorder. Development and Course The age and pattern of onset also should be noted for autism spectrum disorder. Symptoms are typically recognized during the second year of life (12-24 months of age) but may be seen earlier than 12 months if developmental delays are severe, or noted later than 24 months if symptoms are more subtle. The pattern of onset description might include information about early developmental delays or any losses of social or language skills. In cases where skills have been lost, parents or caregivers may give a history of a gradual or relatively rapid deterioration in social behaviors or language skills. Typically, this would occur be- tween 12 and 24 months of age and is distinguished from the rare instances of developmen- tal regression occurring after at least 2 years of normal development (previously described as childhood disintegrative disorder). The behavioral features of autism spectrum disorder first become evident in early childhood, with some cases presenting a lack of interest in social interaction in the first year of life. Some children with autism spectrum disorder experience developmental pla- taus or regression, with a gradual or relatively rapid deterioration in social behaviors or use of language, often during the first 2 years of life. Such losses are rare in other disor- ders and may be a useful "red flag" for autism spectrum disorder. Much more unusual and warranting more extensive medical investigation are losses of skills beyond social communication (e.g., loss of self-care, toileting, motor skills) or those occurring after the second birthday (see also Rett syndrome in the section "Differential Diagnosis" for this disorder). First symptoms of autism spectrum disorder frequently involve delayed language de- velopment, often accompanied by lack of social interest or unusual social interactions (e.g., pulling individuals by the hand without any attempt to look at them), odd play patterns (e.g., carrying toys around but never playing with them), and unusual communication patterns (e.g., knowing the alphabet but not responding to own name). Deafness may be suspected but is typically ruled out. During the second year, odd and repetitive behaviors and the absence of typical play become more apparent. Since many typically developing young children have strong preferences and enjoy repetition (e.g., eating the same foods, watching the same video multiple times), distinguishing restricted and repetitive behav- iors that are diagnostic of autism spectrum disorder can be difficult in preschoolers. The clinical distinction is based on the type, frequency, and intensity of the behavior (e.g., a child who daily lines up objects for hours and is very distressed if any item is moved). Autism spectrum disorder is not a degenerative disorder, and it is typical for learning and compensation to continue throughout life. Symptoms are often most marked in early childhood and early school years, with developmental gains typical in later childhood in at least some areas (e.g., increased interest in social interaction). A small proportion of in- dividuals deteriorate behaviorally during adolescence, whereas most others improve. Only a minority of individuals with autism spectrum disorder live and work indepen- dently in adulthood; those who do tend to have superior language and intellectual abilities and are able to find a niche that matches their special interests and skills. In general, indi- viduals with lower levels of impairment may be better able to function independently. However, even these individuals may remain socially naive and vulnerable, have difficul- ties organizing practical demands without aid, and are prone to anxiety and depression. Many adults report using compensation strategies and coping mechanisms to mask their difficulties in public but suffer from the stress and effort of maintaining a socially accept- able facade. Scarcely anything is known about old age in autism spectrum disorder. Some individuals come for first diagnosis in adulthood, perhaps prompted by the diagno- sis of autism in a child in the family or a breakdown of relations at work or home. Obtaining de- tailed developmental history in such cases may be difficult, and it is important to consider self- reported difficulties. Where clinical observation suggests criteria are currently met, autism spectrum disorder may be diagnosed, provided there is no evidence of good social and com- munication skills in childhood. For example, the report (by parents or another relative) that the individual had ordinary and sustained reciprocal friendships and good nonverbal communi- cation skills throughout childhood would rule out a diagnosis of autism spectrum disorder; however, the absence of developmental information in itself should not do so. Manifestations of the social and communication impairments and restricted/ repeti- tive behaviors that define autism spectrum disorder are clear in the developmental period. In later life, intervention or compensation, as well as current supports, may mask these dif- ficulties in at least some contexts. However, symptoms remain sufficient to cause current impairment in social, occupational, or other important areas of functioning. Risk and Prognostic Factors The best established prognostic factors for individual outcome within autism spectrum disorder are presence or absence of associated intellectual disability and language impair- ment (e.g., functional language by age 5 years is a good prognostic sign) and additional mental health problems. Epilepsy, as a comorbid diagnosis, is associated with greater in- tellectual disability and lower verbal ability. Environmental. A variety of nonspecific risk factors, such as advanced parental age, low birth weight, or fetal exposure to valproate, may contribute to risk of autism spectrum dis- order. Genetic and physiological. Heritability estimates for autism spectrum disorder have ranged from 37% to higher than 90%, based on twin concordance rates. Currently, as many as 15% of cases of autism spectrum disorder appear to be associated with a known genetic mutation, with different de novo copy number variants or de novo mutations in specific genes associated with the disorder in different families. However, even when an autism spectrum disorder is associated with a known genetic mutation, it does not appear to be fully penetrant. Risk for the remainder of cases appears to be polygenic, with perhaps hun- dreds of genetic loci making relatively small contributions. Culture-Related Diagnostic Issues Cultural differences will exist in norms for social interaction, nonverbal communication, and relationships, but individuals with autism spectrum disorder are markedly impaired against the norms for their cultural context. Cultural and socioeconomic factors may affect age at recognition or diagnosis; for example, in the United States, late or underdiagnosis of autism spectrum disorder among African American children may occur. Gender-Related Diagnostic Issues Autism spectrum disorder is diagnosed four times more often in males than in females. In clinic samples, females tend to be more likely to show accompanying intellectual disabil- ity, suggesting that girls without accompanying intellectual impairments or language delays may go unrecognized, perhaps because of subtler manifestation of social and com- munication difficulties. Functional Consequences of Autism Spectrum Disorder In young children with autism spectrum disorder, lack of social and communication abil- ities may hamper learning, especially learning through social interaction or in settings with peers. In the home, insistence on routines and aversion to change, as well as sensory sensitivities, may interfere with eating and sleeping and make routine care (e.g., haircuts, dental work) extremely difficult. Adaptive skills are typically below measured IQ. Ex- treme difficulties in planning, organization, and coping with change negatively impact academic achievement, even for students with above-average intelligence. During adult- hood, these individuals may have difficulties establishing independence because of con- tinued rigidity and difficulty with novelty. Many individuals with autism spectrum disorder, even without intellectual disability, have poor adult psychosocial functioning as indexed by measures such as independent living and gainful employment. Functional consequences in old age are unknown, but so- cial isolation and communication problems (e.g., reduced help-seeking) are likely to have consequences for health in older adulthood. Differential Diagnosis Rett syndrome. Disruption of social interaction may be observed during the regressive phase of Rett syndrome (typically between 1-4 years of age); thus, a substantial proportion of affected young girls may have a presentation that meets diagnostic criteria for autism spectrum disorder. However, after this period, most individuals with Rett syndrome im- prove their social communication skills, and autistic features are no longer a major area of concern. Consequently, autism spectrum disorder should be considered only when all di- agnostic criteria are met. Selective mutism. In selective mutism, early development is not typically disturbed. The affected child usually exhibits appropriate communication skills in certain contexts and settings. Even in settings where the child is mute, social reciprocity is not impaired, nor are restricted or repetitive patterns of behavior present. Language disorders and social (pragmatic) communication disorder. In some forms of language disorder, there may be problems of communication and some secondary so. cial difficulties. However, specific language disorder is not usually associated with abnor- mal nonverbal communication, nor with the presence of restricted, repetitive patterns of behavior, interests, or activities. When an individual shows impairment in social communication and social interactions but does not show restricted and repetitive behavior or interests, criteria for social (prag- matic) communication disorder, instead of autism spectrum disorder, may be met. The di- agnosis of autism spectrum disorder supersedes that of social (pragmatic) communication disorder whenever the criteria for autism spectrum disorder are met, and care should be taken to enquire carefully regarding past or current restricted / repetitive behavior. Intellectual disability (intellectual developmental disorder) without autism spectrum disorder. Intellectual disability without autism spectrum disorder may be difficult to differentiate from autism spectrum disorder in very young children. Individuals with in- tellectual disability who have not developed language or symbolic skills also present a challenge for differential diagnosis, since repetitive behavior often occurs in such individ- uals as well. A diagnosis of autism spectrum disorder in an individual with intellectual disability is appropriate when social communication and interaction are significantly im- paired relative to the developmental level of the individual's nonverbal skills (e.g., fine motor skills, nonverbal problem solving). In contrast, intellectual disability is the appropri- ate diagnosis when there is no apparent discrepancy between the level of social-commu- nicative skills and other intellectual skills. Stereotypic movement disorder. Motor stereotypes are among the diagnostic charac- teristics of autism spectrum disorder, so an additional diagnosis of stereotypic movement disorder is not given when such repetitive behaviors are better explained by the presence of autism spectrum disorder. However, when stereotypies cause self-injury and become a focus of treatment, both diagnoses may be appropriate. Attention-deficit/hyperactivity disorder. Abnormalities of attention (overly focused or easily distracted) are common in individuals with autism spectrum disorder, as is hy- peractivity. A diagnosis of attention-deficit/hyperactivity disorder (ADHD) should be considered when attentional difficulties or hyperactivity exceeds that typically seen in in- dividuals of comparable mental age. Schizophrenia. Schizophrenia with childhood onset usually develops after a period of normal, or near normal, development. A prodromal state has been described in which so- cial impairment and atypical interests and beliefs occur, which could be confused with the social deficits seen in autism spectrum disorder. Hallucinations and delusions, which are defining features of schizophrenia, are not features of autism spectrum disorder. How- ever, clinicians must take into account the potential for individuals with autism spectrum disorder to be concrete in their interpretation of questions regarding the key features of schizophrenia (e.g., "Do you hear voices when no one is there?" "Yes [on the radio]). Comorbidity Autism spectrum disorder is frequently associated with intellectual impairment and struc- tural language disorder (i.e., an inability to comprehend and construct sentences with proper grammar), which should be noted under the relevant specifiers when applicable. Many in- dividuals with autism spectrum disorder have psychiatric symptoms that do not form part of the diagnostic criteria for the disorder (about 70% of individuals with autism spectrum dis- order may have one comorbid mental disorder, and 40% may have two or more comorbid mental disorders). When criteria for both ADHD and autism spectrum disorder are met, both diagnoses should be given. This same principle applies to concurrent diagnoses of autism spectrum disorder and developmental coordination disorder, anxiety disorders, depressive disorders, and other comorbid diagnoses. Among individuals who are nonverbal or have language deficits, observable signs such as changes in sleep or eating and increases in chal- lenging behavior should trigger an evaluation for anxiety or depression. Specific learning dif- ficulties (literacy and numeracy) are common, as is developmental coordination disorder. Medical conditions commonly associated with autism spectrum disorder should be noted under the "associated with a known medical/genetic or environmental /acquired condition' specifier. Such medical conditions include epilepsy, sleep problems, and constipation. Avoidant-restrictive food intake disorder is a fairly frequent presenting feature of autism spectrum disorder, and extreme and narrow food preferences may persist.

male hypoactive sexual desire disorder (DSM)

DIAGNOSTIC CRITERIA A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and socio-cultural contexts of the individual's life. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to thes effects of a substance/medication or another medical condition. Specify whether: Lifelong: The disturbance has been present since the individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function. Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners. Situational: Only occurs with certain types of stimulation, situations, or partners. Specify current severity: Mild: Evidence of mild distress over the symptoms in Criterion A. Moderate: Evidence of moderate distress over the symptoms in Criterion A. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A. Diagnostic Features When an assessment for male hypoactive sexual desire disorder is being made, inter- personal context must be taken into account. A " desire discrepancy, ." in which a man has lower desire for sexual activity than his partner, is not sufficient to diagnose male hypo- active sexual desire disorder. Both low /absent desire for sex and deficient / absent sexual thoughts or fantasies are required for a diagnosis of the disorder. There may be variation across men in how sexual desire is expressed. The lack of desire for sex and deficient / absent erotic thoughts or fantasies must be per- sistent or recurrent and must occur for a minimum duration of approximately 6 months. The inclusion of this duration criterion is meant to safeguard against making a diagnosis in cases in which a man's low sexual desire may represent an adaptive response to adverse life conditions (e.g., concern about a partner's pregnancy when the man is considering ter- minating the relationship). The introduction of "approximately " in Criterion B allows for clinician judgment in cases in which symptom duration does not meet the recommended 6-month threshold. Associated Features Supporting Diagnosis Male hypoactive sexual desire disorder is sometimes associated with erectile and / or ejac- ulatory concerns. For example, persistent difficulties obtaining an erection may lead a man to lose interest in sexual activity. Men with hypoactive sexual desire disorder often report that they no longer initiate sexual activity and that they are minimally receptive to a part- ner's attempt to initiate. Sexual activities (e.g., masturbation or partnered sexual activity) may sometimes occur even in the presence of low sexual desire. Relationship-specific pref- erences regarding patterns of sexual initiation must be taken into account when making a diagnosis of male hypoactive sexual desire disorder. Although men are more likely to ini- tiate sexual activity, and thus low desire may be characterized by a pattern of non-initiation, many men may prefer to have their partner initiate sexual activity. In such situations, the man's lack of receptivity to a partner's initiation should be considered when evaluating low desire. In addition to the subtypes "lifelong/ acquired" and "generalized/ situational," the fol- lowing five factors must be considered during assessment and diagnosis of male hypo- active sexual desire disorder given that they may be relevant to etiology and/or treatment: 1) partner factors (e.g., partner's sexual problems, partner's health status); 2) relationship factors (e.g., poor communication, discrepancies in desire for sexual activity); 3) individ- ual vulnerability factors (e.g., poor body image, history of sexual or emotional abuse), psy- chiatric comorbidity (e.g., depression, anxiety), or stressors (e.g. job loss, bereavement); 4) cultural/ religious factors (e.g., inhibitions related to prohibitions against sexual activity; attitudes toward sexuality); and 5) medical factors relevant to prognosis, course, or treatment ment. Each of these factors may contribute differently to the presenting symptoms of dif. ferent men with this disorder. Prevalence The prevalence of male hypoactive sexual desire disorder varies depending on country of origin and method of assessment. Approximately 6% of younger men (ages 18-24 years) and 41% of older men (ages 66-74 years) have problems with sexual desire. However, a persistent lack of interest in sex, lasting 6 months or more, affects only a small proportion of men ages 16-44 (1.8%). Development and Course By definition, lifelong male hypoactive sexual desire disorder indicates that low or no sex- ual desire has always been present, whereas the acquired subtype would be assigned if the man's low desire developed after a period of normal sexual desire. There is a requirement that low desire persist for approximately 6 months or more; thus, short-term changes in sexual desire should not be diagnosed as male hypoactive sexual desire disorder. There is a normative age-related decline in sexual desire. Like women, men identify a variety of triggers for their sexual desire, and they describe a wide range of reasons that they choose to engage in sexual activity. Although erotic visual cues may be more potent elicitors of desire in younger men, the potency of sexual cues may decrease with age and must be considered when evaluating men for hypoactive sexual desire disorder. Risk and Prognostic Factors Temperamental. Mood and anxiety symptoms appear to be strong predictors of low de- sire in men. Up to half of men with a past history of psychiatric symptoms may have mod- erate or severe loss of desire, compared with only 15% of those without such a history. A man's feelings about himself, his perception of his partner's sexual desire toward him, feelings of being emotionally connected, and contextual variables may all negatively (as well as positively) affect sexual desire. Environmental. Alcohol use may increase the occurrence of low desire. Among gay men, self-directed homophobia, interpersonal problems, attitudes, lack of adequate sex educa- tion, and trauma resulting from early life experiences must be taken into account in ex- plaining the low desire. Social and cultural contextual factors should also be considered. Genetic and physiological. Endocrine disorders such as hyperprolactinemia signifi- cantly affect sexual desire in men. Age is a significant risk factor for low desire in men. It is unclear whether or not men with low desire also have abnormally low levels of testoster- one; however, among hypogonadal men, low desire is common. There also may be a crit- ical threshold below which testosterone will affect sexual desire in men and above which there is little effect of testosterone on men's desire. Culture-Related Diagnostic Issues There is marked variability in prevalence rates of low desire across cultures, ranging from 12.5% in Northern European men to 28% in Southeast Asian men ages 40-80 years. Just as there are higher rates of low desire among East Asian subgroups of women, men of East Asian ancestry also have higher rates of low desire. Guilt about sex may mediate this as- sociation between East Asian ethnicity and sexual desire in men. Gender-Related Diagnostic Issues In contrast to the classification of sexual disorders in women, desire and arousal disorders have been retained as separate constructs in men. Despite some similarities in the experience of desire across men and women, and the fact that desire fluctuates over time and is dependent on contextual factors, men do report a significantly higher intensity and fre- quency of sexual desire compared with women. Differential Diagnosis Nonsexual mental disorders. Nonsexual mental disorders, such as major depressive disorder, which is characterized by "markedly diminished interest or pleasure in all, or al- most all, activities, ." may explain the lack of sexual desire. If the lack of desire is better explained by another mental disorder, then a diagnosis of male hypoactive sexual desire disorder would not be made. Substance/medication use. Substance/ medication use may explain the lack of sexual desire. Another medical condition. If the low /absent desire and deficient / absent erotic thoughts or fantasies are better explained by the effects of another medical condition (e.g., hypogo- nadism, diabetes mellitus, thyroid dysfunction, central nervous system disease), then a di- agnosis of male hypoactive sexual desire disorder would not be made. Interpersonal factors. If interpersonal or significant contextual factors, such as severe relationship distress or other significant stressors, are associated with the loss of desire in the man, then a diagnosis of male hypoactive sexual desire disorder would not be made. Other sexual dysfunctions. The presence of another sexual dysfunction does not rule out a diagnosis of male hypoactive sexual desire disorder; there is some evidence that up to one-half of men with low sexual desire also have erectile difficulties, and slightly fewer may also have early ejaculation difficulties. If the man's low desire is explained by self-identification as an asexual, then a diagnosis of male hypoactive sexual desire disorder is not made. Comorbidity Depression and other mental disorders, as well as endocrinological factors, are often co- morbid with male hypoactive sexual desire disorder.

Opioid withdrawal (DSM)

DIAGNOSTIC CRITERIA A. Presence of either of the following: 1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e., several weeks or longer). 2. Administration of an opioid antagonist after a period of opioid use. B. Three (or more) of the following developing within minutes to several days after Criterion A: 1. Dysphoric mood. 2. Nausea or vomiting. 3. Muscle aches. 4. Lacrimation or rhinorrhea. 5. Pupillary dilation, piloerection, or sweating. 6. Diarrhea. 7. Yawning. 8. Fever. 9. Insomnia. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. Diagnostic Features The essential feature of opioid withdrawal is the presence of a characteristic withdrawal syndrome that develops after the cessation of (or reduction in) opioid use that has been heavy and prolonged (Criterion A1). The withdrawal syndrome can also be precipitated by administration of an opioid antagonist (e.g., naloxone or naltrexone) after a period of opioid use (Criterion A2). This may also occur after administration of an opioid partial ag- onist such as buprenorphine to a person currently using a full opioid agonist. Opioid withdrawal is characterized by a pattern of signs and symptoms that are oppo- site to the acute agonist effects. The first of these are subjective and consist of complaints of anxiety, restlessness, and an "achy feeling" that is often located in the back and legs, along with irritability and increased sensitivity to pain. Three or more of the following must be present to make a diagnosis of opioid withdrawal: dysphoric mood; nausea or vomiting; muscle aches; lacrimation or rhinorrhea; pupillary dilation, piloerection, or increased sweating; diarrhea; yawning; fever; and insomnia (Criterion B). Piloerection and fever are associated with more severe withdrawal and are not often seen in routine clinical practice because individuals with opioid use disorder usually obtain substances before with- drawal becomes that far advanced. These symptoms of opioid withdrawal must cause clinically significant distress or impairment in social, occupational, or other important ar- eas of functioning (Criterion C). The symptoms must not be attributable to another med- ical condition and are not better explained by another mental disorder (Criterion D). Meeting diagnostic criteria for opioid withdrawal alone is not sufficient for a diagnosis of opioid use disorder, but concurrent symptoms of craving and drug-seeking behavior are suggestive of comorbid opioid use disorder. ICD-10-CM codes only allow a diagnosis of opioid withdrawal in the presence of comorbid moderate to severe opioid use disorder. The speed and severity of withdrawal associated with opioids depend on the half-life of the opioid used. Most individuals who are physiologically dependent on short-acting drugs such as heroin begin to have withdrawal symptoms within 6-12 hours after the last dose. Symptoms may take 2-4 days to emerge in the case of longer-acting drugs such as metha- done, LAAM (L-alpha-acetylmethadol), or buprenorphine. Acute withdraw al symptoms for a short-acting opioid such as heroin usually peak within 1-3 days and gradually subside over a period of 5-7 days. Less acute withdrawal symptoms can last for weeks to months. These more chronic symptoms include anxiety, dysphoria, anhedonia, and insomnia. Associated Features Supporting Diagnosis Males with opioid withdrawal may experience piloerection, sweating, and spontaneous ejaculations while awake. Opioid withdrawal is distinct from opioid use disorder and does not necessarily occur in the presence of the drug-seeking behavior associated with opioid use disorder. Opioid withdrawal may occur in any individual after cessation of re- peated use of an opioid, whether in the setting of medical management of pain, during opioid agonist therapy for opioid use disorder, in the context of private recreational use, or following attempts to self-treat symptoms of mental disorders with opioids. Prevalence Among individuals from various clinical settings, opioid withdrawal occurred in 60% of individuals who had used heroin at least once in the prior 12 months. Development and Course Opioid withdrawal is typical in the course of an opioid use disorder. It can be part of an es- calating pattern in which an opioid is used to reduce withdrawal symptoms, in turn lead- ing to more withdrawal at a later time. For persons with an established opioid use disorder, withdrawal and attempts to relieve withdrawal are typical. Differential Diagnosis Other withdrawal disorders. The anxiety and restlessness associated with opioid with- drawl resemble symptoms seen in sedative-hypnotic withdrawal. However, opioid with- drawl is also accompanied by rhinorrhea, lacrimation, and pupillary dilation, which are not seen in sedative-type withdrawal. Other substance intoxication. Dilated pupils are also seen in hallucinogen intoxication and stimulant intoxication. However, other signs or symptoms of opioid withdrawal, such as nausea, vomiting, diarrhea, abdominal cramps, rhinorrhea, and lacrimation, are not present. Other opioid-induced disorders. Opioid withdrawal is distinguished from the other opioid-induced disorders (e.g., opioid-induced depressive disorder, with onset during withdrawal) because the symptoms in these latter disorders are in excess of those usually associated with opioid withdrawal and meet full criteria for the relevant disorder.

obsessive-compulsive disorder (OCD) (DSM)

DIAGNOSTIC CRITERIA 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; stereotypes, 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). Specify if: With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true. With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. Specify if: Tic-related: The individual has a current or past history of a tic disorder. Specifiers Many individuals with obsessive-compulsive disorder (OCD) have dysfunctional beliefs, These belies can include an inflated sense of responsibility and the tendency to overest. mate threat perfectionism and intolerance of uncertainty; and over-importance of thoughts (eg, believing that having a forbidden thought is as bad as acting on it) and the need to control thoughts. Individuals with OCD vary in the degree of insight they have about the accuracy of the beliefs that underlie their obsessive-compulsive symptoms. Many individuals have good or fair insight (e.g., the individual believes that the house definitely will not, probably will not. or may or may not burn down if the stove is not checked 30 times). Some have poor insight (e.g, the individual believes that the house will probably burn down if the stove is not checked 30 times), and a few (4% or less) have absent insight /delusional beliefs (e.g., the in. dividual is convinced that the house will burn down if the stove is not checked 30 times). Insight can vary within an individual over the course of the illness. Poorer insight has been linked to worse long-term outcome. Up to 30% of individuals with OCD have a lifetime tic disorder. This is most common in males with onset of OCD in childhood. These individuals tend to differ from those with- out a history of tic disorders in the themes of their OCD symptoms, comorbidity, course, and pattern of familial transmission. Diagnostic Features The characteristic symptoms of OCD are the presence of obsessions and compulsions (Cri- terion A). Obsessions are repetitive and persistent thoughts (e.g., of contamination), images (e.g., of violent or horrific scenes), or urges (e.g., to stab someone). Importantly, obsessions are not pleasurable or experienced as voluntary: they are intrusive and unwanted and cause marked distress or anxiety in most individuals. The individual attempts to ignore or suppress these obsessions (e.g., avoiding triggers or using thought suppression) or to neu- tralize them with another thought or action (e.g., performing a compulsion). Compulsions (or rituals) are repetitive behaviors (e.g., washing, checking) or mental acts (e.g., 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. Most individuals with OCD have both obsessions and compulsions. Compulsions are typically performed in response to an obsession (e.g., thoughts of contamination leading to washing rituals or that some- thing is incorrect leading to repeating rituals until it feels "just right"). The aim is to reduce the distress triggered by obsessions or to prevent a feared event (e.g., becoming ill). How- ever, these compulsions either are not connected in a realistic way to the feared event (e.g., arranging items symmetrically to prevent harm to a loved one) or are clearly excessive (e.g., showering for hours each day). Compulsions are not done for pleasure, although some individuals experience relief from anxiety or distress. Criterion B emphasizes that obsessions and compulsions must be time-consuming (e.g., more than 1 hour per day) or cause clinically significant distress or impairment to warrant a diagnosis of OCD. This criterion helps to distinguish the disorder from the occasional in- trusive thoughts or repetitive behaviors that are common in the general population (e-g: double-checking that a door is locked). The frequency and severity of obsessions and com- pulsions vary across individuals with OCD (e.g., some have mild to moderate symptoms, spending 1-3 hours per day obsessing or doing compulsions, whereas others have nearly constant intrusive thoughts or compulsions that can be incapacitating). Associated Features Supporting Diagnosis The specific content of obsessions and compulsions varies between individuals. However, certain themes, or dimensions, are common, including those of cleaning (contamination obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeating, ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive, sexual, or religious obsessions and related compulsions); and harm (e.g., fears of harm to oneself or others and checking compulsions). Some individuals also have difficulties discarding and accumulate (hoard) objects as a consequence of typical obsessions and compulsions, such as fears of harming others. These themes occur across different cultures, are rela- tively consistent over time in adults with the disorder, and may be associated with differ- ent neural substrates. Importantly, individuals often have symptoms in more than one dimension. Individuals with OCD experience a range of affective responses when confronted with situations that trigger obsessions and compulsions. For example, many individuals expe- rience marked anxiety that can include recurrent panic attacks. Others report strong feel- ings of disgust. While performing compulsions, some individuals report a distressing sense of "incompleteness" or uneasiness until things look, feel, or sound "just right." It is common for individuals with the disorder to avoid people, places, and things that trigger obsessions and compulsions. For example, individuals with contamination con- cerns might avoid public situations (e.g., restaurants, public restrooms) to reduce ex- posure to feared contaminants; individuals with intrusive thoughts about causing harm might avoid social interactions. Prevalence The 12-month prevalence of OCD in the United States is 1.2%, with a similar prevalence in- ternationally (1.1%-1.8%). Females are affected at a slightly higher rate than males in adulthood, although males are more commonly affected in childhood. Development and Course In the United States, the mean age at onset of OCD is 19.5 years, and 25% of cases start by age 14 years. Onset after age 35 years is unusual but does occur. Males have an earlier age at onset than females: nearly 25% of males have onset before age 10 years. The onset of symptoms is typically gradual; however, acute onset has also been reported. If OCD is untreated, the course is usually chronic, often with waxing and waning symp- toms. Some individuals have an episodic course, and a minority have a deteriorating course. Without treatment, remission rates in adults are low (e.g., 20% for those reevalu- ated 40 years later). Onset in childhood or adolescence can lead to a lifetime of OCD. How- ever, 40% of individuals with onset of OCD in childhood or adolescence may experience remission by early adulthood. The course of OCD is often complicated by the co-occurrence of other disorders (see section "Comorbidity" for this disorder). Compulsions are more easily diagnosed in children than obsessions are because com- pulsions are observable. However, most children have both obsessions and compulsions (as do most adults). The pattern of symptoms in adults can be stable over time, but it is more variable in children. Some differences in the content of obsessions and compulsions have been reported when children and adolescent samples have been compared with adult samples. These differences likely reflect content appropriate to different develop- mental stages (e.g., higher rates of sexual and religious obsessions in adolescents than in children; higher rates of harm obsessions [e.g., fears of catastrophic events, such as death or illness to self or loved ones] in children and adolescents than in adults). Risk and Prognostic Factors Temperamental. Greater internalizing symptoms, higher negative emotionality, and behavioral inhibition in childhood are possible temperamental risk factors. Environmental. Physical and sexual abuse in childhood and other stressful or traumatic events have been associated with an increased risk for developing OCD. Some children may develop the sudden onset of obsessive-compulsive symptoms, which has been asso. cited with different environmental factors, including various infectious agents and a post-infectious autoimmune syndrome. Genetic and physiological. The rate of OCD among first-degree relatives of adults with OCD is approximately two times that among first-degree relatives of those without the disorder; however, among first-degree relatives of individuals with onset of OCD in child. hood or adolescence, the rate is increased 10-fold. Familial transmission is due in part to genetic factors (e.g, a concordance rate of 0.57 for monozygotic vs. 0.22 for dizygotic twins). Dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum have been most strongly implicated. Culture-Related Diagnostic Issues OCD occurs across the world. There is substantial similarity across cultures in the gender distribution, age at onset, and comorbidity of OCD. Moreover, around the globe, there is a similar symptom structure involving cleaning, symmetry, hoarding, taboo thoughts, or fear of harm. However, regional variation in symptom expression exists, and cultural factors may shape the content of obsessions and compulsions. Gender-Related Diagnostic Issues Males have an earlier age at onset of OCD than females and are more likely to have co- morbid tic disorders. Gender differences in the pattern of symptom dimensions have been reported, with, for example, females more likely to have symptoms in the cleaning dimen- sion and males more likely to have symptoms in the forbidden thoughts and symmetry di- mensions. Onset or exacerbation of OCD, as well as symptoms that can interfere with the mother-infant relationship (e.g., aggressive obsessions leading to avoidance of the infant), have been reported in the peripartum period. Suicide Risk Suicidal thoughts occur at some point in as many as about half of individuals with OCD. Suicide attempts are also reported in up to one-quarter of individuals with OCD; the pres- ence of comorbid major depressive disorder increases the risk. Functional Consequences of Obsessive-Compulsive Disorder OCD is associated with reduced quality of life as well as high levels of social and occupa- tional impairment. Impairment occurs across many different domains of life and is asso- ciated with symptom severity. Impairment can be caused by the time spent obsessing and doing compulsions. Avoidance of situations that can trigger obsessions or compulsions can also severely restrict functioning. In addition, specific symptoms can create specific obstacles. For example, obsessions about harm can make relationships with family and friends feel hazardous; the result can be avoidance of these relationships. Obsessions about symmetry can derail the timely completion of school or work projects because the project never feels "just right, ." potentially resulting in school failure or job loss. Health consequences can also occur. For example, individuals with contamination concerns may avoid doctors' offices and hospitals (e.g., because of fears of exposure to germs) or develop dermatological problems (e.g., skin lesions due to excessive washing). Sometimes the symptoms of the disorder interfere with its own treatment (e.g., when medications are con- sidered contaminated). When the disorder starts in childhood or adolescence, individuals may experience developmental difficulties. For example, adolescents may avoid socializ- ing with peers; young adults may struggle when they leave home to live independently. The result can be few significant relationships outside the family and a lack of autonomy and financial independence from their family of origin. In addition, some individuals with OCD try to impose rules and prohibitions on family members because of their disorder (e.g., no one in the family can have visitors to the house for fear of contamination), and this can lead to family dysfunction. Differential Diagnosis Anxiety disorders. Recurrent thoughts, avoidant behaviors, and repetitive requests for reassurance can also occur in anxiety disorders. However, the recurrent thoughts that are present in generalized anxiety disorder (i.e., worries) are usually about real-life concerns, whereas the obsessions of OCD usually do not involve real-life concerns and can include content that is odd, irrational, or of a seemingly magical nature; moreover, compulsions are often present and usually linked to the obsessions. Like individuals with OCD, indi- viduals with specific phobia can have a fear reaction to specific objects or situations; how- ever, in specific phobia the feared object is usually much more circumscribed, and rituals are not present. In social anxiety disorder (social phobia), the feared objects or situations are limited to social interactions, and avoidance or reassurance seeking is focused on re- ducing this social fear. Major depressive disorder. OCD can be distinguished from the rumination of major depressive disorder, in which thoughts are usually mood-congruent and not necessarily experienced as intrusive or distressing; moreover, ruminations are not linked to compul- sions, as is typical in OCD. Other obsessive-compulsive and related disorders. In body dysmorphic disorder, the obsessions and compulsions are limited to concerns about physical appearance; and in trichotillomania (hair-pulling disorder), the compulsive behavior is limited to hair pulling in the absence of obsessions. Hoarding disorder symptoms focus exclusively on the per- sistent difficulty discarding or parting with possessions, marked distress associated with discarding items, and excessive accumulation of objects. However, if an individual has ob- sessions that are typical of OCD (e.g., concerns about incompleteness or harm), and these obsessions lead to compulsive hoarding behaviors (e.g., acquiring all objects in a set to attain a sense of completeness or not discarding old newspapers because they may contain information that could prevent harm), a diagnosis of OCD should be given instead. Eating disorders. OCD can be distinguished from anorexia nervosa in that in OCD the obsessions and compulsions are not limited to concerns about weight and food. Tics (in tic disorder) and stereotyped movements. A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization (e.g., eye blinking, throat clearing). A ste- reotyped movement is a repetitive, seemingly driven, nonfunctional motor behavior (e.g., head banging, body rocking, self-biting). Tics and stereotyped movements are typically less complex than compulsions and are not aimed at neutralizing obsessions. However, distinguishing between complex tics and compulsions can be difficult. Whereas compul- sions are usually preceded by obsessions, tics are often preceded by premonitory sensory urges. Some individuals have symptoms of both OCD and a tic disorder, in which case both diagnoses may be warranted. Psychotic disorders. Some individuals with OCD have poor insight or even delusional OCD beliefs. However, they have obsessions and compulsions (distinguishing their condition from delusional disorder) and do not have other features of schizophrenia or schizoaffective disorder (e.g., hallucinations or formal thought disorder). Other compulsive-like behaviors. Certain behaviors are sometimes described as "com- pulsive," including sexual behavior (in the case of paraphilias), gambling (i.e, gambling disorder), and substance use (e.g., alcohol use disorder). However, these behaviors differ from the compulsions of OCD in that the person usually derives pleasure from the activity and may wish to resist it only because of its deleterious consequences. Obsessive-compulsive personality disorder. Although obsessive-compulsive person- ality disorder and OCD have similar names, the clinical manifestations of these disorders are quite different. Obsessive-compulsive personality disorder is not characterized by in- trusive thoughts, images, or urges or by repetitive behaviors that are performed in re- sponse to these intrusions; instead, it involves an enduring and pervasive maladaptive pattern of excessive perfectionism and rigid control. If an individual manifests symptoms of both OCD and obsessive-compulsive personality disorder, both diagnoses can be given. Comorbidity Individuals with OCD often have other psychopathology. Many adults with the disorder have a lifetime diagnosis of an anxiety disorder (76%; e.g., panic disorder, social anxiety disorder, generalized anxiety disorder, specific phobia) or a depressive or bipolar disorder (63% for any depressive or bipolar disorder, with the most common being major depres- sive disorder [41%]). Onset of OCD is usually later than for most comorbid anxiety disor- ders (with the exception of separation anxiety disorder) and PTSD but often precedes that of depressive disorders. Comorbid obsessive-compulsive personality disorder is also common in individuals with OCD (e.g., ranging from 23% to 32%). Up to 30% of individuals with OCD also have a lifetime tic disorder. A comorbid tic disorder is most common in males with onset of OCD in childhood. These individuals tend to differ from those without a history of tic disorders in the themes of their OCD symptoms, comorbidity, course, and pattern of familial transmission. A triad of OCD, tic disorder, and attention-deficit/hyperactivity disorder can also be seen in children. Disorders that occur more frequently in individuals with OCD than in those without the disorder include several obsessive-compulsive and related disorders such as body dysmorphic disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-pick- ing) disorder. Finally, an association between OCD and some disorders characterized by impulsivity, such as oppositional defiant disorder, has been reported. OCD is also much more common in individuals with certain other disorders than would be expected based on its prevalence in the general population; when one of those other disorders is diagnosed, the individual should be assessed for OCD as well. For ex- ample, in individuals with schizophrenia or schizoaffective disorder, the prevalence of OCD is approximately 12%. Rates of OCD are also elevated in bipolar disorder; eating dis- orders, such as anorexia nervosa and bulimia nervosa; and Tourette's disorder.

Brief psychotic disorder (DSM)

DIAGNOSTIC CRITERIA 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. Specity if: With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual's culture. Without marked stressor(s): If symptoms do not occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circum- stances in the individual's culture. With postpartum onset: If onset is during pregnancy or within 4 weeks postpartum. Specify if: With catatonia (refer to the criteria for catatonia associated with another mental dis- order, pp. 119-120, for definition) Coding note: Use additional code 293.89 (F06.1) catatonia associated with brief psychotic disorder to indicate the presence of the comorbid catatonia. Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor be- havior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter "Assessment Measures.") Note: Diagnosis of brief psychotic disorder can be made without using this severity specifier. Diagnostic Features The essential feature of brief psychotic disorder is a disturbance that involves the sudden onset of at least one of the following positive psychotic symptoms: delusions, hallucina- tions, disorganized speech (e.g., frequent derailment or incoherence), or grossly abnormal psychomotor behavior, including catatonia (Criterion A). Sudden onset is defined as change from a nonpsychotic state to a clearly psychotic state within 2 weeks, usually with- out a prodrome. An episode of the disturbance lasts at least 1 day but less than 1 month, and the individual eventually has a full return to the premorbid level of functioning (Criterion B). The disturbance is not better explained by a depressive or bipolar disorder with psychotic features, by schizoaffective disorder, or by schizophrenia and is not attributable to the physiological effects of a substance (e.g., a hallucinogen) or another medical condi- tion (e.g., subdural hematoma) (Criterion C). In addition to the five symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and mania symptom domains is vital for making crit- ically important distinctions between the various schizophrenia spectrum and other psy- chotic disorders. Associated Features Supporting Diagnosis Individuals with brief psychotic disorder typically experience emotional turmoil or over- whelming confusion. They may have rapid shifts from one intense affect to another. Although the disturbance is brief, the level of impairment may be severe, and supervision may be required to ensure that nutritional and hygienic needs are met and that the indi- vidual is protected from the consequences of poor judgment, cognitive impairment, or act- ing on the basis of delusions. There appears to be an increased risk of suicidal behavior, particularly during the acute episode. Prevalence In the United States, brief psychotic disorder may account for 9% of cases of first-onset psychosis. Psychotic disturbances that meet Criteria A and C, but not Criterion B, for brief psychotic disorder (i.e., duration of active symptoms is 1-6 months as opposed to remis- sion within 1 month) are more common in developing countries than in developed coun- tries. Brief psychotic disorder is twofold more common in females than in males. Development and Course Brief psychotic disorder may appear in adolescence or early adulthood, and onset can oc- cur across the lifespan, with the average age at onset being the mid 30s. By definition, a diagnosis of brief psychotic disorder requires a full remission of all symptoms and an eventual full return to the premorbid level of functioning within 1 month of the onset of the disturbance. In some individuals, the duration of psychotic symptoms may be quite brief (e.g., a few days). Risk and Prognostic Factors Temperamental. Preexisting personality disorders and traits (e.g., schizotypal person- ality disorder; borderline personality disorder; or traits in the psychoticism domain, such as perceptual dysregulation, and the negative affectivity domain, such as suspiciousness) may predispose the individual to the development of the disorder. Culture-Related Diagnostic Issues It is important to distinguish symptoms of brief psychotic disorder from culturally sanc- tioned response patterns. For example, in some religious ceremonies, an individual may report hearing voices, but these do not generally persist and are not perceived as abnormal by most members of the individual's community. In addition, cultural and religious back- ground must be taken into account when considering whether beliefs are delusional. Functional Consequences of Brief Psychotic Disorder Despite high rates of relapse, for most individuals, outcome is excellent in terms of social functioning and symptomatology.

Alcohol Intoxication (DSM)

DIAGNOSTIC CRITERIA A. Recent ingestion of alcohol. B. Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol ingestion. C. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use: 1. Slurred speech. 2. Incoordination. 3. Unsteady gait. 4. Nystagmus. 5. Impairment in attention or memory. 6. Stupor or coma. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Diagnostic Features The essential feature of alcohol intoxication is the presence of clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that develop during, or shortly after, alcohol ingestion (Criterion B). These changes are accompanied by evidence of impaired functioning and judgment and, if intoxication is intense, can result in a life-threaten- ing coma. The symptoms must not be attributable to another medical condition (e.g., diabetic ketoacidosis), are not a reflection of conditions such as delirium, and are not related to intoxi- cation with other depressant drugs (e.g., benzodiazepines) (Criterion D). The levels of incoor- dination can interfere with driving abilities and performance of usual activities to the point of causing accidents. Evidence of alcohol use can be obtained by smelling alcohol on the individ- ual's breath, eliciting a history from the individual or another observer, and, when needed, having the individual provide breath, blood, or urine samples for toxicology analyses. Associated Features Supporting Diagnosis Alcohol intoxication is sometimes associated with amnesia for the events that occurred during the course of the intoxication ("blackouts"). This phenomenon may be related to the presence of a high blood alcohol level and, perhaps, to the rapidity with which this level is reached. During even mild alcohol intoxication, different symptoms are likely to be observed at different time points. Evidence of mild intoxication with alcohol can be seen in most individuals after approximately two drinks (each standard drink is approximately 10-12 grams of ethanol and raises the blood alcohol concentration approximately 20 mg/ dL). Early in the drinking period, when blood alcohol levels are rising, symptoms often include talkativeness, a sensation of well-being, and a bright, expansive mood. Later, es- pecially when blood alcohol levels are falling, the individual is likely to become progres- sively more depressed, withdrawn, and cognitively impaired. At very high blood alcohol levels (e.g., 200-300 mg/dL), an individual who has not developed tolerance for alcohol is likely to fall asleep and enter a first stage of anesthesia. Higher blood alcohol levels (e.g., in excess of 300-400 mg/ dL) can cause inhibition of respiration and pulse and even death in nontolerant individuals. The duration of intoxication depends on how much alcohol was consumed over what period of time. In general, the body is able to metabolize approxi- mately one drink per hour, so that the blood alcohol level generally decreases at a rate of 15-20 mg/dL per hour. Signs and symptoms of intoxication are likely to be more intense when the blood alcohol level is rising than when it is falling. Alcohol intoxication is an important contributor to suicidal behavior. There appears to be an increased rate of suicidal behavior, as well as of completed suicide, among persons intoxicated by alcohol. Prevalence The large majority of alcohol consumers are likely to have been intoxicated to some degree at some point in their lives. For example, in 2010, 44% of 12th-grade students admitted to having been "drunk in the past year," with more than 70% of college students reporting the same. Development and Course Intoxication usually occurs as an episode usually developing over minutes to hours and typi- cally lasting several hours. In the United States, the average age at first intoxication is approx- imately 15 years, with the highest prevalence at approximately 18-25 years. Frequency and intensity usually decrease with further advancing age. The earlier the onset of regular intoxi- cation, the greater the likelihood the individual will go on to develop alcohol use disorder. Risk and Prognostic Factors Temperamental. Episodes of alcohol intoxication increase with personality characteris- tics of sensation seeking and impulsivity. Environmental. Episodes of alcohol intoxication increase with a heavy drinking envi- ronment. Culture-Related Diagnostic Issues The major issues parallel the cultural differences regarding the use of alcohol overall. Thus, college fraternities and sororities may encourage alcohol intoxication. This condi- tion is also frequent on certain dates of cultural significance (e.g., New Year's Eve) and, for some subgroups, during specific events (e.g., wakes following funerals). Other subgroups encourage drinking at religious celebrations (e.g., Jewish and Catholic holidays), while still others strongly discourage all drinking or intoxication (e.g., some religious groups, such as Mormons, fundamentalist Christians, and Muslims). Gender-Related Diagnostic Issues Historically, in many Western societies, acceptance of drinking and drunkenness is more tolerated for males, but such gender differences may be much less prominent in recent years, especially during adolescence and young adulthood. Diagnostic Markers Intoxication is usually established by observing an individual's behavior and smelling alcohol on the breath. The degree of intoxication increases with an individual's blood or breath alcohol level and with the ingestion of other substances, especially those with sedating effects. Functional Consequences of Alcohol Intoxication Alcohol intoxication contributes to the more than 30,000 alcohol-related drinking deaths in the United States each year. In addition, intoxication with this drug contributes to huge costs associated with drunk driving, lost time from school or work, as well as interpersonal arguments and physical fights. Differential Diagnosis Other medical conditions. Several medical (e.g., diabetic acidosis) and neurological condi- tions (e.g., cerebellar ataxia, multiple sclerosis) can temporarily resemble alcohol intoxication. Sedative, hypnotic, or anxiolytic intoxication. Intoxication with sedative, hypnotic, or anxiolytic drugs or with other sedating substances (e.g., antihistamines, anticholinergic drugs) can be mistaken for alcohol intoxication. The differential requires observing alco- hol on the breath, measuring blood or breath alcohol levels, ordering a medical workup, and gathering a good history. The signs and symptoms of sedative-hypnotic intoxication are very similar to those observed with alcohol and include similar problematic behavioral or psychological changes. These changes are accompanied by evidence of impaired func- toning and judgment--which, if intense, can result in a life-threatening coma--and levels of incoordination that can interfere with driving abilities and with performing usual activities. However, there is no smell as there is with alcohol, but there is likely to be evi- dence of misuse of the depressant drug in the blood or urine toxicology analyses. Comorbidity Alcohol intoxication may occur comorbidly with other substance intoxication, especially in individuals with conduct disorder or antisocial personality disorder.

Inhalant intoxication (DSM)

DIAGNOSTIC CRITERIA A. Recent intended or unintended short-term, high-dose exposure to inhalant substances, including volatile hydrocarbons such as toluene or gasoline. B. Clinically significant problematic behavioral or psychological changes (e.g., belligerence, assaultiveness, apathy, impaired judgment) that developed during, or shortly after, exposure to inhalants. C. Two (or more) of the following signs or symptoms developing during, or shortly after, inhalant use or exposure: 1. Dizziness. 2. Nystagmus. 3. Incoordination. 4. Slurred speech. 5. Unsteady gait. 6. Lethargy. 7. Depressed reflexes. 8. Psychomotor retardation. 9. Tremor. 10. Generalized muscle weakness. 11. Blurred vision or diplopia. 12. Stupor or coma. 13. Euphoria. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Diagnostic Features Inhalant intoxication is an inhalant-related, clinically significant mental disorder that de- velops during, or immediately after, intended or unintended inhalation ot a volatile hy- drocarbon substance. Volatile hydrocarbons are toxic gases from glues, fuels, paints, and other volatile compounds. When it is possible to do so, the particular substance involved should be named (e.g., toluene intoxication). Among those who do, the intoxication clears within a few minutes to a few hours after the exposure ends. Thus, inhalant intoxication usually occurs in brief episodes that may recur. Associated Features Supporting Diagnosis Inhalant intoxication may be indicated by evidence of possession, or lingering odors, of in- halant substances (e.g., glue, paint thinner, gasoline, butane lighters); apparent intoxica- tion occurring in the age range with the highest prevalence of inhalant use (12-17 years); and apparent intoxication with negative results from the standard drug screens that usu- ally fail to identify inhalants. Prevalence The prevalence of actual episodes of inhalant intoxication in the general population is un- known, but it is probable that most inhalant users would at some time exhibit use that would meet criteria for inhalant intoxication disorder. Therefore, the prevalence of inhal- ant use and the prevalence of inhalant intoxication disorder are likely similar. In 2009 and 2010, inhalant use in the past year was reported by 0.8% of all Americans older than 12 years; the prevalence was highest in younger age groups (3.6% for individuals 12 to 17 years old, and 1.7% for individuals 18 to 25 years old). Gender-Related Diagnostic Issues Gender differences in the prevalence of inhalant intoxication in the general population are unknown. However, if it is assumed that most inhalant users eventually experience inhal- ant intoxication, gender differences in the prevalence of inhalant users likely approximate those in the proportions of males and females experiencing inhalant intoxication. Regard- ing gender differences in the prevalence of inhalant users in the United States, 1% of males older than 12 years and 0.7% of females older than 12 years have used inhalants in the pre- vious year, but in the younger age groups more females than males have used inhalants (e.g., among 12- to 17-year-olds, 3.6% of males and 4.2% of females). Functional Consequences of Inhalant Intoxication Use of inhaled substances in a closed container, such as a plastic bag over the head, may lead to unconsciousness, anoxia, and death. Separately, ' "sudden sniffing death," likely from cardiac arrhythmia or arrest, may occur with various volatile inhalants. The en- hanced toxicity of certain volatile inhalants, such as butane or propane, also causes fatal- ities. Although inhalant intoxication itself is of short duration, it may produce persisting medical and neurological problems, especially if the intoxications are frequent. Differential Diagnosis Inhalant exposure, without meeting the criteria for inhalant intoxication disorder. The individual intentionally or unintentionally inhaled substances, but the dose was in- sufficient for the diagnostic criteria for inhalant use disorder to be met. Intoxication and other substance/medication-induced disorders from other sub- stances, especially from sedating substances (e.g., alcohol, benzodiazepines, barbi- turates). These disorders may have similar signs and symptoms, but the intoxication is attributable to other intoxicants that may be identified via a toxicology screen. Differenti- ating the source of the intoxication may involve discerning evidence of inhalant exposure as described for inhalant use disorder. A diagnosis of inhalant intoxication may be sug- gested by possession, or lingering odors, of inhalant substances (e.g., glue, paint thinner, gasoline, butane lighters,); paraphernalia possession (e.g., rags or bags for concentrating glue fumes); perioral or perinasal "glue-sniffer's rash"; reports from family or friends that the intoxicated individual possesses or uses inhalants; apparent intoxication despite neg- ative results on standard drug screens (which usually fail to identify inhalants); apparent intoxication occurring in that age range with the highest prevalence of inhalant use (12-17 years); association with others known to use inhalants; membership in certain small com- munities with prevalent inhalant use (e.g., some native or aboriginal communities, home- less street children and adolescents); or unusual access to certain inhalant substances. Other inhalant-related disorders. Episodes of inhalant intoxication do occur during, but are not identical with, other inhalant-related disorders. Those inhalant-related disorders are recognized by their respective diagnostic criteria: inhalant use disorder, inhalant- induced neurocognitive disorder, inhalant-induced psychotic disorder, inhalant-induced depressive disorder, inhalant-induced anxiety disorder, and other inhalant-induced dis- orders. Other toxic, metabolic, traumatic, neoplastic, or infectious disorders that impair brain function and cognition. Numerous neurological and other medical conditions may pro- duce the clinically significant behavioral or psychological changes (e.g., belligerence, as- saultiveness, apathy, impaired judgment) that also characterize inhalant intoxication.

Other Hallucinogen Intoxication (DSM)

DIAGNOSTIC CRITERIA A. Recent use of a hallucinogen (other than phencyclidine). B. Clinically significant problematic behavioral or psychological changes (e.g., marked anxiety or depression, ideas of reference, fear of "losing one's mind," paranoid ideation, impaired judgment) that developed during, or shortly after, hallucinogen use. C. Perceptual changes occurring in a state of full wakefulness and alertness (e.g., subjective intensification of perceptions, depersonalization, derealization, illusions, hallucinations, synesthesias) that developed during, or shortly after, hallucinogen use. D. Two (or more) of the following signs developing during, or shortly after, hallucinogen use: 1. Pupillary dilation. 2. Tachycardia. 3. Sweating. 4. Palpitations. 5. Blurring of vision. 6. Tremors. 7. Incoordination. E. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Diagnostic Features Other hallucinogen intoxication reflects the clinically significant behavioral or psycholog- ical changes that occur shortly after ingestion of a hallucinogen. Depending on the specific hallucinogen, the intoxication may last only minutes (e.g., for salvia) or several hours or longer (e.g., for LSD [lysergic acid diethylamide] or MDMA [3,4-methylenedioxymetham- phetamine]). Prevalence The prevalence of other hallucinogen intoxication may be estimated by use of those sub- stances. In the United States, 1.8% of individuals age 12 years or older report using hallu- cinogens in the past year. Use is more prevalent among younger individuals, with 3.1% of 12- to 17-year-olds and 7.1% of 18- to 25-year-olds using hallucinogens in the past year, compared with only 0.7% of individuals age 26 years or older. Twelve-month prevalence for hallucinogen use is more common in males (2.4%) than in females (1.2%), and even more so among 18- to 25-year-olds (9.2% for males vs. 5.0% for females). In contrast, among individuals ages 12-17 years, there are no gender differences (3.1% for both gen- ders). These figures may be used as proxy estimates for gender-related differences in the prevalence of other hallucinogen intoxication. Suicide Risk Other hallucinogen intoxication may lead to increased suicidality, although suicide is rare among users of hallucinogens. Functional Consequences of Other Hallucinogen Intoxication Other hallucinogen intoxication can have serious consequences. The perceptual distur- bances and impaired judgment associated with other hallucinogen intoxication can result in injuries or fatalities from automobile crashes, physical fights, or unintentional self- injury (e.g., attempts to "fly" from high places). Environmental factors and the personality and expectations of the individual using the hallucinogen may contribute to the nature of and severity of hallucinogen intoxication. Continued use of hallucinogens, particularly MDMA, has also been linked with neurotoxic effects. Differential Diagnosis Other substance intoxication. Other hallucinogen intoxication should be differentiated from intoxication with amphetamines, cocaine, or other stimulants; anticholinergics; in- halants; and phencyclidine. Toxicological tests are useful in making this distinction, and determining the route of administration may also be useful. Other conditions. Other disorders and conditions to be considered include schizophre- nia, depression, withdrawal from other drugs (e.g., sedatives, alcohol), certain metabolic disorders (e.g., hypoglycemia), seizure disorders, tumors of the central nervous system, and vascular insults. Hallucinogen persisting perception disorder. Other hallucinogen intoxication is dis- tinguished from hallucinogen persisting perception disorder because the symptoms in the latter continue episodically or continuously for weeks (or longer) after the most recent in- toxication. Other hallucinogen-induced disorders. Other hallucinogen intoxication is distinguished from the other hallucinogen-induced disorders (e.g., hallucinogen-induced anxiety disor- der, with onset during intoxication) because the symptoms in these latter disorders pre- dominate the clinical presentation and are severe enough to warrant independent clinical attention.

Sedative, hypnotic, anxiolytic intoxication (DSM)

DIAGNOSTIC CRITERIA A. Recent use of a sedative, hypnotic, or anxiolytic. B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, sedative, hypnotic, or anxiolytic use. C. One (or more) of the following signs or symptoms developing during, or shortly after, sedative, hypnotic, or anxiolytic use: 1. Slurred speech. 2. Incoordination. 3. Unsteady gait. 4. Nystagmus. 5. Impairment in cognition (e.g., attention, memory). 6. Stupor or coma. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Diagnostic Features The essential feature of sedative, hypnotic, or anxiolytic intoxication is the presence of clini- cally significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that develop during, or shortly after, use of a sedative, hypnotic, or anxiolytic (Criteria A and B). As with other brain depressants, such as alcohol, these behaviors may be ac- companied by slurred speech, incoordination (at levels that can interfere with driving abilities and with performing usual activities to the point of causing falls or automobile accidents), an unsteady gait, nystagmus, impairment in cognition (e.g., attentional or memory problems), and stupor or coma (Criterion C). Memory impairment is a prominent feature of sedative, hyp- notic, or anxiolytic intoxication and is most often characterized by an anterograde amnesia that resembles "alcoholic blackouts, " which can be disturbing to the individual. The symptoms must not be attributable to another medical condition and are not better explained by another mental disorder (Criterion D). Intoxication may occur in individuals who are receiving these liberately taking the substance to achieve intoxication. substances by prescription, are borrowing the medication from friends or relatives, or are de- Associated Features Supporting Diagnosis Associated features include taking more medication than prescribed, taking multiple dif- ferent medications, or mixing sedative, hypnotic, or anxiolytic agents with alcohol, which can markedly increase the effects of these agents. Prevalence The prevalence of sedative, hypnotic, or anxiolytic intoxication in the general population is unclear. However, it is probable that most nonmedical users of sedatives, hypnotics, or anxiolytics would at some time have signs or symptoms that meet criteria for sedative, hypnotic, or anxiolytic intoxication; if so, then the prevalence of nonmedical sedative, hypnotic, or anxiolytic use in the general population may be similar to the prevalence of sedative, hypnotic, or anxiolytic intoxication. For example, tranquilizers are used non- medically by 2.2% of Americans older than 12 years. Differential Diagnosis Alcohol use disorders. Since the clinical presentations may be identical, distinguishing sed- ative, hypnotic, or anxiolytic intoxication from alcohol use disorders requires evidence for re- cent ingestion of sedative, hypnotic, or anxiolytic medications by self-report, informant report, or toxicological testing. Many individuals who misuse sedatives, hypnotics, or anxiolytics may also misuse alcohol and other substances, and so multiple intoxication diagnoses are possible. Alcohol intoxication. Alcohol intoxication may be distinguished from sedative, hypnotic, or anxiolytic intoxication by the smell of alcohol on the breath. Otherwise, the features of the two disorders may be similar. Other sedative-, hypnotic-, or anxiolytic-induced disorders. Sedative, hypnotic, or anx- iolytic intoxication is distinguished from the other sedative-, hypnotic-, or anxiolytic- induced disorders (e.g., sedative-, hypnotic-, or anxiolytic-induced anxiety disorder, with onset during withdrawal) because the symptoms in the latter disorders predominate in the clinical presentation and are severe enough to warrant clinical attention. Neurocognitive disorders. In situations of cognitive impairment, traumatic brain in- jury, and delirium from other causes, sedatives, hypnotics, or anxiolytics may be intoxi- cating at quite low dosages. The differential diagnosis in these complex settings is based on the predominant syndrome. An additional diagnosis of sedative, hypnotic, or anxio- lytic intoxication may be appropriate even if the substance has been ingested at a low dos- age in the setting of these other (or similar) co-occurring conditions.

Stimulant Intoxication (DSM)

DIAGNOSTIC CRITERIA A. Recent use of an amphetamine-type substance, cocaine, or other stimulant. B. Clinically significant problematic behavioral or psychological changes (e.g., euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment) that developed during, or shortly after, use of a stimulant. C. Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use: 1. Tachycardia or bradycardia. 2. Pupillary dilation. 3. Elevated or lowered blood pressure. 4. Perspiration or chills. 5. Nausea or vomiting. 6. Evidence of weight loss. 7. Psychomotor agitation or retardation. 8. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias. 9. Confusion, seizures, dyskinesias, dystonias, or coma. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Diagnostic Features The essential feature of stimulant intoxication, related to amphetamine-type stimulants and cocaine, is the presence of clinically significant behavioral or psychological changes that develop during, or shortly after, use of stimulants (Criteria A and B). Auditory hallu- cinations may be prominent, as may paranoid ideation, and these symptoms must be dis- tinguished from an independent psychotic disorder such as schizophrenia. Stimulant intoxication usually begins with a "high" feeling and includes one or more of the follow- ing: euphoria with enhanced vigor, gregariousness, hyperactivity, restlessness, hypervig- ilance, interpersonal sensitivity, talkativeness, anxiety, tension, alertness, grandiosity, stereotyped and repetitive behavior, anger, impaired judgment, and, in the case of chronic intoxication, affective blunting with fatigue or sadness and social withdrawal. These be- havioral and psychological changes are accompanied by two or more of the following signs and symptoms that develop during or shortly after stimulant use: tachycardia or bra- dycardia; pupillary dilation; elevated or lowered blood pressure; perspiration or chills; nausea or vomiting; evidence of weight loss; psychomotor agitation or retardation; mus- cular weakness, respiratory depression, chest pain, or cardiac arrhythmias; and confu- sion, seizures, dyskinesias, dystonias, or coma (Criterion C). Intoxication, either acute or chronic, is often associated with impaired social or occupational functioning. Severe in- toxication can lead to convulsions, cardiac arrhythmias, hyperpyrexia, and death. For the diagnosis of stimulant intoxication to be made, the symptoms must not be attributable to another medical condition and not better explained by another mental disorder (Crite- rion D). While stimulant intoxication occurs in individuals with stimulant use disorders, in- toxication is not a criterion for stimulant use disorder, which is confirmed by the presence of two of the 11 diagnostic criteria for use disorder. Associated Features Supporting Diagnosis The magnitude and direction of the behavioral and physiological changes depend on many variables, including the dose used and the characteristics of the individual using the sub- stance or the context (e.g., tolerance, rate of absorption, chronicity of use, context in which it is taken). Stimulant effects such as euphoria, increased pulse and blood pressure, and psychomotor activity are most commonly seen. Depressant effects such as sadness, brady- cardia, decreased blood pressure, and decreased psychomotor activity are less common and generally emerge only with chronic high-dose use. Differential Diagnosis Stimulant-induced disorders. Stimulant intoxication is distinguished from the other stimulant-induced disorders (e.g., stimulant-induced depressive disorder, bipolar disor- der, psychotic disorder, anxiety disorder) because the severity of the intoxication symp- toms exceeds that associated with the stimulant-induced disorders, and the symptoms warrant independent clinical attention. Stimulant intoxication delirium would be distin- guished by a disturbance in level of awareness and change in cognition. Other mental disorders. Salient mental disturbances associated with stimulant intoxi- cation should be distinguished from the symptoms of schizophrenia, paranoid type; bi- polar and depressive disorders; generalized anxiety disorder; and panic disorder as described in DSM-5.

Opioid Intoxication (DSM)

DIAGNOSTIC CRITERIA A. Recent use of an opioid. B. Clinically significant problematic behavioral or psychological changes (e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment) that developed during, or shortly after, opioid use. C. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs or symptoms developing during, or shortly after, opioid use: 1. Drowsiness or coma. 2. Slurred speech. 3. Impairment in attention or memory. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Specify if: With perceptual disturbances: This specifier may be noted in the rare instance in which hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Diagnostic Features The essential feature of opioid intoxication is the presence of clinically significant prob- lematic behavioral or psychological changes (e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment) that develop dur- ing, or shortly after, opioid use (Criteria A and B). Intoxication is accompanied by pupil- lary constriction (unless there has been a severe overdose with consequent anoxia and pupillary dilation) and one or more of the following signs: drowsiness (described as be- ing "on the nod"), slurred speech, and impairment in attention or memory (Criterion C); drowsiness may progress to coma. Individuals with opioid intoxication may demonstrate inattention to the environment, even to the point of ignoring potentially harmful events. The signs or symptoms must not be attributable to another medical condition and are not better explained by another mental disorder (Criterion D). Differential Diagnosis Other substance intoxication. Alcohol intoxication and sedative-hypnotic intoxication can cause a clinical picture that resembles opioid intoxication. A diagnosis of alcohol or sedative-hypnotic intoxication can usually be made based on the absence of pupillary con- striction or the lack of a response to a naloxone challenge. In some cases, intoxication may be due both to opioids and to alcohol or other sedatives. In these cases, the naloxone chal- lenge will not reverse all of the sedative effects. Other opioid-related disorders. Opioid intoxication is distinguished from the other opioid-induced disorders (e.g., opioid-induced depressive disorder, with onset during in- toxication) because the symptoms in the latter disorders predominate in the clinical pre- sentation and meet full criteria for the relevant disorder.

binge eating disorder (DSM)

DIAGNOSTIC CRITERIA 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. Specify if: In partial remission: After full criteria for binge-eating disorder were previously met, binge eating occurs at an average frequency of less than one episode per week for a sustained period of time. In full remission: After full criteria for binge-eating disorder were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based on the frequency of episodes of binge eating (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. Mild: 1-3 binge-eating episodes per week. Moderate: 4-7 binge-eating episodes per week. Severe: 8-13 binge-eating episodes per week. Extreme: 14 or more binge-eating episodes per week. COMORBIDITY Binge-eating disorder is associated with significant psychiatric comorbidity that is comparable to that of bulimia nervosa and anorexia nervosa. The most common comorbid disorders are bipolar disorders, depressive disorders, anxiety disorders, and, to a lesser degree, substance use disorders. The psychiatric comorbidity is linked to the severity of binge eating and not to the degree of obesity.

schizophreniform disorder (DSM)

DIAGNOSTIC CRITERIA 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. Specify if: With good prognostic features: This specifier requires the presence of at least two of the following features: onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity; good premorbid social and occupational functioning; and absence of blunted or flat affect. Without good prognostic features: This specifier is applied if two or more of the above features have not been present. Specify if: With catatonia (refer to the criteria for catatonia associated with another mental disor- der, pp. 119-120, for definition). Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizo- phreniform disorder to indicate the presence of the comorbid catatonia. Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor be- havior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter "Assessment Measures.") Note: Diagnosis of schizophreniform disorder can be made without using this severity specifier. Note: For additional information on Associated Features Supporting Diagnosis, Develop- ment and Course (age-related factors), Culture-Related Diagnostic Issues, Gender-Related Diagnostic Issues, Differential Diagnosis, and Comorbidity, see the corresponding sec- tions in schizophrenia. Diagnostic Features The characteristic symptoms of schizophreniform disorder are identical to those of schizo- phrenia (Criterion A). Schizophreniform disorder is distinguished by its difference in du- ration: the total duration of the illness, including prodromal, active, and residual phases, is at least 1 month but less than 6 months (Criterion B). The duration requirement for schizo- phreniform disorder is intermediate between that for brief psychotic disorder, which lasts more than 1 day and remits by 1 month, and schizophrenia, which lasts for at least 6 months. The diagnosis of schizophreniform disorder is made under two conditions. 1) when an ep- isode of illness lasts between 1 and 6 months and the individual has already recovered, and 2) when an individual is symptomatic for less than the 6 months' duration required for the diagnosis of schizophrenia but has not yet recovered. In this case, the diagnosis should be noted as "schizophreniform disorder (provisional)" because it is uncertain if the indi- vidual will recover from the disturbance within the 6-month period. If the disturbance per- sists beyond 6 months, the diagnosis should be changed to schizophrenia. Another distinguishing feature of schizophreniform disorder is the lack of a criterion requiring impaired social and occupational functioning. While such impairments may potentially be present, they are not necessary for a diagnosis of schizophreniform disorder. In addition to the five symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and mania symptom domains is vital for making crit- ically important distinctions between the various schizophrenia spectrum and other psy. chotic disorders. Associated Features Supporting Diagnosis As with schizophrenia, currently there are no laboratory or psychometric tests for schizo- phreniform disorder. There are multiple brain regions where neuroimaging, neuropa- thological, and neurophysiological research has indicated abnormalities, but none are diagnostic. Prevalence Incidence of schizophreniform disorder across sociocultural settings is likely similar to that observed in schizophrenia. In the United States and other developed countries, the in- cidence is low, possibly fivefold less than that of schizophrenia. In developing countries, the incidence may be higher, especially for the specifier "with good prognostic features"; in some of these settings schizophreniform disorder may be as common as schizophrenia. Development and Course The development of schizophreniform disorder is similar to that of schizophrenia. About one-third of individuals with an initial diagnosis of schizophreniform disorder (provi- sional) recover within the 6-month period and schizophreniform disorder is their final diagnosis. The majority of the remaining two-thirds of indiyiduals will eventually receive a diagnosis of schizophrenia or schizoaffective disorder. Risk and Prognostic Factors Genetic and physiological. Relatives of individuals with schizophreniform disorder have an increased risk for schizophrenia. Functional Consequences of Schizophreniform Disorder For the majority of individuals with schizophreniform disorder who eventually receive a diagnosis of schizophrenia or schizoaffective disorder, the functional consequences are similar to the consequences of those disorders. Most individuals experience dysfunction in several areas of daily functioning, such as school or work, interpersonal relationships, and self-care. Individuals who recover from schizophreniform disorder have better functional outcomes. Differential Diagnosis Other mental disorders and medical conditions. A wide variety of mental and medical conditions can manifest with psychotic symptoms that must be considered in the differ- ential diagnosis of schizophreniform disorder. These include psychotic disorder due to another medical condition or its treatment; delirium or major neurocognitive disorder; substance / medication-induced psychotic disorder or delirium; depressive or bipolar disorder with psychotic features; schizoaffective disorder; other specified or unspecified bi- polar and related disorder; depressive or bipolar disorder with catatonic features; schizophrenia nia; brief psychotic disorder; delusional disorder; other specified or unspecified schizophrenia spectrum and other psychotic disorder; schizotypal, schizoid, or paranoid personality disorders; autism spectrum disorder; disorders presenting in childhood with disorganized speech; attention-deficit/hyperactivity disorder; obsessive-compulsive dis- order; posttraumatic stress disorder; and traumatic brain injury. Since the diagnostic criteria for schizophreniform disorder and schizophrenia differ primarily in duration of illness, the discussion of the differential diagnosis of schizophre- nia also applies to schizophreniform disorder. Brief psychotic disorder. Schizophreniform disorder differs in duration from brief psy. chotic disorder, which has a duration of less than 1 month.

Facticious Disorder (DSM)

DIAGNOSTIC CRITERIA 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. Specify: Single episode Recurrent episodes (two or more events of falsification of illness and/or induction of injury) Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy) A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception. B. The individual presents another individual (victim) 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. Note: The perpetrator, not the victim, receives this diagnosis. Specify: Single episode Recurrent episodes (two or more events of falsification of illness and/or induction of injury) Recording Procedures When an individual falsifies illness in another (e.g., children, adults, pets), the diagnosis is factitious disorder imposed on another. The perpetrator, not the victim, is given the diag- nosis. The victim may be given an abuse diagnosis (e.g., 995.54 [T74.12X]; see the chapter "Other Conditions That May Be a Focus of Clinical Attention'). Diagnostic Features The essential feature of factitious disorder is the falsification of medical or psychological signs and symptoms in oneself or others that are associated with the identified deception. Individuals with factitious disorder can also seek treatment for themselves or another following induction of injury or disease. The diagnosis requires demonstrating that the individual is taking surreptitious actions to misrepresent, simulate, or cause signs or symptoms of ill- ness or injury in the absence of obvious external rewards. Methods of illness falsification can include exaggeration, fabrication, simulation, and induction. While a preexisting medical condition may be present, the deceptive behavior or induction of injury associated with deception causes others to view such individuals (or another) as more ill or impaired, and this can lead to excessive clinical intervention. Individuals with factitious disorder might, for example, report feelings of depression and suicidality following the death of a spouse despite the death not being true or the individual's not having a spouse; decep- tively report episodes of neurological symptoms (e.g., seizures, dizziness, or blacking out); manipulate a laboratory test (e.g., by adding blood to urine) to falsely indicate an abnormality; falsify medical records to indicate an illness; ingest a substance (e.g., insulin or warfarin) to induce an abnormal laboratory result or illness; or physically injure them- selves or induce illness in themselves or another (e.g., by injecting fecal material to produce an abscess or to induce sepsis). Associated Features Supporting Diagnosis Individuals with factitious disorder imposed on self or factitious disorder imposed on an- Other are at risk for experiencing great psychological distress or functional impairment by causing harm to themselves and others. Family, friends, and health care professionals are also often adversely affected by their behavior. Factitious disorders have similarities to substance use disorders, eating disorders, impulse-control disorders, pedophilic disorder, and some other established disorders related to both the persistence of the behavior and the intentional efforts to conceal the disordered behavior through deception. Whereas some aspects of factitious disorders might represent criminal behavior (e.g., factitious disorder imposed on another, in which the parent's actions represent abuse and maltreat- ment of a child), such criminal behavior and mental illness are not mutually exclusive. The diagnosis of factitious disorder emphasizes the objective identification of falsification of signs and symptoms of illness, rather than an inference about intent or possible underly- ing motivation. Moreover, such behaviors, including the induction of injury or disease, are associated with deception. Prevalence The prevalence of factitious disorder is unknown, likely because of the role of deception in this population. Among patients in hospital settings, it is estimated that about 1% of individuals have presentations that meet the criteria for factitious disorder. Development and Course The course of factitious disorder is usually one of intermittent episodes. Single episodes and episodes that are characterized as persistent and unremitting are both less common. Onset is usually in early adulthood, often after hospitalization for a medical condition or a mental disorder. When imposed on another, the disorder may begin after hospitalization of the individual's child or other dependent. In individuals with recurrent episodes of fal- sification of signs and symptoms of illness and / or induction of injury, this pattern of suc- cessive deceptive contact with medical personnel, including hospitalizations, may become lifelong. Differential Diagnosis Caregivers who lie about abuse injuries in dependents solely to protect themselves from liability are not diagnosed with factitious disorder imposed on another because protection from liability is an external reward (Criterion C, the deceptive behavior is evident even in the absence of obvious external rewards). Such caregivers who, upon observation, analysis of medical records, and/ or interviews with others, are found to lie more extensively than needed for immediate self-protection are diagnosed with factitious disorder imposed on another. Somatic symptom disorder. In somatic symptom disorder, there may be excessive at- tention and treatment seeking for perceived medical concerns, but there is no evidence that the individual is providing false information or behaving deceptively. Malingering. Malingering is differentiated from factitious disorder by the intentional re- porting of symptoms for personal gain (e.g., money, time off work). In contrast, the diag- nosis of factitious disorder requires the absence of obvious rewards. Conversion disorder (functional neurological symptom disorder). Conversion disorder is characterized by neurological symptoms that are inconsistent with neurological pathophysiology. Factitious disorder with neurological symptoms is distinguished from con- version disorder by evidence of deceptive falsification of symptoms. Borderline personality disorder. Deliberate physical self-harm in the absence of suicidal intent can also occur in association with other mental disorders such as borderline person- ality disorder. Factitious disorder requires that the induction of injury occur in association with deception. Medical condition or mental disorder not associated with intentional symptom falsification. Presentation of signs and symptoms of illness that do not conform to an identi- fable medical condition or mental disorder increases the likelihood of the presence of a factitious disorder. However, the diagnosis of factitious disorder does not exclude the presence of true medical condition or mental disorder, as comorbid illness often occurs in the individual along with factitious disorder. For example, individuals who might manip ulate blood sugar levels to produce symptoms may also have diabetes.

Bipolar I disorder (DSM)

Diagnostic Criteria For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospi talization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a sig- nificant degree and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis. Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder. Hypomanic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, rep- resent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupa- tional functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly in- creased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bi- polar diathesis. Note: Criteria A-F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Major Depressive Episode 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 subjec- tive 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 delu- sional) 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 with- out 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, occupa- tional, 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 AC 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 Cri- terion A, which may resemble a depressive episode. Although such symptoms may be un- derstandable 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. Bipolar I Disorder A. Criteria have been met for at least one manic episode (Criteria A-D under "Manic Episode" above). B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. Diagnostic Features The essential feature of a manic episode is a distinct period during which there is an ab- normally, persistently elevated, expansive, or irritable mood and persistently increased activity or energy that is present for most of the day, nearly every day, for a period of at least 1 week (or any duration if hospitalization is necessary), accompanied by at least three additional symptoms from Criterion B. If the mood is irritable rather than elevated or ex- pansive, at least four Criterion B symptoms must be present. Mood in a manic episode is often described as euphoric, excessively cheerful, high, or "feeling on top of the world." In some cases, the mood is of such a highly infectious quality that it is easily recognized as excessive and may be characterized by unlimited and hap- hazard enthusiasm for interpersonal, sexual, or occupational interactions. For example, the individual may spontaneously start extensive conversations with strangers in public. Often the predominant mood is irritable rather than elevated, particularly when the indi- vidual's wishes are denied or if the individual has been using substances. Rapid shifts in mood over brief periods of time may occur and are referred to as lability (i.e., the alternation among euphoria, dysphoria, and irritability). In children, happiness, silliness and "goofiness" are normal in the context of special occasions; however, if these symptoms are recurrent, inappropriate to the context, and beyond what is expected for the developmen- tal level of the child, they may meet Criterion A. If the happiness is unusual for a child (i.e., distinct from baseline), and the mood change occurs at the same time as symptoms that meet Criterion B for mania, diagnostic certainty is increased; however, the mood change must be accompanied by persistently increased activity or energy levels that are obvious to those who know the child well. During the manic episode, the individual may engage in multiple overlapping new projects. The projects are often initiated with little knowledge of the topic, and nothing seems out of the individual's reach. The increased activity levels may manifest at unusual hours of the day. Inflated self-esteem is typically present, ranging from uncritical self-confidence to marked grandiosity, and may reach delusional proportions (Criterion B1). Despite lack of any partic- ular experience or talent, the individual may embark on complex tasks such as writing a novel or seeking publicity for some impractical invention. Grandiose delusions (e.g., of having a special relationship to a famous person) are common. In children, overestimation of abilities and belief that, for example, they are the best at a sport or the smartest in the class is normal; however, when such beliefs are present despite clear evidence to the contrary or the child at- tempts feats that are clearly dangerous and, most important, represent a change from the child's normal behavior, the grandiosity criterion should be considered satisfied. One of the most common features is a decreased need for sleep (Criterion B2) and is distinct from insomnia in which the individual wants to sleep or feels the need to sleep but is unable. The individual may sleep little, if at all, or may awaken several hours earlier than usual, feeling rested and full of energy. When the sleep disturbance is severe, the individ- ual may go for days without sleep, yet not feel tired. Often a decreased need for sleep her- alds the onset of a manic episode. Speech can be rapid, pressured, loud, and difficult to interrupt (Criterion B3). Individ- uals may talk continuously and without regard for others' wishes to communicate, often in an intrusive manner or without concern for the relevance of what is said. Speech is sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality, with dramatic mannerisms, singing, and excessive gesturing. Loudness and forcefulness of speech often become more important than what is conveyed. If the individual's mood is more irritable than expansive, speech may be marked by complaints, hostile comments, or angry tirades, particularly if attempts are made to interrupt the individual. Both Criterion A and Criterion B symptoms may be accompanied by symptoms of the opposite (i.e., de- pressive) pole (see "with mixed features" specifier, pp. 149-150). Often the individual's thoughts race at a rate faster than they can be expressed through speech (Criterion B4). Frequently there is flight of ideas evidenced by a nearly continuous flow of accelerated speech, with abrupt shifts from one topic to another. When flight of ideas is se- vere, speech may become disorganized, incoherent, and particularly distressful to the individ- ual. Sometimes thoughts are experienced as so crowded that it is very difficult to speak. Distractibility (Criterion B5) is evidenced by an inability to censor immaterial external stimuli (e.g., the interviewer's attire, background noises or conversations, furnishings in the room) and often prevents individuals experiencing mania from holding a rational con- versation or attending to instructions. The increase in goal-directed activity often consists of excessive planning and partici- pation in multiple activities, including sexual, occupational, political, or religious activi- ties. Increased sexual drive, fantasies, and behavior are often present. Individuals in a manic episode usually show increased sociability (e.g., renewing old acquaintances or calling or contacting friends or even strangers), without regard to the intrusive, domineering, and demanding nature of these interactions. They often display psychomotor agitation or rest- lessness (i.e., purposeless activity) by pacing or by holding multiple conversations simultaneously. Some individuals write excessive letters, e-mails, text messages, and so forth, on many different topics to friends, public figures, or the media. The increased activity criterion can be difficult to ascertain in children; however, when the child takes on many tasks simultaneously, starts devising elaborate and unrealistic plans for projects, develops previously absent and developmentally inappropriate sexual preoccupations (not accounted for by sexual abuse or exposure to sexually explicit mate- rial), then Criterion B might be met based on clinical judgment. It is essential to determine whether the behavior represents a change from the child's baseline behavior; occurs most of the day, nearly every day for the requisite time period; and occurs in temporal associa- tion with other symptoms of mania. The expansive mood, excessive optimism, grandiosity, and poor judgment often lead to reckless involvement in activities such as spending sprees, giving away possessions, reckless driving, foolish business investments, and sexual promiscuity that is unusual for the individual, even though these activities are likely to have catastrophic consequences (Criterion B7). The individual may purchase many unneeded items without the money to pay for them and, in some cases, give them away. Sexual behavior may include infidelity or indiscriminate sexual encounters with strangers, often disregarding the risk of sexually transmitted diseases or interpersonal consequences. The manic episode must result in marked impairment in social or occupational func- toning or require hospitalization to prevent harm to self or others (e.g., financial losses, il- legal activities, loss of employment, self-injurious behavior). By definition, the presence of psychotic features during a manic episode also satisfies Criterion C. Manic symptoms or syndromes that are attributable to the physiological effects of a drug of abuse (e.g., in the context of cocaine or amphetamine intoxication), the side effects of medications or treatments (e.g., steroids, L-dopa, antidepressants, stimulants), or an- other medical condition do not count toward the diagnosis of bipolar I disorder. However, a fully syndromal manic episode that arises during treatment (e.g., with medications, elec- troconvulsive therapy, light therapy) or drug use and persists beyond the physiological ef- fect of the inducing agent (i.e., after a medication is fully out of the individual's system or the effects of electroconvulsive therapy would be expected to have dissipated completely) is sufficient evidence for a manic episode diagnosis (Criterion D). Caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation follow- ing antidepressant use) are not taken as sufficient for diagnosis of a manic or hypomanic episode, nor necessarily an indication of a bipolar disorder diathesis. It is necessary to meet criteria for a manic episode to make a diagnosis of bipolar I disorder, but it is not re- quired to have hypomanic or major depressive episodes. However, they may precede or follow a manic episode. Full descriptions of the diagnostic features of a hypomanic epi- sode may be found within the text for bipolar II disorder, and the features of a major de- pressive episode are described within the text for major depressive disorder. Associated Features Supporting Diagnosis During a manic episode, individuals often do not perceive that they are ill or in need of treat- ment and vehemently resist efforts to be treated. Individuals may change their dress, makeup, or personal appearance to a more sexually suggestive or flamboyant style. Some perceive a sharper sense of smell, hearing, or vision. Gambling and antisocial behaviors may accompany the manic episode. Some individuals may become hostile and physically threatening to others and, when delusional, may become physically assaultive or suicidal. Catastrophic conse- quences of a manic episode (e.g., involuntary hospitalization, difficulties with the law, serious financial difficulties) often result from poor judgment, loss of insight, and hyperactivity. Mood may shift very rapidly to anger or depression. Depressive symptoms may occur during a manic episode and, if present, may last moments, hours, or, more rarely, days (see "with mixed features" specifier, pp. 149-150). Prevalence The 12-month prevalence estimate in the continental United States was 0.6% for bipolar I disorder as defined in DSM-IV. Twelve-month prevalence of bipolar I disorder across 11 countries ranged from 0.0% to 0.6%. The lifetime male-to-female prevalence ratio is ap- proximately1.1:1. Development and Course Mean age at onset of the first manic, hypomanic, or major depressive episode is approxi- mately 18 years for bipolar I disorder. Special considerations are necessary to detect the di- agnosis in children. Since children of the same chronological age may be at different developmental stages, it is difficult to define with precision what is "normal" or "ex- pected" at any given point. Therefore, each child should be judged according to his or her own baseline. Onset occurs throughout the life cycle, including first onsets in the 60s or 70s. Onset of manic symptoms (e.g., sexual or social disinhibition) in late mid-life or late- life should prompt consideration of medical conditions (e.g., frontotemporal neurocogni- tive disorder) and of substance ingestion or withdrawal. More than 90% of individuals who have a single manic episode go on to have recurrent mood episodes. Approximately 60% of manic episodes occur immediately before a major depressive episode. Individuals with bipolar I disorder who have multiple (four or more) mood episodes (major depressive, manic, or hypomanic) within 1 year receive the speci- fier "with rapid cycling Culture-Related Diagnostic Issues Little information exists on specific cultural differences in the expression of bipolar I dis- order. One possible explanation for this may be that diagnostic instruments are often translated and applied in different cultures with no transcultural validation. In one U.S. study, 12-month prevalence of bipolar I disorder was significantly lower for Afro-Carib- beans than for African Americans or whites. Gender-Related Diagnostic Issues Females are more likely to experience rapid cycling and mixed states, and to have patterns of comorbidity that differ from those of males, including higher rates of lifetime eating disor- ders. Females with bipolar I or Il disorder are more likely to experience depressive symptoms than males. They also have a higher lifetime risk of alcohol use disorder than are males and a much greater likelihood of alcohol use disorder than do females in the general population. Suicide Risk The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. In fact, bipolar disorder may account for one-quar- ter of all completed suicides. A past history of suicide attempt and percent days spent de- pressed in the past year are associated with greater risk of suicide attempts or completions. Functional Consequences of Bipolar I Disorder Although many individuals with bipolar disorder return to a fully functional level be- tween episodes, approximately 30% show severe impairment in work role function. Func- tional recovery lags substantially behind recovery from symptoms, especially with respect to occupational recovery, resulting in lower socioeconomic status despite equivalent lev- els of education when compared with the general population. Individuals with bipolar I disorder perform more poorly than healthy individuals on cognitive tests. Cognitive im- pairments may contribute to vocational and interpersonal difficulties and persist through the lifespan, even during euthymic periods. Differential Diagnosis Major depressive disorder. Major depressive disorder may also be accompanied by hy- pomanic or manic symptoms (i.e., fewer symptoms or for a shorter duration than required for mania or hypomania). When the individual presents in an episode of major depression, one must depend on corroborating history regarding past episodes of mania or hypoma- nia. Symptoms of irritability may be associated with either major depressive disorder or bipolar disorder, adding to diagnostic complexity. Other bipolar disorders. Diagnosis of bipolar I disorder is differentiated from bipolar Il disorder by determining whether there have been any past episodes of mania. Other spec- ified and unspecified bipolar and related disorders should be differentiated from bipolar I and Il disorders by considering whether either the episodes involving manic or hypo- manic symptoms or the episodes of depressive symptoms fail to meet the full criteria for those conditions. Bipolar disorder due to another medical condition may be distinguished from bipolar I and II disorders by identifying, based on best clinical evidence, a causally related medical condition. Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety disorders. These disorders need to be considered in the differential diagnosis as either the primary disorder or, in some cases, a comorbid disorder. A careful history of symptoms is needed to differentiate generalized anxiety disorder from bipolar disorder, as anxious ruminations may be mistaken for racing thoughts, and efforts to minimize anx- ious feelings may be taken as impulsive behavior. Similarly, symptoms of posttraumatic stress disorder need to be differentiated from bipolar disorder. It is helpful to assess the ep- isodic nature of the symptoms described, as well as to consider symptom triggers, in mak- ing this differential diagnosis. Substance/medication-induced bipolar disorder. Substance use disorders may mani- fest with substance. medication-induced manic symptoms that must be distinguished from bipolar I disorder; response to mood stabilizers during a substance/ medication- induced mania may not necessarily be diagnostic for bipolar disorder. There may be sub- stantial overlap in view of the tendency for individuals with bipolar I disorder to overuse substances during an episode. A primary diagnosis of bipolar disorder must be estab- lished based on symptoms that remain once substances are no longer being used. Attention-deficit/hyperactivity disorder. This disorder may be misdiagnosed as bipolar disorder, especially in adolescents and children. Many symptoms overlap with the symptoms of mania, such as rapid speech, racing thoughts, distractibility, and less need for sleep. The "double counting of symptoms toward both ADHD and bipolar disorder can be avoided if the clinician clarifies whether the symptom(s) represents a distinct episode. Personality disorders. Personality disorders such as borderline personality disorder may have substantial symptomatic overlap with bipolar disorders, since mood lability and impulsivity are common in both conditions. Symptoms must represent a distinct ep- isode, and the noticeable increase over baseline required for the diagnosis of bipolar disorder must be present. A diagnosis of a personality disorder should not be made during an untreated mood episode. Disorders with prominent irritability. In individuals with severe irritability, particularly children and adolescents, care must be taken to apply the diagnosis of bipolar disorder only to those who have had a clear episode of mania or hypomania--that is, a distinct time period, of the required duration, during which the irritability was clearly different from the individual's baseline and was accompanied by the onset of Criterion B symptoms. When a child's irritability is persistent and particularly severe, the diagnosis of disruptive mood dysregulation disorder would be more appropriate. Indeed, when any child is being assessed for mania, it is essential that the symptoms represent a clear change from the child's typical behavior. Comorbidity Co-occurring mental disorders are common, with the most frequent disorders being any anxiety disorder (e.g., panic attacks, social anxiety disorder [social phobia], specific pho- bia), occurring in approximately three-fourths of individuals; ADHD, any disruptive, im- pulse-control, or conduct disorder (e.g., intermittent explosive disorder, oppositional defiant disorder, conduct disorder), and any substance use disorder (e.g., alcohol use dis- order) occur in over half of individuals with bipolar I disorder. Adults with bipolar I dis- order have high rates of serious and/ or untreated co-occurring medical conditions. Metabolic syndrome and migraine are more common among individuals with bipolar dis- order than in the general population. More than half of individuals whose symptoms meet criteria for bipolar disorder have an alcohol use disorder, and those with both disorders are at greater risk for suicide attempt.

Bipolar II Disorder (DSM)

Diagnostic Criteria Hypomanic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, rep- resent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupa- tional functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly in- creased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bi- polar diathesis Major Depressive Episode 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 subjec- tive 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 delu- sional) 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 with- out 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, occupa- tional, 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 AC constitute a major depressive episode. Bipolar I Disorder A. Criteria have been met for at least one hypomanic episode (Criteria AF under "Hypo- manic Episode" above) and at least one major depressive episode (Criteria AC under "Major Depressive Episode" above). B. There has never been a manic episode. C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disor- der, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Diagnostic Features Bipolar Il disorder is characterized by a clinical course of recurring mood episodes con- sisting of one or more major depressive episodes (Criteria AC under "Major Depressive Episode") and at least one hypomanic episode (Criteria A-F under "Hypomanic Epi- sode"). The major depressive episode must last at least 2 weeks, and the hypomanic epi- sode must last at least 4 days, to meet the diagnostic criteria. During the mood episode(s), the requisite number of symptoms must be present most of the day, nearly every day, and represent a noticeable change from usual behavior and functioning. The presence of a manic episode during the course of illness precludes the diagnosis of bipolar Il disorder (Criterion B under "Bipolar Il Disorder"). Episodes of substance/ medication-induced de- pressive disorder or substance / medication-induced bipolar and related disorder (repre- senting the physiological effects of a medication, other somatic treatments for depression, drugs of abuse, or toxin exposure) or of depressive and related disorder due to another medical condition or bipolar and related disorder due to another medical condition do not count toward a diagnosis of bipolar Il disorder unless they persist beyond the physiolog- ical effects of the treatment or substance and then meet duration criteria for an episode. In addition, the episodes must not be better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum or other psychotic disorders (Cri- terion C under "Bipolar Il Disorder"). The depressive episodes or hypomanic fluctuations must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion D under "Bipolar Il Disorder"); however, for hy- pomanic episodes, this requirement does not have to be met. A hypomanic episode that causes significant impairment would likely qualify for the diagnosis of manic episode and, therefore, for a lifetime diagnosis of bipolar I disorder. The recurrent major depressive ep- isodes are often more frequent and lengthier than those occurring in bipolar I disorder. Individuals with bipolar II disorder typically present to a clinician during a major de- pressive episode and are unlikely to complain initially of hypomania. Typically, the hy- pomanic episodes themselves do not cause impairment, Instead, the impairment results from the major depressive episodes or from a persistent pattern of unpredictable mood changes and fluctuating, unreliable interpersonal or occupational functioning. Individu- als with bipolar II disorder may not view the hypomanic episodes as pathological pr dis- advantageous, although others may be troubled by the individual's erratic behavior. Clinical information from other informants, such as close friends or relatives, is often use- ful in establishing the diagnosis of bipolar Il disorder. A hypomanic episode should not be confused with the several days of euthymia and re- stored energy or activity that may follow remission of a major depressive episode. Despite the substantial differences in duration and severity between a manic and hypomanic episode, bi- polar Il disorder is not a "milder form" of bipolar I disorder. Compared with individuals with bipolar I disorder, individuals with bipolar Il disorder have greater chronicity of illness and spend, on average, more time in the depressive phase of their illness, which can be severe and / or disabling. Depressive symptoms co-occurring with a hypomanic episode or hypomanic symptoms co-occurring with a depressive episode are common in individuals with bipolar Il disorder and are overrepresented in females, particularly hypomania with mixed features. In- dividuals experiencing hypomania with mixed features may not label their symptoms as hy- pomania, but instead experience them as depression with increased energy or irritability. Associated Features Supporting Diagnosis A common feature of bipolar II disorder is impulsivity, which can contribute to suicide at- tempts and substance use disorders. Impulsivity may also stem from a concurrent person- ality disorder, substance use disorder, anxiety disorder, another mental disorder, or a medical condition. There may be heightened levels of creativity in some individuals with a bipolar disorder. However, that relationship may be nonlinear; that is, greater lifetime creative accomplishments have been associated with milder forms of bipolar disorder, and higher creativity has been found in unaffected family members. The individual's attach- ment to heightened creativity during hypomanic episodes may contribute to ambivalence about seeking treatment or undermine adherence to treatment. Prevalence The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the United States, 12-month prevalence is 0.8%. The prevalence rate of pediatric bipolar Il disorder is difficult to establish. DSM-IV bipolar I, bipolar II, and bipolar disorder not otherwise spec- ified yield a combined prevalence rate of 1.8% in U.S. and non-U.S. community samples, with higher rates (2.7% inclusive) in youths age 12 years or older. Development and Course Although bipolar II disorder can begin in late adolescence and throughout adulthood, av- erage age at onset is the mid-20s, which is slightly later than for bipolar I disorder but ear. lier than for major depressive disorder. The illness most often begins with a depressive episode and is not recognized as bipolar Il disorder until a hypomanic episode occurs; this happens in about 12% of individuals with the initial diagnosis of major depressive disor- der. Anxiety, substance use, or eating disorders may also precede the diagnosis, compli- cating its detection. Many individuals experience several episodes of major depression prior to the first recognized hypomanic episode. The number of lifetime episodes (both hypomanic and major depressive episodes) tends to be higher for bipolar II disorder than for major depressive disorder or bipolar I disorder. However, individuals with bipolar I disorder are actually more likely to experi- ence hypomanic symptoms than are individuals with bipolar Il disorder. The interval between mood episodes in the course of bipolar Il disorder tends to decrease as the indi- vidual ages. While the hypomanic episode is the feature that defines bipolar Il disorder, depressive episodes are more enduring and disabling over time. Despite the predomi- nance of depression, once a hypomanic episode has occurred, the diagnosis becomes bi- polar II disorder and never reverts to major depressive disorder. Approximately 5%-15% of individuals with bipolar Il disorder have multiple (four or more) mood episodes (hypomanic or major depressive) within the previous 12 months. If this pattern is present, it is noted by the specifier "with rapid cycling." By definition, psy- chotic symptoms do not occur in hypomanic episodes, and they appear to be less frequent in the major depressive episodes in bipolar Il disorder than in those of bipolar I disorder. Switching from a depressive episode to a manic or hypomanic episode (with or with- out mixed features) may occur, both spontaneously and during treatment for depression. About 5%-15% of individuals with bipolar II disorder will ultimately develop a manic ep- isode, which changes the diagnosis to bipolar I disorder, regardless of subsequent course. Making the diagnosis in children is often a challenge, especially in those with irritabil- ity and hyperarousal that is nonepisodic (i.e., lacks the well-demarcated periods of altered mood). Nonepisodic irritability in youth is associated with an elevated risk for anxiety dis- orders and major depressive disorder, but not bipolar disorder, in adulthood. Persistently irritable youths have lower familial rates of bipolar disorder than do youths who have bi- polar disorder. For a hypomanic episode to be diagnosed, the child's symptoms must ex- ceed what is expected in a given environment and culture for the child's developmental stage. Compared with adult onset of bipolar II disorder, childhood or adolescent onset of the disorder may be associated with a more severe lifetime course. The 3-year incidence rate of first-onset bipolar Il disorder in adults older than 60 years is 0.34%. However, dis- tinguishing individuals older than 60 years with bipolar Il disorder by late versus early age at onset does not appear to have any clinical utility. Risk and Prognostic Factors Genetic and physiological. The risk of bipolar II disorder tends to be highest among rel- atives of individuals with bipolar Il disorder, as opposed to individuals with bipolar I dis- order or major depressive disorder. There may be genetic factors influencing the age at onset for bipolar disorders. Course modifiers. A rapid-cycling pattern is associated with a poorer prognosis. Return to previous level of social function for individuals with bipolar I disorder is more likely for individuals of younger age and with less severe depression, suggesting adverse effects of prolonged illness on recovery. More education, fewer years of illness, and being mar- ried are independently associated with functional recovery in individuals with bipolar disorder, even after diagnostic type (I vs. II), current depressive symptoms, and presence of psychiatric comorbidity are taken into account. Gender-Related Diagnostic Issues Whereas the gender ratio for bipolar I disorder is equal, findings on gender differences in bipolar Il disorder are mixed, differing by type of sample (i.e., registry, community, or clinical) and country of origin. There is little to no evidence of bipolar gender differences, whereas some, but not all, clinical samples suggest that bipolar Il disorder is more com- mon in females than in males, which may reflect gender differences in treatment seeking or other factors. Patterns of illness and comorbidity, however, seem to differ by gender, with females being more likely than males to report hypomania with mixed depressive features and a rapid-cycling course. Childbirth may be a specific trigger for a hypomanic episode, which can occur in 10%-20% of females in nonclinical populations and most typically in the early postpartum period. Distinguishing hypomania from the elated mood and reduced sleep that normally accompany the birth of a child may be challenging. Postpartum hypomania may foreshadow the onset of a depression that occurs in about half of females who expe- tience postpartum "highs." Accurate detection of bipolar Il disorder may help in estab- lishing appropriate treatment of the depression, which may reduce the risk of suicide and infanticide Suicide Risk Suicide risk is high in bipolar Il disorder. Approximately one-third of individuals with bi- polar Il disorder report a lifetime history of suicide attempt. The prevalence rates of life- time attempted suicide in bipolar Il and bipolar I disorder appear to be similar (32.4% and 36.3%, respectively). However, the lethality of attempts, as defined by a lower ratio of at- tempts to completed suicides, may be higher in individuals with bipolar II disorder com- pared with individuals with bipolar I disorder. There may be an association between genetic markers and increased risk for suicidal behavior in individuals with bipolar dis- order, including a 6.5-fold higher risk of suicide among first-degree relatives of bipolar Il probands compared with those with bipolar I disorder. Functional Consequences of Bipolar II Disorder Although many individuals with bipolar Il disorder return to a fully functional level be- tween mood episodes, at least 15% continue to have some inter-episode dysfunction, and 20% transition directly into another mood episode without inter-episode recovery. Func- tional recovery lags substantially behind recovery from symptoms of bipolar I disorder, especially in regard to occupational recovery, resulting in lower socioeconomic status de- spite equivalent levels of education with the general population. Individuals with bipolar I disorder perform more poorly than healthy individuals on cognitive tests and, with the exception of memory and semantic fluency, have similar cognitive impairment as do in- dividuals with bipolar I disorder. Cognitive impairments associated with bipolar Il disor- der may contribute to vocational difficulties. Prolonged unemployment in individuals with bipolar disorder is associated with more episodes of depression, older age, increased rates of current panic disorder, and lifetime history of alcohol use disorder. Differential Diagnosis Major depressive disorder. Perhaps the most challenging differential diagnosis to con- sider is major depressive disorder, which may be accompanied by hypomanic or manic symptoms that do not meet full criteria (i.e., either fewer symptoms or a shorter duration than required for a hypomanic episode). This is especially true in evaluating individuals with symptoms of irritability, which may be associated with either major depressive dis- order or bipolar Il disorder. Cyclothymic disorder. In cyclothymic disorder, there are numerous periods of hypo- manic symptoms and numerous periods of depressive symptoms that do not meet symp- tom or duration criteria for a major depressive episode. Bipolar Il disorder is distinguished from cyclothymic disorder by the presence of one or more major depressive episodes. If a major depressive episode occurs after the first 2 years of cyclothymic disorder, the addi- tional diagnosis of bipolar Il disorder is given. Schizophrenia spectrum and other related psychotic disorders. Bipolar I disorder must be distinguished from psychotic disorders (e.g., schizoaffective disorder, schizophrenia, and delusional disorder). Schizophrenia, schizoaffective disorder, and delusional disor- der are all characterized by periods of psychotic symptoms that occur in the absence of prominent mood symptoms. Other helpful considerations include the accompanying symptoms, previous course, and family history. Panic disorder or other anxiety disorders. Anxiety disorders need to be considered in the differential diagnosis and may frequently be present as co-occurring disorders. Substance use disorders. Substance use disorders are included in the differential diagnosis. Attention-deficit/hyperactivity disorder. Attention-deficit/hyperactivity disorder (ADHD) may be misdiagnosed as bipolar Il disorder, especially in adolescents and children. Many symptoms of ADHD, such as rapid speech, racing thoughts, distractibility, and less need for sleep, overlap with the symptoms of hypomania. The double counting of symptoms to- ward both ADHD and bipolar Il disorder can be avoided if the clinician clarifies whether the symptoms represent a distinct episode and if the noticeable increase over baseline re- quired for the diagnosis of bipolar Il disorder is present. Personality disorders. The same convention as applies for ADHD also applies when evaluating an individual for a personality disorder such as borderline personality disor- der, since mood lability and impulsivity are common in both personality disorders and bi- polar Il disorder. Symptoms must represent a distinct episode, and the noticeable increase over baseline required for the diagnosis of bipolar II disorder must be present. A diagnosis of a personality disorder should not be made during an untreated mood episode unless the lifetime history supports the presence of a personality disorder. Other bipolar disorders. Diagnosis of bipolar Il disorder should be differentiated from bipolar I disorder by carefully considering whether there have been any past episodes of mania and from other specified and unspecified bipolar and related disorders by confirm- ing the presence of fully syndromal hypomania and depression. Comorbidity Bipolar Il disorder is more often than not associated with one or more co-occurring mental disorders, with anxiety disorders being the most common. Approximately 60% of individ- uals with bipolar Il disorder have three or more co-occurring mental disorders; 75% have an anxiety disorder; and 37% have a substance use disorder. Children and adolescents with bipolar Il disorder have a higher rate of co-occurring anxiety disorders compared with those with bipolar I disorder, and the anxiety disorder most often predates the bi- polar disorder. Anxiety and substance use disorders occur in individuals with bipolar Il disorder at a higher rate than in the general population. Approximately 14% of individuals with bipolar Il disorder have at least one lifetime eating disorder, with binge-eating dis- order being more common than bulimia nervosa and anorexia nervosa, These commonly co-occurring disorders do not seem to follow a course of illness that is truly independent from that of the bipolar disorder, but rather have strong associations with mood states. For example, anxiety and eating disorders tend to associate most with depressive symptoms, and substance use disorders are moderately associated with manic symptoms.

Persistent Depressive Disorder (Dysthymia) (DSM)

Diagnostic Criteria This disorder represents a consolidation of DSM-IV-defined chronic major depressive dis- order and dysthymic 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 individ- ual 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 de- pressive 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. Specify if: With anxious distress (p. 184) With mixed features (pp. 184-185) With melancholic features (p. 185) With atypical features (pp. 185-186) With mood-congruent psychotic features (p. 186) With mood-incongruent psychotic features (p. 186) With peripartum onset (pp. 186-187) Specify it: In partial remission (p. 188) In full remission (p. 188) Specify if: Early onset: If onset is before age 21 years, Late onset: If onset is at age 21 years or older. Specify if (for most recent 2 years of persistent depressive disorder): With pure dysthymic syndrome: Full criteria for a major depressive episode have not been met in at least the preceding 2 years. With persistent major depressive episode: Full criteria for a major depressive epi- sode have been met throughout the preceding 2-year period. With intermittent major depressive episodes, with current episode: Full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode. With intermittent major depressive episodes, without current episode: Full crite- ria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years. Specify current severity: Mild (p. 188) Moderate (p. 188) Severe (p. 188) Diagnostic Features The essential feature of persistent depressive disorder (dysthymia) is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years, or at least 1 year for children and adolescents (Criterion A). This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. Major de- pression may precede persistent depressive disorder, and major depressive episodes may occur during persistent depressive disorder. Individuals whose symptoms meet major de- pressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder. Individuals with persistent depressive disorder describe their mood as sad or "down in the dumps." During periods of depressed mood, at least two of the six symptoms from Criterion B are present. Because these symptoms have become a part of the individual's day-to-day experience, particularly in the case of early onset (e.g, "I've always been this way"), they may not be reported unless the individual is directly prompted. During the 2-year period (1 year for children or adolescents), any symptom-free intervals last no longer than 2 months (Criterion C). Prevalence Persistent depressive disorder is effectively an amalgam of DSM-IV dysthymic disorder and chronic major depressive episode. The 12-month prevalence in the United States is approxi- mately0.5% for persistent depressive disorder and 1.5% for chronic major depressive disorder. Development and Course Persistent depressive disorder often has an early and insidious onset (i.e., in childhood, adolescence, or early adult life) and, by definition, a chronic course. Among individuals with both persistent depressive disorder and borderline personality disorder, the covari- ance of the corresponding features over time suggests the operation of a common mecha- nism. Early onset (i.e., before age 21 years) is associated with a higher likelihood of comorbid personality disorders and substance use disorders. When symptoms rise to the level of a major depressive episode, they are likely to sub- sequently revert to a lower level. However, depressive symptoms are much less likely to resolve in a given period of time in the context of persistent depressive disorder than they are in a major depressive episode. Risk and Prognostic Factors Temperamental. Factors predictive of poorer long-term outcome include higher levels of neuroticism (negative affectivity), greater symptom severity, poorer global functioning, and presence of anxiety disorders or conduct disorder. Environmental. Childhood risk factors include parental loss or separation. Genetic and physiological. There are no clear differences in illness development, course, or family history between DSM-IV dysthymic disorder and chronic major depressive dis- order. Earlier findings pertaining to either disorder are therefore likely to apply to per- sistent depressive disorder. It is thus likely that individuals with persistent depressive disorder will have a higher proportion of first-degree relatives with persistent depressive disorder than do individuals with major depressive disorder, and more depressive disor- ders in general. A number of brain regions (e.g., prefrontal cortex, anterior cingulate, amygdala, hip- pocampus) have been implicated in persistent depressive disorder. Possible polysomno- graphic abnormalities exist as well. Functional Consequences of Persistent Depressive Disorder The degree to which persistent depressive disorder impacts social and occupational func- depressive disorder. toning is likely to vary widely, but effects can be as great as or greater than those of MDD Differential Diagnosis Major depressive disorder. If there is a depressed mood plus two or more symptoms meeting criteria for a persistent depressive episode for 2 years or more, then the diagnosis of persistent depressive disorder is made. The diagnosis depends on the 2-year duration which distinguishes it from episodes of depression that do not last 2 years. if the symptom criteria are sufficient for a diagnosis of a major depressive episode at any time during this pe- riod, then the diagnosis of major depression should be noted, but it is coded not as a separate diagnosis but rather as a specifier with the diagnosis of persistent depressive disorder. If the individual's symptoms currently meet full criteria for a major depressive episode, then the specifier of "with intermittent major depressive episodes, with current episode" would be made. If the major depressive episode has persisted for at least a 2-year duration and re- mains present, then the specifier "with persistent major depressive episode" is used. When full major depressive episode criteria are not currently met but there has been at least one previous episode of major depression in the context of at least 2 years of persistent depres- sive symptoms, then the specifier of "with intermittent major depressive episodes, without current episode" is used. If the individual has not experienced an episode of major depres- sion in the last 2 years, then the specifier "with pure dysthymic syndrome" is used. Psychotic disorders. Depressive symptoms are a common associated feature of chronic psychotic disorders (e.g., schizoaffective disorder, schizophrenia, delusional disorder). A separate diagnosis of persistent depressive disorder is not made if the symptoms occur only during the course of the psychotic disorder (including residual phases). Depressive or bipolar and related disorder due to another medical condition. Persistent depressive disorder must be distinguished from a depressive or bipolar and related dis- order due to another medical condition. The diagnosis is depressive or bipolar and related disorder due to another medical condition if the mood disturbance is judged, based on his- tory, physical examination, or laboratory findings, to be attributable to the direct patho- physiological effects of a specific, usually chronic, medical condition (e.g., multiple sclerosis). If it is judged that the depressive symptoms are not attributable to the physiolog- ical effects of another medical condition, then the primary mental disorder (e.g., persistent depressive disorder) is recorded, and the medical condition is noted as a concomitant med- ical condition (e.g., diabetes mellitus). Substance/medication-induced depressive or bipolar disorder. A substance/ medi- cation-induced depressive or bipolar and related disorder is distinguished from persis- tent depressive disorder when a substance (e.g., a drug of abuse, a medication, a toxin) is judged to be etiologically related to the mood disturbance. Personality disorders. Often, there is evidence of a coexisting personality disturbance. When an individual's presentation meets the criteria for both persistent depressive disor- der and a personality disorder, both diagnoses are given. Comorbidity In comparison to individuals with major depressive disorder, those with persistent de- pressive disorder are at higher risk for psychiatric comorbidity in general, and for anxiety disorders and substance use disorders in particular. Early-onset persistent depressive dis- order is strongly associated with DSM-IV Cluster B and C personality disorders.

Specific phobias (DSM)

Diagnostic Criteria A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). o 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 sep- aration anxiety disorder); or social situations (as in social anxiety disorder). Specity it: Code based on the phobic stimulus: 300.29 (F40.218) Animal (e.g., spiders, insects, dogs). 300.29 (F40.228) Natural environment (e.g., heights, storms, water). 300.29 (F-40.23x) Blood-injection-injury (e.g., needles, invasive medical procedures). Coding note: Select specific ICD-10-CM code as follows: FA0.230 fear of blood: 7A0.231 fear of injections and transfusions; F40.232 fear of other medical care; oi F40.233 fear of injury. 300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places). 300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting; in chil. dren, e.g., loud sounds or costumed characters). Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and F40.248 specific phobia, situational). Specifiers It is common for individuals to have multiple specific phobias. The average individual with specific phobia fears three objects or situations, and approximately 75% of individuals with specific phobia fear more than one situation or object. In such cases, multiple specitic phobia diagnoses, each with its own diagnostic code reflecting the phobic stimulus, would need to be given. For example, if an individual fears thunderstorms and flying, then two diagnoses would be given: specific phobia, natural environment, and specific phobia, situational. Diagnostic Features A key feature of this disorder is that the fear or anxiety is circumscribed to the presence of a particular situation or object (Criterion A), which may be termed the phobic stimulus. The cat. egories of feared situations or objects are provided as specifiers. Many individuals fear objects or situations from more than one category, or phobic stimulus. For the diagnosis of spécific phobia, the response must differ from normal, transient fears that commonly occur in the pop- ulation. To meet the criteria for a diagnosis, the fear or anxiety must be intense or severe (ie, "marked") (Criterion A). The amount of fear experienced may vary with proximity to the feared object or situation and may occur in anticipation of or in the actual presence of the object or situation. Also, the fear or anxiety may take the form of a full or limited symptom panic at- tack (i.e., expected panic attack). Another characteristic of specific phobias is that fear or anxi- ety is evoked nearly every time the individual comes into contact with the phobic stimulus (Criterion B). Thus, an individual who becomes anxious only occasionally upon being con- fronted with the situation or object (e.g., becomes anxious when flying only on one out of every five airplane flights) would not be diagnosed with specific phobia. However, the degree of fear or anxiety expressed may vary (from anticipatory anxiety to a full panic attack) across different occasions of encountering the phobic object or situation because of various contextual factors such as the presence of others, duration of exposure, and other threatening elements such as turbulence on a flight for individuals who fear flying. Fear and anxiety are often expressed dif- ferently between children and adults. Also, the fear or anxiety occurs as soon as the phobic ob- ject or situation is encountered (i.e., immediately rather than being delayed). The individual actively avoids the situation, or if he or she either is unable or decides not to avoid it, the situation or object evokes intense fear or anxiety (Criterion C). Active avoidance means the individual intentionally behaves in ways that are designed to prevent or minimize contact with phobic objects or situations (e,g, takes tunnels instead of bridges on daily commute to work for fear of heights; avoids entering a dark room for fear of spr ders; avoids accepting a job in a locale where a phobic stimulus is more common). Avoidance behaviors are often obvious (e.g,, an individual who fears blood refusing to go to the doctor) but are sometimes less obvious (e.g., an individual who fears snakes refusing to look at pictures that resemble the form or shape of snakes). Many individuals with specific phobias have suffered over many years and have changed their living circumstances in ways designed to avoid the phobic object or situation as much as possible (e.g., an indi- vidual diagnosed with specific phobia, animal, who moves to reside in an area devoid of the particular feared animal). Therefore, they no longer experience fear or anxiety in their daily life. In such instances, avoidance behaviors or ongoing refusal to engage in activities that would involve exposure to the phobic object or situation (e.g., repeated refusal to ac- cept offers for work-related travel because of fear of flying) may be helpful in confirming the diagnosis in the absence of overt anxiety or panic. The fear or anxiety is out of proportion to the actual danger that the object or situation poses, or more intense than is deemed necessary (Criterion D). Although individuals with specific phobia often recognize their reactions as disproportionate, they tend to overesti- mate the danger in their feared situations, and thus the judgment of being out of propor- tion is made by the clinician. The individual's sociocultural context should also be taken into account. For example, fears of the dark may be reasonable in a context of ongoing violence, and fear of insects may be more disproportionate in settings where insects are consumed in the diet. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more (Criterion E), which helps distinguish the disorder from transient fears that are common in the population, particularly among children. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility. The specific phobia must cause clinically significant distress or impairment in social, oc- cupational, or other important areas of functioning in order for the disorder to be diag- nosed (Criterion F). Associated Features Supporting Diagnosis Individuals with specific phobia typically experience an increase in physiological arousal in anticipation of or during exposure to a phobic object or situation. However, the physi- ological response to the feared situation or object varies. Whereas individuals with situa- tional, natural environment, and animal specific phobias are likely to show sympathetic nervous system arousal, individuals with blood-injection-injury specific phobia often demonstrate a vasovagal fainting or near-fainting response that is marked by initial brief acceleration of heart rate and elevation of blood pressure followed by a deceleration of heart rate and a drop in blood pressure. Current neural systems models for specific phobia emphasize the amygdala and related structures, much as in other anxiety disorders. Prevalence In the United States, the 12-month community prevalence estimate for specific phobia is approximately 7%-9%. Prevalence rates in European countries are largely similar to those in the United States (e.g., about 6%), but rates are generally lower in Asian, African, and Latin American countries (2%- 4%). Prevalence rates are approximately 5% in children and are approximately 16% in 13- to 17-year-olds. Prevalence rates are lower in older individ- uals (about 3%-5%), possibly reflecting diminishing severity to subclinical levels. Females are more frequently affected than males, at a rate of approximately 2:1, although rates vary across different phobic stimuli. That is, animal, natural environment, and situational spe- cific phobias are predominantly experienced by females, whereas blood-injection-injury phobia is experienced nearly equally by both genders. Development and Course Specific phobia sometimes develops following a traumatic event (e.g., being attacked by an animal or stuck in an elevator), observation of others going through a traumatic event (e.g., watching someone drown) an unexpected panic atack in thronbi fantersituation(eg., in titoine-eton panic attick while on the subway), or informatigual5 Whimision(e-g.%. (chune nectad evorageafa plane crash). However, many individuals with specific prof; are unable to cca the specific reason for the onset of their phobias- Specific phobia up ally develops in early childhood, with the majority of cases developins prior to age 10 sears. The Median age at Onset is between ? and 11 years, with the mean at about 10 year, Situational specific phobias tend to have a later age at onset than natural environment, an. imal. or blood iniection. injury specific phobias. Specific phobias that develop in child. hood and adolescence are likely to wax and wane during that period. However, phobias that do persist into adulthood are unlikely to remit for the majority of individuals. When specific phobia is being diagnosed in children, two issues should be considered First young children may express their fear and anxiety by crying, tantrums, freezing or clinging: Second, young children typically are not able to understand the concept of avoidance: Therefore, the clinician should assemble additional information from parents, teachers, or others who know the child well. Excessive fears are quite common in young children but are usually transitory and only mildly impairing and thus considered devel opmentally appropriate. In such cases a diagnosis of specific phobia would not be made. When the diagnosis of specific phobia is being considered in a child, it is important to assess the degree of impairment and the duration of the fear, anxiety, or avoidance, and whether it is typical for the child's particular developmental stage. Although the prevalence of specific phobia is lower in older populations, it remains one of the more commonly experienced disorders in late life. Several issues should be con- sidered when diagnosing specific phobia in older populations. First, older individuals may be more likely to endorse natural environment specific phobias, as well as phobias of falling. Second, specific phobia (like all anxiety disorders) tends to co-occur with medical concerns in older individuals, including coronary heart disease and chronic obstructive pulmonary disease. Third, older individuals may be more likely to attribute the symptoms of anxiety to medical conditions. Fourth, older individuals may be more likely to manifest anxiety in an atypical manner (e.g., involving symptoms of both anxiety and depression) and thus be more likely to warrant a diagnosis of unspecified anxiety disorder. Addition- ally, the presence of specific phobia in older adults is associated with decreased quality of life and may serve as a risk factor for major neurocognitive disorder. Although most specific phobias develop in childhood and adolescence, it is possible for a specific phobia to develop at any age, often as the result of experiences that are traumatic. for example, phobias of choking almost always follow a near-choking event at any age. Risk and Prognostic Factors Temperamental. Temperamental risk factors for specific phobia, such as negative affec- tivity (neuroticism) or behavioral inhibition, are risk factors for other anxiety disorders as well. Environmental. Environmental risk factors for specific phobias, such as parental over- protectiveness, parental loss and separation, and physical and sexual abuse, tend to pre- dict other anxiety disorders as well. As noted earlier, negative or traumatic encounters specific phobia. with the feared object or situation sometimes (but not always) precede the development of Genetic and physiological. There may be a genetic susceptibility to a certain category of specific phobia (e.g, an individual with a first-degree relative with a specific phobia of an- imals is significantly more likely to have the same specific phobia than any other category of phobia). Individuals with blood-injection-injury phobia show a unique propensity to vasovagal syncope (fainting) in the presence of the phobic stimulus. Culture-Related Diagnostic Issues In the United States, Asians and Latinos report significantly lower rates of specific phobia than non-Latino whites, African Americans, and Native Americans. In addition to having lower prevalence rates of specific phobia, some countries outside of the United States, par- ticularly Asian and African countries, show differing phobia content, age at onset, and gender ratios. Suicide Risk Individuals with specific phobia are up to 60% more likely to make a suicide attempt than are individuals without the diagnosis. However, it is likely that these elevated rates are primarily due to comorbidity with personality disorders and other anxiety disorders. Functional Consequences of Specific Phobia Individuals with specific phobia show similar patterns of impairment in psychosocial functioning and decreased quality of life as individuals with other anxiety disorders and alcohol and substance use disorders, including impairments in occupational and inter- personal functioning. In older adults, impairment may be seen in caregiving duties and volunteer activities. Also, fear of falling in older adults can lead to reduced mobility and reduced physical and social functioning, and may lead to receiving formal or informal home support. The distress and impairment caused by specific phobias tend to increase with the number of feared objects and situations. Thus, an individual who fears four ob- jects or situations is likely to have more impairment in his or her occupational and social roles and a lower quality of life than an individual who fears only one object or situation. Individuals with blood-injection-injury specific phobia are often reluctant to obtain med- ical care even when a medical concern is present. Additionally, fear of vomiting and chok- ing may substantially reduce dietary intake. Differential Diagnosis Agoraphobia. Situational specific phobia may resemble agoraphobia in its clinical pre- sentation, given the overlap in feared situations (e.g., flying, enclosed places, elevators). If an individual fears only one of the agoraphobia situations, then specific phobia, situa- tional, may be diagnosed. If two or more agoraphobic situations are feared, a diagnosis of agoraphobia is likely warranted. For example, an individual who fears airplanes and ele- vators (which overlap with the "public transportation" agoraphobic situation) but does not fear other agoraphobic situations would be diagnosed with specific phobia, situa- tional, whereas an individual who fears airplanes, elevators, and crowds (which overlap with two agoraphobic situations, "using public transportation" and "standing in line and or being in a crowd") would be diagnosed with agoraphobia. Criterion B of agoraphobia (the situations are feared or avoided "because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other inca- pacitating or embarrassing symptoms") can also be useful in differentiating agoraphobia from specific phobia. If the situations are feared for other reasons, such as fear of being harmed directly by the object or situations (e.g., fear of the plane crashing, fear of the an- imal biting), a specific phobia diagnosis may be more appropriate. Social anxiety disorder. If the situations are feared because of negative evaluation, so- cal anxiety disorder should be diagnosed instead of specific phobia. Separation anxiety disorder. If the situations are feared because of separation from a primary caregiver or attachment figure, separation anxiety disorder should be diagnosed instead of specific phobia. Panic disorder. Individuals with specific phobia may experience panic attacks when con. fronted with their feared situation or object. A diagnosis of specific phobia would be given it the panic attacks only occurred in response to the specific object or situation, whereas a di. agnosis of panic disorder would be given if the individual also experienced panic attacks that were unexpected (i.e., not in response to the specific phobia object or situation). Obsessive-compulsive disorder. If an individual's primary fear or anxiety is of an ob. lector situation as a result of obsessions (e.g., fear of blood due to obsessive thoughts about contamination from blood-borne pathogens (i.e., HIV]; fear of driving due to obsessive im- ages of harming others), and if other diagnostic criteria for obsessive-compulsive disorder are met, then obsessive-compulsive disorder should be diagnosed. Trauma- and stressor-related disorders. If the phobia develops following a traumatic event, posttraumatic stress disorder (PTSD) should be considered as a diagnosis. How- ever, traumatic events can precede the onset of PTSD and specific phobia. In this case, a di- agnosis of specific phobia would be assigned only if all of the criteria for PTSD are not met. Eating disorders. A diagnosis of specific phobia is not given if the avoidance behavior is exclusively limited to avoidance of food and food-related cues, in which case a diagnosis of anorexia nervosa or bulimia nervosa should be considered. Schizophrenia spectrum and other psychotic disorders. When the fear and avoidance are due to delusional thinking (as in schizophrenia or other schizophrenia spectrum and other psychotic disorders), a diagnosis of specific phobia is not warranted. Comorbidity Specific phobia is rarely seen in medical-clinical settings in the absence of other psycho- pathology and is more frequently seen in nonmedical mental health settings. Spacific pho- bia is frequently associated with a range of other disorders, especially deprescion in older adults. Because of early onset, specific phobia is typically the temporally primary disorder. Individuals with specific phobia are at increased risk for the development of other dis- orders, including other anxiety disorders, depressive and bipolar disorders, substance- related disorders, somatic symptom and related disorders, and personality disorders (par- ticularly dependent personality disorder).

Buspirone (Buspar)

Mechanism of action: •Partial Serotonin (5HT-1A) receptor agonist & dopamine receptor antagonist. Indications: •Generalized anxiety disorder (often used in combo with an SSRI). Does not cause sedation & does not potentiate the CNS depression of alcohol (almost negligible abuse or addiction potential). •Takes 1-2 weeks to take full effect. Adverse effects: •Headache, nausea, dizziness, restless legs syndrome, & extrapyramidal symptoms.

Social Anxiety Disorder (Social Phobia)

Most common type of phobia (public speaking) DIAGNOSTIC CRITERIA •Disabling, persistent (at least 6 months) intense fear of social or performance situation in which the person is exposed to the scrutiny of others for fear of embarrassment (eg, public speaking, meeting new people, eating or drinking in front of people, using public restrooms). •Exposure to social situations almost always provokes anxiety & causes expected panic attacks. •May realize feelings are excessive & out of proportion to any actual threat or danger. May avoid those situations. MANAGEMENT •Psychotherapy: initial treatment of choice - cognitive behavioral therapy (eg, desensitization), relaxation techniques, insight-oriented therapy. •Pharmacotherapy: SSRIs (eg, Fluoxetine, Sertraline), SNRIs (eg, Venlafaxine). Adjunctive use of Benzodiazepines can be used until full effect of SSRIs for patients with need of faster relief. •Most patients with moderate-severe cases benefit from combination pharmacotherapy & psychotherapy. SITUATIONAL •Beta-blockers for performance anxiety & public speaking (eg, Propranolol, Atenolol) 30-60 minutes before the performance.

Suicide

RISK FACTORS •Plan: previous attempt strongest single predictive factor (70% of people who committed suicide succeeded on their first try). Organized plan > no organized plans. •Access to firearms is an increased risk. •Gender: females attempt suicide more than men but men are more successful at committing suicide. •Age; increases with age. Elderly white men have the highest risk in the US. •Race: whites > blacks. •Psychiatric disorders: majority who attempt or commit suicide have underlying psychiatric disorders. •Substance abuse: increased risk. •Marital status: alone > never married > widowed > separated or divorced > married without children > married with children (marriage is protective). •Others: positive family history of suicide, history of impulsivity, chronic illness. Among highly skilled workers, physicians are at an increased risk of suicide. MANAGEMENT •Assuring the patient's safety to prevent the patient from committing suicide. •Admission and psychiatric evaluation. •Once safety is established, treatment is aimed at diagnosing and treating any underlying mental disorder, including psychotherapy.

histrionic personality disorder

Think of the H's for Histrionic: • Hey look at me - attention-seeking with the need to be the center of attention, overly emotional, dramatic, seductive. • Hissy fits - temper tantrums, self-absorbed. • Come Hither - often inappropriate, sexually provocative, seductive. • Hype me up - seeks reassurance & praise often. Can be easily influenced by others. • Hyperinflated - may believe their relationships are more intimate than they really are. MANAGEMENT • Behavioral therapy (eg, cognitive, dialectical).

Cluster B disorders

antisocial, borderline, histrionic, narcissistic "Dramatic, wild, erratic, impulsive and emotional"

alcohol dependence

• Alcohol abuse becomes dependence when withdrawal symptoms develop or tolerance. CAGE ALCOHOL SCREENING ≥2 considered a positive screen. Cutdown Have you felt the need to cut down on drinking? Annoyed Have people told you that they were annoyed at you when you drink? Guilt Have you ever felt guilty about your drinking? Eye opener Have you ever needed an eye opener to start your day or reduce jitteriness? MANAGEMENT • Supportive: psychotherapy: eg, individual, group (eg, Alcoholics Anonymous); Inpatient & residential rehabilitation programs. • Disulfiram (Antabuse) can be a deterrent to alcohol use. MOA: inhibits aldehyde dehydrogenase (enzyme needed to metabolize alcohol), leading to increased acetaldehyde when coupled with alcohol intake - uncomfortable symptoms including: hypotension, palpitations, flushing, hyperventilation, dizziness, nausea, vomiting, & headache. CI: cardiovascular disease, diabetes mellitus, hypothyroidism, epilepsy, kidney or liver disease. • Naltrexone; opioid antagonist that reduces alcohol craving & reduces alcohol-induced euphoria. • Gabapentin, Topiramate.

GRIEF REACTION

• Altered emotional state as a response to a major loss (eg, death of a loved one). • Only persistent complex bereavement disorder is considered a mental disorder. • 5 stages of grief: denial, anger, bargaining, depression, & acceptance. Normal grief: • Usually resolves within 6 months to 1 year. • It peaks usually within the first couple of months after the loss. Usually characterized by intense emotions, appetite or sleep disturbances. • Symptoms may include illusions or hallucinations of the deceased that the patient understands is not real. • Patients are usually able to function. Abnormal grief: • Severe symptoms, symptoms > 1 ear or positive suicidal ideation, psychosis, illusions or hallucinations that the patient perceives are real. Persistent complex bereavement disorder: • Severe grief reactions that persist > 1 year (or 6 months in children) after the death of the bereaved. MANAGEMENT: • Psychotherapy. • Short course of Benzodiazepines may be needed for insomnia in some.

antisocial personality disorder

• Behaviors deviating sharply from the norms, values, & laws of society (harmful or hostile to society). Their deceitful nature may be masked and may be seemed as charming or nice to those who don't know their history. • May commit criminal acts with disregard to the violation of laws. • 3 times more common in males. DIAGNOSTIC CRITERIA • Must be at least 18 years old (must have history by 15 years of age consistent with Conduct disorder). At least 3 of the following: • Failure to conform to social norms with disregard & violation of the rights of others or committing unlawful acts. • Irritability or aggressive towards others (eg, assaults). • Exploiting others for personal gain (eg, lying, manipulating, or deceitful acts). • Recklessness & disregard for the safety of self or others (eg, drunk driving common). Impulsivity. • Lack of remorse for actions. • Irresponsibility or failure to maintain work or honor financial obligations. MANAGEMENT • Psychotherapy: establishing limits. Otherwise, psychotherapy & pharmacotherapy generally ineffective. Avoid medications with abusive potential.

schizotypal personality disorder

• Characterized by odd, eccentric, bizarre behavior and thought patterns suggestive of Schizophrenia without psychosis (no delusions or hallucinations). • Usually early adulthood onset. Small percentage may develop Schizophrenia DIAGNOSTIC CRITERIA: At least 5 of the following: • Ideas of reference (excluding delusions of reference), suspiciousness. • Odd beliefs or magical thinking or speech (eg, belief in clairvoyance, telepathy, superstition, bizarre fantasies etc.). • May talk to self in public. • Unusual perceptual experiences; distorted cognition and reasoning. • Inappropriate or restricted affect. • Pervasive discomfort with close relationships (increased social anxiety, may have few close friends). MANAGEMENT • Psychotherapy first-line treatment - cognitive behavioral, individual, or group therapy. • Pharmacologic; short term low-dose antipsychotics for psychotic episodes or suspiciousness occur.

obsessive-compulsive personality disorder

• Characterized by preoccupation with order, details, & perfectionism without obsessions or compulsions. • Their behavior is ego-syntonic (they don't see anything wrong with their behaviors). • 2 times more common in men. DIAGNOSTIC CRITERIA • Preoccupation with order, details, & perfectionism, characterized at least 4 of the following: • Perfectionism that may make completion of a task difficult or in a timely fashion. • Preoccupation with rules, lists, minute details, & organization that the primary goal of the activity is lost. • Hesitance to delegate task to others. • Extreme devotion to work, morals, and ethics. • Rigid, stubborn, serious, or restricted affect. • Inability to discard useless objects MANAGEMENT • Psychotherapy: eg, social training, cognitive behavioral or group therapy. • Pharmacologic: ‡ Beta blockers for anxiety or SSRIs for depression.

avoidant personality disorder

• Characterized by social inhibition due to an intense fear of rejection, affecting their daily lives. • Timid, shy, & lacks confidence. DIAGNOSTIC CRITERIA • Pattern of hypersensitivity, social inhibition, and feelings of inferiority or inadequacy + at least 4 of the following: • Unwilling to interact with others unless certain of being liked. • Avoids occupations that require interpersonal contact due to a fear of rejection & criticism. • Cautious of interpersonal relationships. • Inferiority or inadequacy complex. • Averseness to participate in new activities due to fear of embarrassment • Preoccupation with being rejected in social situations. MANAGEMENT • Psychotherapy: eg, social training, cognitive behavioral, or group therapy.

dependent personality disorder

• Characterized by the inability to assume responsibility, dependent or submissive behavior, fear of being alone, & difficulty making day to day decisions. DIAGNOSTIC CRITERIA • Pattern of excessive need to be taken care of, leading to needy or clingy behavior characterized by at least 5 of the following: • Need for others to assume responsibilities for most things in life • Difficulty expressing disagreement for fear or decreased approval. • Difficulty making day to day decision without external help. Often will not initiate things or may volunteer for unpleasant tasks. • Feeling of helplessness and intense discomfort when they are alone with a quickness to enter a relationship after one ends. • Preoccupation with fears of being left to take care of self. • Goes to extreme lengths to obtain approval of others. MANAGEMENT • Psychotherapy: cognitive behavioral therapy social skills training and assertiveness skills treatment of choice.

Somatic symptom disorder

• Chronic condition in which the patient has physical symptoms involving at least 1 body system but no physical cause found on workup. • Excessive thoughts, feelings, or behaviors related to the somatic symptoms - disproportionate & persistent thoughts about the seriousness of the symptoms, persistently high level of anxiety about symptoms or health, or excessive time & energy devoted to the symptoms & health concerns. • They frequently seek treatment from many medical providers, resulting in extensive lab work, diagnostic procedures, and/or surgeries. • May or may not be associated with other medical condition. RISK FACTORS • Most common in young women (10:1) with onset usually before 30 years age, older age, unemployment, history of sexual abuse, & lower socioeconomic status. DIAGNOSTIC CRITERIA • 1 or more vague physical symptoms that are distressing or result in significant disruption of daily life. These symptoms cannot be explained by a physical or medical cause. At least 2 symptoms increase the likelihood of somatization disorder. • Although any one of the somatic symptoms may not be continuously present, the state of being symptomatic is persistent (usually > 6 months). • Specifiers: with predominant pain (previously pain disorder in DM IV) & Persistent. MANAGEMENT • Regularly scheduled visits to a healthcare provider. • Psychotherapy (source of the symptoms are psychological). Patients may be reticent to seek mental health counseling (they truly believe there is an organic cause).

Psychotic disorders

• Disorder of abnormal thinking, behavior, & emotion. Schizophrenia diagnostic criteria: • 2 or more of the following symptoms positive symptoms, negative symptoms, grossly disorganized or catatonic behavior for at least 6 months. Schizophreniform: • Symptoms of Schizophrenia but duration between 1- 6 months. Brief psychotic disorder: • At least 1 psychotic symptom with onset & remission <1 month. Schizoaffective disorder: • Schizophrenia + mood disorder (major depressive or manic episode).

Acute psychosis

• Emergency: (eg, extremely agitated psychotic) - Haloperidol, Risperidone, or Paliperidone can be used. • Hospitalize patient. • Urine toxicology to rule out substance abuse, CBC, chem-7, LFTs, ECG (baseline QTc interval), & fasting glucose. • Emergency: (eg, extremely agitated psychotic) - intramuscular Ziprasidone, Olanzapine, or Aripiprazole may be used. IM Haloperidol may be used, but has more adverse effects.

Body Dysmorphic Disorder

• Excessive preoccupation with at least 1 perceived flaw or defect in physical appearance that is not observable by others or appears slight to others. • This preoccupation often causes them to be ashamed or feel self-conscious, leading to functional impairment or significant distress. • May commit repetitive acts in response to this preoccupation of physical flaw/defect (mirror checking, skin picking, seeking reassurance) or mental acts (comparison to others). • Average age of onset 15 years of age. May be associated with anxiety disorder or depression. MANAGEMENT • Antidepressants (eg, SSRIs) &/or Cognitive behavioral therapy. • CAs (eg, Clomipramine) are an alternative to SSRIs.

Functional Neurological Symptom Disorder

• Formerly known as Conversion disorder (patients "convert" their psychological distress into neurological symptoms). • 2-3 times more common in women. Often preceded by a traumatic event. • May have comorbid depressive, anxiety, or neurological disorder. DIAGNOSTIC CRITERIA • At least 1 symptom of neurologic dysfunction (voluntary motor or sensory) that cannot be explained clinically & not explained by another medical or psychiatric condition. • Patients are often calm or seem unconcerned about the deficits. • Symptoms are NOT intentionally produced or feigned. • Motor dysfunction: paralysis, aphonia, mutism, seizures, gait abnormalities, involuntary movements, tics, weakness, swallowing, globus sensation (lump in throat). • Sensory dysfunction: blindness, anesthesia, paresthesias, visual changes, & deafness. • Causes significant distress and/or impairment in function (social, occupational etc.). MANAGEMENT • Patient education about the illness first-line treatment. • Cognitive behavioral therapy with or without physical therapy if education not successful.

narcissistic personality disorder

• Grandiose often excessive sense of self-importance, superiority, need for admiration, & lack of empathy. • Despite this exaggerated self-importance, they may have a fragile self-esteem (eg, difficulty with aging process etc., loss of power, higher incidence of mid-life crises, & may become depressed when they don't get the recognition they feel they deserve). CLINICAL MANIFESTATIONS • Inflated self-image - belief he or she is special, entitled, or requires extra special admiration. • Preoccupation with fantasies of brilliance, wealth, success etc. • Takes advantage of or exploit others for self-gain (eg recognition or status). Arrogance. • Envy of others or belief that others are envious of them. • Lacks empathy for others. May reacts to rejection or criticism with rage. MANAGEMENT • Psychotherapy initial treatment of choice (cognitive behavioral therapy, individual or group therapy).

Trichotillomania

• Hair-pulling disorder. 1-2% of the adult population. RISK FACTORS • More common in women (10:1). • Increased incidence with OCD, excoriation (skin picking disorder), & Depressive disorders. CLINICAL MANIFESTATIONS • Hair loss usually involving the scalp, eyebrows, eyelashes but can be hair loss anywhere. • Physical exam: decreased hair density, coarse hairs in the affected area and hair of different lengths. DIAGNOSTIC CRITERIA • Recurrent pulling of hair, resulting in hair loss. Repeated attempts to stop or minimize hair pulling. • Not due to another medication or psychiatric disorder. MANAGEMENT • Cognitive behavior therapy g, habit reversal therapy. • SSRIs, second generation antipsychotics, N-acetylcysteine, or Lithium

Malingering

• Intentional falsification or exaggeration of signs & symptoms of a medical or psychiatric illness for external (secondary) gain eg, financial gain (insurance money, lawsuits), food, shelter, avoidance of prison, school, work, military services, to obtain drugs (eg, narcotics). • Malingering is NOT a mental illness. • Both factitious disorder and malingering are associated with intentionally faking signs and symptoms. The difference is that in malingering, they feign illness for secondary gain whereas in Factitious disorder the primary motive is to 'assume the sick role' & get sympathy.

Factitious disorder

• Intentional falsification or exaggeration of signs & symptoms of medical or psychiatric illness for "primary gain" (inner need to be seen as ill or injured) but NOT for external rewards (aka secondary gain, as seen in Malingering). • Factitious disorder imposed on self - presents themselves as injured, impaired, or ill. • Factitious disorder imposed on another - presents another as injured, impaired, or ill (eg, child, elder or mentally disabled family member). Considered a form of premeditated child or elder abuse. CLINICAL MANIFESTATIONS • Intentional creation or exaggeration of symptoms of illness - eg, may hurt themselves to bring on symptoms, alter diagnostic tests, lie, or mimic symptoms. May inject themselves with substances to make themselves sick, etc. Medical history may be dramatic but inconsistent. • May be willing or eager to undergo surgery repeatedly or painful tests in order to obtain sympathy. They may "hospital jump", use other aliases, or go to different cities to access care. They often have extensive knowledge about medical terminology, hospitals, or great detail about their "illness" (may even work in healthcare). DIAGNOSTIC CRITERIA • Intentional falsification or exaggeration of signs & symptoms of a medical or psychiatric illness for "primary gain" (motivation of their actions is to assume the sick role to get sympathy). • Induction of an injury or disease with intent to deceive. The deceptive behavior is evident even in the absence of obvious external rewards (as seen in Malingering). • Presentation of the individual or another individual (imposed on another). • Behavior is not explained by another psychiatric disorder (eg, Delusional disorder). MANAGEMENT • Nonspecific treatment eg, collect information from medical providers & family members to avoid unnecessary procedures. May require confrontation in a non-threatening manner. When confronted, patients often leave against medical advice. • Child or adult protective services if imposed on another.

schizoid personality disorder

• Lifelong pattern of voluntary social withdrawal & anhedonic introversion (constricted affect). • Most common in males. Usually early childhood onset. Think Schizoids AVOID people: • Anhedonic - little pleasure in activities, appears indifferent, lacks response to praise or criticism • Voluntary social withdrawal - prefers to be alone (unlike avoidant PD). No desire for close or sexual relationships, prefers solitary activities. • Odd-appearing or eccentric. • Introvert - loner "hermit-like behavior", quiet. • Detached, flat, cold, constricted affect MANAGEMENT • Psychotherapy: including individual or group therapy first-line management. • Pharmacologic: ‡ short-term low dose antipsychotics, antidepressants or psychostimulants.

Adjustment disorder

• Maladaptive emotional or behavioral reaction to an identifiable stressor (eg, job loss, physical illness, leaving home, divorce, etc.) or a non-life threatening event that causes a disproportionate response than would normally be expected within 3 months of the stressor (does not include bereavement) & usually resolves within 6 months of the stressor. CLINICAL MANIFESTATIONS • One or both of the following - marked distress out of proportion to the severity of stressor and/or significant impairment in areas of functioning (eg, occupational, social, etc.). • May manifest as depressed mood, anxiety, or disturbance of conduct. MANAGEMENT • Psychotherapy initial management of choice (including individual or group therapy). • Medications may be used in selected cases but they are not the preferred treatment. • Patients may self-medicate with alcohol or other drugs.

Hoarding Disorder

• Persistent difficulty discarding possession, regardless of value resulting in accumulation of a large number of possessions that may clutter living spaces to the point they may become unusable. • The issue is due to the need to save the possessions with distress associated with discarding them. • Hoarding causes impairment of social, occupational, or other areas of function. RISK FACTORS • Most prevalent in the older population but behavior often begins in the early teens. • 20% have associated Obsessive-compulsive disorder. MANAGEMENT • Cognitive behavioral therapy specific for hoarding (very difficult to treat). • SSRIs can be used (not as effective unless concurrent OCD).

paranoid personality disorder

• Pervasive pattern of distrust & suspiciousness of others. • Begins in early adulthood. • More common in males. More common if family history of Schizophrenia. DIAGNOSTIC CRITERIA • Suspicion of others with interpretation of their motives as malevolent without sufficient basis. • Preoccupation with unjustified doubts regarding the loyalty & trustworthiness of others. Reluctance to confide in others. Blames their problems on others. • Misinterpretation of the benign remarks of others as threatening or demeaning - sees hidden messages, is easily insulted, bears grudges, doesn't forgive. • Perception of attacks on his or her character that is not apparent to others & may react angrily to counterattack. • Suspicion regarding the faithfulness of their partner or spouse without justification. MANAGEMENT • Cognitive behavioral therapy first-line treatment (patients may be suspicious of group therapy). • Short-term antipsychotics if severe or if psychosis occurs.

illness anxiety disorder

• Preoccupation with having or acquiring a serious illness despite constant reassurance and medical workups showing no disease. • Formerly known as Hypochondriasis. • The patient exhibits high level of concern & anxiety about their health. • Care seeking type: frequently gets tested, , "doctor shop". • Care avoidance may be seen. • Age of onset usually 20-30 years of age. DIAGNOSTIC CRITERIA • Preoccupation causes the patient to perform excessive health-related behaviors or may develop maladaptive behaviors. • Preoccupation or behaviors must last at least 6 months. • Somatic symptoms are usually not present. If they are present, they are mild in intensity. • Not explained by another disorder (eg, Somatic symptom disorder). MANAGEMENT • Regularly-scheduled appointments with their medical provider for continued reassurance. • Psychotherapy: eg, cognitive behavioral therapy. • Comorbid anxiety & depressive disorders should be treated with SSRIs or other antidepressants

Tobacco Use/Dependence

• Smoking is the most important modifiable risk factor in the US for preventable pulmonary, cardiac, and cancer deaths. • Smoking cessation should be discussed with all smokers at every clinical contact. NICOTINE WITHDRAWAL • Symptoms include restlessness, anxiety, irritability, sleep abnormalities, headaches, depression, increased appetite, weight gain, chest tightness, and nicotine craving. MANAGEMENT OF DEPENDENCE • Includes counseling and support therapy, cognitive behavioral therapy. • Relapse after abstinence is common. • Nicotine tapering therapy: gum, nasal sprays, transdermal patches, inhaler & lozenges. • Bupropion: antidepressant drug often used in combination with nicotine tapering therapy. Mechanism: Dopamine & norepinephrine reuptake inhibitor that reduces nicotine cravings and withdrawal symptoms. • Varenicline: blocks the nicotine receptors, reducing nicotine activity. Partial agonist that mimics the effects of nicotine, reducing the reward effect and preventing withdrawal symptoms. Therapy should begin 1 week prior to quit date and continued 4 months after quit date. Adverse effects: headache, nausea, insomnia, increased suicidality or neuropsychiatric conditions.

borderline personality disorder

• Unstable, unpredictable mood & affect. UNSTABLE SELF-IMAGE & RELATIONSHIPS. • Most commonly seen in women. DIAGNOSTIC CRITERIA Think of the B's for Borderline: • "Bat" - mood swings • Black & white thinking': thinks in extremes "all good" or "bad" '- no middle ground (splitting). • Blown up (intense) reaction disproportionate to the event. • Broken: unstable relationships • Breaking up - fear of abandonment • Bad behavior: impulsivity in self-damaging behaviors: suicide, self-mutilation, substance abuse, reckless driving, binge eating, spending. Bad sense of self. MANAGEMENT • Behavioral therapy: eg, cognitive, dialectical

Physical abuse

•Abuser often female and usually the primary caregiver. •Signs may include cigarette burns, burns in a stocking glove pattern, lacerations, healed fractures on radiographs, subdural hematoma, multiple bruises, or retinal hemorrhages. •Hyphema or retinal hemorrhages seen in shaken baby syndrome

Intimate partner abuse

•According to the CDC, 1 in 4 women and 1 in 7 men will experience physical violence by their intimate partner at some point during their lifetimes. About 1 in 3 women and nearly 1 in 6 men experience some form of sexual violence during their lifetimes. •A woman who leaves an abusive partner has a 70% greater risk of being killed by the abuser compared to staying. •Abuse during pregnancy can make up about 10% of pregnant pregnancy-related hospital admissions. •Barriers to screening include lack of privacy, low self-esteem, fear and sensitive nature of intimate partner violence. • Clues to violence: contusions to breast, chest, abdomen, face, neck, musculoskeletal injuries, and "accidental" injuries. They may have multiple injuries in various stages of healing. Patients may have nonspecific general symptoms, such as fatigue & headache. MANAGEMENT •All healthcare facilities should have a plan that includes screening, assessing and referring patients for intimate partner violence. •Once suspected, patients should be addressed directly with a nonthreatening question to confirm if intimate partner abuse has occurred. If it has occurred, then alternatives should be discussed with referral if the patient accepts as it is the patient's right to accept or refuse help.

Sexual abuse

•According to the National sexual Violence Resource Center 2015 report, more than one-quarter to one-third of female children have experienced sexual abuse before 18 years of age. •Common ages of sexual abuse is between ages 9-12 years. •Perpetrators are most commonly males and most are relatives to the child or known by the child (have access). ~33% of sexual offenders were once themselves victims of sexual abuse. •Any of the following should increase the index of suspicion for child abuse - children that exhibit sexual knowledge, initiate sex acts with peers, show knowledge of sexual acts, bruises, pain, or pruritus in the genital or anal area or evidence of a sexually transmitted infection.

Panic disorder

•Average age of onset in early - mid 20s. Greater risk if 1st-degree relative is affected. •>60% may also have major depression. •More common in females. DIAGNOSTIC CRITERIA: •Recurrent, unexpected panic attacks (at least 2 attacks) may or may not be related to a trigger. •At least one of the following must occur for at least 1 month: 1. Panic attacks often followed by persistent concern about future attacks, 2. persistent worry about the implication of the attacks (eg, losing control) or 3. significant maladaptive behavior related to the attacks. •Symptoms are not due to substance use, medical condition (eg, thyroid, hypoglycemia, cardiac), or other mental disorder. •Agoraphobia: anxiety about being in places or situations from which escape may be difficult (eg, open spaces, enclosed spaces, crowds, public transportation, or outside of the home alone). Agoraphobia now seen as a separate entity from panic disorders & can occur with other psychiatric disorders. MANAGEMENT •Long-term: SSRIs first-line medical treatment (eg, Sertraline, Citalopram, Fluoxetine). May initiate therapy with SSRIs + benzodiazepines, then taper and discontinue the benzodiazepine. SNIs also used (eg, Venlafaxine). TCAs option if SSRIs are ineffective. •Cognitive Behavioral Therapy (CBT): adjunctive treatment that focuses on thinking & behavior (eg, relaxation, desensitization, examining behavior consequences etc.). Psychotherapy may be used in mild cases as initial therapy. Pharmacotherapy + CBT most effective. •Acute panic attacks: Benzodiazepines (eg, Alprazolam, Clonazepam). Watch for dependence or abuse.

Persistent Depressive Disorder (Dysthymia)

•DSM V combined Dysthymia & chronic major depressive disorder into PDD. •More common in women. Onset often in childhood, adolescence, or early adulthood. DIAGNOSTIC CRITERIA •Chronic depressed mood for at least 2 years in adults (at least 1 year in children/adolescents) that last most of the day, more days than not. In that 2 year period, the patient is not symptom free for >2 months at a time. •At least 2 of the following conditions must be present - insomnia or hypersomnia, fatigue, low self- esteem, decreased appetite or overeating, hopelessness, poor concentration or indecisiveness. •May have major depressive episodes or meet the criteria for Major depressive disorder continuously. •Must never have had a manic episode (rules out Bipolar I) or hypomanic episode (rules out cyclothymic disorder). MANAGEMENT •Combination treatment with psychotherapy & pharmacotherapy more efficacious than either alone. •Pharmacotherapy: SSRIs, SNRIs, TCAs, & MAO inhibitors. •Psychotherapy includes interpersonal, cognitive, and insight-oriented psychotherapies.

delusional disorder

•Delusion = fixed belief despite evidence to the contrary. • Nonbizarre delusion = false + plausible but highly unlikely (eg, being poisoned). CRITERIA • At least 1 delusion lasting at least 1 month WITHOUT other psychotic symptoms + no significant impairment in function. • Apart from the delusion, behavior is not obviously odd or bizarre & there is no significant impairment of function. • Does not meet the criteria for Schizophrenia. • Not explained by another disorder, substance, or medication. MANAGEMENT • Atypical (2nd-generation) antipsychotics first-line medical management. • Psychotherapy may be additive in some patients (with the exception of group therapy).

Oppositional Defiant Disorder

•Disorder in which children are generally defiant towards authority but is not associated with physical aggression, violating others' basic rights or breaking laws (unlike Conduct disorder). •Persistent pattern of negative, angry or irritable mood, argumentative, or defiant behavior, & intentional vindictiveness or spitefulness. •50% associated with ADHD. May occasionally lead to Conduct disorder. DIAGNOSTIC CRITERIA •Characterized by at least 4 symptoms present at least 6 months (with at least one individual that is not a sibling). •Angry or irritable mood (eg, loses temper, anger or resentment, often blames others for their misbehaviors & negative attitude). •Argumentative or defiant behavior: breaks rules, often blames others for their behavior, argues with authority & deliberately annoys others. •Vindictiveness: spiteful at least 2 times in the past 6 months. MANAGEMENT •Psychotherapy behavioral modification therapy, problem-solving skills and conflict management training, & teaching parents child management (parenting skills, parent-child interaction therapy.

Bulimia Nervosa

•Eating disorder characterized by frequent binge eating combined with compensatory behaviors to prevent weight gain. •Unlike Anorexia, patients with Bulimia nervosa usually maintain a normal weight (or may be overweight) & their compensatory behaviors are ego-dystonic (troublesome to the patient). •More common in females 10:1. •Average onset of age in the late teens or early adulthood. PHYSICAL EXAMINATION •Teeth pitting or enamel erosion (from vomiting). •Russell's sign: calluses on the dorsum of the hand from self-induced vomiting. •Parotid gland hypertrophy. LAB FINDINGS •Hypokalemia, hypomagnesemia (electrolyte imbalance may lead to cardiac arrhythmias). •Increased amylase (salivary gland hypertrophy + vomiting). Metabolic alkalosis from vomiting. DIAGNOSTIC CRITERIA •Recurrent episodes of binge eating - recurrent episodes characterized by eating within a 2-hour period more than people would in a similar period with lack of control during an overeating episode. Occurs at least weekly for 3 months. May be triggered by stress or mood changes. •Compensatory behaviors: Purging type - primarily engages in self-induced vomiting, diuretic, laxative or enema abuse. - Non-purging type: reduced calorie intake, dieting, fasting, excessive exercise, & diet pills. •Perception of self-worth is excessively influenced by shape and body weight. MANAGEMENT •Psychotherapy; cognitive behavioral therapy, group therapy, interpersonal therapy. Combination psychotherapy & pharmacotherapy more effective. •Pharmacotherapy: Fluoxetine is the only FDA-approved medication for Bulimia nervosa - has been shown to reduce the binge-purge cycle. Fluoxetine associated with cardiovascular adverse effects especially if electrolyte abnormalities are present.

Child neglect

•Failure to provide the basic needs of a child (ex. supervision, food, shelter, affection, education) etc. •Signs include malnutrition, withdrawal, poor hygiene, and failure to thrive.

Agoraphobia

•Intense fear or anxiety about being in places or situations from which escape or obtaining help may be difficult (eg, open spaces such as bridges, enclosed spaces, crowds, public transportation or being outside of the home alone). •Although commonly seen with Panic disorder, Agoraphobia is now seen as a separate entity from panic disorders & can occur with other psychiatric disorders. •The triggering situation causes anxiety or fear out of proportion to the potential danger of the situation. •Symptoms last at least 6 months, cause significant social or occupational dysfunction, & not better explained by another disorder. •Risk factors: strong genetic factor & may follow a traumatic event MANAGEMENT •Similar to Panic disorder: Cognitive behavioral therapy & SSRIs

Generalized Anxiety Disorder (GAD)

•More common in females. •Onset of symptoms usually occurs in early 20s. DIAGNOSTIC CRITERIA •Excessive anxiety or worry a majority of days for at least 6 months about various aspects of life. The anxiety is usually out of proportion to the event. •Associated with at least 3 of the following symptoms: fatigue, restlessness, difficulty concentrating, muscle tension, sleep disturbance, irritability, shakiness, & headaches. •It is not episodic (as in panic disorders), situational (as in phobias) nor focal. •The symptoms cause significant social or occupational dysfunction. •Not due to medical illness or substance abuse. MANAGEMENT •Antidepressants - SSRIs first-line (eg, Fluoxetine, Paroxetine, Escitalopram), SNRIs (eg, Venlafaxine). •Buspirone can be an adjunct to SSRIs (does not cause sedation). •Cognitive behavioral therapy & psychotherapy. Psychotherapy + pharmacotherapy more effective than either alone. •Benzodiazepines can be used for short-term use only until long-term therapy takes effect (watch for dependence or abuse). •Beta-blockers or TCAs.

premenstrual dysphoric disorder

•PMS: cluster of physical, behavioral and mood changes with cyclical occurrence during the luteal phase of the menstrual cycle. •Premenstrual dysphoric disorder: severe PMS with functional impairment where anger, irritability, & internal tension are prominent (DSM V diagnostic criteria). CLINICAL MANIFESTATIONS •Physical: abdominal bloating & fatigue most common, breast swelling or pain, weight gain, headache, changes in bowel habits, muscle or joint pain. •Emotional: irritability most common, tension, depression, anxiety, hostility, libido changes, aggressiveness. •Behavioral: food cravings, poor concentration, noise sensitivity, loss of motor senses. DIAGNOSIS •Symptoms occurring 1-2 weeks before menses (luteal phase), relieved within 2-3 days of the onset of menses plus at least 7 symptom-free days during the follicular phase. •Patient should record a diary of symptoms for >2 cycles. MANAGEMENT •Lifestyle modifications: stress reduction & exercise most beneficial. Caffeine, alcohol, cigarette, & salt reduction. NSAIDs, vitamin B6 & E. •SSRIs first-line medical therapy for emotional symptoms with dysfunction (eg, Fluoxetine, Sertraline, Citalopram). •Oral contraceptives (especially Drospirenone-containing OPs) can be used in patients who do not want to take SSRIs. •Gonadotropin-releasing hormone (GnRH) agonist therapy with estrogen-progestin addback if no response to SSRIs or OCPs.

Conduct Disorder

•Persistent pattern of behaviors that deviate sharply from the age-appropriate norms and violates the rights of others and animals. •These individuals engage in physical and/or sexual violence, lack empathy for their victims, and may lack remorse for committing crimes. •More common in males. High incidence of ADHD and Oppositional defiance disorder. •May progress to Antisocial personality disorder. DIAGNOSTIC CRITERIA • Persistent pattern of violation of the rights of others or age-appropriate societal norms with at least 3 behaviors over the last year and at least one incidence within the last 6 months: •Aggression to humans or animals threatens, intimidates, or bullies others, uses weapons, physically cruel to animals or humans, sexual violence. •Destruction of property - engages in fire setting, vandalism, etc. •Serious violation of rules - runs away from home, stays out past curfew, engages in truancy (often before 13 years old). •Deceitfulness or theft - lies to obtain goods and favors, breaks into buildings, cars or homes etc., steals the properties of others. Lacks remorse for actions. <18 years of age. MANAGEMENT •Multimodal: behavioral modification, community and family involvement, parent management training (eg enforcing rules and setting limits). PROGNOSIS •Good prognosis: positive relationship with at least 1 parent, adolescent onset of symptoms, female gender, good interpersonal skills, high IQ, good academic performance. •Poor prognosis: onset of symptoms prior to 10 years, low IQ poor academic performance.

Bipolar II Disorder

•Recurrent major depressive episodes with hypomania. DIAGNOSTIC CRITERIA FOR BIPOLAR II •History of at least 1 major depressive episode + at least 1 hypomanic episode. Any current or prior Manic episode makes the diagnosis Bipolar I. •Hypomania = abnormal & persistently elevated, expansive or irritable mood <1 week, does not require hospitalization, not associated with marked impairment of social/occupational function, & not associated with psvchotic features. At least 3 symptoms affecting mood, thinking, or behavior (symptoms otherwise similar to Manic episodes). MANAGEMENT: same as Bipolar I •Mood Stabilizers: Lithium first line (also decreases suicide risk) or second-generation (atypical) antipsychotics (eg, Risperidone, Quetiapine, Olanzapine, & Ziprasidone). •Valproic acid or Carbamazepine useful for rapid cycling. •Psychotherapy: cognitive, behavioral & interpersonal. Good sleep hygiene recommended.

Bipolar I Disorder

•Risk factors: family history (1s-degree relatives) strongest risk factor (10 times more likely). Men = women. •1% of population. Average age of onset is 20s - 30s. New onset rare after 50y. •The earlier the onset, the greater likelihood of psychotic features & the poorer the prognosis. DIAGNOSTIC CRITERIA •At least 1 Manic or mixed episode (only requirement). The manic episodes often cycle with occasional depressive episodes but major depressive episodes are not required for the diagnosis. •Mania = abnormal & persistently elevated, expansive or irritable mood at least 1 week (or less if hospitalization is required) with marked impairment of social/occupational function At least 3: Mood: euphoria, irritable, labile or dysphoric; Thinking: racing, flight of ideas, disorganized, easily distracted, expansive or grandiose thoughts (highly inflated self-esteem). Judgment is impaired (eg, spending sprees); Behavior: physical hyperactivity, pressured speech, decreased need for sleep (may go days without sleep), increased impulsivity, excessive involvement in pleasurable activities including risk-taking, hypersexuality, disinhibition, & increased goal directed activity. •Psychotic symptoms (paranoia, delusions, hallucinations) may be seen in these patients. •Symptoms not due to medical condition or substance use. MANAGEMENT •Mood Stabilizers: Lithium first-line (acute mania & long-term management). Lithium also decreases suicide risk. •Valproic acid or Carbamazepine useful for rapid cycling or mixed features. •2nd-generation (atypical) antipsychotics: (eg, Risperidone, Quetiapine, Olanzapine & Ziprasidone) are effective as monotherapy or as adjunctive therapy to mood stabilizers (combination of mood stabilizers and antipsychotics is faster & more effective than monotherapy). •Psychotherapy: cognitive, behavioral & interpersonal. Good sleep hygiene recommended. •Bipolar depression: Lithium, Quetiapine, Lurasidone, or Lamotrigine. •Antidepressant therapy may be used as adjunct to mood stabilizers for severe depression but antidepressant monotherapy may precipitate mania or hypomania. ACUTE MANIA •Antipsychotics (eg, Risperidone or Olanzapine > Haloperidol) or mood stabilizers (eg, Lithium, Valproic acid) are most effective. •Antipsychotics or benzodiazepines (Lorazepam) can be used for acute psychosis or agitation. •Electroconvulsive therapy especially helpful for refractory or life-threatening acute mania or depression (also best treatment for pregnant women with manic episodes).

Bipolar I Disorder

•Risk factors: family history (1s-degree relatives) strongest risk factor (10 times more likely). Men = women. •1% of population. Average age of onset is 20s - 30s. New onset rare after 50y. •The earlier the onset, the greater likelihood of psychotic features & the poorer the prognosis. DIAGNOSTIC CRITERIA •At least 1 Manic or mixed episode (only requirement). The manic episodes often cycle with occasional depressive episodes but major depressive episodes are not required for the diagnosis. •Mania = abnormal & persistently elevated, expansive or irritable mood at least 1 week (or less if hospitalization is required) with marked impairment of social/occupational function At least 3: Mood: euphoria, irritable, labile or dysphoric; Thinking: racing, flight of ideas, disorganized, easily distracted, expansive or grandiose thoughts (highly inflated self-esteem). Judgment is impaired (eg, spending sprees); Behavior: physical hyperactivity, pressured speech, decreased need for sleep (may go days without sleep), increased impulsivity, excessive involvement in pleasurable activities including risk-taking, hypersexuality, disinhibition, & increased goal directed activity. •Psychotic symptoms (paranoia, delusions, hallucinations) may be seen in these patients. •Symptoms not due to medical condition or substance use. MANAGEMENT •Mood Stabilizers: Lithium first-line (acute mania & long-term management). Lithium also decreases suicide risk. •Valproic acid or Carbamazepine useful for rapid cycling or mixed features. •2nd-generation (atypical) antipsychotics: (eg, Risperidone, Quetiapine, Olanzapine & Ziprasidone) are effective as monotherapy or as adjunctive therapy to mood stabilizers (combination of mood stabilizers and antipsychotics is faster & more effective than monotherapy). •Psychotherapy: cognitive, behavioral & interpersonal. Good sleep hygiene recommended. •Bipolar depression: Lithium, Quetiapine, Lurasidone, or Lamotrigine. •Antidepressant therapy may be used as adjunct to mood stabilizers for severe depression but antidepressant monotherapy may precipitate mania or hypomania. ACUTE MANIA •Antipsychotics (eg, Risperidone or Olanzapine > Haloperidol) or mood stabilizers (eg, Lithium, Valproic acid) are most effective. •Antipsychotics or benzodiazepines can be used for acute psychosis or agitation. •Electroconvulsive therapy especially helpful for refractory or life-threatening acute mania or depression (also best treatment for pregnant women with manic episodes).

cyclothymic disorder

•Similar to Bipolar II but is less severe. •Approximately 1/3 will eventually develop Bipolar disorder. Men = women. •May coexist with Borderline personality disorder. DIAGNOSIS •Characterized by at least 2 years of prolonged, milder elevations and milder depressions in mood that do not meet the criteria for full hypomanic episodes or major depressive episodes (at least 1 year in children). •The symptom free periods don't last longer than 2 months at a time for those 2 years. •Major depressive, manic or mixed episodes do not occur. MANAGEMENT •Similar to bipolar I: mood stabilizers (eg, Lithium, Valproic acid) or 2nd-generation antipsychotics (eg, Risperidone, Olanzapine, Quetiapine, Ziprasidone).

Autism Spectrum Disorder

•Spectrum of developmental disorders characterized by impairment in social interaction or communication, restricted, repetitive stereotyped behaviors as well as other signs leading to impaired social functioning. •Male: female 4:1. •Should be suspected if there is a rapid deterioration of social or language skills during the first 2 years of life. •Symptoms usually recognized between 12 and 24 months old. DIAGNOSTIC CRITERIA •Social interaction difficulties: significant emotional discomfort or detachment (eg, avoiding eye contact, no response to cuddling or affection). •Impaired communication: either inability to communicate or has the ability to communicate but chooses not to in social settings. Difficulties in understanding what is not explicitly stated (eg, metaphors, humor in jokes etc.). •Restricted, repetitive, stereotyped behaviors & patterns of activities (eg, peculiar interest in objects, rigid, inflexible thought patterns), repetitive motor patterns. •Other signs: persistent failure to develop social relationships, failure to show preference to parents over other adults; unusual sensitivity to visual, auditory or olfactory stimuli; unusual attachments to ordinary objects. Savantism (unusual talents). •These disturbances are not better explained by intellectual disability (intellectual development disorder) or global developmental delay. MANAGEMENT •Referral for neuropsychologic testing, behavioral modification strategies, & medications.

Panic attacks

•Sudden, abrupt, discrete episode of intense fear or discomfort that usually peaks within 10 minutes & rarely last more than 1 hour (most end in 20-30 minutes). •Patients may feel anxious for hours after the attack. CLINICAL MANIFESTATIONS •At least 4 of the following symptoms of sympathetic system overdrive - sense of impending doom or dread (hallmark) PANIC ATTACK SYMPTOMS: sympathetic overdrive 1. Dizziness 6. Shortness of breath 11. Palpitations, increased heart rate 2. Trembling 7. Chest pain/discomfort 12. Nausea or abdominal distress 3. Choking feeling 8. Chills or hot flashes 13. Depersonalization (being detached from oneself) or derealization (feelings of unreality) 4. Paresthesias 9. Fear of losing control 5. Sweating 10. Fear of dying MANAGEMENT OF ACUTE ATTACK •Benzodiazepines first-line medical management (eg, Alprazolam, Lorazepam, Diazepam etc.). Watch for dependence or abuse. •With a panic attack (even in patients with Panic disorder), one must rule out potentially life-threating conditions (eg, heart attack, thyrotoxicosis etc.). •Panic attacks are a feature of many different anxiety disorders but is not a disorder in & of itself.