Tri 1 Clinical Psych Exam 2

Gender Related Issues (Alcohol)

"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 (DSM 5)."

Cluster A includes three disorders with odd, aloof features.

Paranoid, Schizoid, and Schizotypal

Suicide Warning Signs: Feeling, Thoughts, and Behaviors

*Can't: --Stop the pain --Think clearly --Make decisions --See any way out --Sleep eat or work --Get out of depression --Make the sadness go away --See the possibility of change --See themselves as worthwhile --Get someone's attention --Seem to get control

Absorption Rates and BAC (What affects your absorption of alcohol and your Blood Alcohol content?)

*Eating before or during drinking - Food in the stomach cuts down on the rate at which it's absorbed. *Gender - Females at the same weight have a slight disadvantage. Hormones, less water in the body and muscle is a factor. *Time - The more time between drinks, the less gets absorbed. *Weight - Has to do with blood and water. It is simple math *Drinking something with bubbles - It flickers the valve from your stomach to your small intestine where alcohol gets absorbed more quickly. *Menstrual Cycle. - Right before menstruation is where alcohol gets most absorbed. *Stress and lack of sleep - Will increase the rate of absorption. *Artificial Sweeteners - Shown that alcohol leaves the stomach quicker when mixed with artificial sweeteners. *Point out that the only way to sober up is time. Once the alcohol is in the blood you have to wait for the liver to do the work.

Method of entering the body (drugs)

*Orally -Passes through the esophagus and stomach to the small intestine where it is absorbed by capillaries. -20 -30 Minute lag time before effects are felt. *Inhaling -The vaporized drug enters the lungs and is rapidly absorbed through tiny blood vessels lining the air sacs of the bronchi it then gets pumped back into the heart. -7-10 second lag time before effects are felt. *Injecting -Put directly into the body with a needle. -Dangers include exposing body to many health related problems (HIV and hepatitis) -15-30 seconds lag time in a vain, 3-5 min in a muscle mass) *Snorting and Mucosal Exposure -Snorted into the nose and absorbed by tiny blood vessels enmeshed in the mucous membranes lining the nasal passages. -3-5 min lag time *Contact -Dropped into the eye or on the skin. -Eye - 3-5 min lag time -Patches can release quantities of the drug for a long period of time.

Endogenous Drugs - Drugs produced within the body.

- Examples: Endorphins (the brains own narcotics), Serotonin and GABA (natural downers), The body even makes its own psychedelics (DMT).

Semisynthetic Drugs - Taking refined natural drugs and changing the chemical structure.

- Examples: LSD, Freebase cocaine, heroin.

Synthetic Drugs - Made from scratch in a laboratory and do not occur naturally.

- Examples: Valium, PCP

U.S. Suicide Stats

--1 suicide every 17 minutes (84 suicides every day) --3,921 people age 15-24 die by suicide each year (This is the 3rd leading cause of death in this age group) --25-100 attempts for each documented death (31,000 suicides translates into 775,000attempts annually)

Stages of Crisis (5:Regrouping and Resolution)

--3 possible outcomes: 1.Development of new maladaptive coping mechanisms (flight, AOD, Suicide attempt, psychosis, etc.) 2.Restoration of former coping methods (minimal goal of the intervention) Development of new adaptive coping methods (maximum goal)

Suicide thoughts, plans, and attempts: The national Youth Risk Behavior Survey found that among high school students

--6.3 percent self-reported having attempted suicide one or more times in the previous 12 months. --Attempts were reported more frequently by female students (8.1 percent vs. 4.6 percent for males) and Hispanic females reported attempts more than other racial and ethnic groups (11.1 percent). --1.9 percent reported having made a suicide attempt in the previous 12 months that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse. --10.9 percent reported having made a plan for a suicide attempt in the previous 12 months. --13.8 percent reported having seriously considered attempting suicide in the previous 12 months.

What is a Substance Use Disorder?

--A cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. --The diagnosis of a substance use disorder can be applied to all 10 classes included in except caffeine. --For certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for phencyclidine use disorder, other hallucinogen use disorder, or inhalant use disorder). --Important characteristic - There is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. Behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli. These persistent drug effects may benefit from long-term approaches to treatment. --Overall, the diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to use of the substance.

Do Young Children Plan, Attempt, and Die by Suicide?

--A growing body of research has shown that young children do plan, attempt and die by suicide—in contrast to earlier false assumptions that young children are not capable of either contemplating or performing suicidal acts. --Rates of suicide in children ages 10-14 have increased since the 1950s by 300 percent. --One 2009 published study showed most males who completed suicide and/or made serious suicide attempts in adolescence or early adulthood had psychiatric problems by the age of 8 years (Finnish 1981 Birth Cohort Study). --Given these and other data, researchers contend there is good reason to pay special attention to children's own intimations of distress in elementary school.

Irrationality

--A person acts or talks in a way that is not rational or that is incomprehensible ▪Man hearing voices and telling you that you want to eat his brain.

Unconventionality

--A person behaves in a way that is statistically rare ▪Low score on an IQ test (what about high score?)

Violation of standards and societal norms

--A person violates standards that are considered societal norms. ▪A person punching people when they don't like them.

Substance/Medication Induced Mental Disorders

--A. The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder. --B. There is evidence from the history, physical examination, or laboratory findings of both of the following: 1. The disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication; and 2. The involved substance/medication is capable of producing the mental disorder. --C. The disorder is not better explained by an independent mental disorder (i.e., one that is not substance- or medication-induced). Such evidence of an independent mental disorder could include the following: 1. The disorder preceded the onset of severe intoxication or withdrawal or exposure to the medication; or 2. The full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication. This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which persist beyond the cessation of acute intoxication or withdrawal. --D. The disorder does not occur exclusively during the course of a delirium. --E. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Increased Mood Recognition

--About 20% of children will experience an episode of major depression before age 18 ◦At any one point in time, up to 2% of pre-pubertal and up to 8% of post pubertal kids have depression --Frequency of bipolar disorder is controversial ◦Reports range from 0.6% to 6%

The U.S. Department of Health & Human Services 2013 National Survey on Drug Use and Health: Mental Health Findings.

--An estimated 43.8 million adults aged 18 or older in the United States had any mental illness (AMI) in the past year (18.5 percent of all adults) n10.0 million (4.2 percent) adults aged 18 or older had serious mental illness (SMI) in the past year. --17. 5 percent (7.7 million adults) met criteria for a substance use disorder --Estimated 9.3 million adults (3.9 percent) aged 18 or older had serious thoughts of suicide in the past year. --Among adults aged 18 or older in 2013, 2.7 million (1.1 percent) made suicide plans in the past year, and 1.3 million (0.6 percent) attempted suicide in the past year. --34.6 million adults (14.6 percent of the population aged 18 or older) received mental health care during the past 12 months --In 2013, there were 2.6 million youths aged 12 to 17 (10.7 percent) who had major depressive episode (MDE) during the past year. --Among youths aged 12 to 17 in 2013, females were more likely than males to have past year MDE (16.2 vs. 5.3 percent). --Among youths aged 12 to 17 in 2013 who had past year MDE, 33.2 percent used illicit drugs in the past year compared with 15.1 percent among youths who did not have past year MDE. --In 2013, youths aged 12 to 17 with MDE in the past year were more likely than those without MDE to have a substance use disorder in the past year (13.9 vs. 4.1 percent). --In 2013, 3.3 million youths aged 12 to 17 (13.6 percent) received treatment or counseling for problems with emotions or behavior in a specialty mental health setting (inpatient or outpatient care) in the past 12 months. The percentage in 2013 was higher than those in 2007 through 2012 (ranging from 12.0 to 12.7 percent). --The most common reason that youths aged 12 to 17 gave for receiving specialty mental health services in 2013 was feeling depressed (50.2 percent).

Observer Discomfort

--An individual creates distress or threat in someone else observing. ▪A person running through the street naked stating that the end of the world is near.

DSM-5 Elimination of Multiaxial System

--Axis I (clinical disorders), Axis II (personality and mental retardation) and Axis III (medical conditions) listed together --Axis IV (psychosocial and environmental stressors) can be coded along with disorders --Axis V (GAF) eliminated completely. WHO-DAS score indicates functioning but no provision for including it in assessment

DSM-5 moves towards dimensionality

--Combining categories with lower and higher severities into single broad categories with dimensional severity indicators *Autistic Disorder (more severe) and Asperger's disorder (less severe) combined into Autism Spectrum Disorder with two dimensions (social communication, restricted interests/repetitive behaviors) each having 3 levels of severity *Disadvantage: no way to reflect this in coding system

Persistent Depressive Disorder (dysthymia)

--Depressed mood for most of the day, for more days than not, for at least 2 years, or at least 1 year for children and adolescents --2 of the following 6 symptoms ◦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. --Typical Report - "I've always been this way" --Double Depression (MDE on top)

Stages of Crisis (4: The Last Straw)

--Event of situation (even minor) propels individual into a state of disorganization. --This might be thought of as the problem by the helper (not always but should be dealt with 1st before real problems can be addressed)

Premenstrual Dysphoric Disorder

--Expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around the onset of menses or shortly thereafter.

Stages of Crisis (1:Warning/ Arousal Stage)

--External or internal influence that causes a person to feel unbalanced from the environment. --Most cases the problem fades. --Some cases where problem and stress persists and familiar coping methods do not seem to help.

Protective Factors for Youth Suicide

--Family connectedness and school connectedness --Reduced access to firearms --Safe schools --Academic achievement --Self-esteem

Self Care

--Get enough sleep. Ideally, adults require 7-8 hours of sleep, while some may need more. --Eat balanced and nutritious meals. --Exercise regularly. --Engage in hobbies and leisure activities. --Try self-expressive activities such as painting or writing. --Spend adequate time with family and friends. --Plan your day and stay organized. --Be early to events and appointments. --Practice relaxation techniques such as deep breathing or guided imagery. --Evaluate how you spend your day. Does how you spend your time match your values? --Be familiar with policies and procedures. This is part of self care. --Rest when you're sick. --Participate in supervision. --Attend individual and/or group therapy, if appropriate.

Suicide Warning Signs (cont)

--Have attempted suicide before --Take unnecessary risks (reckless and/or impulsive) --Lose interest in their personal appearance --Increased use of AOD --Express hopelessness --Be faced with a situation of humiliation or failure --Have a history of violence or hostility --Have been unwilling to "connect" with potential helpers --Sudden lift in depression

Assessing Suicide

--I: Ideation --S: Substance Abuse --P: Purposelessness --A: Anxiety --T: Trapped --H: Hopelessness --W: Withdrawal --A: Anger --R: Recklessness --M: Mood Change

Substance-Induced Disorders

--Includes intoxication, withdrawal, and other substance/medication-induced mental disorders (e.g., substance-induced psychotic disorder, substance-induced depressive disorder). --Route of Administration and Speed of Substance Effects-more rapid and efficient absorption into the bloodstream (e.g., intravenous, smoking, intranasal "snorting") tend to result in a more intense intoxication and an increased likelihood of an escalating pattern of substance use leading to withdrawal. Similarly, rapidly acting substances are more likely than slower-acting substances to produce immediate intoxication. --Individuals ages 18-24 years have relatively high prevalence rates for the use of virtually every substance.

Why DSM-5 was needed

--Longest gap between DSM's ever *DSM-IV criteria sets reflect research base circa 1993 (20 year gap) *Text reflects research base circa 1999 (14 year gap) --Need to coordinate with ICD-11 (to be published in 2015) --Potential for DSM-5 to address identified weaknesses and to update definitions to reflect most recent research findings

Risk Factors for Youth Suicide

--Mental illness and substance abuse --Previous suicide attempts --Firearms in the household --Nonsuicidal self injury --Exposure to friend's or family member's suicidal behavior --Low self-esteem

History of Childhood Mood Disorders

--Mood Disorders once not well recognized ◦Pre 1970s *Depression was not generally believed to be "possible" in kids *Multiple researchers in the 70's showed this to be false ◦Pre 1980s *Bipolar was rarely diagnosed in kids *Around 1980 multiple studies reported that ~20% of bipolar adults had symptoms start in childhood

2007 Data For Youth aged 10 to 24: Suicide

--NUMBER OF SUICIDES: 4,320 died by suicide --LEADING CAUSE OF DEATH: Suicide was the third leading cause of death for 10- to 24-year-olds. --SUICIDE RATES: Rates of suicide are highest for older youth. For youth aged 20 to 24, 12.5 per 100,000 youth died by suicide. For youth aged 15 to 19, 6.9 per 100,000 died, while for youth aged 10 to 14 less than one per 100,000 died. --GENDER: Male youth die by suicide five times more frequently than female youth. --RACE: Native American/Alaska Native youth have the highest rate with 14.8 suicides per 100,000.White youth are next highest with 7.3 deaths per 100,000. --METHODS: The majority of youth who died by suicide used firearms (45 percent of deaths). Suffocation was the second most commonly used method (38 percent).

My Patient is Suicidal, Now What?

--Notice that it is a combination of risk factors that increases one's risk for suicidal thought or behavior. DO NOT STRESS OUT. --Ask the question: "Have you thought about killing yourself." --Do a thorough lethality assessment: 1. Lethality of the proposed method, e.g. shotgun to the head vs. taking pills 2. Availability of the means, e.g. is gun in room or do they have to buy one? 3. Specificity of the plan, e.g. where, when and how does the person plan to commit the act --Assess for immediate safety. --Use basic listening skills and DO NOT start problem solving right away. --Mental Health Commitment ? (Call Mobile Crisis)

Cyclothymic Disorder

--Numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet symptom or duration criteria for a major depressive episode. --Bipolar II 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 additional diagnosis of bipolar II disorder is given.

Major Depressive Disorder

--Period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities --In children and adolescents, the mood may be irritable rather than sad. w/ anxious distress w/ melancholic features w/ mixed features w/ mood-[congruent, incongruent] psychotic features w/ catatonia w/ atypical features w/ seasonal pattern w/ postpartum onset

Mal-adaptiveness

--Person acts in a way that hinder goals, does not contribute to personal wellbeing, or interferes with others and the needs of society ▪A person drinking a lot of alcohol whenever they are going through stress and as a result perform poorly at work or school

Unpredictability

--Person experiences a loss of control and acts unpredictably ▪Teenage girl throwing their notebook across the room.

Distress / Disability

--Person experiences distress and/or disabled functioning leading to a loss of freedom of action. ▪A person staying in their house because they are afraid to go outside.

Stages of Crisis (2:Impact Stage)

--Person tries to resist and uses up a lot of energy. --Increase the resistance, Increase amount of energy required. --Increase levels of emotion. --Decrease coping mechanisms.

Suicide Warning Signs

--Talk about suicide, death, and/or no reason to live --Preoccupation with death and dying --Withdraw from friends and/or social activities --Have a recent severe loss (esp. relationship) or threat of significant loss --Drastic changes in behavior --Lose interest in hobbies, work, school, etc. --Prepare for death by making out a will (unexpectedly) and final arrangements. --Give away prized possessions.

Updated Stats on Suicide (cont)

--The CDC's thus recommended increasing counseling, job placement and financial services that can help reduce the mental distress that can increase suicide risk. --Between 2008 and 2009 an estimated 8.3 million adults (almost 4 percent of the U.S. adult population) reported having serious thoughts of suicide in the past year, according to the CDC. --More than 2.2 million adults reported making suicide plans in the past year, and more than 1 million adults reported attempting suicide in the past year. --According to the Substance Abuse and Mental Health Services Administration, 20 percent of American adults suffered from mental illness in 2010, but only 39.2 percent of that group said they received treatment. --With this decrease in U.S. mental health services, the general public, schools, law enforcement, healthcare providers, and military personnel would all benefit from education on suicide

Overview from the NHS (UK) of DSM-5

--The DSM was created to enable mental health professionals to communicate using a common diagnostic language. Its forerunner was published in 1917, primarily for gathering statistics across mental hospitals. It had the politically incorrect title Statistical Manual for the Use of Institutions for the Insane and included just 22 diagnoses. --The DSM was first published in 1952 when the US armed forces wanted a guide on the diagnosis of servicemen. There was also an increasing push against the idea of treating people in institutions. --The first version had many concepts and suggestions that would be shocking to today's mental health professional. Infamously, homosexuality was listed as a "sociopathic personality disorder" and remained so until 1973. Autistic spectrum disorders were also thought to be a type of childhood schizophrenia. --¡Because our understanding of mental health is evolving, the DSM is periodically updated. In each revision, mental health conditions that are no longer considered valid are removed, while newly defined conditions are added.

Updated Recent Stats on Suicide

--The latest data reported by the Centers for Disease Control and Prevention (CDC) shows that the rate of U.S. suicide has been increasing since 2000, with 2009 marking the highest number of suicides in 15 years. --The CDC report showed that between 2008 and 2009, the suicide rate increased 2.4 percent, with 36,909 suicide deaths reported nationally. --In August 2011, a report from the CDC showed that in 2008, 13.4 percent of people who committed suicide had experienced job and financial problems. --The National Suicide Prevention Lifeline, an emergency crisis hotline reported a 14 percent increase in call volume between 2010 and 2011.

Stages of Crisis (3:Exhaustion or Recoil Stage)

--Zero coping Mechanisms (energy depleted) --Pain and discomfort. --Most likely to reach out for help. --You can convert anxiety into energy for enacting change

Personality Disorder Definition(DSM-5)

--an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.

Classes of Drugs

-Alcohol -Caffeine -Cannabis -Hallucinogens (with separate categories for phencyclidine [or similarly acting arylcyclohexylamines (like PCP)] and other hallucinogens) -Inhalants -Opioids -Sedatives, Hypnotics, and Anxiolytics -Stimulants (amphetamine-type substances, cocaine, and other stimulants) -Tobacco -Other (or unknown) Substances

Crisis

-Definition: --The point at where a person can no longer depend on or make use of his or her usual ways of coping. -The crisis is the end point of a series of events or situations that happened previously. -The crisis is a response to a situation

Golden Gate Bridge & suicides

-Over 1,000 documented suicides off this bridge (document means there has to be at least 2 witnesses) -Staff stop an average of 2-3 people per week -Studied 515 people who were restrained -At the end of the 1st year it was found that 95% had not gone on to commit suicide -Strong winds so the body flattens out and you can die of impact or drowning -16 people jumped but did not die (240 foot drop) -First thoughts after they jumped --Female: " I want to live, I want to live! I wish I wouldn't have done this" --Male: Swam through the air to avoid impact - This action probably saved his life -No one who survived swam to shore and tried again -Bad news: Over 1,000 people have died after jumping -Really Bad News: No reason to believe that those who jumped and died did not feel the same immediately after jumping than those who died -Good News: 95% will not go on to commit suicide if an intervention occurs

Name/Terminology Changes in DSM-5

1.Not Otherwise Specified--->Other Specified/Unspecified 2.General Medical Condition--->Another Medical Condition 3.Dysthymia--->Persistent Depressive D/O 4.Social Phobia--->Social Anxiety D/O 5.Trichotillomania--->Hair-Pulling D/O 6.Mental Retardation--->Intellectual D/O 7.Stuttering--->Childhood-onset fluency D/O 8.Reading, Mathematics, WrittenExpression D/Os---> Specific Learning D/O

DSM -I

1952

DSM-IV-TR

2000: the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, with an updated "text revision"; a widely used system for classifying psychological disorders.

Looking at the different regions (and states within those regions) which state would have the highest rate of suicide out of the answer choices a. Colorado b. California c. New York d. Texas

A

The Hallmark of_____________ Personality Disorder is preferring to be isolated from others. a. Schizoid b. Schizotypal c. Avoidant d. Dependent

A

The first DSM was published in what year? a. 1952 b.1977 c.1902 d.1945

A

This disorder includes periods of manic symptoms and depressive symptoms that meet the criteria for a Major Depressive Episode. a. Bipolar 1 Disorder b. Cyclothymic Disorder c. Bipolar 2 Disorder d. Major Depressive Disorder

A

This substance has the worse detox symptoms a. Alcohol b. Heroin c. Cocaine d. Marijuana

A

With respect to crisis the last straw means? a. Situation that propels an individual into a state of disorganization. b. The time on a farm when you have to go shopping. c. When a person starts having a crisis d. When a person reconciles their crisis.

A

With respect to self care which of the choices below are important? a. Planning to be early to appointments. b. Make sure to work as hard as you can and only rest when everything is done. c. Don't talk to friends when you are upset. d. Blow off steam by slapping a shovel against a tree.

A

___________ Disorder involves Depressed mood for most of the day, for more days than not, for at least 2 years (in adults and 1 year for children) a. Persistent Depressive Disorder b. Premenstrual Dysphoric Disorder c. Disruptive Mood Dysregulation Disorder d. Cyclothymic Disorder

A

Dependent Personality Disorder Diagnostic Criteria 301.6(F60.7)

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.

Histrionic Personality Disorder Diagnostic Criteria 301.50 (F60.4)

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

Narcissistic Personality Disorder Diagnostic Criteria 301.81 (F60.81)

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

Borderline Personality Disorder Diagnostic Criteria 301.83 (F60.3)

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

Obsessive-Compulsive Personality Disorder Diagnostic Criteria 301.4 (F60.5)

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 over-conscientious, 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.

Avoidant Personality Disorder Diagnostic Criteria 301.82 (F60.6)

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.

Alcohol Use Disorder

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.

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, represent 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 occupational 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 increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar 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.

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 hospitalization 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 significant 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.

Bipolar II

A. Criteria have been met for at least one hypomanic episode (Criteria A-F under "Hypomanic Episode" above) and at least one major depressive episode (Criteria A-C 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 disorder, 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 an hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Bipolar I

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.

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 subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.

Paranoid Personality Disorder Diagnostic Criteria 301.0 (F60.0)

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

Antisocial Personality Disorder Diagnostic Criteria 301.7 (F60.2)

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.

Schizotypal Personality Disorder Diagnostic Criteria 301.22 (F21)

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)."

Schizoid Personality Disorder Diagnostic Criteria 301.20 (F60.1)

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)."

Cluster C includes three disorders sharing anxious and fearful features.

Avoidant Dependent Obsessive-compulsive

I am distrustful of people and go to great lengths to be vigilant about other. I most likely have_____ Personality Disorder. a. Withdrawn b. Paranoid c. Obsessive Compulsive d. Suspecious

B

Comorbidity with Alcohol Use Disorder

Bipolar disorders Schizophrenia Antisocial Personality Disorder Several anxiety and depressive disorders

Cluster B includes four disorders with dramatic, impulsive, and erratic features.

Borderline Antisocial Narcissistic Histrionic

All are criteria for Major Depressive Disorder Except: a. Insomnia or hypersomnia nearly every day b. Fatigue or loss of energy nearly every day c. Treating loved ones badly d. Feelings of worthlessness

C

Having a weak ego that is covered up by the need to feel special and important, usually shows through feeling superior that most people, is most characteristic of which disorder: a. Obsessive Compulsive Personality Disorder b. Histrionic Personality Disorder c. Narcissistic Personality Disorder d. Borderline Personality Disorder

C

____________Personality Disorder is usually shown through needing attention at any cost. a. Borderline b. Antisocial c. Histrionic d. Narcissistic

C

(A) Risk factor(s) for suicide include: a. Can't make the pain go away b. Loss of interest in personal appearance c. Sudden lift in depression d. All of the above

D

Difficulty in relationships and self mutilating behavior is most characteristic of which disorder: a. Obsessive Compulsive Personality Disorder b. Histrionic Personality Disorder c. Narcissistic Personality Disorder d. Borderline Personality Disorder

D

In order to be diagnosed with Persistent Depressive Disorder you must have had symptoms for at least: a. 2 weeks b. 1 month c. 6 months d. 2 years

D

The DSM-5 defines mental disorders as a. A clinically significant disturbance in cognition, emotion regulation, or behavior. b. Indicating a dysfunction in mental functioning. c. Usually associated with significant distress or disability in work, relationships, or other areas of functioning. d. All of the above

D

The Warning or Arousal Stage contains all but which one? a. External or internal influence that causes a person to feel unbalanced from the environment. b. Most cases the problem fades. c. Some cases where problem and stress persists and familiar coping methods do not seem to help. d. A time where people get depressed right away.

D

The gap between the DSM IV, TR and DSM 5 is a. 10 years b. 15 years c. 50 years d. 20 years

D

Which substance cannot be diagnosed as a Use Disorder? a. Marijuana b. Alcohol c. Cocaine d. Caffeine

D

Controversy with DSM-5

Dr. Allen Frances - In his own words (Chair of the DSM-IV TR) : Didn't like that the authors of the DSM-5 were changing his work.

Do we replace one substance for another?

Examples include: •Interchangeable use of alcohol and caffeine: Alcohol when we become "wired" or stressed and caffeine when we are tired/hung-over. •Speedball (mix of heroin and cocaine): to mitigate each other's effects. •Red Bull and Vodka: To offset alcohol's depressant effects. It makes you a more "alert" drunk.

Natural Drugs - Drugs found in nature.

Examples: Plants like Coca leaves, marijuana, DMT (Virola tree). Just because it is natural does not mean it is healthy. DMT for example is a hallucinogen that can be potentially harmful.

True/False A Substance Abuse Disorder is not a mental disorder and the reason why people continue using a substance despite significant substance-related problems, is because of a lack of self-control.

False

True/False: Asking the question: "Have you thought about killing yourself," can make a patient want to kill themselves.

False

True/False: In the DSM 5 there continues to be a 5 axis system.

False

True/False: Mental Retardation is still a diagnosis in the DSM .

False

True/False: Specificity of a persons plan to commit suicide is not that important to assess

False

True/False: Those who talk about suicide don't do it

False

True/False: You can't be diagnosed with a depressive disorder that was induced by a substance.

False

True/False: The number one method for suicide is poisoning.

False (firearms)

True/False: Once a person decides to complete suicide, there is nothing anyone can do to stop them.

False: Suicide is the most preventable kind of death, and almost any positive action may save a life

Specifiers for Bipolar

Same as w/ MDD (Major Depressive Disorder) plus: rapid cycling (4 mood episodes / 1yr) affects 10-20% BD pts •2/3 are ♀

Alcohol Use Disorder (specify)

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 FI 0.229 for a moderate or severe alcohol use disorder with alcohol intoxication. Specify current severity: 305.00 (FI 0.10) Mild: Presence of 2-3 symptoms. 303.90 (FI 0.20) Moderate: Presence of 4-5 symptoms. 303.90 (FI 0.20) Severe: Presence of 6 or more symptoms.

Drugs: Why do we use them?

To treat disease, to escape boredom, to be social, to enhance sensory experience and pleasure, to stimulate creativity, to improve physical performance, to rebel, peer pressure, to establish an identity, to have "fun"

When does the use of a drugs become a problem?

Tolerance, Use to cope with life difficulties, affects your life and the lives of the people around you negatively, when you "can't" stop, when you become a person you don't want to become and to mitigate effects of another drug. When the behaviors you exhibit on the drug affect you negatively.

True/False: Bipolar I is different than Bipolar II with respect to Manic vs. Hypomanic Episodes respectively.

True

True/False: Often, suicidal people communicate their intent sometime preceding their attempt.

True

True/False: People who abuse drugs and/or alcohol are more likely to commit suicide

True

True/False: Semisynthetic Drugs have aspects of it that are found in nature.

True

Treatment for Bipolar Disorder

}Medication such as Mood Stabilizers }Cognitive behavioral therapy }Psychoeducation }Family therapy }Group therapy

Major Depressive Disorder Treatment Options

• Therapy --• cognitive bx therapy (CBT) --• interpersonal therapy (IPT) --• psychodynamic therapy • Other interventions --• electroconvulsive therapy (ECT) --• transcranial magnetic stimulation (TMS) --• vagal nerve stimulation (VNS) --• deep brain stimulation (DBS) • Other --lightbox therapy (mostly for MDD w/ seasonal features)

Types of Mood Disorders

•Bipolar and Related Disorders is a separate category from Depressive Disorders in the DSM 5 •Major depressive disorder (MDD) •Persistent depressive disorder •Premenstrual dysphoric disorder •Disruptive mood dysregulation disorder • Bipolar disorder (BD) (I and II) • Cyclothymic disorder

Bipolar I vs. Bipolar II

◦Bipolar I --modern understanding of the classic manic-depressive disorder or affective psychosis described in the nineteenth century, differing from that classic description only to the extent that neither psychosis nor the lifetime experience of a major depressive episode is a requirement. However, the vast majority of individuals whose symptoms meet the criteria for a fully syndromic manic episode also experience major depressive episodes during the course of their lives. ◦Bipolar II --Requiring the lifetime experience of at least one episode of major depression and at least one hypomanic episode, is no longer thought to be a "milder" condition than bipolar I disorder, largely because of the amount of time individuals with this condition spend in depression and because the instability of mood experienced by individuals with bipolar II disorder is typically accompanied by serious impairment in work and social functioning.