Midterm

Manic Episode

A) Mania refers to abnormally and persistently elevated, expansive, or irritable mood and increased goal-directed activity or energy, decreased need for sleep, and may include grandiose plans. Speech is typically rapid and may even become incoherent or flight of ideas. o Sleep - revved up and do not need sleep o Plans - can get them in trouble o Mania can be psychotic o Dr. Redfield Jamison books on bi-polar disorder · DSM-5 criteria for a manic episode also include: o 1. duration of at least one week (can be less if severe) and last most of day nearly every day (unless hospitalized) o 2. irritability often present at the end of episode o 3. excessive involvement in pleasurable, high-risk activities (examples?) B) 3 (4 if mood is only irritable) - inflated self-appraisal - decreased need for sleep - more talkative that usual or pressure to keep talking - flight of ideas or experience racing thoughts - distractibility - increase in goal-oriented activity - high-risk activity C) marked impairment, or hospitalization to prevent harm to self or others, or psychotic features D) no substance/medial catalyst mild, mod, severe based on symptoms

DSM-5-TR (6)

Bipolar and Related Disorders (BP-1, BP-2, Cyclothymic Disorder, Substance/Medication-induced bipolar and related disorder, bipolar and related disorder due to another medical condition, other specified BP and related disorder, and unspecified BP and related disorder) Depressive Disorders (disruptive mood dysregulation disorder, MDD, persis dep dis, premenstrual dysphoric disorder, re sub, re med cond, other/un Anxiety Disorders (selective mutism, specific phobia, social anxiety disorder, separation anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder, sub/med-ind anxiety disorder) Trauma- and Stressor-Related Disorders (reactive attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, adjustment disorders, and prolonged grief disorder) Substance-Related and Addictive Disorders (10 classes of drugs) Schizophrenia Spectrum and Other Psychotic Disorders (schizophrenia, other psychotic disorders, schizotypal personality disorder)

Generalized Anxiety Disorder

Is often considered the "basic" anxiety disorder because it is characterized by intense, unfocused, and uncontrollable anxiety. Adults with GAD typically worry about minor daily events like finances, job performance (children with GAD worry about academic, athletic or social competence or physical injury; elderly patients with GAD tend to focus on health issues) The DSM-5 criteria for GAD specify that excessive anxiety and worry must be present more days than not for a period of at least 6 months about a number of activities (work/school) The excessive worry must be accompanied by at least three of six associated physical symptoms (these include restlessness, muscle tension, being easily fatigued, concentration difficulties, irritability, and sleep disturbance) · It is estimated that approximately 4% of the population meets criteria for GAD; however, few seek treatment compared with those with panic disorder · Onset is usually in early adulthood and is usually in response to some life stressor. · The course tends to be chronic but fluctuating and often worsens during times of stress. -mean onset is 35 in north america sig clin d/im no sub/med not better explained by another mental disorder

Genetic & Biological Factors

Most psychopathologists accept that heredity and biology play a role in disorder development, but such genetic dispositions are modified substantially by the operation of environmental factors. Thus, genetic and biological factors serve as predispositions to certain traits, but the expression of these traits is contingent upon other variables

TED Talk) [BLANK %] lead contributing at % of all disability from medical causes leads to disease categories to DALYs (Disability Adjusted Life Years)

Nearly 30%

Psychological Disorder Definition

The DSM-5 defines a mental disorder as "a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities."

another medical condition

a) symptoms b) his/exam/lab findings c) not better explained by mental dis d) not excl during delirium e) signif clin distress/imp

A diagnosis should have...

clinical utility - prognosis; treatment plans; and potential treatment outcomes

principal diagnosis v. provisional diagnosis

condition establishing symptoms for coming in v. when highly likely but insufficient info

What is not a mental disorder?

o In addition, the DSM provides further clarification: "An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described in the above definition. § Discussion: adjustment disorder is different from the expected action - i.e. someone seeking help after a significant life change; if someone if grieving normally, but it is prolonged - adjustment disorder or depression; beyond the norm (impact ability to keep going) § Social deviance does not equal pathology; times where mental disorders can contribute to social deviance, but not enough by itself

Causes of Psychopathology? (Past v. Present)

o In the not so distant past, the major debate was nature vs. nurture o Today, the scientific community is in better agreement that the causes of mental disorders should be seen as a complex interaction between biogenic, environmental, and developmental factors. o In psychopathology, causes are generally divided into predisposing and precipitating factors. § 1) A predisposing factor is a contributory condition that is usually neither necessary nor sufficient to bring about the disorder but that serves as a foundation for its development. (Examples: heredity, family environment) § 2) Precipitating factors refer to clearly demarcated events that occur shortly before the onset of the psychopathology that trigger the expression of dispositional factors. (Examples: death of a parent, exposure to other traumatic experiences)

Developmental Factors

o Psychological disorders are also the result of early childhood experiences that dispose individuals to lifelong patterns of adaptation (which are considered pathological) o Although single severe or traumatic experiences can result in a disorder, most pathological behaviors accrue gradually through repetitive learning experiences

Role of clinical judgement?

o The DSM's most recent definition focuses on clarifying what constitutes disturbance and distress/disability, but clinical judgment still needs to be used in applying these concepts.

Phobia

· A Specific phobia is characterized by clinically significant anxiety provoked by exposure to (or anticipation of exposure to) a specific feared object or situation, often leading to avoidance behaviors. · Social Anxiety Disorder (Used to be called Social Phobia) is characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations o many like the move away from phobia title because "phobias" are sometimes trivialized by society · In all phobias, being exposed to the feared object or situation almost invariably provokes an anxiety response, which may take the form of a situationally bound Panic Attack. · Phobias are common (12.5% of the general population), the most common types of specific phobia are of snakes and heights · Exposure therapy is often helpful · The clinical DSM term is all clinicians use - not the fancy fake titles Specific Phobia a) marked fear or anxiety re obj or sit b) provokes immediate f/a c) actively avoided or endured with intense f/a d) out of proportion to real danger e) 6 plus months f) clin sig dist/imp g) not better explained by another mental disorder sp - animal - natural envir - blood-injection-injury - situational - other Social Anxiety a) f/a about one or more social situations in which the individ is exposed to possible scrutiny by others (in kids must also happen with peers) b) fears act in a way or show anxiety symptoms that will be negatively evaluated c) social situations almost always provoke fear or anxiety d) social situations are avoided or endured with intense anxiety or fear e) f/a out of proportion f) f/a persistent - 6 months g) sign clin d/i h) no sub/med i) not better explained by another mental dis j) if med cond present, unrelated specify is performance only

DSM Specific Criticism

· A dimensional system would be better, especially since there seems to be a high degree of comorbidity or diagnostic overlap that suggests a problem with the classification system itself · Good in some areas, problems in others (ex: future of Personality Disorders) o Incorporating a dimensional approach re personality disorders · Arbitrary symptom cut-offs in diagnosing disorder (e.g., needs to meet 5 criteria for a dx) · Since recent versions of the DSM have remained atheoretical, many criticize that the failure to apply a theory to guide the classification system results in definitional problems and hinders scientific progress.

Major Depressive Episode

· A major depressive episode includes: o a. depressed mood most of the day, nearly every day lasting at least 2 weeks o b. Cognitive symptoms (feeling worthless, excessive guilt, indecisiveness) o c. Disturbed physical functions (disturbed sleep patterns, changes in appetite/weight, loss of energy). These are often referred to as somatic or vegetative symptoms o d. Anhedonia (loss of interest or pleasure in usual activities) o e. Recurrent thoughts of death and/or suicide § does not necessarily mean imminent risk; need to be comfortable with asking those questions · To meet DSM-5 criteria, symptoms must be present for at least two weeks · Prolonged Grief Disorder is a new diagnosis in DSM-5 to provide an option for people grieving - in trauma and stressor-related disorders · A lot of people do not respond well to medication; if someone's life is truly terrible - medication is only going to take the edge off · Different types of depression will see different symptoms in differing amounts · Depression can be psychotic

Substance Use Disorder

· A maladaptive pattern of use leading to impairment or distress, in at least two of the following, occurring within a 12-month period: o the substance is often taken in larger amounts or over a longer period than was intended o there is a persistent desire or unsuccessful efforts to cut down or control substance use o a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects o Craving, or a strong desire or urge to use the substance o recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home o recurrent substance use in situations in which it is physically hazardous o continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance o important social, occupational, or recreational activities are given up or reduced because of substance use o the substance 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 substance o Tolerance o Withdrawal - first episode of alc intox in mid-teens; not before 20 full criteria; also late 30s specifiers: -early/sustained remission -controlled environment -mild/mod/sever + early/sustained remission, if applicable

Panic Attack Definition

· A panic attack is an abrupt surge of intense fear or discomfort accompanied by physical symptoms such as heart palpitations, chest pain, shortness of breath, and dizziness as well as feelings of losing control and fear of dying. o Very abrupt, acute, and intense · There are three types of panic attacks: situationally bound or cued (when exposed to a situational trigger or even just anticipating (the thought of) the trigger), unexpected or uncued, or situationally predisposed (usually, but not necessarily occur when exposed to the trigger). Research indicates that there may be different categories of panic attacks depending on the symptoms and the most useful interventions used with each one may vary. 4 or more - palps, pounding, accelerated - sweating - trembling or shaking - sensations or shortness of breath or smothering - feelings of choking - chest pain or discomfort - nausea or abdominal distress - feeling dizzy, unsteady, light-headed, or faint - chills or heat sensations - paresthesias (numbness or tingling sensations) - derealization or depersonalization - fear of losing control or "going crazy" - fear of dying

Substance Intoxication

· A reversible substance-specific syndrome of maladaptive behavioral or psychological changes due to the recent ingestion of or exposure to a substance that acts upon the CNS. · Symptoms develop during or shortly after the use of the substance. · Symptoms may include belligerence, mood lability, cognitive impairment, impaired judgment. · Used when person at the time of diagnosis is intoxicated a) recent ingestation of alcohol b) clin signif prob behavior or psych changes during or after alcohol ingestation c)Alcohol symptoms 1 or more: - cursive - incoordination - unsteady gait - nystagmus (a vision condition in which the eyes make repetitive, uncontrolled movements) - impairment in attention or memory - stupor or coma d) no med cond, another mental disorder avg 1st intox - 15; highest prevalence - 18-25

Bipolar II Disorder

· A) In Bipolar II Disorder, major depressive episodes alternate with hypomanic episodes, B) with no history of a manic episode C) 1 hypomanic episode not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional dis, os or uns schizo spec and other psych disorder D) symptoms of depression or unpredictability caused by frequent alternation btw periods of depression and hypomanic causes clinically significant distress or impairment · Often misinterpreted as the "milder" version of bipolar · Average age of onset is 19-22 years, but can also begin in childhood · Only about 10% of cases progress to a full bipolar I disorder · Suicide attempt rates are estimated at 24% specifiers r/c hypomanic - anxious distress - mixed features - rapid cycling - peripartum onset - seasonal pattern mde - anxious distress - mixed features - rapid cycling - peripartum onset - seasonal pattern -melancholic features -atypical features -mood-congruent psychotic features -m-inc psych feat -catatonia

Hypomanic Episode

· A) distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased activity or energy, lasting at least 4 days that is clearly different from the non-depressed mood; present most of the day, nearly every day · The list of symptoms is identical to those of a manic episode except that delusions or hallucinations may not be present · It is differentiated from a manic episode because it is not severe enough to cause marked impairment in social or occupational functioning and there are no psychotic features o Required duration is shorter o No psychotic features o Level of impairment is not as marked as with a manic episode B) 3 (4 if mood is only irritable) - inflated self-appraisal - decreased need for sleep - more talkative that usual or pressure to keep talking - flight of ideas or experience racing thoughts - distractibility - increase in goal-oriented activity - high-risk activity C) episode associated w/ change in functioning uncharacteristic of individual when not symptomatic D) mood disturbance and change in functioning noticeable to others E) no marked impairment, hospitalization, or psychotic features F) no substance/medial catalyst

Prevalence of Mood Disorders

· About 16% of individuals experience some type of mood disorder during their lifetimes. · Females are twice as likely to have a mood disorder compared to males (the imbalance is primarily in the number of cases of MDD and dysthymia, bipolar disorder is equal in males and females) · With regards to differences across different ethnic groups, when variables like socioeconomic status are matched, current research does not suggest markedly different rates of mood disorders.

Classes of substances identified in the DSM-5

· Alcohol · Caffeine (not clearly established) · Cannabis · Tobacco · Stimulants (Amphetamine, Cocaine) · Hallucinogens · Inhalants · Opioids · Sedatives/hypnotics/anxiolytics · Other substances (e.g., steroids, nitrous oxide)

Psychotropic Treatment of Mood Disorders

· Antidepressant medications include tricyclics, MAO inhibitors, and SSRI's. Recent studies suggest switching between medications is beneficial in cases of persistent depression. · Studies show that 30% of depressed persons do not respond to medications · For Bipolar Disorder, drug of choice is lithium but side effects may be severe (toxicity, thyroid problems, substantial weight gain). More recently, anticonvulsants (like Valproate) have been successful in the treatment of bipolar disorder

Anxiety Definition/Anxiety Disorders

· Anxiety is a mood state characterized by marked negative affect and somatic symptoms of tension in which the person apprehensively anticipates future danger or misfortune. · In humans, it may be expressed as subjective unease, worried behaviors, and/or physiological responses. · Anxiety is a normal emotion that is adaptive when experienced in moderate amounts, it prepares us to take action. · It only becomes problematic when it is experienced in excessive amounts and interferes with our functioning. o Anxiety can be useful; peak performance demands a moderate amount of anxiety / · Rates of comorbidity among anxiety disorders are high - major depression is the most common secondary diagnosis in persons suffering from anxiety disorders · Anxiety disorders are also associated with a higher risk of suicidal thoughts and attempts; comorbid anxiety and depression increase the likelihood of suicide more than depression alone

Bipolar I Disorder

· Bipolar I Disorder is the alternation of full manic episodes and major depressive episodes (hypomanic episodes can also be present). Most often begins with depressive episode. · Untreated manic episodes last up to about 3 months, the interval between manic episodes is every 6-9 months (if 4-6 episodes a year, it is classified as rapid cycling) · Average age of onset is 18 years, but it can begin in childhood · Suicide attempts are estimated to occur in 17% of patients, usually in a depressive episode A) 1 manic episode B) 1 manic episode not better explained by schizoaffective disorder and is not superimposed on shizophrenia, schizophreniform disorder, delusional dis, os or uns schizo spec and other psych disorder specifiers: anxious distress mixed features rapid cycling melancholic features atypical features mood-congruent psychotic features m-inc psych feat catatonia peripartum onset (after birth) seasonal pattern peak onset - 20-30, but occurs throughout lifecycle

Diagnostic Systems (2)

· Categorical: A person needs to meet the criteria for diagnosis, otherwise the person's symptoms are subclinical · Dimensional: A person is rated on a continuum for their symptoms. o Example: Instead of saying a person is clinically depressed or not, the depression would be rated based on the severity. · DSM-5: what system? o Primarily categorical system § Ex) autism; now austism spectrum disorder; dimensionality comes from how sever it is; Aspergers is in the moderate realm

Major Depressive Disorder (MDD)

· Characterized by one or more major depressive episodes without a manic or hypomanic episode · The occurrence of a single, isolated episode in a lifetime is rare, usually it is a chronic condition · As many as 85% of patients experience a second episode · The median lifetime number of major depressive episodes is four and the median duration is 4 to 5 months · Untreated episodes can last from 6 to 13 months · 15% of those with a history of MDD die by suicide · High degree of co-occurrence with alcohol abuse - any age, but increases with puberty -US incidence peaks in 20s; late-in-life onset is not uncommon - course is extremely variable A) +5 symptoms at same time during same 2-week period and rep change from previous functioning; at least one of the symptoms is 1) depressed mood or 2) loss of interest or pleasure - depressed mood most of day almost every day by self-report or observation (kids can be irritable) - loss or interest or pleasure in activities most day/almost every day - weight loss/gain - insomnia or hyposomnia every day - psychomotor agitation or retardation nerly every day (obs by others) - fatigue/loss of energy nearly every day - worthlessness or excessive or inappropriate guilt ned - less ability to think or concentrate or indecisiveness ned bsoo - recurrent thoughts of death, recurrent suicidal ideation wo plan, attempt or planning B) clinically significant distress or impairment C) no substance/med expl D) 1 mde not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional dis, os or uns schizo spec and other psych disorder E) never manic or hypomanic specifiers - anxious distress - mixed features - peripartum onset - seasonal pattern -melancholic features -atypical features -mood-congruent psychotic features -m-inc psych feat -catatonia mild, mod, severe based on symptoms

Criticisms of all Classification Systems

· Classifying someone reduces the uniqueness of an individual person o Categorizing individuals takes away uniqueness · Difficult to say what symptoms are most relevant in any particular case · Also, classifying increases social stigma and can be self-fulfilling o Societal beliefs and how they seen these issues; manifestation of an underlying problem; people react to the behavior o Caution in labeling people

Communication

· Clients often have a large number of symptoms · Communication among mental health professionals is difficult if they have to list symptoms · It is much easier to communicate a code or a syndrome

Therapy Interventions for Mood Disorders

· Cognitive therapy involves teaching clients to examine the types of thinking processes they engage in while depressed and changing faulty thinking patterns. Treatment usually lasts between 10-20 sessions · Interpersonal therapy focuses on resolving problems in existing relationships and building skills to develop new relationships, also around 15-20 sessions. · Therapy has been found to be as effective as medications.

Therapy vs. Medication

· Combining medication and therapy may provide better benefits than each treatment alone, however not always feasible. · Therapy seems to be more helpful than medications in preventing relapse of depression · Though medication is the preferred treatment for bipolar disorder, most clinicians emphasize the need for therapy interventions geared towards managing interpersonal and practical problems. Family therapy is also beneficial for bipolar disorder · Other advances in treatments include TMS, esketamine (and other psychedelics)

DSM-5 Organization

· DSM-5 chapters are organized on developmental and lifespan considerations. It begins with diagnoses that manifest early in life, followed by those that commonly manifest in adolescence and young adulthood and ends with diagnoses relevant in later life. · In addition, chapters are clustered according to internalizing and externalizing factors. Thus, those with prominent anxiety, depression, and somatic symptoms are first, followed by those disorders with prominent impulsive, disruptive conduct, and substance use symptoms. · Each disorder includes sections on the following: Diagnostic Criteria, Diagnostic Features, Prevalence, Development and Course, Risk and Prognostic Factors, Differential Diagnosis, and Comorbidity. o Think of the DSM as a reference manual; not something you should try to memorize o Pay attention to certain sections more (bolded) · In addition, when relevant, certain disorders will include sections on specifiers, associated features supporting diagnosis, culture-related diagnostic issues, gender-related diagnostic issues, diagnostic markers, suicide risk, and others.

Comparing DSM IV and V

· DSM-IV format o Axis I § 309.81 Posttraumatic Stress Disorder, Chronic § 312.89 Conduct Disorder, Unspecified Onset § 995.54 Physical Abuse of Child (coding tells you if victim or perp) o Axis II § V71.09 No Diagnosis on Axis II o Axis III § No known medical factors o Axis IV § Problems with primary support group § Educational problems § Problems related to interaction with the legal system o Axis V § GAF=40 · DSM-5 format o 309.81 Posttraumatic Stress Disorder (principal diagnosis) o 312.89 Conduct Disorder, Unspecified Onset o 995.54 Child Physical Abuse o V61.8 Upbringing away from parents o V62.3 Educational Problem o V62.5 Imprisonment or other incarceration o WHODAS 2.0 Scores: general disability - mild Moderate disability in life activities and participation in society

Treatment

· Diagnosis allows clinicians to focus on effective treatments · The diagnosis helps the clinician determine how to best treat the client and helps predict prognosis. · Example - paranoid symptoms are not alleviated by therapy...treatment of choice? o Start with anti-psychotics o When you bring them down - then try therapy · Example - unknown bipolar o Consider not just a depressive state - also potential manic; if give anti-depressants to bipolar, can trigger a manic episode o Going to treat with mood stabilizers instead

Aid to Science

· Diagnosis groups people together with like syndromes · This allows for systematic investigation · Scientific community can examine what syndromes have in common in terms of etiology and treatment

Other specified disorder and unspecified disorder category

· Each class of disorders will include the other specified disorder and unspecified disorder category, to provide maximum flexibility for diagnosis. · These two categories are utilized when a case generally conforms to the general guidelines but does not quite meet criteria or when there is an atypical presentation. · The other specified disorder category is used when the clinician can specify the reason that the presentation does not meet criteria (ex: Other specified ADHD, with insufficient inattention symptoms) · The unspecified disorder category is used when the clinician is unable to specify the reason (ex: Unspecified ADHD) · Choosing between these two categories is left up to clinical judgment. · This replaces the Not Otherwise Specified (NOS) category in the DSM-IV.

Treatment for GAD; Panic Disorder; PTSD; OCD

· For GAD, treatment typically involves the prescription of benzodiazepines (Valium, Xanax) and therapy focusing on altering the worry process and increasing coping skills when dealing with worrisome thoughts. · For Panic Disorder, benzodiazepines are also effective in blocking panic attacks but because of dependence issues, the preferred treatment is using SSRI's (Paxil, Prozac). Therapy treatment usually involves cognitive behavioral techniques and studies show increased effectiveness with combined treatments. · Treatment for PTSD focuses on having the person gradually re-experience aspects of the traumatic event within a supportive context. SSRI's are often prescribed to address the severe anxiety and panic attacks often present in PTSD. · Treatment for OCD includes the use of SSRI's, although not always effective and high rate of relapse when medication is discontinued. Most effective treatment is exposure and ritual prevention (ERP).

Where to treat SUDs

· Hospitalization o Due to drug OD; risk of severe withdrawal; medical comorbidities; psychiatric illness with suicidal ideation · Residential treatment unit o Do not require intensive medical/psychiatric monitoring o Do require a restricted environment · Outpatient Program o No risk of medical/psychiatric comorbidity and usually for highly motivated patients Opioid Epidemic

Prodromal Phase

· In medical terms, a prodrome refers to the early symptoms and signs of an illness that come before the characteristic symptoms appear. · In the prodromal stage of schizophrenia, people tend to isolate themselves, school and work performance suffers, lose interest in activities, and may show inappropriate or blunted emotions. - decrease in adaptive functioning · Since these signs are not specific to schizophrenia, one cannot really identify the prodromal stage until the active phase is reached.

DSM-IV's Multiaxial system vs. DSM-5

· In the DSM-IV, five axes of classification o Axis I - Clinical Syndromes (psych disorders) o Axis II - Personality Disorders and MR/Mental Retardation (psych disorders) § high time of considering personality disorders § Axis II stuff = personality pathologies; much more ingrained and unchangeable o Axis III - General Medical Condition § Relevant to psychological picture; significant medical issues listed here o Axis IV - Psychosocial and Environmental Problems § Kind of psychosocial stressors that a person was dealing with o Axis V - Current level of functioning (GAF) § Meant to provide standard rating of person's functioning at time of diagnosis; very unreliable · In the DSM-5, all disorders are listed together (formerly Axis I, II, and III) with separate but optional notations for important psychosocial and contextual factors (formerly Axis IV) and disability (Axis V). For disability assessment, DSM-5 recommends the WHODAS 2.0 (World Health Organization Disability Assessment Schedule) - handout

From DSM-IV: Subtypes of Schizophrenia

· In the DSM-IV, schizophrenia was classified into the following five subtypes: o Paranoid Type - marked preoccupation with one or more delusions and/or frequent hallucinations. These individuals have relatively intact cognition and affect and delusions are of a coherent theme (often persecutory or grandiose). o Disorganized Type - marked disruptions in their speech and behavior, including flat and inappropriate affect. When delusions or hallucinations are present, they are fragmented and no coherent theme. o Catatonic Type - the predominant symptoms are unusual motor responses and odd mannerisms o Undifferentiated type - diagnosed when the symptoms do not meet criteria for more specific subtype o Residual type - diagnosed when the person is not currently exhibiting prominent symptoms but has had at least one episode of schizophrenia. These individuals will often display negative or attenuated positive symptoms such as odd beliefs, social withdrawal, inactivity, or flat affect. This type would now fall under the "currently in full remission" specifier. o These were removed due to limited diagnostic stability, and low reliability and validity. § In the DSM-5, there is an optional severity specifier (which can be determined with the Clinician-rated Dimensions of Psychosis Symptom Severity - p. 743 in the DSM-5)

Schizophrenia

· Is characterized by a broad spectrum (these disorders have a variety of symptoms that can be a part of the presentation) of cognitive, behavioral and emotional dysfunctions that include hallucinations and delusions, disorganized speech and behavior, and inappropriate emotions. · The term is derived from the Greek words from "split mind" o Renaming examples: ultra-perception syndrome; attunement disorder; integration disorder; disorder of thoughts and perception · To be diagnosed with Schizophrenia per the DSM-5, the individual must exhibit symptoms for at least 6 months, including at least one month of active-phase symptoms (or less if successfully treated) and their level of functioning is markedly below the level prior to onset in one or more areas (work, interpersonal relations, self-care) 2 or more (must be 1/2/or 3) sig portion of 1 mo - delusions - hallucinations - disorganized speech - grossly disorganized or catatonic behavior - negative symptoms schizoaffective, mdd, and BP ruled out bc 1) no manic or Mdd episodes in active phase or 2) or if episodes minor time in grand scheme sub/med/autism ruled out specifiers: first/multiple episodes, currently in acute/partial/full remission continuous unspecified catatonia severity (not needed) late teens - mid-30s early-mid 20s men and late 20s women young is rare

Schizophrenia Facts

· It affects about 1 out of 100 people at some point in their lives and complete recovery is rare despite advances in treatment · A better prognosis is associated with a good premorbid adjustment, an acute and late onset, female gender, the presence of a precipitating life event, brief duration of active-phase symptoms, family history positive for Mood disorders but negative for Schizophrenia. · Rates of the disorder are about equal for males and females, but typical age of onset is slightly younger in males · Onset is typically in the late teens to mid-30's. The acute phase of the disorder is usually preceded by a prodromal phase · Between acute episodes, people with schizophrenia may still be unable to think clearly, may speak in a flat tone, may have difficulty perceiving emotions in other people's facial expressions, and may show little if any facial expressions of emotions themselves.

Cyclothymic Disorder

· It is a more chronic version of bipolar disorder where hypomanic and depressive symptom periods are less severe. These cases tend to fluctuate between a hypomanic or depressive mood state for several years with very few periods of neutral mood. · Criteria for a major depressive, manic, or hypomanic episode have never been met. · The pattern must be present for at least 2 years (one year in children) - present for half time and not been wo symptoms for more than 2m at a time - symptoms not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional dis, os or uns schizo spec and other psych disorder - no sub/med cond - clinically signif distress/impairment - high risk for bp -majority ep b4 10

Assigning a diagnosis

· Major change in the recommended format used to list a diagnosis from the DSM-IV to the DSM-5 · Move to a nonaxial system to replace the multiaxial system o Way in which diagnosis were listed o Personality disorder and how do we diagnose

Substance Withdrawal

· Maladaptive behavioral change with physiological & cognitive effects that occurs when concentration of a substance declines in the body after heavy and prolonged use · Most individuals in withdrawal have an urge to re-administer the substance to avoid withdrawal symptoms. · In DSM-5, symptoms/substance-specific syndrome OR sustained use to avoid withdrawal is included for withdrawal to be counted as a symptom · Example: delirium tremens or DT's- can range from insomnia and confusion to hallucinations, paranoia, severe anxiety/fear of imminent death, seizures, etc. a) cessation of alcohol use that was recurrent and prolonged b) alchohol symptoms 2 or more: - autonomic hyperactivity - increased hand tremor - insomnia - nausea or vomiting - transient visual, tactile, or auditory hallucinations or illusions - psychomotor agitation - anxiety - generalized tonic-clonic seizures c) clin sign d/i d) no med or other disorder specifiers: - w/wo perceptual disturbances - normally 4-5 days after period of heavy drinking - rare in younger than 30

PTSD in Forensic Populations

· Many studies suggest that the rate of PTSD in forensic populations is significantly higher than in the general population. · How can this be explained? o Triggers; symptoms; abuse cycle; similar risk factors

Mood Disorders Definition

· Mood Disorders are characterized by clinically significant symptoms related to a mood disturbance · They include a presentation of depression, mania, or both · Individuals suffering from a mood disorder tend to go through periods of symptoms, also known as episodes o Periods of symptoms that fluctuate; you do not diagnose an episode - timeframes are crucial for diagnosis purposes (not super rigid; just to give you a sense of when you start to count it as an episode)

Why is it good to have a system of diagnosis?

· Multiple professionals · Furthers research nationally and internationally · Allows for treatment · Helps society support patients and patients support themselves · Sense of legitimacy o Ex) legal system · Rare diagnosis; cross-check symptoms; check symptoms of same diagnosis

Obsessive Disorders are new to the DSM-5 OCD

· Obsessive Compulsive Disorder is characterized by recurrent obsessions and/or compulsions that are severe enough to be time consuming or cause significant distress or impairment. · Obsessions are defined as recurrent and persistent thoughts, urges, or images that are intrusive and cause marked anxiety and distress. Typical obsessions include thoughts about contamination, aggressive impulses, somatic concerns, and the need for symmetry · Compulsions are defined as repetitive behaviors or mental acts that are engaged in to prevent or reduce anxiety or distress. Compulsions can be behavioral (checking, washing, hoarding) or mental (counting, praying) · Lifetime prevalence rate of OCD is 1.6% · OCD typically onsets between adolescence and mid-20's but earlier and later onset is not uncommon. Most patients describe a gradual onset and exacerbation of symptoms is often seen during periods of stress. · OCD is associated with high rates of comorbidity with mood disorders, other anxiety disorders, and personality disorders.

Etiology (cause of disease)

· Often times, a diagnostic category will have a specific etiology. · The cause of the mental problem may be the same for every disorder in a category. · Thus, diagnosis will help explain known causes.

Acute Stress Disorder

· PTSD cannot be diagnosed if symptoms have only been present for less than one month · Acute Stress Disorder is used when PTSD symptomatology is present within one month after exposure to a traumatic event · Most common traumas in both disorders are combat and sexual assault B) duration of disturbance is 3 days to 1 month after trauma exposure (cannot be diagnosed until after 3 days) D) cs d/i E) no s/m

Substance - Typical Presentation & Course

· Patients tend to present in acute intoxication, acute / chronic withdrawal or substance induced mental disorder or with medical complications · Remission and relapses are the rule (just like any other chronic medical illness) - 2/3 relapse rate · Frequency, intensity and duration of treatment predicts outcome · 70% of patients are eventually able to abstain or decrease use to not meet criteria

Insurance

· People with mental disorders require treatment, insurance or government programs will often cover the cost · The diagnosis that is assigned to the patient is needed for insurance or other agencies to process and pay for services

PTSD

· Posttraumatic Stress Disorder is characterized by the development of symptoms related to exposure to one or more traumatic events. · Exposure to actual or threatened death, serious injury (not limited to physical injury), or sexual violence in one or more following ways (Compare to DSM-IV description: There must have been exposure to some event during which the individual feels intense fear, helplessness, or horror) o Historically interpreted too broadly; was more about the symptomatic experience rather than the traumatic experience o Leads to excluding people who should be included - racial trauma; or leads to a new diagnosis · Exposure is defined in the DSM-5 as directly experiencing, witnessing in person, learning about trauma to close family member or friend, or extreme exposure to the details of a traumatic event (include people who are exposed to chronic terrible events, like first-responders; behavioral analysts) o A lot of people are exposed to trauma, but do not develop ptsd; once there is a history of trauma, next time exposed, can increase the chances of develop PTSD; everyone can cope, but everyone has their limit 1 or more Symptoms of PTSD after traumatic event: · The clinical presentation of PTSD varies, and it can include: o 1) Intrusion symptoms - intrusive memories, distressing dreams, flashbacks o 2) Avoidance symptoms - avoiding thoughts or feelings associated with the trauma, avoiding activities, places that bring back the trauma, inability to recall important aspect of the trauma, detachment from others o 3) Increased arousal symptoms - difficulties sleeping, irritability, anger outbursts, difficulty concentrating, hypervigilance, exaggerated startle response, reckless behavior. § Can create a recipe for person to engage in out of character aggressive and violent behavior o 4) Negative cognitions and dysphoric mood - negative beliefs about oneself, others and the world, blaming self for the trauma, depressed-like presentation · For some individuals, presentation may include dissociative symptoms (specifier would apply) - symptoms for more than 1 month -clin signif d/i - no sub/med specifiers: - with dissociative symptoms - depersonalization - derealization - delayed expression - different for children 6 and under - cannot be repetitive exposure More on PTSD · Lifetime prevalence rate of PTSD is 7%. · Rates are higher among veterans and in other vocations with increased risk of traumatic exposure (among Iraq/Afghanistan vets rate is estimated around 20%) · About one-half of those diagnosed with PTSD will see complete recovery within three months. · Comorbidity with other disorders is high, with the most common conditions being major depression and alcohol dependence.

Positive Symptoms of Schizophrenia

· Refer to active manifestations of abnormal behavior or an excess of distortion of normal behavior. o 1. Delusions - a belief that is not based in reality, also called a disorder of thought content. Include: § delusions of persecution (e.g., "The CIA is out to get me") § grandiose delusions (e.g., believing oneself to be Jesus or believing one has extraordinary abilities) § referential delusions (e.g., "People on TV are making fun of me," or "They've put bugs in the walls of my house") § delusions of being controlled (believing that one's thoughts, feelings, impulses, or actions are controlled by external forces, such as agents of the devil) o 2. Hallucinations - experiencing a sensory event without any actual input from the environment (can include any of the senses, most common are auditory) o 3. Disorganized thinking/speech - includes cognitive slippage (illogical and incoherent speech), tangentiality, loose associations, word salad. o 4. Grossly disorganized or abnormal motor behavior - includes acting in unusual ways, marked agitation, dressing unusually or appearing markedly disheveled, and catatonia (3+ motor dysfunctions that range from complete immobility to wild agitation, like stupor, mutism, negativism)

Negative Symptoms of Schizophrenia

· Refer to the absence or insufficiency of normal behavior and include emotional and social withdrawal o 1. avolition or apathy - refers to the inability to initiate and engage in activities, even basic ones like personal hygiene o 2. alogia - relative absence of speech (could manifest as brief replies, slowed responses, or delayed comments) o 3. anhedonia - a lack of pleasure or indifference to activities that are considered pleasurable o 4. affective flattening - an absence of normally expected emotional responses (difficulty in expressing emotion - not an inability to feel emotion)

Persistent Depressive Disorder (Dysthymia)

· Shares many of the symptoms of MDD, but unlike it, the symptoms tend to be milder and remain relatively unchanged over long periods of time · Must be present for at least 2 years and during this time, the person cannot be symptom free for more than 2 months at a time · One recent study suggests that 22% of patients diagnosed with dysthymia eventually experienced a major depressive episode · Double depression refers to both major depressive episodes and dysthymic disorder. · Often co-morbid with MDD, anxiety disorder, BPD, and substance use disorders combines DSM-4 chronic major depressive disorder and dysthymic disorder a) depressed mood mod, more days than not, soo for 2 years b) 2 or more - poor appetite or overeating - insomnia or hypersomnia - low energy or fatigue - low self-esteem - poor concent or indecisive -hopelessness c) no no symptoms for more than 2 months in 2yr/1yr (kids) period d) criteria for mdd pres for 2 years e) no manic/hypo f) disturbance not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional dis, os or uns schizo spec and other psych disorder g) no sub/med cond h) clin sign distress/imp specfiy -anxious distress -atypical features - partial rem - full rem - early onset - late onset - pure dysthymic syndrome - persistent mde - intermittent mdes, with current episode - intermittent mdes, without current episode mild/mod/severe

Substance-related Disorders

· Substance-related disorders are divided into two groups - substance use and substance-induced disorders. · Substance use disorder in DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum - mild (2-3 symptoms), moderate (4-5), and severe (6 or more). o Used to have substance dependence and substance abuse and now just one o In DSM 4 only needed one symptom; DSM 5 demands at least 2 o Stigma to substance abuse v. dependence · Substance-induced disorders include intoxication, withdrawal, and other substance-induced mental disorders (intox or exposure; capable of producing symptoms; not better explained by acutal syndrome; no exclus during delirium; clin signif distress/impairment) substance-use specifiers: - in early remission, in sustained remission, on maintenance therapy, in a controlled environment - 18-24 high-risk for every substance · 40% of hospital admissions have drug/alcohol as a factor · 100,000 deaths/year from drug/alcohol (approx. 25% of all deaths) · Intoxication is associated with 50% of all MVAs, 50% of all DV cases and 50% of all murders Other disorders in this category · The DSM-5 includes gambling disorder, as a new addition to the manual. · Why? o Same pleasure activation; same physiological reaction · How do we differentiate between gambling and other "behavioral" addictions like sex, exercise, internet, etc.? gambling a) persistent and recurrent problematic gambling behavior leading to clin signif i/d by 4 or mor ein 12-mo period: - increasing money to achieve desired excitement - restless or uncomfortable with attempts to stop - preoccupied with gambling - often gambles when feeling distressed - after losing, returns to get even - lies to conceal extent - lost or jeopardized relation/opport - relies on others to relieve gambling debt b) not better explained by manic episode Specifiers: - episodic v persistent - early remis v sustained remis - mild/mod/severe based on 4-5; 6-7; 8-9 manifests at any age; develops over time

Subtypes v Specifiers

· Subtypes define mutually exclusive and jointly exhaustive subgroupings within a diagnosis (ex: delusional disorder, persecutory type). o One subtype per diagnosis · Specifiers are not intended to be mutually exclusive, so more than one specifier may be given for the same disorder. Specifiers can relate to severity (e.g., mild) course (e.g., in full remission), or descriptive features (e.g., in a controlled environment). o Can have more than one specifier for one individual · Not all disorders include subtypes or specifiers.

Bipolar Disorders Definition

· The core feature of bipolar disorder is the occurrence of manic and/or hypomanic episodes, most often alternating with major depressive episodes. o Depressive episodes are no longer required for bipolar I in DSM-V · Two types: Bipolar I and Bipolar II

Adjustment Disorder

· The essential feature of an Adjustment disorder is a psychological response to an identifiable stressor that results in clinically significant emotional or behavioral symptoms. · This category is used to describe presentations that are a response to an identifiable stressor AND that do not meet criteria for another specific clinical disorder. · So, for example, when an individual has symptoms that meet criteria for a Major Depressive Episode in response to a stressor, a diagnosis of Adjustment disorder is not appropriate. · Adjustment Disorders have several subtypes depending on the predominant symptoms: o 1. with Depressed Mood o 2. With Anxiety o 3. With Mixed Anxiety and Depressed Mood o 4. with Disturbance of Conduct o 5. With Mixed Disturbance of Emotions and Conduct o 6. Unspecified Additional criteria for this category of disorders - the symptoms begin within 3 months of the onset of the stressor and once the stressor (or its consequences) have subsided, the symptoms do not persist for more than an additional 6 months. - out of proportion distress specifiers: - acute - persistent (chronic) - chronic stressor or enduring consequences

Schizophrenia Spectrum Treatment

· The introduction of antipsychotic drugs in the 1950's is considered the most important development in the treatment of Schizophrenia. These drugs affect the positive symptoms of schizophrenia and help people think more clearly. · Conventional or "typical" antipsychotics include Thorazine and Haldol but many negative side effects. Newer antipsychotics called second generation or "atypical" include Risperdal, Abilify, Seroquel, and Zyprexa · Although effective, many patients stop taking their medication due to the unwanted negative side effects, including extrapyramidal symptoms like tardive dyskinesia (which are often irreversible) and the exacerbation of negative symptoms · Research suggests that combining drug and psychosocial interventions are more effective than drugs alone (including behavioral family therapy, behavioral approaches, vocational and social skills training)

Tolerance

· The need to use increasing amounts of a substance in order to achieve the desired effect OR A markedly diminished effect being associated with continued use of the same amount of the substance · The degree to which tolerance develops varies greatly between drugs (opioids, alcohol vs. marijuana) · Tolerance is the result of CNS changes that occur following repeated use of a drug

New mood disorders added in DSM-5-TR

· The newest addition to the DSM's mood disorders is Brief o 1. Prolonged Grief Disorder continued presence, for at least 12 months after the death of a loved one, of intense yearning for the deceased and/or persistent preoccupation, along with other grief-related symptoms that are sufficiently severe to cause impairment in functioning o 2. Unspecified Mood Disorder added to provide a broader alternative for presentations that do not fall under either bipolar or depressive disorders

SUDs Comorbidity

· There are high rates of comorbidity associated with substance related disorders and other psychiatric disorders, including depression, BD, anxiety, PTSD, schizophrenia, conduct disorder/Antisocial Personality Disorder. · Referred to as "dual diagnosis," current estimates indicate that 50% of people with a SRD have another mental disorder · What are likely reasons for this? Factors involved in comorbidity · The drug abuse may be a coping mechanism, an escape, or a way to self-medicate. · There is a degree of positive reinforcement, since the drug does provide short-term relief for symptoms of anxiety and depression. · Substance use may precipitate or exacerbate symptoms to diagnostic levels. · There may be common genetic or environmental risk factors associated with substance abuse and mental illness. · Severe trauma greatly increases the risk of drug abuse. · Comorbidity may increase the likelihood of seeking or being referred to treatment

Residual Phase

· This is the final stage of schizophrenia. The features of the residual phase are very similar to the prodromal stage. · Patients in this stage do not appear psychotic but may experience some negative symptoms such as lack of emotional expression or low energy. Although patients in the residual stage do not have delusions or hallucinations, they may continue to experience strange beliefs.

Disruptive Mood Dysregulation Disorder

· This new addition to the DSM-5 was included to address the concern about the overdiagnosis of bipolar disorder in children. · It is characterized by persistent irritability and frequent episodes of extreme behavioral dyscontrol. · It is to be diagnosed in children between ages 6 and 18. · Children with this pattern of behavioral and mood difficulties most often will go on to develop depressive or anxiety disorders, not bipolar disorder. · Prevalence is estimated at around 2 and 5% of child/adolescent populations. · DSM-5 criteria for DMDD include: o 1. Severe recurrent temper outbursts (verbal and/or behavioral) that are out of proportion to the situation, developmentally inappropriate, and frequent (3x per week). o 2. In addition to temper outbursts, the child's mood is persistently irritable most day ned obs by others o 3. This pattern must be present for at least one year no more than 3-mo reprieve from all symptoms, evident in at least two of three (home, school, w/peers), and must be evident before the age of 10 (by history or observation) -never been more than one day where criteria for manic/hypom met except time -not exclusive to mdd or better explained by another disorder - no sub/med

Panic Disorder

· To meet criteria for Panic Disorder, a person must experience recurrent, unexpected panic attacks and develop anxiety about the possibility of another attack or the implications of the attack or started behavior to avoid attacks for at least 1 month. o Recurrent = Must experience at least two to qualify o Unexpected = unknown trigger · In PD with comorbid Agoraphobia, the individual also experiences fear and avoidance of situations (e.g., public situations, open spaces) where a panic attack may occur. This condition is often very disabling and is associated with a poor quality of life. · Prevalence of Panic Disorder in the general population ranges between 2 and 3%. 20-24 years onset in US and 32 cross-nationally no med/sub not better explained by another mental disorder Agoraphobia a) f/a about 2 or more of the following 5 situations: - public transport - open spaces - enclosed spaces -in line or crowd - outside of home alone b) fears or avoids these situations because thoughts of escape may be difficult or not available in the event of developing panic-like/incapacitating/embarrassing symptoms c) sit almost always provokes fear or anxiety d) avoided; endured with f/a; or with companion e) out of proportion f) f/a/avoidance is persistent 6 plus months g) cin signif distress h) if another med present - f/a/avoid is excessive i) not better explained by another mental disorder

Psychotic Definition

· Usage of this term has varied throughout history. It has fluctuated from broader to more narrow definitions. For instance, symptoms had been considered as psychotic if they "resulted in impairment that grossly interferes with the capacity to meet ordinary demands of life." · Today, the term generally refers to the presence of delusions, hallucinations, disorganized thinking, or disorganized or abnormal motor behavior.

Schizophrenia in Forensic Populations

· Video on untreated mental illness (from 60 Minutes) · Hostility and aggression can be associated with schizophrenia, BUT the large majority of persons with Schizophrenia are not aggressive. A subgroup of those diagnosed may display aggression more frequently than the general population: younger males with history of substance abuse, impulsivity, and non-adherence with treatment. · A review of the current literature does reveal that individuals diagnosed with schizophrenia have been involved in crime and arrested more frequently than the general population, they are overrepresented in correctional settings, and they represent the majority of those found not guilty by reason of insanity. · However, it is unclear whether this is related directly to the mental illness, or to other risk factors like poverty, being unskilled, uneducated, and unmarried (all which are strong predictors of antisocial/violent behavior in the mentally ill)

Formulating a Diagnosis

· What sources of information do you use to formulate a diagnosis? o Medical records esp. those that precede getting into trouble; DSM; criminal records; family history from interviews; *client interview (most important; should not diagnose without meeting the person in question) · After obtaining the data, you should have a systematic process for developing your diagnosis and there are many different approaches to this... o Begin testing after gathering data · Some useful resources as you begin this process: o 1. Cross-cutting symptom measure in DSM-5 (pp. 843-853) o 2. Differential diagnosis sections o 3. Decision trees from DSM-IV § Was taken out of DSM-V; copy on blackboard as a reference aid

Delusional Disorder

· display persistent beliefs (bizarre or nonbizarre) that is contrary to reality in the absence of most other psychotic symptoms. Must not exhibit prominent symptoms of schizophrenia and functioning is not markedly impaired. Delusions include erotomanic, grandiose, jealous, persecutory, and somatic (bodily functions or sensations) types. Only delusions - no other psychotic symptoms. Specify is with bizarre conent -1 month or longer -if manic or mdd episodes, brief relative to duration of delusional periods - no sub/med specifiers: - types of delusions - if bizzare - first/multiple episode(s), currently in acute/partial/full remission -severity on special scale (not needed) - portion go on to develop schizophrenia; all ages but older more normal

Brief Psychotic Disorder

· experience one or more positive symptoms of schizophrenia within one month. It is often precipitated by an extremely stressful situation and commonly dissipates on its own. 1 or more (must be 1/2/3 if one) - delusions - hallucinations - disorganized speech - grossly disorganized or catatonic behavior episode at least 1 day but less than 1 month with return to normal not better explained by mdd or BP with psychotic features or schizo or catatonia and no sub/other med condit childhood or early adulthood possible - avg onset mid-30s

Schizophreniform Disorder

· involves the same symptoms present in Schizophrenia but the time frame is different (at least one month but no more than 6 months) and impaired functioning is not required for the diagnosis. About 2/3 of people with this disorder eventually receive a diagnosis of Schizophrenia. Early phase of schizophrenia -if manic or mdd episodes, brief relative to duration of delusional periods - no sub/med 2 or more (must be 1/2/or 3) - delusions - hallucinations - disorganized speech - grossly disorganized or catatonic behavior - negative symptoms specifiers: - w/wo good prog features - catatonia 2/3 go on to schizo or schizoaffective

Schizoaffective disorder

· when the individual suffers from symptoms of schizophrenia and a mood disorder (manic or depressive). Note that the hallucinations and/or delusions must be present for at least 2 weeks when the symptoms of a mood disorder are not active. mood episode present for majority of total duration active a residuals no sub or med specifiers: bipolar type depressive type first/multiple episodes, currently in acute/partial/full remission continuous unspecified catatonia severity (not needed) early adulthood common, but any time in life